Professional Services and Activities of Occupational Therapists
April 1947 to January 1961
Lieutenant Colonel Myra L. McDaniel, USA (Ret.)
During the 14 years covered by this chapter, forces of change affected occupational therapists in the Army Medical Service and they in turn effected change in the services and activities in their professional field. It was a sequential set of forces which began in 1947 when the opportunity for military status became available. As civilian employees, the occupational therapists had participated on the military medical team but it was a professional relationship with little understanding of the total implications of military life. As members of the Women`s Medical Specialist Corps, they became true members of the military family, experiencing the feelings of satisfaction or frustration in assignments, housing, uniform problems, or in the many policies and regulations that mandate military life. As members of the Army, they were part of the largest military training operation in the free world.
The next forces parallel each other in effect and it is difficult to say which has primary influence on the sequence: participation in specialized professional educational programs or changes and advances in the field of medicine.
Professional educational programs afforded information on changes and advances in the field of medicine. Conversely, changes and advances in the field of medicine many times required further education for understanding of the professional activities involved. Continual emphasis was placed on attending courses or conferences that would result in improvement in care of patients, the major focus of professional medical activity.
The organizational and professional responsibilities of the physical medicine service and its five component sections were formally outlined in June 1949.1 Four types of occupational therapy were identified for use in patient treatment:2
1. Functional. Designed for patients whose disability will be directly improved by its application.
1Army Regulations No. 40-705, 16 June 1949.
2When occupational therapy was included in the reconditioning service organization, in 1944, four types of occupational therapy were available: diversional therapy, functional therapy, industrial therapy, and prevocational training.
2. Psychiatric. Designed for patients with psychiatric disability.
3. Remedial. Designed for patients whose disabilities are directly affected by their emotional state.
4. Selected. Designed for patients whose specific treatment is handicapped due to poor adjustment to hospitalization.
Occupational therapy for tuberculous and psychiatric patients was to be coordinated by the chief of the physical medicine service with the chief of those respective services. Occupational therapy for all other patients was to be prescribed by the chief of physical medicine.
The definition of the four types of occupational therapy and the coordinated supervision set forth in the regulation provided the program control and supervision believed essential at that time by the physiatrist. The names given three of the types of occupational therapy have confounded and confused all who have used them. `Functional,` `remedial,` and `selective,` terms born of expediency, are not self-explanatory. The terms `remedial` and `selective` were supplanted by the term `supportive` in some Army hospitals. Army occupational therapy was still burdened, however, by the medically obscure term `functional` occupational therapy.
By the mid-fifties, the scarcity of physiatrists resulted in the occupational therapists receiving many patient referrals directly from medical officers on the orthopedic, neurological, and medical services. Some referrals, particularly those concerned with neuromuscular conditions, still came from the physiatrist who was also available for consultation with the occupational therapist on problems encountered in the treatment of any of the patients (fig. 154).
By December 1960, physical medicine services directed by a physiatrist were to be found in only five of the seven general hospitals in the United States3 and in Tripler General Hospital, Honolulu, T.H. In the other general hospitals, station hospitals, and hospitals overseas, selection of the medical director for occupational therapy was made by the commanding officer. In the majority of cases, an orthopedic surgeon was so designated.
Continental United States
Within the period covered by this chapter, there was considerable fluctuation in the number of occupational therapy clinics in Army hospitals. Before the Korean War, there was the decrease to be expected in a peacetime period; during the war, the necessary inevitable increase; and following the war, again a decrease to meet the reduced needs of peacetime operations.
3Brooke General Hospital, Fort Sam Houston, Tex., Fitzsimons General Hospital, Denver, Colo., Letterman General Hospital, San Francisco, Calif., Madigan General Hospital, Fort Lewis, Wash., and Walter Reed General Hospital, Washington, D.C.
FIGURE 154-Col. Aniello F. Mastellone, MC, Chief, Physical Medicine Service, Fitzsimons General Hospital, Denver, Colo., checks the scapular motion of a patient in occupational therapy while 1st Lt. Virginia Barr observes.
