Medical Science Publication No. 4, Volume II
MONDAY MORNING SESSION
26 April 1954
MODERATOR
COLONEL FRANK E. HAGMAN, MC
PHYSICAL MEDICINE AND REHABILITATION*
LIEUTENANT COLONELCHARLES D. SHIELDS, MC
Introduction
Physical medicine was established as a service in the Army in 1946 forthe purpose of coordinating treatment in physical therapy, occupationaltherapy and physical reconditioning; and, to render direct medical supervisionto therapists engaged in these activities. The specialty combines diagnosticprocedures, the use of physical agents and therapeutic exercise, and rehabilitationof the disabled. It was highly developed during World War II and was givenits present title shortly after the war.
Physical medicine is an outgrowth of the interest of physicians in theuse of physical agents and therapeutic exercise. Dr. Frank Krusen, Headof the Department of Physical Medicine and Rehabilitation at the Mayo Clinic,and the consultant to The Surgeon General of the Army in this specialty,is an outstanding example of medical leadership in this effort. Rehabilitationhas been defined at a symposium of the National Council on Physical Rehabilitationin New York, 25 May 1952, as follows: "Restoration of the handicappedto the fullest mental, social, vocational and economic usefulness of whichthey are capable." Dr. Howard Rusk, Director of the Institute of PhysicalMedicine and Rehabilitation, New York University, has tirelessly and diligentlypromoted this cause during and since his military service in World WarII. He has popularized the term "The Third Phase of Medical Care."As a result of the efforts of various individuals, the terms physical medicineand rehabilitation have been combined to describe a concept of medicalpractice and, in a more limited sense, a specialty within medicine.
Physical Reconstruction, World War I
The earliest practitioners of the healing arts made some effort to supervisethe period of convalescence, usually with emphasis on rest and inactivity.During World War I there was a concentrated effort to offer purposefulprograms of controlled activity to patients to improve
*Presented 26 April 1954, to the course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.
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clinical results and to shorten the period of hospitalization. Volume13 of the History of the Medical Department of the United States Army inWorld War (1) covers this subject. The introduction to this workbegins with the following statement: "When the United States enteredthe Great War all the countries actively participating in the conflict,on either side, had evolved more or less elaborate and apparently satisfactorysystems by which to restore the wounded to such physical fitness as wouldwarrant their return to the ranks of the fighting forces or to limitedmilitary service, or to such condition of partial physical fitness as wouldmake necessary and possible their re-education or vocational rehabilitationfor living-making in full or in part. Along with the latter phase, in eachcountry was evolved a system of pensions to supplement or to take the placeof restoration to economic capacity."
During World War I an intense effort was made to offer the Americansoldier the best in physical rehabilitation along with vocational guidanceand training. This activity was called physical reconstruction. Followingis an extract from a letter of general instructions published during theearly part of the First World War:
"Physical reconstruction is the completest form of medical andsurgical treatment carried to the point where maximum functional restoration,mental and physical, may be secured. To secure this result, the use ofwork-mental and manual-will he required during the convalescent period.This therapeutic measure, in addition to aiding in greatly shortening theconvalescent period, retains or arouses mental activities preventing hospitalization,and enables the patient to be returned to service or civil life with thefull realization that he can work in his handicapped state, and with habitsof industry much encouraged if not firmly formed.
"Hereafter no member of the military service should be recommendedfor discharge from your hospital until he has attained complete recoveryor as complete recovery as it is to be expected he will attain when thenature of his disability is considered."
On 22 August 1917, the Division of Special Hospitals and Physical Reconstructionwas formed in the office of the Army Surgeon General. Consideration wasgiven at the time to make the Army responsible for vocational trainingfor disabled members of all the services and certain civilians, but thiswas not favorably considered by the then Secretary of War. This effortin physical rehabilitation and vocational training was becoming fairlywell established when on 11 November 1918 the Armistice was signed. Largenumbers of disabled were then returned from France. The Medical Departmentwas faced with increased responsibility along with demobilization and theusual shortages of trained personnel. The question of the place of theArmy in
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long-range rehabilitation efforts was raised. Patients were graduallytransferred to the Bureau of War Risk Insurance. The need for improvedlong-range medical care and vocational training was one of the factorswhich resulted in the establishment of the U. S. Veterans' Bureau on 9August 1921.
Physical Medicine and Rehabilitation, World War II
During World War II numerous hospitals including specialized treatmentcenters were established in the United States and overseas. Many of thedisabled needed the services of various medical specialists and differentgroups of ancillary personnel. The need for coordination of those effortsand for starting rehabilitation practices early was recognized. Physicalmedicine services were organized and were assigned this responsibility.After the war the Army continued training programs for ancillary personneland initiated residency training for physicians in this field.
Korean War
Physical medicine services contributed greatly to the physical rehabilitationof disabled soldiers who were injured in Korea and evacuated to the U.S. Physical medicine services were not established in Korea for the followingreasons:
1. There were few physicians in service who had completed residencytraining (table 1).
2. The specialty is concerned with treatment of disabilities that usuallyrequire evacuation of the patient to the Zone of Interior.
