Professional Services and Activities of Physical Therapists
April 1947 to January 1961
Lieutenant Colonel Mary E. Frazee, AMSC, USA
The major professional service of Army physical therapists from 1947 to 1961 was that of treatment of patients within a hospital situation. The administrative procedure for accomplishing this service was established in June 1949.1 Where a physical medicine service was part of the hospital organization, physical therapy was one section of that service. Others included occupational therapy, physical reconditioning (until 1955), and the administrative and diagnostic sections. In small hospitals, the commanding officer was authorized to place physical therapy, occupational therapy, and physical reconditioning in the professional service he deemed appropriate.
The Army general hospital was similar to a university hospital or medical center in that patients were referred for special consultation or treatment. In addition to the local community, it served a worldwide area. The station hospital served as a feeder unit to the general hospital and was comparable to a community hospital for an Army post. Routine illnesses were usually found in these smaller hospitals. If a patient was expected to return to duty within a certain time period, he remained in the station hospital. Long-term patients or those requiring additional specialized services, however, were normally transferred to the general hospital.
Physical Medicine Service
A physiatrist was chief of the physical medicine service at each of the general hospitals until 1955.2 He was responsible to the commanding officer of the hospital for all physical medicine activities. The chief physical therapist, under the direction of the physiatrist, was generally in charge of all professional and administrative physical therapy activities.
1Army Regulations No. 40-705, 16 June 1949.
2After 1955, a shortage of physical medicine officers precluded their assignment to each general hospital, and by December 1960, physiatrists were assigned only to Brooke General Hospital, Fort Sam Houston, Tex.; Fitzsimons General Hospital, Denver, Colo.; Letterman General Hospital, San Francisco, Calif.; Madigan General Hospital, Fort Lewis, Wash.; Tripler General Hospital, Honolulu, T.H.; and Walter Reed General Hospital, Washington, D.C.
The staff physical therapist was responsible to the chief physical therapist for patient treatment, and senior staff physical therapists were frequently responsible for a definite treatment division of the clinic.
The last echelon of responsibility rested with the noncommissioned officer in charge and his staff of enlisted personnel, all of whom were directly responsible to the chief physical therapist. The duty of these people was the care and maintenance of the clinic and the administering of patient treatment as directed by the chief physical therapist. This group of men and women was due much credit for their contribution to the professional services rendered by physical therapy. They frequently were highly skilled and conscientious technicians, and the normally superior appearance of the clinics attested to the pride the enlisted staff took in the work for which they were responsible.3
Enlisted physical reconditioning personnel became a part of this staff after 1955 as a result of pilot studies conducted at Letterman General Hospital, San Francisco, Calif., and Fitzsimons General Hospital, Denver, Colo., during the summer of 1954. The position of physical reconditioning officer was eliminated and the enlisted specialists were generally placed in either the physical or occupational therapy section, whichever was appropriate. It was believed that effective use could thus be made of the enlisted men`s special training while supervision was shifted to already established programs. Several years later, it became apparent that use of physical reconditioning in physical therapy was declining. Ward programs for medical and surgical patients dwindled perceptibly and physical reconditioning clinic activities for these patients were almost on a patient-volunteer basis. Physical therapists` lack of interest in physical reconditioning was probably the major cause of this decline.
Physical Therapy Clinic
Although the actual physical layout differed from one treatment clinic to another, the same general divisions were found in all. In the division usually referred to as the main clinic, treatment by heat, cold, electrotherapy, and massage was given.
A second area known as the therapeutic gymnasium or exercise room contained exercise equipment for patient use under the close supervision and assistance of the physical therapist. The usual exercise equipment could be found here: barbells, pulleys, exercise mats, stall bars, weights, posture mirrors, shoulder wheels, and finger ladders. In addition, equipment and space were usually allocated for gait training
3Enlisted personnel were called technicians until 1955 after which time the title `specialist` was used. In this chapter they are referred to as specialists.
and mat work. The size of the gymnasium varied with the available space. In most instances, it was a busy and necessarily large section of the physical therapy clinic.
Other lesser divisions included hydrotherapy rooms, ultraviolet rooms, and usually a few private rooms or booths for selected types of treatment. Some departments had separate clinics for women patients, while others provided private rooms or booths in the main clinic for their treatment.
In several instances, general hospitals maintained detached subdivisions. Walter Reed General Hospital, Washington, D.C., staffed a physical therapy clinic at its Forest Glen Section, Silver Spring, Md., until February 1955. Although a number of the patients were amputees, the majority of patients treated there were ambulatory convalescent patients with peripheral nerve injuries. Brooke General Hospital, Fort Sam Houston, Tex., had a physical therapy clinic in the main hospital building, a small separate clinic in an area designated for convalescent patients, and a large clinic at Annex IV (later called Beach Pavilion). At Walter Reed General Hospital, a former physical reconditioning gymnasium became an area specifically used for advanced rehabilitation. Known as the Activities of Daily Living Clinic, its value was apparent as the influx of geriatric patients increased the need for teaching self-care. A somewhat similar gymnasium was developed at Brooke General Hospital. At first, it was called the Combined Activities Clinic because the program was a combination of physical therapy and physical reconditioning activities.
Equipment in one hospital clinic differed very little from that in every other. Maj. Genevieve Pearson, using various sizes and lengths of rubber tubing, devised exercise apparatus which was widely used in Army physical therapy clinics. This equipment was economical, easy to construct, and highly functional. Tilt tables were improvised from discarded radiology tables at both Letterman and Brooke General Hospitals (fig. 147). Improvised equipment was necessary until the mid-fifties when manufacturers began incorporating many of the ideas in their rehabilitation equipment.