A number of modern vertically constructed station hospitals were built during the latter half of the period covered by this chapter to replace the horizontally constructed cantonment-type buildings. Occupational therapy clinics were included in all but one of these new hospitals where the minimum capacity was at least 250 beds. The exception was Ireland Army Hospital, Fort Knox, Ky., constructed during
1956. Here, there had been no occupational therapy clinic since 1948 and the need for space was determined to be so acute by the Commanding Officer, Col. Kenneth Brewer, MC, that the area designed for occupational therapy was assigned to another service.4
In October 1956, the Surgeon, Third U.S. Army, suggested to The Surgeon General, Maj. Gen. Silas B. Hays, that occupational therapy be eliminated in Class I hospitals5 and that occupational therapy spaces be physically eliminated in the new hospitals at Fort Benning, Ga., and Fort Bragg, N.C. His suggestion was based not only on the precedent set by Ireland Army Hospital, but he questioned the need for occupational therapy in view of the type of patient treated and the relatively short hospitalization period in Class I hospitals. When General Hays replied that occupational therapy would be continued in those hospitals in which it was already established in the Third U.S. Army Area, the Third Army surgeon then suggested that the programs be restricted to bedside work and again proposed that no provision for space be made in any new hospitals or modifications of existing ones. A letter from General Hays to the Third Army surgeon, reiterated the earlier decision that space for occupational therapy clinics would continue to be provided in new hospitals and approved the authorization for one occupational therapist space each in the hospitals at Fort Benning, Fort Bragg, Fort Campbell, Ky., and Fort Jackson, S.C.6
Of great impact on the total medical rehabilitation program in Army hospitals in 1952 was an Executive order which gave to the Veterans` Administration the responsibility for hospitalization of those members or former members of the uniformed services who had chronic diseases.7 Chronic diseases were `construed to include chronic arthritis, malignancy, psychiatric or neuropsychiatric disorder, neurological disabilities, poliomyelitis with disability residuals and degenerative disease of the nervous system, severe injuries to the nervous system including quadriplegics, hemiplegics, and paraplegics, tuberculosis, blindness and deafness requiring definitive rehabilitation, major amputees, and such other disease` as might later be defined. Early medical treatment could be administered in the Army hospital until the chronicity of the disease or condition was established, then the patient would be transferred to a Veterans` Administration hospital or domiciliary.
The specific effect of this on occupational therapy was that the challenge and experience of planning and following through on a high percentage of long range and complete rehabilitation programs were removed. This lack of treatment experience throughout ensuing years resulted in some Army-trained occupational therapists leaving the ser-
4An occupational therapy clinic was established at Ireland Army Hospital, Fort Knox, Ky., in the fall of 1962.
5Hospitals under the supervision of Commanding Generals of Army Commands, not under the direct control of The Surgeon General.
6Letter, Lt. Col. Myra L. McDaniel, AMSC (OT), to Colonel Lee, 5 June 1957, subject: Information for Annual Historical Report, FY 1957, p. 3.
7Executive Order No. 10400, 27 Sept. 1952.
vice to obtain that experience in civilian hospitals and institutions. The shortened length of patient stay, however, did not negate the Army occupational therapists` professional responsibility to assess the needs of these patients, initiate treatment, or to fabricate devices to assist these patients to gain as much independence as they could while in the Army hospital.
In May 1954, as a reinforcement measure of the previously mentioned Executive order, a statement of policy regarding the utilization of physical medicine was published.8 Three provisions in that letter were particularly pertinent to occupational therapy:
a. Large comprehensive physical medicine services will be established only in Class II hospitals and in appropriate Class I hospitals that are designated as specialized treatment centers.
* * * * * * *
c. Occupational therapists will be assigned only to Class II hospitals and to Class I hospitals that are designated as specialized treatment centers in psychiatry, tuberculosis, orthopedics and/or neurosurgery.
d. A pilot study will be made at selected Army hospitals to determine the feasibility of eliminating physical reconditioning as a special branch with transfer of this responsibility to physical therapy and occupational therapy branches.9
In compliance with this policy, Class I hospitals not designated as specialized treatment centers were notified that occupational therapy clinics were to be phased out through personnel attrition.10 No occupational therapy clinics had been closed by June 1955 when the designation of Class I hospitals as specialized treatment centers was discontinued. This action made those provisions of the administrative letter which pertained to Class I specialized treatment centers obsolete. The surgeons in each Army Command were then notified by General Hays to base their requirements for occupational therapists upon existing facilities, equipment, and projected workloads.11
Occupational therapists had been assigned in the Territory of Hawaii since World War II, but it was not until 1949 that one was assigned to the 98th General Hospital in Germany, and not until 1951 that one was assigned to the 141st General Hospital in Japan. The latter assign-
8Administrative Letter No. 40-17, Office of The Surgeon General, 6 May 1954.
