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Rehabilitation of the chronically disabled
REHABILITATION
ROBERT
MAZET,
JACQWXINE Los
OF THE
JR.,
PERRY,
ANGELES
AND
M.D.,
CHRONICALLY
DISABLED
From the Orthopaedic Service, Hospital, Veterans Administration Oitiversity of California Medical the Ranch0 Los Amigos
AND
M.D.
DOWNEI’, CALIF.
(Received
T
RADITIONALLY, vention
with chronic save
medicine
and cure of disease. disabilities
patient
our ability
is unable by himself
to adapt
special
necessary
techniques
assistance.
patient
as an active,
ability
from a chronic
For
purposes
is primarily activity
disease upon
is determined
by
the
function
long-term
hospitals,
such
and
efforts as the
despite
in the function
in this
concerned.
Hospital
for Special
As a
to provide
the the
residual
progressive. medical
patient’s
Surgery
if this is
has evolved
centers.
in the
of
is left
are directed
areas
disabled
care
level
What
Efforts
in the uninvolved
resulted
his
service.
dis-
and rehabilitation field
the
areas.
of the chronically
disease
to
is minor,
major
the
uninvolved
is primarily
our ability
therapy,
but
pre-
to re-establish
or slowly
curative
and
of patients
to resume
evolved
designed
be it static
for the treatment
in specialized
have
of involvement,
rehabilitation
system
the experience
well-organized, treat elitis.
site
as well as maintaining,
possible. A workable
special
the
because
sufficiently
of society
prognosis,
life
of rehabilitative
centers
or injury,
of
number
the disability
his habits
is a program member
of diagnosis,
focused
to improving,
treatment
contributing
is the area with which
from
and
Rehabilitation
health,
Unless
the benefit
Nov. 1, 1959)
saving
a formidable
good
to cure.
place at home and on the job without result,
toward
are today
who are in general
lite has outstripped
average
is directed
There
for publication
Wadsworth Center, the Center, a.nd
The
first
establishment
of
in New
York,
to
congenital deformities, tuberculosis, chronic osteomyelitis, and poliomyThese were followed by facilities in the Armed Forces designed for the
treatment agencies to useful massaged,
of amputees, now
support
lives.
hand
centers
In them,
exercised,
injuries,
and spinal
cord injuries.
dedicated
to restoring
patients
the
operated
patients
are analyzed,
on, braced,
trained,
Numerous
with chronic
inspired,
cajoled,
and re-educated
civic
maladies heated,
to become
contributors to, rather than a burden on, society. Experience in these specialized centers demonstrated the similarity of the functional needs and modes of treatment of patients whose medical problems A careful evaluation of the patient’s abilities, needs, are widely divergent. and desires can determine the appropriate program of physical and vocational restoration indicated in each case. The diagnosis may be of value for prognosis. 551
J. Chron. Dis. June, 1961
552 It can indicate
the general
direction
of the therapy
to be followed,
specific restorative measures to be used for the individual. The cardiac muscle has an elasticity and a reserve. patient
with myocardial
spastic etc.,
paralyses
present
tremities lesion. cord
from trauma,
problems
of varying The
and
normal
flaccid
depends
vascular
paralyses, nerve
impulses
such injuries,
with
present
level of the lesion-not
the diagnosis
rheumatic
embarrassment arthritis
and
joints,
from
many
it is more the disability
fracture-dislocation elbow
flexion,
necessary
meaningful of (3-6
for record
Both
purposes
the evaluation
of experts
from
and engineer. cardiologist, the extent the
maker, Other
etc.)
and sometimes
and the treatment many
fields.
consultants
Soft
tissue
deformit? of cause. neck, for
remaining
than
full deltoid
to
with a
function,
is, of course,
of public
health.
worker,
are included
the
our “rehabilitation
nurse, physical
social
of the various
to evaluate
are best accomplished
or occupational
teacher,
members, early
counselor,
(i.e., plastic of course,
but each member in his program. are required
of such a group must be tempered
therapist,
vocational
when indicated of the problem,
patient
by a team.”
problems and ideas, can accomplish individually. The team members are
knowledge, artistry, and skill of many disciplines transformation we seek in the patient. The idealism
b)
level. A patient
in the interests
constitute
1). The complexity
of participation
opportunity
it.
caused
produce
A diagnosis
program
These
the doctor,
psychiatrist,
(Fig.
produced
joints
muscles.
function
vertebral
inand
prognostically.
with his relatives,
or limb
the
joint
impairment
which
may
of the
to loss of the
is the same regardless by cord injury in the
extension.
Such a group, meeting regularly to consider far more than the same persons could acting the patient
causes,
may or may not have retained and wrist
of the ex-
and with
costal
of respiratory
different
to delineate
rotation,
It may also be of value
brace
the frozen
as a lesion of a specific
forearm
power
The
chorea,
and spinal
consequent
to the disease
from
lessening of function. Physical therapy When analyzing the problem presented
designate
of muscles
on the functional
attached
result
palsy,
syringomyelitis,
problems
depends
for the
on the site and extent
loss of, muscle
as well as from paralyses
about
instance,
team
may
cerebral
with spasticity depending
resulting
Prescription
of this is retained.
infantile
as poliomyelitis,
of the disability
contractures
accident,
of severity,
The extent
Respiratory
on how much
of hyperstimulation degrees
peripheral
motor
stabilities.
damage
but not the
surgeon,
determines should
The
to bring about
by recognition
have
combined the
of the limita-
tions imposed by the physical and mental realities. The extent of the disability, prognosis for return of function, and motivation of the patient toward independence and self-support will dictate the course of treatment. For the individual patient then, we must select an attainable goal. He should be guided, not toward the Everest of unimpaired function when this is obviously beyond his capacity, but toward a lower peak which he can climb and, in this accomplishment, find reward. An overly ambitious, unrealistic program will lead to discouragement to result in at least partial the patient
to establish
and lessen the patient’s capabilities, failure. Part of the successful program
or reach
for realistic
goals.