Clinics were adequately supplied with short wave diathermy apparatus, radiant heat lamps, bakers, ultraviolet lamps, paraffin baths, whirlpool baths, and low voltage stimulators. New or improved equipment, including Hydrocollator packs, ultrasound generators, microwave diathermies, constant current impulse stimulators, and Elgin tables, was added as it became available and was approved by the Surgeon General`s Office4 (fig. 148). New plinths became a standard item of issue but the chosen model was to have a stormy course before being ac-
4In the early fifties, a new diagnostic tool-electromyography-came into general use by the physiatrist as an aid in the determination of the location and extent of nerve lesions.
cepted by the physical therapists.5 Objections ranged from dislike of the brown paint to the inconvenient and inadequate shelving. Changes in these were authorized and accomplished in many clinics.
Among the outmoded equipment most universally discarded was the passive vascular exercise boot, a machine for producing intermittent vascular occlusion, elaborate hydrotherapy equipment, and carbon arc lamps. Long wave diathermy apparatus was outlawed by
5The old model plinths were still in use in the physical therapy clinic at Walter Reed General Hospital, Washington, D.C., in 1960.
the Federal Communications Commission and short wave diathermy apparatus was assigned specific wave bands in 1947. Medical maintenance crews with special training converted the existing short wave diathermy machines, manufactured before 1 July 1947, to the proper operating frequencies. The use of Moistaire cabinets decreased largely because they were cumbersome and there were other equally effective forms of treatment.
A physical medicine service was normally nonexistent in a station hospital.6 One of the physicians, usually the chief of the orthopedic service, was appointed to give medical direction to the physical therapy section. Occasionally, occupational therapy was available, depending upon the size of the hospital. Physical reconditioning per se was usually not found in a station hospital because peacetime requirements and length of patient stay did not warrant this program. If one or two enlisted physical reconditioning specialists were assigned, they were normally utilized in their specialty under the supervision of the phys-
6During the Korean War, several station hospitals were designated as specialized treatment centers and staffed with a complete physical medicine service. As the need for expanded facilities decreased, these hospitals were closed or reverted to their normal patient load, for example, Camp Atterbury, Columbus, Ind.; Fort Campbell, Ky.; Fort Carson, Colo.; and Fort Gordon, Augusta, Ga.
ical or occupational therapist, depending upon the treatment program.
During World War II, the standard station hospital was a frame cantonment structure built to last for an expected occupancy of 7 years. Physical therapy clinics occupied one or more ward buildings. Fortunately, these were usually located near the center corridor of the hospital so that as the hospital census dropped and wards were closed, the clinics remained in a convenient location. During the years following the war, there was much fluctuation in the number and size of hospitals required. The wooden buildings which had been expected to last for 7 years were repaired and remodeled many times. Some of these were still in use, nearly 20 years after construction. Physical therapy clinics of this type still operational in 1960 were located at Aberdeen Proving Ground, Md.; Fort Benjamin Harrison, Ind.; Fort Devens, Ayer, Mass.; Fort Eustis, Va.; Fort Gordon, Augusta, Ga.; Fort Huachuca, Ariz.; Fort Hood, Tex.; Fort Jackson, S.C.; Fort McClellan, Ala.; Fort Ord, Calif.; and Fort Rucker, Ozark, Ala.
As of May 1960, 10 new Army station hospitals were completed, 4 were under construction, and 3 were funded, with promise of early construction.7 The physical therapy clinics in these installations were impressive and attractive in appearance and equipment but, as often happens in new construction, deficiencies in planning became apparent with use.8 The most common criticism was that air conditioning did not compensate for the small number or lack of windows, and that space was inadequate for the workload. In addition, such space, as there was, was divided into many small treatment areas which made supervision more difficult. Army physical therapists have long felt that they can operate more effectively and efficiently in a large open treatment area with a minimum of private cubicles reserved for those whose treatment requires privacy.
Composition of Patient Load
In addition to treating the usual number of hospital patients, physical therapists in station hospitals treated an even larger number of outpatients. From 1952 to 1960, the reduction in the size of the Active Army reduced the number of outpatient visits of Active Army personnel (table 23). Surprisingly, the number of visits of military dependents almost doubled during this period. Figures of physical therapy visits reflected a similar picture. This trend has produced a patient load in Army physical therapy clinics similar to that seen in civilian clinics (fig. 149).
7Department of the Army Technical Bulletin (TB) 8-1, 1 May 1960, pp. 3-7.
8Personal correspondence of the author, 1961.
Solutions to Handling Patient Load
Handling a large patient load at the station hospitals frequently taxed the ingenuity of the one or two physical therapists assigned there. At training centers, trainees were penalized for missing training, whether or not the reason was due to an injury. Therefore, immediate, simple, and effective treatment was indicated. In some clinics, the physical therapists concentrated on providing treatment whenever the patients could come-1 or 10 at a time; one installation implemented a dispensary program where patients could step from the physician`s office next door to a small but adequate clinic where they received
physical therapy; one physical therapist supervised a well-trained staff of enlisted specialists in administering the simple procedures required. The assignment of a physical therapist to the orthopedic clinic to give the patients instruction in self-exercise was found to be an effective method which helped particularly in handling the large outpatient load on clinic days.
Opportunities for the continuing education of the Army physical therapist were available through a number of channels, the inservice educational program being one of the most valuable. Because of large staffs in general hospitals, the program was perhaps more formalized than in station hospitals. Also characteristic of the general hospital was the wide variety of patients and the concentration of unusual cases, both of which created a learning situation which was further enhanced by a system of rotation of clinical assignments. Working with many types of patients was of especial value to the young physical therapist who sought to identify with a particular type of condition or patient.