9(1) In 1955, physical reconditioning officers were assigned in other areas within the scope of the Medical Service Corps. Physical reconditioning enlisted personnel and activities were placed under the supervision of the chief of physical or occupational therapy depending upon the kind of treatment program that was indicated, for example, if with neuropsychiatric patients, then occupational therapy was responsible for physical reconditioning activities; if an exercise program, then physical therapy was responsible. (Summary of Major Events and Problems, The Surgeon General, to Chief of Military History, Special Staff, for fiscal year 1955.) (2) A Class II hospital is under the direct control of The Surgeon General.
10Office Memorandum, Chief, Occupational Therapy Branch, to Chief Physical Medicine Consultant, 23 June 1955, subject: 1954-1955 Historical Report (OT).
11Letter, Maj. Gen. S. B. Hays, The Surgeon General, to Brig. Gen. Crawford F. Sams, MC, Surgeon, First Army, 14 June 1955. (Identical letter sent to each Area Surgeon in the continental United States and the Military District of Washington.)
ment was terminated in 1952 because of a compassionate reason and the shortage of personnel precluded further assignments of occupational therapists to the Far East Command.
The patient load in the oversea hospitals did not differ in variety from that in the United States. In Germany, hospital centers were established for the treatment of orthopedic and neuropsychiatric patients and it was to those centers that occupational therapists were generally assigned. Both ward and clinic programs were maintained. An additional program was planned for patients with tuberculosis. Although these patients were usually evacuated to the Zone of Interior for treatment at Fitzsimons General Hospital, Denver, Colo. or Valley Forge General Hospital, Phoenixville, Pa., in accordance with the 120-day evacuation policy, occupational therapy was generally offered while they were confined to the oversea hospital. In the early fifties, a ward program designed specifically for patients with hepatitis was conducted by the occupational therapists at the 98th General Hospital in Munich.
Treatment programs overseas did not differ greatly from those used in the United States. Environmental factors in some instances in Germany, however, did affect the activities used.12 In 1955, many of the patients at the 98th General Hospital, then located in Neubrücke, were either single or did not have their families with them. They were not stimulated to make the more traditional occupational therapy projects-lamps, bookends, or rugs-which would usually be enjoyed or needed by members of their households. Not only was the stimulus for creating these projects decreased, but packing and mailing factors were criteria which affected a project`s size and weight. Too, many times, the soldier was far removed from his usual pastimes which might normally stimulate an interest and need for specific projects. The problem was further complicated in that the soldier had little or no space to keep such items in his wall locker or footlocker. To many a soldier coming directly to the hospital from field duty, making such projects appeared to be completely divergent from anything to which he had become accustomed. Many of the men were restless and did not have the patience to complete projects of their own.
With the soldiers having less motivation for the projects and activities which were usually of interest to patients in occupational therapy, projects were devised which could be worked on by a number of patients and which were used in the hospital or for the enjoyment and pleasure of other patients or hospital personnel. Examples of community projects made at the 98th General Hospital were wall hangings for the chapel and the library, picture frames for watercolor reprints hung in the ward day rooms, and the printing of table napkins for an adjacent military installation.
At the 98th General Hospital, in 1956, Col. Ernest A. Brav, MC, Chief of Orthopedic Surgery, did a series of approximately 100 cases
12Information furnished to the author by Maj. Barbara M. Knickerbocker, AMSC, 98th General Hospital. (See Major Knickerbocker`s unpublished report, `What Constitutes Treatment?`)
of Putti-Platt repairs for shoulder dislocation.13 An occupational therapy program, designed to meet the needs of these patients, was developed by Capt. Barbara Knickerbocker, chief occupational therapist.14
In medicine, new and improved drugs or new surgical procedures change the character and timespan of treatment programs. As change occurs, this is reflected in the occupational therapy programs although the treatment tools-the therapeutic relationship and the activity-remain unchanged. The focus on activity has not changed, it was and is the medium through which the occupational therapist not only works to achieve his treatment objective but also establishes the therapeutic relationship necessary to successful treatment.
Activities of Daily Living
The term `ADL` (activities of daily living) came into popular usage in the fifties. The purpose of the program in activities of daily living was to make the permanently physically limited patients as independent as possible in their daily personal activities: eating, dressing, personal hygiene, communication (writing and telephoning), handling money, and other necessary functions (fig. 155). The basic treatment concepts of this kind of program was not new. In the Army during World War II, a similar program had been used in the treatment of amputees for training them in the use of their prostheses: `Ample opportunity should be given each patient to practice with eating utensils, dressing, shaving, and such common accoutrements of living as faucets, door knobs, keys, coins, and papers.`15 Comparable programs had been carried on in civilian life for patients with brain damage and poliomyelitis.