He must
conceivably is to educate
not be permitted
to
Volume 13 Number 6
REHABILITATION
OF CHRONICALLY
DISABLED
553
become discouraged when the goals hoped for are not achieved, but should be directed and in every way helped toward realistic goals. In each case there must be frequent review of the problems of restoring the patient as nearly as possible to normal. New techniques and devices to help do this must be constantly and avidly sought. The goal is not to make the paraplegic independent in the activities of daily living or the bilateral amputee ambulatory without crutches. These individuals must be motivated to self-support as well as to self-care.
(DOCTOR) BASIC
TEAM
@s%--
(.TEl (!zz] __-__----_-----__--------_ (,,,,,,,) DESIRABLE AODf TIOML
Fig. l.-The
DIRECTING
THE PATIENT
TOWARD
rehabilitation team.
RE-EMPLOYMENT
It is obviously advantageous to commence directing the thinking and activities of 1:he patient toward productivity as early as possible. The family can be helpful here by always presenting an attitude of assurance that the patient will return to outside activity, but they should not appear to be pushing him into an? situation before he is ready. In most instances, the patient thinks and works initially toward improved function. Undoubtedly, there is some subconscious thought: of work. Undirected, he is ordinarily not ready to plan seriously for outside existence and an occupation until he feels that he has regained the maximum function that can be anticipated. In a carefully directed physical restoration program, however, the patient will learn to differentiate between maxima.1 physical recovery and learned functions which he has achieved. With such a realistic interpretation of his problem, vocational planning can be started during the later stages of his functional training program and considerable time saved.
554
MAZET
The rapidly
steps
which
must
and completely
1.
Prevention a.
2.
AND
be taken
as possible
J. Chron. Dis. June, 1961
PERRY
to achieve
restoration
of the patient
as
are:
of aggravating
factors
such as
Deformities
b.
Decubiti
c.
Kidney
d.
Respiratory
complications
Minimization
complications as much as possible
of the emotional
impact
of the illness
(keep home contacts) 3.
Physical
restoration
a.
Muscle
b.
Surgical
4.
training reconstruction
Emotional
readjustment,
including
reorientation
as
to
employment
capabilities 5. 6.
Job training Transitional
7.
Re-employment
Specific diseases
The general by
(or employment)
programs
have
Redkey.16
employment
been subject
Some
Herford
is well covered
Xickerson,4
by* White
and
of various
in a voluminous
of the problems
and
considered
for the treatment
delineated
types
library
of chronic
of books
by the text of Rusk20 and
peculiar
Law,’
to arthritis
and
coauthors2”
Cardiac
articles.
in an article
are discussed
Lowman.Q
disabling
and
by-
in articles
rehabilitation
is
and
Sobin and associates.22 Paraplegic problems are dealt with by Comar3 and Nyquist. l5 Some of the epileptic problems treatment, of are expounded by Risch and Rose. I7 Certain aspects, including poliomyelitis are reviewed by Lowman* and by Nickel and colleagues.14 Selective
placement
of the handicapped
own. Helpful
suggestions
are made in articles
Risch,18 and Rudd
and Feingold.iY
Employed,
Insured”
“Selective
Placement
Two
individual
brochures
by the Association
of its
Irvin,6 Melcher,12
are also valuable:
of Casualty
for the Handicapped”
has a literature
by the following:
and Surety
“Impaired, Carriers5
by the U. S. Employment
and
Service.*]
This list is in no sense complete. Overtreatment from
the
is an ever present
members
psychiatric,
social,
of
the
danger.
rehabilitation
or other assistance
Patients
team.
do need moral
Sometimes
as well. However,
the
support
families
the patients
need
should
be
constantly stimulated to realize a goal of self-support as well as self-care. Where this is attainable, they can benefit from, and learn by, association with other handicapped patients. By the same token, a ward atmosphere of complacency and contentment to make the hospital a home has to be guarded against constantly. An attitude against the patient’s
of overprotection and too much sympathy can militate desire to live outside, which we wish to foster. Hospitalitis
is a virulent but largely preventable disease. Orthopedic surgery can often make valuable contributions Below are case reports which illustrate four specific orthopedic were helpful
in the restoration
of 4 patients.
These
to patient care. operations which
by no means
exhaust
the
Ezr’6”
REHABILITATION
selection of orthopedic possibilities available.
operations
OF CHRONICALLY
DISABLED
555
which can be done. They display a few of the
&se I, J. B.-A 33-year-old man had been discharged from the Navy because of rheumatoid spondylitis. He was forced first to change his occupation from machinist to parking lot attendant. After 2 years, a gradually increasing flexion deformity of the spine and increased pain made any work impossible and led him to seek help. He had marked muscle spasm and aching of the upper thoracic spine and neck after a couple of hours on his feet. His vision was restricted; he could not see straight ahead. In ATlgust, 1948, vertebral osteotomy at L2-3 and L3-4 levels was done, with considerable improvement in posture (Fig. 2). This resulted in bringing the shoulders and head back over the hips, relieved the strain on the upper spine, and enabled him to see well above the horizontal. He gainecl 25 pounds and went back to work promptly. He is a well-motivated person who wants to support his family, He has had recurrent episodes of renal calculi, and the left hip has given him trouble several times. It is wearing out, and we hope for a spontaneous fusion.
B.
A. Fig. P.--C&se
1, J.B. A, Before operation.
B, Improvement in posture and increased range of vision after spinal osteotomy.
In addition to his employment at a parking lot, he has recently been working half time making wooden crates in the shipping department of a manufacturing concern. Supportive therapy by the arthritis clinic and the urologists, with intermittent ministrations by physical medicine, have helped this well-adjusted man to maintain a good employment record, after the operation permitted him to stand up straight on his two feet. Eleven years after the operation, he is working regularly. Case 2, R. G.--An explosion in his home laboratory blew off both forearms of a 15year-old boy. He had a 5-inch stump on the right, a S$$inch stump on the left. He was fitted with an experimental active forearm rotation unit (R), wrist flexion units (B), and inter:hangeable Northrop 2-load hooks and _\PRL hands. This boy and his family made an immediate excellent adjustment to his problem. He learned to use his devices quickly and readily with relatively little training. He resumed his place in school and home. His family encouraged him in photography and set up a dark room in his home. He
556
J. Chron. Dis. June, 1961
MAZET AND PERRY
asked for an adapter to permit pistol shooting. This was made and he has become an expert pistol shot (Fig. 3). He has helped in evaluation of the efficacy of several prosthetic devices. Five years after the accident, he has finished high school and is employed full time as a sales representative for a photographers’ shop. He does the mechanical work on his car. A well-motivated boy, with understanding and sympathetic support from his family and prescription, training, and encouragement from the prosthetic team, has met and conquered a very severe handicap.