The physical therapy staff meetings in a large hospital provided opportunity for discussion of the many professional and administrative problems that arose in the everyday operation of the clinic. At times, a physician discussed subjects pertaining to the interests of physical therapy or a staff member reviewed basic sciences or basic techniques. A disease entity was sometimes reviewed. For example, as the poliomyelitis season approached, this disease was discussed in terms of etiology, pathology, physical findings, management, and the practice of therapeutic procedures. Staff members who attended specialized courses reported their experience and shared their knowledge with the staff, a procedure which vitalized the physical therapy program, bringing to it the most recent thinking, methods, and developments from outside sources.
Experience in administration was provided by giving staff physical therapists the opportunity of supervising the clinic. They scheduled and assigned patients and, in general, were responsible for a smoothly coordinated clinic day. Such an arrangement gave the physical therapists an insight into many of the administrative procedures, helped them develop good interpersonal relationships, and to mature as physical therapists and supervisors. This responsibility, once referred to as `on the desk,` was later dignified in some of the larger hospitals by the title `clinic coordinator.`
The physical therapists in the smaller hospitals, although deprived of the stimulus of association with their professional peers, nevertheless were privileged to participate in an educational program of broader scope and interest. In the small hospital, the physical therapists learned more about other members of the hospital staff, became fa-
miliar with emergency measures, and, because of fewer numbers both of patients and personnel, developed a better insight into the comprehensive care and management of the patient. Since they usually knew more about physical therapy procedures than any other hospital personnel, it was not unusual for them to present an orientation program on physical therapy to the hospital staff. They had a closer relationship with more physicians in more specialties, thereby being exposed to unending professional learning experiences.
In order to note treatment changes and trends from 1947 to 1961, various conditions will be discussed separately and briefly. Omission of discussion of a condition implies only that there was no basic change in the treatment procedures from the World War II period.
Amputees made up a large part of the physical therapy patient load during the periods following World War II and the Korean War. Most amputees were treated at Brooke, Letterman, and Walter Reed General Hospitals.
Except for minor changes in treatment procedures, physical therapy management of most amputees remained the same (fig. 150). The relatively new kineplastic procedure was frequently seen in some of the clinics, and physical therapy was used routinely in the program of treatment.
The development of the kineplastic procedure presented a new problem, that of harnessing intact muscle power to activate a prosthesis. This procedure was most commonly performed for the upper extremity amputee, utilizing the pectoralis major or biceps muscle. On lower extremity below-knee amputees, it was performed occasionally on the rectus femoris muscle. The procedure for exercise was the same in all respects in addition to special exercise for the muscles involved in the kineplasty. A small rod was inserted through the tunnel so that each end protruded on either side of the tunnel. By applying resistance to the rod, counter to the line of pull of the muscle, resistance was applied to the tunnel and consequently to the muscle. This encouraged a gradually increased excursion of the tunnel. A maximum excursion of the tunnel was needed for good control of the prosthesis. By 1960, because of the limited applicability of this procedure, it was used very little.
The suction socket, used on above knee prostheses, came to be widely used and required no new physical therapy procedures other than instruction in the use of the prosthesis. Phantom limb pain continued to present a problem which retarded the progress of some amputees. Although no effective treatment had been determined, an Army phys-
ical therapist reported the successful use of ultrasound on four patients.9
Hospitalized because of injuries sustained in automobile accidents, cerebral vascular disturbances, and birth injuries, patients with brain injuries were found in every Army hospital. No one age group monopolized this classification, for geriatric as well as pediatric patients were represented. As would be expected, the number of patients with brain injuries increased as a result of the Korean War.
9Anderson, M. J.: Four Cases of Phantom Limb Treated With Ultrasound. Phys. Therapy Rev. 38: 419-420, June 1958.
Physical therapy played a major role in the treatment and rehabilitation of the patient with an upper motor neuron lesion. Several new techniques were employed at various times in efforts to improve the function of these patients.
Proprioceptive neuromuscular facilitation, developed by Herman Kabat, M.D., and Margaret Knott, P.T.,10 came to be used widely in Army clinics and variations of this method became almost routine in treatment. Patterns of motion elicited by proprioceptive stimulation were the basis for muscle re-education, a departure from the traditional methods of individual muscle re-education. During a tour of duty in Japan, Capt. Mary Jane Torp completed a study related to the use of proprioceptive neuromuscular facilitation techniques in the exercise program of patients with hemiplegia.11
The Rood concept was based on the exteroceptive stimulation of nerve, muscle, and bone to produce and reinforce muscle contractions. Stroking, positioning, kneading, brushing, pounding, and ice applications were used for this stimulation.12
The Bobath method utilized posture and positioning as a means of stimulating muscle contractions.13 This method was especially developed for use in the treatment of the child with cerebral palsy. 2d Lt. Donald Tresch, AMSC, demonstrated that its principles could also be utilized for treatment of the adult patient with hemiplegia and illustrated its use in a film14 made at Valley Forge General Hospital, Phoenixville, Pa.
Signe Brunnstrom, long a leader in treatment of amputees, turned to neuromuscular disabilities and combined many existing concepts of neuromuscular function which were used in treatment of the brain injured.15
Capt. Walter J. Treanor, MC, physiatrist at Letterman General Hospital, advocated nociceptive stimulation combined with peripheral nerve blockage to overcome disabilities following brain injury.16 A description of these procedures with the adjunctive physical therapy program provided the basis for a complete session of the annual conference of the American Physical Therapy Association in 1954.