The benefit of training in activities of daily living was that the patients were directly learning to do the self-care activities that they needed. Crafts could be used to improve coordination and to increase strength or range of motion of patients whose disabilities were of a temporary nature, but actual training in how to feed themselves, how to use what limited motion they had to dress themselves, and how to accomplish the other necessary hand activities, were essential requirements for the patients who needed assistance to regain some measure of personal independence.
The majority of patients trained in the activities of daily living programs were military, either on active or retired status. Few military
13The purpose of the Putti-Platt operation is to prevent the arm from rotating outward to its most vulnerable point for dislocation. In this surgical procedure, the subscapularis muscle is divided at one point 1 inch medially from its insertion and the lateral portion is attached to the anterior rim of the glenoid cavity of the scapula. The remaining portion is lapped over this in a double-breasted manner and sutured to tissues in the region of the greater tuberosity and the bicipital groove of the humerus.
14An occupational therapy program for patients with Putti-Platt repairs was also developed at Fitzsimons General Hospital, Denver, Colo., by Maj. Kathryn Maurice in 1951.
15War Department Technical Manual (TM) 8-291, December 1944.
FIGURE 155-Activities of daily living. (Top) Young bilateral amputee gains useful experience with the telephone. (Bottom) Use of a Montessori-type training board to teach buttoning and unbuttoning techniques.
dependents required retraining in household activities but when this was indicated, it was done primarily through simulated activity. Army occupational therapy clinics, unlike civilian rehabilitation centers, did not have the facilities for realistic practice (kitchens, beds, bathrooms) nor was there a great need for them. Some work simplification techniques could be explained and demonstrated even though much of the equipment with which homemaking worksaving techniques could be practiced was not available.
In conjunction with many of the activities of daily living programs, it was necessary to design and fabricate self-help devices since many patients, for example, those with brain or spinal cord injuries, were unable to initiate or manage an activity without the assistance of special equipment. Devices were designed for temporary or permanent use (fig. 156).
The first work therapy program to be supervised by occupational therapists since World War II was begun in 1956 at Letterman General Hospital, San Francisco, Calif.16 It was planned specifically to further the rehabilitation of convalescing neuropsychiatric patients by placing them in supervised hospital job assignments. During its first 12 months of operation, over 200 patients participated in the program. The average number of patients assigned to jobs at any given time was 36.17 This particular kind of program was used during World War II and at that time was called `industrial therapy.` Work therapy during that period implied paid employment of hospital patients on industry-type jobs (ch. IX, pp. 326-331).
Work therapy programs available for assignment of medical, surgical, and psychiatric patients were later developed at Brooke General Hospital, Fort Sam Houston, Tex., and Walter Reed General Hospital, Washington D.C., as were programs for patients with tuberculosis at Fitzsimons and Valley Forge General Hospitals.
The primary purpose of these programs was that the job assignments be of therapeutic value and of interest to the patients. The work performed was considered a by-product and secondary to the treatment aspect. It was essential, however, that there be a realistic amount of work to be done so that the patients would get job satisfaction from real accomplishment (fig. 157). The programs provided a method of accurately determining the physical tolerance and social adjustability of the patients and their capacity to work with or overcome a physical disability or mental illness. The occupational therapist in charge of the
16In 1949, a representative of the Neuropsychiatric Consultants Division, Surgeon General`s Office, had recommended that industrial therapy programs for neuropsychiatric patients be established in Army hospitals. The recommendation was never approved because of the shortage of occupational therapists. (Disposition Form, Chief, NP Service (Lt. Col. E. R. Inwood, MC). [Walter Reed General Hospital], to Chief, Physical Medicine, [Surgeon General`s Office], 10 Nov. 1949, subject: Industrial Therapy, with attached correspondence.)
17Sheehan, H. J., and Viesko, B.: Work Therapy in an Army Hospital. Am. J. Occup. Therapy 12: 176, 188-189, July-August 1958.
FIGURE 156-Splints and devices used in activities of daily living. (Top) Plastic opponens splint maintains thumb in functional position for activity. (Bottom) Self-help device enables patient to brush teeth. Hand device can also be adapted for fork or spoon insertion so that patients can eat more independently.
work therapy program periodically conferred with the patients and job supervisors. His report on the patient`s progress in these reality testing situations included not only comments on the patient`s emotional reactions but also gave evidence as to the patient`s success in meeting the physical and social demands of the job. The report was available to the medical officer to use in the evaluation of the patients for disposition from the hospital.