Fig. 3.-Case
2, R.G. Patient at target practice with pistol-holding device
Case 3, A. Y.-This 37-year-old laboratory technician contracted poliomyelitis 7 years ago, which necessitated a tracheostomy and a respirator for 6 months. As a result, he had complete paralysis of both shoulders, his trunk, and both lower extremities and considerable weakness of his diaphragm and both hands. In order to sit up at all, he needed a heavily reinforced corset for both trunk stability and abdominal support for effective breathing (Fig. 4,A). A spine fusion from T3 to L3 and abdominal fascial transplants* have enabled him to sit erect all day without fatigue (Fig. 4,B), and bilateral tendon transfer for his thumb has improved his hand function. He is now employed as a cancer cytology technician. Case 4, C. D.-This 28-year-old, single reservations clerk contracted poliomyelitis 4 years ago, with severe paralysis of both upper extremities and diaphragm. She required part-time respiratory assistance for over 1 year and continues to need it during postoperative periods. Her residual involvement consisted of complete paralysis of the left arm, except for poor elbow flexion and good finger extension. The right arm has good shoulder, elbow, and wrist function, but poor hand function (Fig. 5,A). Much of this strength developed after prolonged use of functional arm and hand braces. Operation on the hand has improved her function and allowed her to be free of a brace. The thumb and first two fingers were stabilized in a position of function by phalangeal fusions and a opponens bone block.rJ Transfer of a wrist extensor muscle to her finger flexor gave a strong grasp. As a result of a similar operation, she has a useful light grasp on the left. The operations and a happy marriage have combined to produce a completely independent housewife, who does her own housework (Fig. 5,B).
The weak link in the chain of total rehabilitation the closely supervised physical restoration program
is in the transition from described previously to
Volume 13 Number
6
REHABILITATION
OF CHRONICALLY
4-t
557
n.
A. Fig.
DISABLED
:aae 3, A.Y. A, Preoperatively. the patient could not sit without support. B, After spine
and fascial abdominal transplants, he sits easily and for as long as he wishes.
B.
Fig. 5.- -Case 4, C.D. A, The preoperative view shows a deformed, paralyzed hand with practically useful function. B, The postoperative view shows pinch (8 pounds) and useful grasp.
IlO
558
MAZET
independent
living
the patient’s
mode of operation
and employment.
the rehabilitation
program,
re-employment This
purposes
of coordination stems
from 1.
Inertia
2.
Prejudice
3. 4.
Necessity Fear of
initial
step of adapting
independent
subsequent
self-care
steps
the home
is usually
which
lead
and
part of
to successful
haphazard.
due to the difficulties as medical
is the
both
the
J. Chron. Dis. June, 1961
PERRY
The
to permit
but
are frequently
is basically
dissimilar
AND
care
reluctance
of integrating
and business.
of employers
real and imaginary
factors
two fields with
Superimposed to hire
which
the
handicapped.
can be classified
for costly outlay in plant modifications potential increase in insurance premiums
for
such
this lack
upon
This
as follows:
handicapped
employees 5.
Fear
6.
Inadequate
of trouble
Inertia.-Most ployees with
between
organizations
are
who are not physically
handicapped
handicapped.
physically
He is unable
to perform
if something
goes amiss,
to shift
from
him
job
counselor
accustomed They
handicapped
creased that
some tasks
premium
In many
one job
to another.
for handicapped
people
states
hiring
personnel
only
with
em-
wish to experiment
no
have
there
Association
penalizing
the employer,
employee,
as the result pays
employees fund
in the event of a second
the
difference
with
of that rate
injury,
employer
The
state pays the remainder. Ulzions.-The unions offer no specific
becomes the
on
the type
of
is no in-
to date has shown
their
normal
the
co-workers.
employee,
without
If a partially
disabled
70 per cent or more disabled, initial
objections
necessar>
There
injury.
as
and spastics
are based
than
not
out of danger
company.
to compensate
between
and
epileptics
per se. Experience
of a second
the
agile
when it becomes
rates
experience
a lower accident
is a special
is less
and is less able to jump
and he is also less adaptable
done and the accident
disabled
have
person
is distressful to some workers. Increased Insurance Premiums.-Insurance work being
and
to operating
people.
Prejudice.-The quick.
with unions
coordination
and
second
disability.
to the hiring of handicapped
persons. In fact, they support the employment of such people. Difficulties do arise in placing a worker in a different job following injury because of seniorit). rules insisted
on
by the unions.
Seniority
earned
by service
in one field does not
carry
over into another kind of work. Coordination Between Job Counselor and Hiring Personnel.-A handicapped employee is of value only when the use of his skills is not obstructed by his disability. Successful placement is therefore dependent upon the understanding of the job requirements as much as the evaluation of the individual’s capacity. This can only come about
when there is adequate
cooperation
between
placement
and counseling personnel. The transitional, or sheltered, workshop can assist in eliminating some of the obstructive factors. It acquaints the medical team with the problems of the business world so they can plan more realistically. The patient is given the
“,:!z: ‘6”
REHABILITATION
opportu+ty adaptive
to develop devices),
situation.
The
efficiency
endurance
prospective
to a program
of aim or method
employers
helping
Others
are primarily
their
shop. Some successfully to meet
compete.