All of these techniques were complex and required precise application. Physical therapists attended courses to learn the various methods and returned to their clinics to instruct others. It can be safely said
10Kabat, H., and Knott, M.: Proprioceptive Facilitation Technics for Treatment of Paralysis. Phys. Therapy Rev. 33: 53-64, February 1953.
11(1) Torp, M. J.: Adaptations of Neuromuscular Facilitation Technics. Phys. Therapy Rev. 36: 577-586, September 1956. (2) Torp, M. J.: An Exercise Program for the Brain-Injured. Phys. Therapy Rev. 36: 664-675, October 1956.
12Rood, M. S.: Neurophysiological Reactions as a Basis for Physical Therapy. Phys. Therapy Rev. 34: 444-449, September 1954.
13Bobath, K., and Bobath, B.: Spastic Paralysis; Treatment of by Use of Reflex Inhibition. Brit. J. Phys. Med. 13: 121-127, June 1950.
14PMF 5347: Physical Therapy in Treatment of the Adult Hemiplegic, 1960 (35 mm., color, sound).
15Brunnstrom, S.: Associated Reactions of the Upper Extremity in Adult Patients With Hemiplegia; An Approach to Training. Phys. Therapy Rev. 36: 225-236, April 1956.
16Treanor, W. J., Cole, O. M., and Dabato, R.: Selective Reeducation and the Use of Assistive Devices. Phys. Therapy Rev. 34: 618-625, December 1954.
that discerning physical therapists had, in the past, utilized many of the principles of muscle function set forth in these techniques, but until these skills were organized into definite methods and procedures, widespread usage did not result.
The general pattern for treatment of a patient with a central nervous system lesion was to encourage early motion in the extremities followed by standing and ambulation as soon as feasible. Training in activities of daily living was often a joint project of occupational and physical therapy with return to duty the goal for some and self-care in the home as a satisfactory achievement for others. Large numbers of patients with hemiplegia were retired elderly persons for whom a home program was indicated.
The child with cerebral palsy did not appear in large numbers in any Army clinic. For several years in the early fifties, a Cerebral Palsy Clinic was operated at Brooke General Hospital. Working closely with the Child Guidance Clinic, it was staffed by both occupational and physical therapists and was fully equipped for treatment of the child with cerebral palsy. Inasmuch as local public school systems provided treatment for most of these children, the Army physical therapist in some situations lacked experience in treating this type of patient.
In 1946, the Surgical Research Unit at Brooke General Hospital began to investigate the problems of mechanical and thermal injuries and the complications arising from such trauma. The Surgical Research Unit implemented this by caring for patients with such injuries, thus providing clinical research material for studies and teaching. Its clinical facilities, within the new building of Brooke General Hospital, occupied half of one floor. By 1949, the emphasis for clinical investigation had shifted to thermal injuries, so much so that the ward was referred to as the `burn ward` and the unit as the `burn unit.`
Patients presenting burns of such seriousness as to contribute to research findings were admitted regardless of their status, civilian or military. The Surgical Research Unit utilized physical therapy both in ward and clinic treatment. In this way, many physical therapists and physical therapy students obtained valuable experience in this highly specialized work. The experience proved useful in treatment of isolated burn patients at other hospitals.
At the request of the Surgical Research Unit, a physical therapist, 1st Lt. JoAnne K. Gronley, was assigned full time to the unit for the purpose of providing improved patient care and also to investigate methods whereby deformity of the burned patient might be decreased or prevented.17 Early in this assignment, Lieutenant Gronley improvised a Hubbard tank from a discarded steam table. This piece of equip-
171st Lt. JoAnne K. Gronley was assigned to the Surgical Research Unit in July 1959. In January 1962, spaces were authorized for one physical therapist and one occupational therapist.
ment was located on the burn ward, allowing the ward patient to receive treatment several times a day and the clinic patient to receive supplementary ward treatment. Prevention of deformity was attempted through early functional positioning and early exercise of the patient. Immobilization was permitted only during the first 5 to 10 days following the burn (while eschar was intact) and during grafting.18
The treatment of thoracic injuries changed somewhat from the program carried on during World War II, although the basic exercise programs for preoperative and postoperative patients remained essentially the same (fig. 151). There was increased use of pressure chest-expansion exercises which were accomplished in many different posi-
18Gronley, J. K.: The Positioning of Severely Burned Hands When Treated by the Exposure Method. Phys. Therapy Rev. 40: 521-522, July 1960.
tions. The patient`s need for deep breathing was increased by gradually increasing the activity of the whole body.19
Use of new drugs in the treatment of tuberculous patients greatly reduced the requirements for surgery. Improved surgical techniques caused less drastic tissue destruction in these patients and thus a shorter period of physical therapy was required. Combat wounds and chest tumors comprised the large majority of nontuberculous surgical patients. Open heart surgery was perfected during this period and these patients followed the general physical therapy routine for the thoracic surgery patients although the progression in treatment was much slower.20 Frequently, these patients were children with congenital heart deformities.
Still another type of chest condition was the nonoperable one, such as that of the patient with asthma, cystic fibrosis, bronchiectasis, or emphysema. Since there was no dramatic episode to impress these patients with the importance of changing their breathing habits, motivation was frequently difficult. Postural drainage and breathing exercises emphasizing controlled exhalation were routinely taught to them. In addition, parents of children with cystic fibrosis were given specific instructions and demonstrations of tapping which helped the children to expel the mucus. Usually one or two sessions of instruction in the clinic were adequate for the patient to start a home program. Written instructions were given in most instances as reinforcement and reminder of the exercise program.