Table 1. Number of Physicians Completing ResidencyTraining by Year
1948-0
1949-1
1950-1
1951-4
1952-3
1953-4
At the beginning of the Korean War physical medicine services were establishedin all Class II hospitals and later eight services were activated in specializedtreatment centers. This expansion raised questions concerning trainingof personnel and demanded a delineation of the borders and scope of thespecialty. Physical medicine was started in the Army as a means of providingsupplementary care for patients on other services. A single physician usuallyestablished an office in a physical therapy clinic and supervised the workof physical, occupational and reconditioning therapists. The patients werereferred from other services and frequently treatment was prescribed bythese services. This situation resulted in the rather obvious questionas to the need for the services of the physician.
When the eight services were established in Class I specialized treatmentcenters, young physicians with 12 weeks of concentrated
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training in the specialty were assigned as chiefs of services in thegrade of 1st Lieutenant or Captain. The responsibility of the service wasnot for any type of patient but for the use of physical agents and exercise.As a result, the physicians were soon assigned other duties, often fulltime, and therapists were left to their own devices. This does not implycriticism of the Commanding Officer who had numerous responsibilities withlimited personnel, nor the physician in physical medicine who followedinstructions. What was wrong? The training of the physician was not adequateto assume the responsibility and our present concept of physical medicineneeds revision. Physical medicine is all too often defined as the use ofheat, light, a multitude of other physical agents, and therapeutic exercise.This is partly true but it implies only prescription of these agents andsupervision of therapists. It lacks the essential responsibility that physiciansmust assume for the welfare of patients.
We have learned to define physical medicine as that specialty concernedwith the diagnosis, treatment and rehabilitation of patients with neuromusculardiseases and certain musculoskeletal defects. This implies that well trainedmedical specialists assume responsibility for the coordinated medical careof severely disabled patients. These patients should be housed in physicalmedicine wards when the major effort is training and physical rehabilitation.Before this period rehabilitation practices are started early on otherservices.
We have learned, therefore, that physical medicine services must beestablished in large hospitals where severely disabled patients are concentratedand that the physicians who practice physical medicine must be properlyand adequately trained to assume these responsibilities.
Physical Therapy and Occupational Therapy
We have learned some lessons concerning the use of physical and occupationaltherapists. The duties of these individuals are now better defined andwhen the medical profession has decided what service is expected for patientsfrom these associated groups it becomes our duty to see that they are properlytrained for their jobs.
The Army provides superior training in our own school system for physicaland occupational therapists and their technical aides. Selected graduatetherapists are eligible for short courses of instruction and for trainingleading to the Master's degree, in civilian educational institutions.
There are occasions when physical therapists and occupational therapistsmust be assigned to stations where there is no physical medicine service.We have learned that if such therapists are to render effective serviceas a part of a complete medical program they must work under the directsupervision of a physician who understands the
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basic fundamentals of these disciplines. These therapists are not trainedin diagnosis and indications, and when physical therapy and occupationaltherapy are used as ends in themselves their value is more than limited.
During World Wars I and II the services of the occupational therapistwere widely used throughout our hospitals. There were many purposes, prominentamong which were: utilization of free time, relief of boredom and adjustmentto hospitalization. Personnel for this broad effort were not availableduring the Korean War and it also seemed that the mission of these highlytrained individuals might be better defined. We now believe that occupationaltherapy as a medical subspecialty is most effective in treating patientswith physical disabilities, psychiatric disorders and tuberculosis, withfunctional improvement as the goal of therapy.
It has been recommended, therefore, that occupational therapists beassigned only to Class II hospitals and to Class I hospitals that are designatedas specialized treatment centers in tuberculosis, neuropsychiatry, orthopedicsand/or neurosurgery.
Physical Reconditioning
Physical reconditioning is a type of controlled exercise that is utilizedin military hospitals. It is not intended to be used for specific therapeuticpurposes or for affected segments of the body. This type of activity hasbeen questioned as duplication of physical therapy. Recently a group ofcivilian consultants in physical medicine to The Surgeon General met inWashington and recommended the abolition of this special field. In theiropinion it is a duplication of physical therapy and it also creates a problemin civilian practice.
Early in World War II physical rehabilitation and training of the disabledbecame recognized as a need. Physical therapy was concerned with physicalagents and therapeutic exercise and occupational therapy with diversionalactivities. The immediate need resulted in the recruitment and trainingof a new group to supervise routine exercises for hospitalized patients.After the war some of these individuals desired to continue their serviceto patients but there were few opportunities. The problem has been partiallymet by encouraging those with proper educational background to become physicaltherapists. Physical reconditioning is a valuable contribution to the patientin an Army hospital because a soldier must be ready for duty when he isdischarged to his unit. It is most essential in wartime.