Several York,
businesses,
groups
them
These what
Hughes
dependable, dividuals
this
appreciation
and
profitable
depend tional, ability jobs
prevailing
and rather
which
level
than
against
The
that
disabled
the
on those
patient
he has lost.
placement
Company. make
record
in-
as a whole. person
restored,
is made a When
a
but the work-
is increased.
is a many
of several
and
loyal,
of these
of a dependent.
retains
who
Company,
Watch people
safety
individual
is then
manufacturers
a handicapped
restoration
the man
man
Ford Motor
and production
of his
analyze
Bulova
instead
workers
in the past
The
of industry
by representatives
skills the
Among
not only is his income
of the chronically
The,-
disabled
Whenever
for him is decreased
be matched
effective
wages,
of handicapped
must his
Physical,
faceted
disciplines
task
working
be strengthened
work
performance
psychologic,
educa-
are employed whenever they can increase an) of the skills needed for performance of specific the skills
that
the patient
possesses
best place him in industry and re-establish his self-support. Closer between the medical rehabilitation team and personnel management make
New
competitive
of businesses
and
placed
a taxpayer
worker,
and surgical techniques of the patient. Analysis must
them
Corporation,
than
for everyone.
he becomes
since
on these
of Hempstead, successful
their jobs.7
employees.
better
which can best be accomplished
developed,
to let
on the work-
who would otherwise
he is incapable.12
Airlines,
properly
been
an injured
men’s compensation
and
paying
of the value
Motors
Eastern that
employee,
as a team. The functions
are disinclined
operate
by a number
have analyzed
found
skillful,
Rehabilitation
directed
in industry.
dependency
as Abilities
personnel,
employment
AiResearch,
have
rehires
such
is the crux of the problem.
This is good business productive
disabled
companies
has consistently
company
employers
These
fosters
of Chicago,
this creed are General
groups
workshops uniformity
no
and find a place
a profit.
he can do, not of what
the job;
Aircraft,
These
only
in their
to determine have embraced
there is
is good for those
persons,
Manufacturing
of increasing
reflected
into
sheltered
into industry.
few years.18J2 fitted
have
of the
create self-reliance in persons who might are partially subsidized and are not forced
others17l’g
of impaired
employing
An attitude has been
productivity
transitional
which
This
not
necessary
to survive.
and Paraplegic
and filtering
does
Still
competition
in showing wages.
but
use of any
However,
his skills
to industry,
pay substandard
nation
are solely
to increase
interested return
no employment,
(including
and skills to cope with his altered
employment.
Some
the individual
good producers
have
these.
the
5.59
DISABLED
can see the successful
throughout
of transitional
among
toward
in his trade
for a full workday,
disabled person. Several communities devoted
OF CHRONICALLY
more general.
in order
to
cooperation is urged to
560
MAZET
AND
J. Chron. Dis. June, 1961
PERRY
REFERENCES
1.
5.
Anderson, M.: Functional Bracing of the Upper Extremity, Springfield, Ill., 1958, Charles C Thomas, Publisher. Campbell, H.: Pistol Attachment Device, Ortho. & Pros. Appliance J. 12:62, 1958. Comar, A. E.: Total Rehabilitation of the Spinal Cord Injury Patient, J. Indiana M. Prof. 4:1928, 1957. Herford, R., and Nickerson, S. H.: Relief of Pain and Rehabilitation of Chronic Arthritic Patients by Extended Sympathetic Denervation, Arch. Phys. Med. 40:133, 1959. Impair;-;yE;opyd, Insured (A Brochure), Association of Casualty and Surety Companies,
6.
Irvin, :95+.:
7. 8. 9.
16.
Law, W. A’.: Lumbar Spine Osteotomy, J. Bone &Joint Surg. 41B:270, 19.59. Lowman, C. L.: Abdominal Fascial Transplants, Ann Arbor, Mich., 19.54, Edwards Bros. Lowman, E. W.: Self-Help Devices for the Arthritic, Institute of Physical Medicine and Rehabilitation, Bellevue Medical Center, New York. Manual of Upper Extremity Prosthetics, Department of Engineering, University of California, Los Angeles, 1958. Mazet, R., and Brooks, M.D.: The Prosthetic Team and the Child Amputee, J. Internat. Coil. Surg. 27:70, 1957. Melcher, K. D.: Employing the Seriously Impaired, Institute of Industrial Relations, University of California, 1959. Nickel, V. L.: Functional Surgery in Patients With Severely Paralyzed Upper Extremities, Papers of the Fourth International Polio Conference, Philadelphia, 1958, J. B. Lippincott Company. Nickel, V. L., Perry, J., affeld, J. E., and Dial, C. W.: Elective Surgery on Patient With Respiratory Paralysis, J. Bone & Joint Surg. 39A:989, 1957. Nyquist, R. H.: Functions of a Physical Medicine Section for a Paralytic Service, Proceedings of the Second International Congress of Physical Medicine, Copenhagen, 1956. Redke;95y.: Rehabilitation Center Concepts Change in Practice, Arch. Phys. Med. 38:227,
17. 18.
Risch, Risch,
2. 3. 4.
10. 11. 12. 13. 14. 15.
19.
23.
Placement
of the Physically
Handicapped,
Arch. Phys.
Med. 37:622,
F., and Rose, A. S.: Community Plan for Epileptics, Pub. Health Rep. 72:813, 1957. F.: A Scale of Employability for Handicapped Persons, 0. V. R. Research Project f6457, Jewish Vocational Service of Chicago, Second Progress Report, July, 19.58. Rudd, J. L., and Feingold, S. N.: A Work Adjustment Center in Vocational Rehabilitation, Arch. Phys. Med. 40:29, 1959. Rusk, H. A.: Rehabilitation Medicine, St. Louis, 1958, The C. V. Mosby Company. Selective Placement for the Handicapped, U. S. Employment Service, Department of Labor, Bulletin No. 923. Sobin, S. S., Frasher, W. G., Alexander, C. A., and Horovitz, L.: Role of Work Classitication Unit of the Los Angeles County Heart Assn., Arch. Phys. Med. 40:161, 1959. White, P. D., Rusk, H. A., Lee, P. R., and Williams, B.: Rehabilitation of Cardiovascular Patient, New York, 1958, McGraw-Hill Book Co., Inc.