Low Back Pain and Herniated Nucleus Pulposus
Herniated nucleus pulposus was recognized as one of the frequent causes of back pain which radiated into one or both extremities. Patients with low back pain were initially treated conservatively with physical measures and medication. Bed rest and traction were augmented by physical therapy. The generally accepted routine stressed mild back flexion exercises to relieve tightness of low back musculature and exercises to strengthen the abdominal muscles. Heat or cold applications often preceded the exercise but massage was seldom employed. In addition, the patient was taught good body mechanics in the hope of preventing a recurrence of symptoms.
The patient with severely involved herniated nucleus pulposus who found only temporary or no relief from pain by conservative treatment usually entered a general hospital. If a final attempt at conservative treatment failed, surgery was indicated. Following surgery, protective body mechanics and a continued exercise program were emphasized.
19Anderson, M. J., and Aronstam, E. M.: Intermittent Positive Pressure Breathing; An Adjunct in the Rehabilitation of Thoracic Surgery Patients. Dis. Chest 30: 168-171, August 1956.
20Cruickshank, H. E.: The Role of Physical Therapy in the Surgical Management of Heart Disease. Phys. Therapy Rev. 35: 641-644, November 1955.
Interest in physical therapy for the obstetrical patient in Army hospitals was initially generated in 1948 by 1st Lt. (later Capt.) Willie R. Harvey in her work at the U.S. Army Hospital, Fort Meade, Md. She taught simple abdominal strengthening and low back flexion exercises following delivery in order to prevent later complaints of back pain from poor posture.21
During the period from 1949 to 1961, many Army hospitals instituted exercise programs for either the prenatal or the postpartum period. For the former, relaxation, breathing, and postural exercises were the most commonly stressed.
The rehabilitation of the orthopedic patient presents problems which utilize almost the entire gamut of physical therapy facilities. Pain, edema, atrophy, muscle weakness, incoordination, and limitation of joint motion are the common problems seen in most orthopedic patients.
Heat has long been the treatment of choice for relieving pain and swelling but in recent years the use of ice therapy has been added. Ultrasound treatment has become widely used for many types of orthopedic conditions.
During the period covered by this chapter, there was increased recognition of exercise as the essence of the rehabilitation program for the orthopedic as well as other patients (fig. 152). The DeLorme technique of progressive resistance exercise increased in popularity and was a valuable method of improving muscle function. Progressive resistance exercise came to be universally used for strengthening the quadriceps muscle in the cases of knee injury and surgery. Because of the adaptive possibilities of the Elgin table, it became possible to apply the technique of progressive resistance exercise to practically any muscle group.
Exercises incorporating isometric contractions against heavy resistance came to be widely used. Maj. Mary S. Lawrence was an early investigator in this area.22 This method was found to be especially effective for those conditions requiring an increase of strength with a minimum of joint motion, as in chondromalacia of the patella.
Facilitation techniques, though most commonly employed in neurological conditions, were used on occasion in certain orthopedic conditions. Selected techniques of the Rood method such as brushing, tapping, and ice applications were frequently used to stimulate weak and atrophied musculature.
21Harvey, W. R.: The Need for Physical Therapy in Postpartum Care. Phys. Therapy Rev. 29: 206-217, May 1949.
22Lawrence, M. S.: Strengthening the Quadriceps: Progressively Prolonged Isometric Tension Method. Phys. Therapy Rev. 36: 658-661, October 1955.
Paraplegia and Quadriplegia
By 1947, the majority of patients with spinal cord injuries received during World War II had been discharged to Veterans` Administration hospitals for final rehabilitation. The number of patients with these injuries increased during the Korean War. Throughout the entire period, however, diving, automobile, and training accidents resulted in an astonishingly large number of spinal cord injuries.
The physical therapy program involved hard work and psychological motivation. Electrical stimulation, heat, and ice packs were among the modalities used to relieve the complications of pain and muscle spasm, with no outstanding success attributed to any one technique. Massage was seldom employed and then only for short periods in selected cases. Facilitation techniques were found effective in treatment of injuries of varying degrees of severity. Emphasis was placed on patient activity.
Physical therapists attended special courses such as the one conducted at the Institute of Physical Medicine and Rehabilitation, Bellevue Medical Center, New York, N.Y., to learn the methods developed there. Mat exercises became part of the treatment of the patient with paraplegia and the accent was on self-help. Physical reconditioning personnel contributed to the mental and physical rehabilitation of
these patients, encouraging and challenging them to overcome their problems.
Active duty personnel with a major disability such as quadriplegia were normally discharged from the Army and transferred to a Veterans` Administration hospital for fitting of braces, final rehabilitation, and vocational training if needed. There was no such provision, however, for the treatment of dependents. Their entire treatment was accomplished in an Army general hospital and required the careful coordination of physician, physical therapist, orthopedic appliance maker, nurse, occupational therapist, and other members of the rehabilitation team.
Rehabilitation of the patient with poliomyelitis has long been associated with the skills of physical therapists. Many of the basic tenets of muscle function held by physical therapists were derived from the treatment of these patients. Re-education of individual muscles and strength grading of individual muscles were concepts which were basic to the treatment of every patient with poliomyelitis. Numerous Army physical therapists attended courses at Georgia Warm Springs Foundation, Warm Springs, Ga., in order to learn current treatment techniques and concepts. In the early fifties, methods of muscle re-education were being reconsidered in light of clinical findings. Newer methods of neuromuscular re-education challenged the concept of individual muscle re-education.