The treatment of neuromuscular dysfunction had remained a fairly routine procedure until new methods for treating neuromuscular dysfunction were developed by Herman Kabat, M.D., Margaret Knott, R.P.T., Karel Bobath, M.D., Berta Bobath, F.C.S.P., Margaret Rood, O.T.R., R.P.T., and Signe Brunnstrom, P.T.18 Although each proposed a different and specific method of treatment, these could be and were used in combination to obtain a treatment objective. For example, the exterostimulation concept of Rood (the stroking, brushing, pound-
18(1) See ch. XVII, section on brain injuries for brief description of treatment concept. (2) R.P.T., Registered Physical Therapist; F.C.S.P., Fellow Chartered Society of Physiotherapy; O.T.R., Occupational Therapist Registered; P.T., Physical Therapist.
ing, or application of ice to the affected part) could be used by the occupational therapist to facilitate motion and could be followed by work on a wood project using the heavy resistance techniques developed by Kabat.
These new methods were not routinely used by all Army occupational therapists but were used for selected patients with neuromuscular disorders. Statistical data concerning the treatment of these selected patients were not accumulated. This clouded immediate or complete acceptance of the new methods. Without factual case report substantiation there could be no basis for assuming that the new methods would prove more beneficial to the patients than the old. The methods were complicated involving precise techniques and were neither easily nor quickly learned.
The challenge to learn the different techniques was met through participation in special courses, specific workshops sponsored by local physical and occupational therapy associations, or through staff in service educational programs given by a physical or occupational therapist who had attended one of the special courses.
To avoid repetition of specialized treatment program material presented previously (ch. IX, p. 287), the treatment of specific conditions which follows will be concerned only with those conditions or disorders in which change or addition to the treatment program was noted. One diagnostic entity-poliomyelitis-was virtually eliminated after 1956 following the successful development and use of the Salk vaccine. Because of the crippling nature of poliomyelitis, very carefully planned and supervised treatment programs had been necessary. These programs were conducted at Army general hospitals by occupational and physical therapists who had received specialized training at the Georgia Warm Springs Foundation, Warm Springs, Ga.
Spurred by the need of the Army to supply prostheses for the large number of soldiers who suffered amputation of one or more limbs in World War II, early in the spring of 1945 the National Academy of Sciences began a research program devoted to the development of prostheses. Initially, it had been believed that the solution to this problem was simply to devise better mechanisms and apply new materials. It was soon realized that fundamental biomechanical studies were essential if realistic design criteria were to be developed. The responsibility for the studies was assigned to the University of California which established two laboratories, one for the study of the upper extremity on the Berkeley campus, and one for the study of the lower extremity on the Los Angeles campus. In 1948, an independent evaluation laboratory was established at New York University to test the
usefulness of the devices and techniques which were being developed.
By 1952, sufficient knowledge regarding upper extremity prosthetic appliances had been accumulated to radically change previous concepts of management of the arm amputee. In general, amputations instead of being performed in certain selected sites could be done at any level because suitable devices and control techniques had been developed to fit every level of amputation. In previous years, improvements in prosthetic fittings many times had not kept pace with improvements in surgical techniques. New knowledge concerning the functions of the extremities was accumulated from the research program. In order to transmit this knowledge to clinic teams, short-term courses were established for physicians, occupational and physical therapists, and prosthetists.19
The concept of the clinic team was not new,20 but the education of teams through special courses was. The more thorough understanding of each team member`s role and function resulted in a much closer relationship between the physician, the physical therapist, the occupational therapist, and the prosthetist and improved care for the amputee.
As during World War II, the occupational therapist continued to do the checkout of the upper extremity prosthesis and to provide activities for the amputee which would aid him in achieving skill and dexterity in the activities of daily living in addition to retraining him in other skills which would be essential to his job. While the majority of the amputee patient load was military, there were some congenital cases treated by occupational therapists.
In the late forties, interest in the kineplasty amputation was revived. This surgical procedure, conceived in 1896, had alternating periods of popularity and disfavor.21 A study to determine the value of the kineplasty procedure was conducted at Walter Reed Army Medical Center, Washington, D.C., over a 6-year period, 1948 through 1953,22 by members of the Orthopedic Service (Colonel Brav, Col. August W. Spittler, MC, Lt. Col. William F. MacDonald, MC, and Maj. George H. Woodard, MC), the Physical Medicine Service (Col. Harold B. Luscombe, MC, Col. John H. Kuitert, MC, and Maj. Frederick E. Vultee, Jr., MC), and the Army Prosthetics Research Laboratory (Lt. Col. Maurice J. Fletcher, MSC, and Fred Leonard, Ph. D.).