2’7: 22.
Industrial
ROBERT
MAZET,
JACQWXINE Los
OF THE
JR.,
PERRY,
ANGELES
AND
M.D.,
CHRONICALLY
DISABLED
From the Orthopaedic Service, Hospital, Veterans Administration Oitiversity of California Medical the Ranch0 Los Amigos
AND
M.D.
DOWNEI’, CALIF.
(Received
T
RADITIONALLY, vention
with chronic save
medicine
and cure of disease. disabilities
patient
our ability
is unable by himself
to adapt
special
necessary
techniques
assistance.
patient
as an active,
ability
from a chronic
For
purposes
is primarily activity
disease upon
is determined
by
the
function
long-term
hospitals,
such
and
efforts as the
despite
in the function
in this
concerned.
Hospital
for Special
As a
to provide
the the
residual
progressive. medical
patient’s
Surgery
if this is
has evolved
centers.
in the
of
is left
are directed
areas
disabled
care
level
What
Efforts
in the uninvolved
resulted
his
service.
dis-
and rehabilitation field
the
areas.
of the chronically
disease
to
is minor,
major
the
uninvolved
is primarily
our ability
therapy,
but
pre-
to re-establish
or slowly
curative
and
of patients
to resume
evolved
designed
be it static
for the treatment
in specialized
have
of involvement,
rehabilitation
system
the experience
well-organized, treat elitis.
site
as well as maintaining,
possible. A workable
special
the
because
sufficiently
of society
prognosis,
life
of rehabilitative
centers
or injury,
of
number
the disability
his habits
is a program member
of diagnosis,
focused
to improving,
treatment
contributing
is the area with which
from
and
Rehabilitation
health,
Unless
the benefit
Nov. 1, 1959)
saving
a formidable
good
to cure.
place at home and on the job without result,
toward
are today
who are in general
lite has outstripped
average
is directed
There
for publication
Wadsworth Center, the Center, a.nd
The
first
establishment
of
in New
York,
to
congenital deformities, tuberculosis, chronic osteomyelitis, and poliomyThese were followed by facilities in the Armed Forces designed for the
treatment agencies to useful massaged,
of amputees, now
support
lives.
hand
centers
In them,
exercised,
injuries,
and spinal
cord injuries.
dedicated
to restoring
patients
the
operated
patients
are analyzed,
on, braced,
trained,
Numerous
with chronic
inspired,
cajoled,
and re-educated
civic
maladies heated,
to become
contributors to, rather than a burden on, society. Experience in these specialized centers demonstrated the similarity of the functional needs and modes of treatment of patients whose medical problems A careful evaluation of the patient’s abilities, needs, are widely divergent. and desires can determine the appropriate program of physical and vocational restoration indicated in each case. The diagnosis may be of value for prognosis. 551
J. Chron. Dis. June, 1961
552 It can indicate
the general
direction
of the therapy
to be followed,
specific restorative measures to be used for the individual. The cardiac muscle has an elasticity and a reserve. patient
with myocardial
spastic etc.,
paralyses
present
tremities lesion. cord
from trauma,
problems
of varying The
and
normal
flaccid
depends
vascular
paralyses, nerve
impulses
such injuries,
with
present
level of the lesion-not
the diagnosis
rheumatic
embarrassment arthritis
and
joints,
from
many
it is more the disability
fracture-dislocation elbow
flexion,
necessary
meaningful of (3-6
for record
Both
purposes
the evaluation
of experts
from
and engineer. cardiologist, the extent the
maker, Other
etc.)
and sometimes
and the treatment many
fields.
consultants
Soft
tissue
deformit? of cause. neck, for
remaining
than
full deltoid
to
with a
function,
is, of course,
of public
health.
worker,
are included
the
our “rehabilitation
nurse, physical
social
of the various
to evaluate
are best accomplished
or occupational
teacher,
members, early
counselor,
(i.e., plastic of course,
but each member in his program. are required
of such a group must be tempered
therapist,
vocational
when indicated of the problem,
patient
by a team.”
problems and ideas, can accomplish individually. The team members are
knowledge, artistry, and skill of many disciplines transformation we seek in the patient. The idealism
b)
level. A patient
in the interests
constitute
1). The complexity
of participation
opportunity
it.
caused
produce
A diagnosis
program
These
the doctor,
psychiatrist,
(Fig.
produced
joints
muscles.
function
vertebral
inand
prognostically.
with his relatives,
or limb
the
joint
impairment
which
may
of the
to loss of the
is the same regardless by cord injury in the
extension.
Such a group, meeting regularly to consider far more than the same persons could acting the patient
causes,
may or may not have retained and wrist
of the ex-
and with
costal
of respiratory
different
to delineate
rotation,
It may also be of value
brace
the frozen
as a lesion of a specific
forearm
power
The
chorea,
and spinal
consequent
to the disease
from
lessening of function. Physical therapy When analyzing the problem presented
designate
of muscles
on the functional
attached
result
palsy,
syringomyelitis,
problems
depends
for the
on the site and extent
loss of, muscle
as well as from paralyses
about
instance,
team
may
cerebral
with spasticity depending
resulting
Prescription
of this is retained.
infantile
as poliomyelitis,
of the disability
contractures
accident,
of severity,
The extent
Respiratory
on how much
of hyperstimulation degrees
peripheral
motor
stabilities.
damage
but not the
surgeon,
determines should
The
to bring about
by recognition
have
combined the
of the limita-
tions imposed by the physical and mental realities. The extent of the disability, prognosis for return of function, and motivation of the patient toward independence and self-support will dictate the course of treatment. For the individual patient then, we must select an attainable goal. He should be guided, not toward the Everest of unimpaired function when this is obviously beyond his capacity, but toward a lower peak which he can climb and, in this accomplishment, find reward. An overly ambitious, unrealistic program will lead to discouragement to result in at least partial the patient
to establish
and lessen the patient’s capabilities, failure. Part of the successful program
or reach
for realistic
goals.