The preferred treatment for patients with acute poliomyelitis consisted of the application of woolen hot packs to the painful areas, mild stretching of the involved musculature, and careful exercise of the joints through range of motion. The small wool hot packs which were wrapped and pinned around an extremity were replaced by large layon packs. Use of these helped to eliminate much of the painful handling of the patient.
The discovery, subsequent development, and Army-wide administration of Salk vaccine in 1956 almost eliminated the patient with acute paralytic poliomyelitis from Army hospitals. Information on the physical status of patients with poliomyelitis 5 years following onset of the disease was collected and used as a basis for a study completed and published by Captain Torp.23
During the period covered by this chapter, physical therapists assigned to Army hospitals in the European Command were faced with many of the same professional problems as those encountered in the
23Torp, M. J.: Poliomyelitis: Functional Progress Report of Fifty Cases Approximately 5 Years-Post Onset. Phys. Therapy Rev. 33: 351-358, July 1953.
United States. In general, hospital facilities fluctuated with the needs of the area. Wartime medical units were moved or reorganized to provide convenient and adequate treatment both for Army personnel and their dependents who began coming into the area. As in the United States, a great increase was noted in demands for outpatient facilities.
Throughout the period covered by this chapter, both general and station hospitals in Europe had physical therapy clinics. Small station and field hospitals were established throughout the original American Zone of Germany, Austria, and France as the need arose. The size of the physical therapy staff in these hospitals was comparable to that in station hospitals in the United States. Occasionally, qualified civilian physical therapists and assistants were employed.
Professional standards were strengthened by a series of professional meetings initiated in 1953. Four meetings a year were held during the first few years of the program, but eventually this pattern changed to one annual meeting which included members of all three sections (dietitian, physical therapist, and occupational therapist) of the Army Medical Specialist Corps who were stationed in Europe.
During the early occupation days, supply problems made it necessary to use German physical therapy equipment which, although strange in appearance, was actually superior in some ways to that manufactured in the United States. The advantage of utilizing indigenous electrical equipment was that it was constructed to function efficiently with the available local electrical current. Transformers were scarce and the difference in frequency lowered the efficiency of American-manufactured equipment constructed to use the 120 volts, 60 cycles per second current. Later, as supply problems diminished, American equipment predominated. By careful planning, supplies were adequately maintained although it required approximately 6 months to obtain replacements from the United States.24
Physical therapy facilities improved as the hospitals themselves improved. The 98th General Hospital, constructed in Neubrücke, Germany, in 1953, had a large spacious physical therapy clinic complete with a physical reconditioning gymnasium and was located across the hall from a well-equipped occupational therapy clinic. Inasmuch as no occupational therapist had been assigned when this hospital opened and an experienced enlisted occupational therapy specialist was available, the chief physical therapist supervised the occupational therapy activities until a chief occupational therapist arrived in 1955.25
The location of the Orthopedic Center in Europe was always of interest because it meant a concentration of physical therapists in that area. During the period under consideration, the Orthopedic Center moved three times in Germany-from Stuttgart to Munich in 1949, from Munich to Neubrücke in 1953, and from Neubrücke to Frankfurt in 1959, which is the air transportation link with Army hospitals in
24Personal correspondence, Lt. Col. Mary Ben Dure to the author, 9 September 1960.
25Personal correspondence, Maj. Emma T. Harr to the author, 13 September 1960.
the United States. Physical therapists and clinic equipment accompanied each move.
Routine practice alerts, begun in 1950, were unique to the European Command and became almost as commonplace as fire drills. The alerts in the various hospitals were similar in that they required the hospital personnel to respond to an alarm by reporting to their mobilization assignments in field clothing. Some required the personnel to carry out the mobilization assignment for many hours under hardship conditions, while others were mere token drills. In all cases, these practice alerts demonstrated that the hospital personnel were aware of their dual role in the theater. As has been the case in various disaster tests in the United States, physical therapists at first complained that they were not used in a capacity consistent with their professional background. Discussion of this problem led to an understanding of the skills level of physical therapists and eventually to an appropriate utilization of their abilities.
Far East Command
Two professional accomplishments of physical therapists in the Far East Command during 1947-61 were their contribution to the treatment of Korean War casualties and their participation in the training of Korean Army medical personnel in rehabilitation measures.
As in the European Command between 1947-50, considerable shifting and re-settling was experienced. Physical therapists were gradually withdrawn from their assignments in the Philippine Islands and Korea; hospital units in Japan consolidated and moved to new areas as required.
Suddenly in mid-1950, combat casualties overloaded the existing facilities. Through the efforts of Maj. Ethel M. Theilmann, physical therapy consultant in the Far East Command, the limited number of physical therapists were assigned where they could make their maximum contribution. In the fall and winter of 1950, the situation was alleviated with the arrival of hospital units26 with their full complement of physical therapists and enlisted specialists. Occasionally, a physiatrist was assigned as chief of a physical medicine service, but this specialty was rare in this command and usually the assignment fell to the chief of the orthopedic service. As a result, more professional responsibility was placed on the physical therapists who proved themselves more than equal to the demands made upon them.
Adding to the complexity of the situation was the influx of the United Nations soldiers. These men represented many countries which had contributed fighting soldiers to the Korean War. Although the various languages and cultures of these countries presented many per-
26Tables of Organization and Equipment units.
plexities, they also added an unexpected zest to the hospital atmosphere.