The candidate for the kineplasty procedure was given a conventional prosthesis for a 6-week trial period before the kineplasty was performed. The occupational therapist instructed him in its control and trained him in its proper use to develop maximum skill in prehension. Since there was little difference between the kineplastic prosthesis and the
19University of California, Los Angeles, Calif.; New York University, New York, N.Y.; and Northwestern University, Chicago, Ill.
20See footnote 15, p. 573. `The surgeon, the limb manufacturer, the limb fitter, the occupational therapist, the physical therapist, and the amputee, are all combining their knowledge, experience and resourcefulness to discover and develop new methods and improve appliances for the amputee` (p. 30).
21The kineplasty procedure is described in chapter XVII, p. 551.
22Brav, E. A., et al.: Kineplasty; An End-Result Study. J. Bone & Joint Surg. 39-A: 59-76, January 1957.
conventional device, it was believed the 6-week trial period was worthwhile.23 Having been trained in the use of the conventional prosthesis, it was found that the patient rapidly learned to use the kineplastic controls and in most cases only a few additional days of training were required.
The criterion for success of the procedure was whether or not the patient was wearing his prosthesis at the end of a year or more. The results of the study showed that 61.7 percent of the patients had worn their prostheses for that period. The percentage within the kineplasty groups were: biceps kineplasty, 73.1 and pectoral kineplasty, 31.0 (fig. 158). In general, the authors of the study believed that kineplasty operations would be applicable to only a relatively small percentage of arm amputees and should be limited to carefully selected patients. It was not advised for amputee patients before adolescence and was found usually not cosmetically acceptable to women.
In the early fifties, the Physical Medicine Service at Letterman General Hospital made a study of the patterns of motor recovery in 70 brain-injured patients.24 Four levels of motor recovery were determined (these were ranked from low to high level): gross extremity synergy, restored phasic activity at second joints, restored distal muscle function, and restored fixator function of proximal muscles.
The use of occupational therapy during the early levels of the recovery cycle was definitely contraindicated as `Muscle retraining * * * was directed exclusively toward restoration of the flexor groups in the leg and of the extensor groups in the arm. In the arm, all stimuli which were found to excite increased activity in the flexor muscles therefore were rigidly excluded.`25
Occupational therapy was introduced into the program during the third level of recovery-the restoration of distal muscle function. As discussed by those participating in the study at Letterman General Hospital-
* * * patients had to be trained to perform extension and abduction movements of individual digits. When they had mastered this ability, many still had difficulty in using the hand for skilled activities because of an inability to perform rapid alternations in movement, or because of persistent impairment of joint sensibility. We found that occupational therapy had most to offer as a means of overcoming these deficits. Because of the delayed return in supinator function and also in the fixator muscles of the proximal extremity, the occupational therapist was always particular about prior fixation of the arm at the shoulder and elbow. Hence, no activity was recommended which demanded the use of the arm in an unsupported position. The occupational therapist was also
23If, at the end of that trial period, the candidate preferred the conventional prosthesis-the kineplasty procedure was not performed. The patient was never persuaded to accept kineplasty nor was kineplasty performed if the team felt it inadvisable.
24Treanor, W. J., and Psaki, R. C.: Patterns of Restitution of Motor Function. Phys. Therapy Rev. 34: 610-617, December 1954.
25Treanor, W. J., Cole, O. M., and Dabato, R.: Selective Reeducation and the Use of Assistive Devices. Phys. Therapy Rev. 34: 620, December 1954.
careful to exclude hand activities, such as squeezing rubber balls and handling doorknobs, which further accentuated earlier return in finger flexors. Patients were instructed in methods of using the less involved hand for strengthening of finger and thumb extension on the more involved side.26
Enthusiasm and interest in this particular program of selective muscle re-education decreased abruptly when the initiators of the study left Letterman General Hospital. At this same time, however, increased understanding of the purpose and use of the different facilitation techniques gave new impetus to the programs for the brain-injured patients in the Army general hospital.
The occupational therapist who specialized in the treatment of psychiatric patients saw two major changes occur in the patient population of this group in Army hospitals during the years covered by this chapter. One change was in the drastic reduction in numbers and in the type of open ward patients. Those hospitalized for psychoneurosis, emotional incapability reactions, and character behavior disorders were replaced by closed ward patients convalescing from psychoses and other affective disorders. The other change was noticeable in the closed ward patient group as chemotherapy gradually replaced the extensive use of the somatic therapies (electroshock therapy or insulin shock therapy). Patients become more responsive to environmental influences and more accessible to therapeutic endeavor.