He must
conceivably is to educate
not be permitted
to
Volume 13 Number 6
REHABILITATION
OF CHRONICALLY
DISABLED
553
become discouraged when the goals hoped for are not achieved, but should be directed and in every way helped toward realistic goals. In each case there must be frequent review of the problems of restoring the patient as nearly as possible to normal. New techniques and devices to help do this must be constantly and avidly sought. The goal is not to make the paraplegic independent in the activities of daily living or the bilateral amputee ambulatory without crutches. These individuals must be motivated to self-support as well as to self-care.
(DOCTOR) BASIC
TEAM
@s%--
(.TEl (!zz] __-__----_-----__--------_ (,,,,,,,) DESIRABLE AODf TIOML
Fig. l.-The
DIRECTING
THE PATIENT
TOWARD
rehabilitation team.
RE-EMPLOYMENT
It is obviously advantageous to commence directing the thinking and activities of 1:he patient toward productivity as early as possible. The family can be helpful here by always presenting an attitude of assurance that the patient will return to outside activity, but they should not appear to be pushing him into an? situation before he is ready. In most instances, the patient thinks and works initially toward improved function. Undoubtedly, there is some subconscious thought: of work. Undirected, he is ordinarily not ready to plan seriously for outside existence and an occupation until he feels that he has regained the maximum function that can be anticipated. In a carefully directed physical restoration program, however, the patient will learn to differentiate between maxima.1 physical recovery and learned functions which he has achieved. With such a realistic interpretation of his problem, vocational planning can be started during the later stages of his functional training program and considerable time saved.
554
MAZET
The rapidly
steps
which
must
and completely
1.
Prevention a.
2.
AND
be taken
as possible
J. Chron. Dis. June, 1961
PERRY
to achieve
restoration
of the patient
as
are:
of aggravating
factors
such as
Deformities
b.
Decubiti
c.
Kidney
d.
Respiratory
complications
Minimization
complications as much as possible
of the emotional
impact
of the illness
(keep home contacts) 3.
Physical
restoration
a.
Muscle
b.
Surgical
4.
training reconstruction
Emotional
readjustment,
including
reorientation
as
to
employment
capabilities 5. 6.
Job training Transitional
7.
Re-employment
Specific diseases
The general by
(or employment)
programs
have
Redkey.16
employment
been subject
Some
Herford
is well covered
Xickerson,4
by* White
and
of various
in a voluminous
of the problems
and
considered
for the treatment
delineated
types
library
of chronic
of books
by the text of Rusk20 and
peculiar
Law,’
to arthritis
and
coauthors2”
Cardiac
articles.
in an article
are discussed
Lowman.Q
disabling
and
by-
in articles
rehabilitation
is
and
Sobin and associates.22 Paraplegic problems are dealt with by Comar3 and Nyquist. l5 Some of the epileptic problems treatment, of are expounded by Risch and Rose. I7 Certain aspects, including poliomyelitis are reviewed by Lowman* and by Nickel and colleagues.14 Selective
placement
of the handicapped
own. Helpful
suggestions
are made in articles
Risch,18 and Rudd
and Feingold.iY
Employed,
Insured”
“Selective
Placement
Two
individual
brochures
by the Association
of its
Irvin,6 Melcher,12
are also valuable:
of Casualty
for the Handicapped”
has a literature
by the following:
and Surety
“Impaired, Carriers5
by the U. S. Employment
and
Service.*]
This list is in no sense complete. Overtreatment from
the
is an ever present
members
psychiatric,
social,
of
the
danger.
rehabilitation
or other assistance
Patients
team.
do need moral
Sometimes
as well. However,
the
support
families
the patients
need
should
be
constantly stimulated to realize a goal of self-support as well as self-care. Where this is attainable, they can benefit from, and learn by, association with other handicapped patients. By the same token, a ward atmosphere of complacency and contentment to make the hospital a home has to be guarded against constantly. An attitude against the patient’s
of overprotection and too much sympathy can militate desire to live outside, which we wish to foster. Hospitalitis
is a virulent but largely preventable disease. Orthopedic surgery can often make valuable contributions Below are case reports which illustrate four specific orthopedic were helpful
in the restoration
of 4 patients.
These
to patient care. operations which
by no means
exhaust
the
Ezr’6”
REHABILITATION
selection of orthopedic possibilities available.
operations
OF CHRONICALLY
DISABLED
555
which can be done. They display a few of the
&se I, J. B.-A 33-year-old man had been discharged from the Navy because of rheumatoid spondylitis. He was forced first to change his occupation from machinist to parking lot attendant. After 2 years, a gradually increasing flexion deformity of the spine and increased pain made any work impossible and led him to seek help. He had marked muscle spasm and aching of the upper thoracic spine and neck after a couple of hours on his feet. His vision was restricted; he could not see straight ahead. In ATlgust, 1948, vertebral osteotomy at L2-3 and L3-4 levels was done, with considerable improvement in posture (Fig. 2). This resulted in bringing the shoulders and head back over the hips, relieved the strain on the upper spine, and enabled him to see well above the horizontal. He gainecl 25 pounds and went back to work promptly. He is a well-motivated person who wants to support his family, He has had recurrent episodes of renal calculi, and the left hip has given him trouble several times. It is wearing out, and we hope for a spontaneous fusion.
B.
A. Fig. P.--C&se
1, J.B. A, Before operation.
B, Improvement in posture and increased range of vision after spinal osteotomy.
In addition to his employment at a parking lot, he has recently been working half time making wooden crates in the shipping department of a manufacturing concern. Supportive therapy by the arthritis clinic and the urologists, with intermittent ministrations by physical medicine, have helped this well-adjusted man to maintain a good employment record, after the operation permitted him to stand up straight on his two feet. Eleven years after the operation, he is working regularly. Case 2, R. G.--An explosion in his home laboratory blew off both forearms of a 15year-old boy. He had a 5-inch stump on the right, a S$$inch stump on the left. He was fitted with an experimental active forearm rotation unit (R), wrist flexion units (B), and inter:hangeable Northrop 2-load hooks and _\PRL hands. This boy and his family made an immediate excellent adjustment to his problem. He learned to use his devices quickly and readily with relatively little training. He resumed his place in school and home. His family encouraged him in photography and set up a dark room in his home. He
556
J. Chron. Dis. June, 1961
MAZET AND PERRY
asked for an adapter to permit pistol shooting. This was made and he has become an expert pistol shot (Fig. 3). He has helped in evaluation of the efficacy of several prosthetic devices. Five years after the accident, he has finished high school and is employed full time as a sales representative for a photographers’ shop. He does the mechanical work on his car. A well-motivated boy, with understanding and sympathetic support from his family and prescription, training, and encouragement from the prosthetic team, has met and conquered a very severe handicap.