The majority of enlisted personnel assigned to the clinics were untrained in physical therapy techniques. Because of the urgent need for physical therapy specialists, on-the-job training was accomplished in most of the hospitals during the entire emergency period. A formal training program was established in March 1952 at the U.S. Army Hospital, 8164th Army Unit, Kyoto, Japan, with 1st Lt. (later Capt.) Catherine Owen in charge. Following the recommended Army program for the training of physical therapy technicians, four 12-week courses were conducted. Twenty-one enlisted men were graduated and reassigned to physical therapy clinics throughout the Far East Command. By December 1952, the critical shortage had been relieved and the course was discontinued.27
When a Cold Injury Center was established on 1 December 1950 at Osaka Army Hospital, Osaka, Japan, over 4,000 patients were treated the first winter. The program which was resumed the following winter was reported by Capt. (later Maj.) Mary E. Sacksteder, chief physical therapist.28 Injuries ranged from simple frostbite and trenchfoot to deep freezing, necessitating amputation. On admission, patients were routinely started on a ward physical therapy program consisting of specific active exercises to be conscientiously performed for 10 minutes of every waking hour. The goals were to restore and maintain the effectiveness of the injured extremity, to prevent atrophy and deformity, and to achieve maximum range of motion. Buerger-Allen exercises were used only in treatment of selected patients, for it was believed the resultant increase in circulation was contraindicated where extensive necrosis was present.
Late in 1950, 1st Lt. (later Maj.) Clarissa Hicks, assigned to the 118th Station Hospital, Fukuoka, Kyushu, Japan, found herself in the midst of an epidemic of the newly identified Japanese B encephalitis.29 Approximately 280 patients with this diagnosis, all of whom had been on duty in Korea, were treated in this hospital. Forty of these patients were treated in the physical therapy clinic over a 3-month period.
Patients with Japanese B encephalitis demonstrated generalized paresis, often with superimposed localized paresis of either upper or lower motor neuron origin.30 Muscular rigidity, incoordination, tremor, poor posture, and limitation of joint motion due to muscle shortening were some of the symptoms which responded to physical therapy measures. Lieutenant Hicks, never having encountered the disease before, was permitted to treat patients symptomatically as there was no precedent for her to follow. Debilitated patients with generalized weakness were started with full body infrared irradiation and general
27Annual Report of Medical Service Activities, Headquarters, U.S. Army Hospital, 8164th Army Unit, U.S. Army Forces, Far East, 1952.
28Sacksteder, M.: Physical Therapy in the Early Care of Cold Injuries. Phys. Therapy Rev. 31: 518-522, December 1951.
29Annual Report of Army Medical Service Activities, 118th Station Hospital, U.S. Army Forces, Far East, 1950.
30War Department Technical Bulletin (TB MED) 181, 6 Apr. 1947.
strengthening exercises on a plinth. Gradually, patients progressed to a sitting position; active resistive exercises and whirlpool bath treatment were added as tolerated. As general strength returned, specific weaknesses were noted and given special attention.
In September 1953, a poliomyelitis epidemic broke out in Japan. The victims included many United Nations troops as well as United States military personnel. To provide physical therapy for these patients, a special program was set up at Tokyo Army Hospital, Tokyo, Japan, under the supervision of Maj. (later Lt. Col.) Elizabeth C. Jones, chief physical therapist.
In addition to the many hospital activities, a program of instruction for Korean medical personnel was undertaken by Army physical therapists. In the early fifties, Major Theilmann implemented the rehabilitation program for amputees in three Republic of Korea Army hospitals. She not only designed suitable facilities but managed to train Korean personnel despite the multiple problems posed by language barriers and lack of equipment.31
Maj. Christine Ehlers and 1st Lt. (later Capt.) Winifred Nesbit, on 30-day tours in 1953, worked with the Armed Forces Assistance to Korea Program in Taegu and Pusan. They instructed a total of 13 Korean medical personnel in basic principles and practices of physical therapy.32
By 1954, Army physical therapists were again permanently assigned to U.S. Army hospitals in Korea (fig. 153). Clinics were housed in quonset huts as a general rule. At this time, U.S. Army troops in Japan were being gradually withdrawn and hospitals were being closed. By 1958, only the U.S. Army Hospital at Camp Zama, outside Tokyo, required a physical therapist. Physical therapists continued to be assigned to Okinawa.
Busy as the Army physical therapists were during the Korean War, they managed to get together for theaterwide professional meetings. Both in 1951 and in 1952, meetings were held in Japan in which Army and Air Force physical therapists discussed their professional problems. Later, when stationed in Korea, some of the Army physical therapists met with the United Nations physical therapists in order that they could be better informed as to what each was doing and pool information and ideas on effective treatment and training procedures.
Territory of Hawaii
Among the first of the new Army hospitals to be completed following World War II, Tripler General Hospital, Honolulu, T.H., was opened in August 1948. The following year, Aiea Naval Hospital closed, and the staff and patients were transferred to Tripler General Hospital.33
31Theilmann, E. M.: The Beginning of an Amputee Program in Pusan. Phys. Therapy Rev. 33: 306-307, June 1953.
32Ehlers, C.: Army Physical Therapists in Taegu and Pusan. Phys. Therapy Rev. 34: 523-524, October 1954.
33Annual Report of Medical Department Activities, Headquarters, Tripler General Hospital, Honolulu, T.H. 1949.
Simultaneously, Air Force personnel declared their identification apart from the Army. Thus Tripler General Hospital became, for a while, essentially an Armed Forces hospital, jointly used and staffed by all three services.
In 1954, an increased incidence of poliomyelitis overtaxed both the facilities and the assigned physical therapy personnel. The situation was somewhat alleviated by the addition of a civilian physical therapist furnished by the National Foundation for Infantile Paralysis and the establishment of a joint Orthopedic-Physical Medicine Evaluation Clinic.