The consultant group is fully aware of this fact and does not recommendabolition of the service to patients, but of the special group that performsthese duties. The physical and occupational therapists are already highlytrained in the theory and practice of therapeutic ex-
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ercise. It is proposed that general reconditioning exercises be givento patients by physical therapy technicians under the supervision of thephysical therapist, and that reconditioning for the psychiatric patientbe done by the occupational therapy technician under the supervision ofthe occupational therapist. This recommendation has great merit and inour opinion could be further extended by combining all enlisted trainingto produce one enlisted aide (physical medicine aide) who would be availableto assist the physical therapist and/or the occupational therapist.
These recommendations will probably be followed but because of the intrinsicvalue of reconditioning exercises and because of their particular valuein military hospitals, a preliminary pilot study will be made in a largeArmy hospital. In this study physical and occupational therapists willbecome responsible for all reconditioning activities for a 3-month period.
This also raises the question of the convalescent center Table of Organizationand Equipment 8-590, to which large numbers of reconditioning officersare assigned. This unit was not requested for use in the Korean Theaterby the Surgeon of the Far East Forces; therefore, its particular valuecannot be evaluated in relation to the Korean War. This does present anopportunity to mention convalescence. A new emphasis has been placed onpurposeful medical management to shorten the convalescent period and toprovide the patient with as complete functional capacity as is possible.Convalescent patients frequently profit by training and therapy renderedby the physical medicine service. They also need other specialized medicalservices. All convalescent patients should receive reconditioning exercises.It is my opinion that acceptance of the responsibility of medical supervisionin the third phase of medical care merits special planning and considerationfor the period of convalescence rather than segregation into special installationsfor exercise and recreation.
The importance of exercise to maintain or improve physical fitness isobvious, but it must not be overemphasized. It is an individual responsibilityand a responsibility of command. Reconditioning for hospitalized patientsis a function of the Army Medical Service and proper facilities for thispurpose should be established in all of our hospitals and this will eliminatethe need for specialized hospitals devoted to exercise and recreation.
Transfer of Patients with Chronic Diseases to Veterans Administration
Executive Order No. 10400, dated 27 September 1952, vests in the Administratorof Veterans' Affairs all duties, powers, and functions incident to thehospitalization of members or former members of the uniformed serviceswho require hospitalization for chronic diseases.
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The Order states in part: "that chronic diseases shall be construedto include chronic arthritis, malignancy, psychiatric or neuropsychiatricdisorder, neurological disabilities, poliomyelitis with disability residualsand degenerative disease of the nervous system, severe injuries to thenervous system including quadriplegics, hemiplegics, and paraplegics, tuberculosis,blindness and deafness requiring definitive rehabilitation, major amputees,and such other diseases as may be so defined jointly by the Secretary ofDefense, the Administrator of Veterans' Affairs, and the Federal SecurityAdministrator and so described in appropriate regulations of the respectivedepartments and agencies concerned."
This directive, issued during the Korean War, obviously affects themagnitude of our efforts but does not alter the need for our services.It is not always possible to determine immediately that certain patientsmay not return to duty and there are classes of patients not eligible fortransfer to the Veterans Administration.
The Medical Statistics Division, Office of The Surgeon General, wasasked to supply the number of patients who developed major amputationsand paraplegia for a period during the Korean War. They have furnishedprovisional data for the period January 1952 through June 1953. The numberof permanent disability retirements by cause of separation is shown intable 2.
Table 2. Provisional Data, January 1952-June1953, Permanent Disability Retirements
Cause of separation | Total | Permanently retired |
Major amputations1 | 988 | 969 |
One upper extremity | 233 | 228 |
Both upper extremities | 4 | 4 |
One lower extremity | 692 | 678 |
Both lower extremities | 59 | 59 |
Paraplegia2 | 258 | 247 |
1Includes only amputations at the wrist andankle, or above.
2 Includes quadriplegia.
The number of these patients transferred to the Veterans Administrationduring this same period is shown in table 3.
Table 3. Provisional Data-January 1952-June1953-Patients Transferred to Veterans Administration
Total | To Veterans Administration | |
Amputations | 988 | 177 |
Paraplegia | 258 | 355 |
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Conclusions
1. The Korean War has affected the practice of physical medicine.
2. Physical medicine must be defined in terms of medical practice andmust assume responsibility for specific service to selected patients.
3. Physical medicine services must be established where groups of severelydisabled patients are concentrated.
4. Occupational therapists should be assigned only to Class II hospitalsand to Class I hospitals that are designated as specialized treatment centersin psychiatry, tuberculosis, orthopedics and/or neurosurgery.
5. It has been recommended that physical reconditioning be eliminatedas a special branch because it is a duplication of a segment of physicaltherapy. General reconditioning could become the responsibility of physicaltherapy and reconditioning for psychiatric patients could be made the responsibilityof occupational therapy. A pilot study along these lines is being made.
6. Executive Order No. 10400, dated 27 September 1952, has diminishedthe volume of our efforts in physical medicine but has not eliminated theneed for these services.
Reference
1. The Medical Department of the United States Army inThe World War, Volume XIII, 1927.