The decrease in the numbers of open ward patients was directly attributable to the work of the psychiatric staffs in the mental hygiene facilities located on Army posts which had large troop populations. The psychiatrists treated the soldier on an outpatient basis in the soldier`s own unit area. This early recognition and prompt management of emotional and behavioral problems served to reduce noneffectiveness and afforded the unit more understanding and thus better management of the soldier. Hospitalization, looked upon by the soldier as a secondary gain and a means of removal from a difficult situation, was limited essentially to soldiers requiring closed ward care. The patients with psychoses constituted the major mental health problem in the military hospital.
In the middle forties, treatment principles were established for the different diagnostic conditions. Specific kinds of activities were delineated by means of which the reduction of gross symptomatology might be achieved. By 1950, the concept of a total push program had become firmly entrenched within the departments of neuropsychiatry in Army general hospitals. By the wards and on the hour, patients were escorted to the occupational therapy clinic, the physical reconditioning gymnasium or pool, or the Red Cross recreational hall or dayroom. On the next hour, the groups were shifted to another activity. The prevailing
26Ibid., p. 623.
concept seemed to be that every closed ward patient should be given the opportunity to go to the occupational therapy clinic. `Work has long been recognized as a useful means of diverting the mind from its troubles and anxieties. Occupational therapy employs this age-old concept in the treatment of nervous and mental disorders.`27
In the late fifties, interest in acquiring a dynamic orientation and renewed recognition of the significance of the therapeutic relationship influenced the occupational therapists` thinking about the use of the traditional modalities. The activity per se tended to lose some of its importance and became more of a basis for bridging or developing the therapeutic relationship (fig. 159). Less project planning was done for the patient. Emphasis was placed on the significant verbal and nonverbal interactions of the patient. More concern was focused on understanding why and how the patient did or did not participate. However, when there were heavy caseloads (30 or more patients per occupational therapist) patient-therapist interactions were diminished, and the resultant observations were inclined to be superficial and thus of little use to the patient`s psychiatrist. The limitation of the hourly schedule provided little opportunity to work with the withdrawn and
27See footnote 15, p. 573
uncommunicative patient. The demanding patient was usually successful in gaining the occupational therapist`s full attention.
Few occupational therapists had the opportunity to limit the size of the patient groups with whom they were working in order to realize the maximum capability of the staff and to utilize working areas most effectively. With groups scheduled every hour, it was also extremely difficult for the occupational therapists to arrange time for conferences or discussion of patients. To combat this problem, occupational therapists, in some instances, were assigned to certain wards or psychiatrists with the responsibility of attending ward rounds, intake conferences, and presenting verbal or written progress notes on those patients as required. In this way, better continuity was maintained in observing and reporting on patient attitudes and behavior.
In 1956, a milieu therapy28 ward was opened at Walter Reed General Hospital to explore the possibilities for more effective treatment of schizophrenia in young military personnel.29 The number of patients was limited to 10 in order to afford a maximum opportunity to increase their abilities to form satisfactory relationships and to provide experiences in group living which would increase their social skills. A similar program was established at Valley Forge General Hospital in 1959.
Occupational therapy, utilized with the milieu therapy program in a 1-hour daily clinic program, provided an opportunity in which the occupational therapists could work closely with the patient as well as with the psychiatric team. At the weekly staff conferences, attended by the entire staff concerned with the milieu therapy project, the occupational therapist reported on patients` behavior while in the clinic.30 Written reports were also submitted, and these, together with reports prepared by the psychiatric nurse and the neuropsychiatric technicians, provided the psychiatrist with a complete report of each patient`s behavior in the different environmental elements in which he was observed.
During World War I and in the years that followed, tuberculosis was the cause of a tremendous loss of manpower to the Army and of enormous expense to the country in terms of disability pensions and hospital care. In World War II, careful screening before induction greatly reduced the manpower losses due to tuberculosis, but treatment of the disease was never satisfactory. The relapse rate after any therapeutic method was so high that it was not practical to return the afflicted soldiers to military duty. All patients with active disease were therefore permanently separated or retired from service.
28`Milieu therapy in psychiatry refers to procedures directed toward modification of the environmental part of the patient-environment process with a view to facilitating more satisfactory patterns of interaction-that is, transactions or relationships-in this process. It thus includes all of the field of psychiatric therapy outside of those methods designed to modify the functions of the patient otherwise than through communication broadly conceived.` (Rioch, D. McK., and Stanton, A. H.: Milieu Therapy. A. Res. Nerv. & Ment. Dis. Proc.: 31: 94, 1953.)