Fig. 3.-Case
2, R.G. Patient at target practice with pistol-holding device
Case 3, A. Y.-This 37-year-old laboratory technician contracted poliomyelitis 7 years ago, which necessitated a tracheostomy and a respirator for 6 months. As a result, he had complete paralysis of both shoulders, his trunk, and both lower extremities and considerable weakness of his diaphragm and both hands. In order to sit up at all, he needed a heavily reinforced corset for both trunk stability and abdominal support for effective breathing (Fig. 4,A). A spine fusion from T3 to L3 and abdominal fascial transplants* have enabled him to sit erect all day without fatigue (Fig. 4,B), and bilateral tendon transfer for his thumb has improved his hand function. He is now employed as a cancer cytology technician. Case 4, C. D.-This 28-year-old, single reservations clerk contracted poliomyelitis 4 years ago, with severe paralysis of both upper extremities and diaphragm. She required part-time respiratory assistance for over 1 year and continues to need it during postoperative periods. Her residual involvement consisted of complete paralysis of the left arm, except for poor elbow flexion and good finger extension. The right arm has good shoulder, elbow, and wrist function, but poor hand function (Fig. 5,A). Much of this strength developed after prolonged use of functional arm and hand braces. Operation on the hand has improved her function and allowed her to be free of a brace. The thumb and first two fingers were stabilized in a position of function by phalangeal fusions and a opponens bone block.rJ Transfer of a wrist extensor muscle to her finger flexor gave a strong grasp. As a result of a similar operation, she has a useful light grasp on the left. The operations and a happy marriage have combined to produce a completely independent housewife, who does her own housework (Fig. 5,B).
The weak link in the chain of total rehabilitation the closely supervised physical restoration program
is in the transition from described previously to
Volume 13 Number
6
REHABILITATION
OF CHRONICALLY
4-t
557
n.
A. Fig.
DISABLED
:aae 3, A.Y. A, Preoperatively. the patient could not sit without support. B, After spine
and fascial abdominal transplants, he sits easily and for as long as he wishes.
B.
Fig. 5.- -Case 4, C.D. A, The preoperative view shows a deformed, paralyzed hand with practically useful function. B, The postoperative view shows pinch (8 pounds) and useful grasp.
IlO
558
MAZET
independent
living
the patient’s
mode of operation
and employment.
the rehabilitation
program,
re-employment This
purposes
of coordination stems
from 1.
Inertia
2.
Prejudice
3. 4.
Necessity Fear of
initial
step of adapting
independent
subsequent
self-care
steps
the home
is usually
which
lead
and
part of
to successful
haphazard.
due to the difficulties as medical
is the
both
the
J. Chron. Dis. June, 1961
PERRY
The
to permit
but
are frequently
is basically
dissimilar
AND
care
reluctance
of integrating
and business.
of employers
real and imaginary
factors
two fields with
Superimposed to hire
which
the
handicapped.
can be classified
for costly outlay in plant modifications potential increase in insurance premiums
for
such
this lack
upon
This
as follows:
handicapped
employees 5.
Fear
6.
Inadequate
of trouble
Inertia.-Most ployees with
between
organizations
are
who are not physically
handicapped
handicapped.
physically
He is unable
to perform
if something
goes amiss,
to shift
from
him
job
counselor
accustomed They
handicapped
creased that
some tasks
premium
In many
one job
to another.
for handicapped
people
states
hiring
personnel
only
with
em-
wish to experiment
no
have
there
Association
penalizing
the employer,
employee,
as the result pays
employees fund
in the event of a second
the
difference
with
of that rate
injury,
employer
The
state pays the remainder. Ulzions.-The unions offer no specific
becomes the
on
the type
of
is no in-
to date has shown
their
normal
the
co-workers.
employee,
without
If a partially
disabled
70 per cent or more disabled, initial
objections
necessar>
There
injury.
as
and spastics
are based
than
not
out of danger
company.
to compensate
between
and
epileptics
per se. Experience
of a second
the
agile
when it becomes
rates
experience
a lower accident
is a special
is less
and is less able to jump
and he is also less adaptable
done and the accident
disabled
have
person
is distressful to some workers. Increased Insurance Premiums.-Insurance work being
and
to operating
people.
Prejudice.-The quick.
with unions
coordination
and
second
disability.
to the hiring of handicapped
persons. In fact, they support the employment of such people. Difficulties do arise in placing a worker in a different job following injury because of seniorit). rules insisted
on
by the unions.
Seniority
earned
by service
in one field does not
carry
over into another kind of work. Coordination Between Job Counselor and Hiring Personnel.-A handicapped employee is of value only when the use of his skills is not obstructed by his disability. Successful placement is therefore dependent upon the understanding of the job requirements as much as the evaluation of the individual’s capacity. This can only come about
when there is adequate
cooperation
between
placement
and counseling personnel. The transitional, or sheltered, workshop can assist in eliminating some of the obstructive factors. It acquaints the medical team with the problems of the business world so they can plan more realistically. The patient is given the
“,:!z: ‘6”
REHABILITATION
opportu+ty adaptive
to develop devices),
situation.
The
efficiency
endurance
prospective
to a program
of aim or method
employers
helping
Others
are primarily
their
shop. Some successfully to meet
compete.