Because of the increased popularity of scuba-diving in the waters of the Pacific, the physical therapists at Tripler General Hospital were confronted with the treatment of patients with spinal cord involvement resulting from decompression sickness, one of the possible hazards of the sport. Muscle evaluations were used as a preliminary procedure to the symptomatic treatment which followed for paresis and paralysis usually observed in these patients. The facilitation techniques used by Rood appeared to be helpful to the patients in `locating` muscles, but vigorous exercise was found to be the most effective treatment measure.34
34McDowell, J., and Amizich, A. D.: Physical Therapy in the Treatment of Decompression Sickness With Spinal Involvement. Phys. Therapy Rev. 40: 737-740, October 1960.
As part of the Army Medical Service standing ready to lend medical help in times of need, physical therapists have been called upon to render assistance in several different kinds of missions, as follows:
During a poliomyelitis epidemic in Greece in 1949, Capt. (later Lt. Col.) Mary L. Ben Dure was assigned by the Chief Surgeon of the European Command to the Public Health Division of the Economic Cooperation Administration`s Mission to Greece. During her 6 weeks` tour she helped to establish a physical therapy clinic in a new wing of Athens` St. Sophia Hospital, assisted in caring for the 100 poliomyelitis patients in that hospital, and instructed personnel in physical therapeutic procedures. She worked with the Greek hospital staff as well as two Greek physical therapists borrowed from the Near East Foundation Rehabilitation Center.35
Saudi Arabia Mission
Early in 1957, King Ibn Saud of Saudi Arabia and his young son, Prince Mashhur paid a visit to the United States. During his brief stay in this country, Prince Mashhur received treatment and consultative care at Walter Reed General Hospital for a mild congenital deformity on his right side. At the time of his departure, a medical team was detached from Walter Reed General Hospital to accompany the patient to Saudi Arabia. This team consisted of Col. Aniello F. Mastellone, MC, Chief, Physical Medicine Service, 1st Lt. Howard A. Appleby, Jr., physical therapist, and Mr. Andrew Matzel, specialist in bracing and splinting. The mission of this team was the continuation of treatment already initiated and instruction of personnel surrounding the Prince as to future treatment. The team remained on duty in Saudi Arabia for 2 months.
In 1958, the U.S. Army Mission to Peru requested mobile training teams be assigned to the mission for the purpose of training personnel for the newly constructed 960-bed Central Military Hospital in Lima,
Peru.36 One of these teams consisted of Capt. (later Maj.) Rachel H. Adams and Sgt. R. G. DeFreitas, a physical therapy specialist. Their mission was to instruct and train Peruvian personnel in physical therapy procedures which would be needed in the operation of the new fully equipped physical medicine service.
During its 60-day stay, the team was received with a great deal of
35Ben Dure, M. L.: Physical Therapy Assistance for Poliomyelitis Cases in Greece. Phys. Therapy Rev. 30: 171-174, May 1950.
36Report of Mobile Medical Training Team (Peru), RCS: CSGPO-125, to Department of the Army, 20 June 1958.
professional interest, and enthusiasm was displayed by the 31 students as well as by other medical personnel of the hospital.
During the fall of 1952, the city of Flint was stricken by a severe poliomyelitis epidemic. There were over 400 victims, 90 of whom had the bulbar spinal type. A team consisting of Captain Sacksteder, 1st Lt. Phyllis Ramsey, Sgt. John Lady, and Cpl. Luther Dever was detached from Percy Jones General Hospital, Battle Creek, for a period of 6 weeks to assist in this epidemic. Along with many others, these people worked long hours each day treating patients in hospitals and instructing families to care for patients who would be discharged early because of crowded hospital conditions.
Captain Sacksteder`s tour was extended for an additional 2 weeks, during which she gave a course of instruction to nurses and also to members of families of the most seriously afflicted patients. From the latter course evolved the Polio Club of Flint, Mich., which received wide publicity because of its value in the rehabilitation of the patient and in the adjustment of family members to the changed situation.
The need for standardized blank forms for use by all government agencies included those which would constitute a part of the patient`s permanent medical record. In 1949, a committee which included physical therapist representatives of the Army, Air Force, Navy, Veterans` Administration, and U.S. Public Health Service met to establish standard blank forms for use in muscle and nerve evaluation and joint motion measurements. The forms were completed in 1950 and accepted by the agencies.
In August 1954, the forms were revised and reissued and were still in use in 1960.37 This standardization was helpful to physical evaluation boards, medical review boards, and to the patient`s medical staff when interservice hospital transfers were made.
In March 1956, a manual on joint measurements was published.38 This manual had originally been planned as a common effort in 1953, but was taken over by the Army when committee interest lagged. Since the manual contained information approved for use by the Air Force, it carries their designation number also.39
The last manual to be published during this period was a handbook for physical therapy specialists. Written by the Training Doctrine Department, Medical Field Service School, Fort Sam Houston, Tex., assisted by the physical therapy faculty, it was issued in August 1959.40
37SF 527, Manual Muscle Evaluation; SF 527a, Joint Motion Measurements; SF 528; Muscle and/or Nerve Evaluation-Manual and Electrical: Upper Extremity; SF 529, Muscle Evaluation-Trunk, Lower Extremity, Face.
38Department of the Army Technical Manual (TM) 8-640, March 1956.
39Air Force Publication 160-14-1, March 1956.
40Department of the Army Technical Manual (TM) 8-295, August 1959.