Several York,
businesses,
groups
them
These what
Hughes
dependable, dividuals
this
appreciation
and
profitable
depend tional, ability jobs
prevailing
and rather
which
level
than
against
The
that
disabled
the
on those
patient
he has lost.
placement
Company. make
record
in-
as a whole. person
restored,
is made a When
a
but the work-
is increased.
is a many
of several
and
loyal,
of these
of a dependent.
retains
who
Company,
Watch people
safety
individual
is then
manufacturers
a handicapped
restoration
the man
man
Ford Motor
and production
of his
analyze
Bulova
instead
workers
in the past
The
of industry
by representatives
skills the
Among
not only is his income
of the chronically
The,-
disabled
Whenever
for him is decreased
be matched
effective
wages,
of handicapped
must his
Physical,
faceted
disciplines
task
working
be strengthened
work
performance
psychologic,
educa-
are employed whenever they can increase an) of the skills needed for performance of specific the skills
that
the patient
possesses
best place him in industry and re-establish his self-support. Closer between the medical rehabilitation team and personnel management make
New
competitive
of businesses
and
placed
a taxpayer
worker,
and surgical techniques of the patient. Analysis must
them
Corporation,
than
for everyone.
he becomes
since
on these
of Hempstead, successful
their jobs.7
employees.
better
which can best be accomplished
developed,
to let
on the work-
who would otherwise
he is incapable.12
Airlines,
properly
been
an injured
men’s compensation
and
paying
of the value
Motors
Eastern that
employee,
as a team. The functions
are disinclined
operate
by a number
have analyzed
found
skillful,
Rehabilitation
directed
in industry.
dependency
as Abilities
personnel,
employment
AiResearch,
have
rehires
such
is the crux of the problem.
This is good business productive
disabled
companies
has consistently
company
employers
These
fosters
of Chicago,
this creed are General
groups
workshops uniformity
no
and find a place
a profit.
he can do, not of what
the job;
Aircraft,
These
only
in their
to determine have embraced
there is
is good for those
persons,
Manufacturing
of increasing
reflected
into
sheltered
into industry.
few years.18J2 fitted
have
of the
create self-reliance in persons who might are partially subsidized and are not forced
others17l’g
of impaired
employing
An attitude has been
productivity
transitional
which
This
not
necessary
to survive.
and Paraplegic
and filtering
does
Still
competition
in showing wages.
but
use of any
However,
his skills
to industry,
pay substandard
nation
are solely
to increase
interested return
no employment,
(including
and skills to cope with his altered
employment.
Some
the individual
good producers
have
these.
the
5.59
DISABLED
can see the successful
throughout
of transitional
among
toward
in his trade
for a full workday,
disabled person. Several communities devoted
OF CHRONICALLY
more general.
in order
to
cooperation is urged to
560
MAZET
AND
J. Chron. Dis. June, 1961
PERRY
REFERENCES
1.
5.
Anderson, M.: Functional Bracing of the Upper Extremity, Springfield, Ill., 1958, Charles C Thomas, Publisher. Campbell, H.: Pistol Attachment Device, Ortho. & Pros. Appliance J. 12:62, 1958. Comar, A. E.: Total Rehabilitation of the Spinal Cord Injury Patient, J. Indiana M. Prof. 4:1928, 1957. Herford, R., and Nickerson, S. H.: Relief of Pain and Rehabilitation of Chronic Arthritic Patients by Extended Sympathetic Denervation, Arch. Phys. Med. 40:133, 1959. Impair;-;yE;opyd, Insured (A Brochure), Association of Casualty and Surety Companies,
6.
Irvin, :95+.:
7. 8. 9.
16.
Law, W. A’.: Lumbar Spine Osteotomy, J. Bone &Joint Surg. 41B:270, 19.59. Lowman, C. L.: Abdominal Fascial Transplants, Ann Arbor, Mich., 19.54, Edwards Bros. Lowman, E. W.: Self-Help Devices for the Arthritic, Institute of Physical Medicine and Rehabilitation, Bellevue Medical Center, New York. Manual of Upper Extremity Prosthetics, Department of Engineering, University of California, Los Angeles, 1958. Mazet, R., and Brooks, M.D.: The Prosthetic Team and the Child Amputee, J. Internat. Coil. Surg. 27:70, 1957. Melcher, K. D.: Employing the Seriously Impaired, Institute of Industrial Relations, University of California, 1959. Nickel, V. L.: Functional Surgery in Patients With Severely Paralyzed Upper Extremities, Papers of the Fourth International Polio Conference, Philadelphia, 1958, J. B. Lippincott Company. Nickel, V. L., Perry, J., affeld, J. E., and Dial, C. W.: Elective Surgery on Patient With Respiratory Paralysis, J. Bone & Joint Surg. 39A:989, 1957. Nyquist, R. H.: Functions of a Physical Medicine Section for a Paralytic Service, Proceedings of the Second International Congress of Physical Medicine, Copenhagen, 1956. Redke;95y.: Rehabilitation Center Concepts Change in Practice, Arch. Phys. Med. 38:227,
17. 18.
Risch, Risch,
2. 3. 4.
10. 11. 12. 13. 14. 15.
19.
23.
Placement
of the Physically
Handicapped,
Arch. Phys.
Med. 37:622,
F., and Rose, A. S.: Community Plan for Epileptics, Pub. Health Rep. 72:813, 1957. F.: A Scale of Employability for Handicapped Persons, 0. V. R. Research Project f6457, Jewish Vocational Service of Chicago, Second Progress Report, July, 19.58. Rudd, J. L., and Feingold, S. N.: A Work Adjustment Center in Vocational Rehabilitation, Arch. Phys. Med. 40:29, 1959. Rusk, H. A.: Rehabilitation Medicine, St. Louis, 1958, The C. V. Mosby Company. Selective Placement for the Handicapped, U. S. Employment Service, Department of Labor, Bulletin No. 923. Sobin, S. S., Frasher, W. G., Alexander, C. A., and Horovitz, L.: Role of Work Classitication Unit of the Los Angeles County Heart Assn., Arch. Phys. Med. 40:161, 1959. White, P. D., Rusk, H. A., Lee, P. R., and Williams, B.: Rehabilitation of Cardiovascular Patient, New York, 1958, McGraw-Hill Book Co., Inc.
2’7: 22.
Industrial