29Artiss, K. L., et al.: The Symptom as Communication in Schizophrenia. New York: Grune & Strattan, Inc., 1959.
30Rodeman, Charlotte R.: The Nursing Service in Milieu Therapy. Washington: U.S. Government Printing Office, 1960, p. 18.
Over the past 10 years, this situation has completely altered. With the introduction of specific drug therapy and the development of new surgical techniques, it has become possible to treat successfully and to return to active duty more than 90 percent of well-trained, career-motivated soldiers either immediately after treatment or after temporary retirement. In more than 3,000 military patients treated in this manner, the relapse rate has been less than 2 percent, with a resultant savings to the Government of more than a million dollars annually.31
Occupational therapy programs for the treatment of the tuberculous patient underwent radical change in the period from 1947 to 1961. This change was predicated on the medical advancements in the development and increased use of chemotherapy. Early in this period, all treatment was based on an ultraconservative regimen of bed rest. This was in abrupt contrast to the total ambulation and activity policies upon which treatment was based in the late fifties.
Occupational therapy changed from a limited, carefully graded program to an early active ambulation program with virtually no limitation except for Class I patients32 in the use of occupational therapy activities. Instead of developing the patient`s work tolerance during the later stages of rehabilitation, the change in emphasis was to maintain work tolerance and muscle tone throughout hospitalization.
Policies were changed to permit patients with positive sputums to attend occupational therapy clinics in contrast to their former restriction to ward programs necessitated by their prolonged confinement in bed (fig. 160). In a daily clinic program, the occupational therapist could help the patient over a much longer period of time than was possible in a ward program. In a 1958 survey made of the ward programs for tuberculous patients at Valley Forge General Hospital, it was estimated that the occupational therapist was able to spend an average of 5 minutes with each ward patient twice a week.
A 1960 report on 105 tuberculous patients treated at Fitzsimons General Hospital dramatically illustrates the benefits accruing from a combined program of chemotherapy, graduated active physical rehabilitation, and reconditioning.33 Of the 105 patients so treated, 100 were returned to full military duty. The average duration of hospitalization was 12 months.
The program at Fitzsimons General Hospital is described as follows:34
Within two to four weeks of admission, following initial workup and institution of chemotherapy, patients were started on regular occupational therapy and educational programs. In addition, when asymptomatic, they were expected to participate in active calisthenics for fifteen minutes per day on a five-day
31Annual Report of The Surgeon General, U.S. Army, Fiscal Year 1960, Washington: U.S. Government Printing Office, 1961, pp. 14-15.
32For definition of classifications, see Diagnostic Standards and Classifications, 1940 and 1950 Editions, National Tuberculosis Association, New York, N.Y.
33Weir, J. A., Schless, J. M., O`Connor, L. E., and Weiser, O. L.: Results on 105 Tuberculosis Patients at Fitzsimons General Hospital Treated With More Adequate Combined Chemotherapy and Active Physical Rehabilitation. In Transactions of the 19th Conference on the Chemotherapy of Tuberculosis, 8-11 Feb. 1960, pp. 78-84.
34Ibid., p. 79.
FIGURE 160-Occupational therapy with pulmonary tuberculosis patients. (Top) Leatherworking and metalworking supervised by Capt. Eileen O`Brien are but a few of the activities available to tuberculous patients, Fitzsimons General Hospital, Denver, Colo. (Bottom) Furniture upholstery activities benefit both the patient and the hospital, Valley Forge General Hospital, Phoenixville, Pa.
week basis. This was usually started in from two to four weeks of admission as above, but occasionally in patients with far advanced disease and large cavities the active calisthenics were not started until the end of two months although in others in the same category, particularly later in the program, these were introduced initially. The calisthenics were at about the level of activity given to regular troops during their basic training period. Rest periods for these patients were eliminated and maintenance of bedside and ward areas were accomplished by the patients. When the patients reached the non-communicable stage, without regard to X-ray change, active sports were added to the program, including basketball, volley ball, golf, bowling, and swimming. A minimum of one hour per day for five days a week was required. However, in practice, due to patient enthusiasm, most patients received about two hours a day of active, competitive sports. In addition at the time the non-communicable stage was reached on-the-job training was added to the program; the patient being given a job on the post commensurate with his skills and training. He was then gainfully employed on a full eight-hour-a-day schedule for several months prior to his discharge. Previously prolonged periods of convalescent leave were discontinued and patients returned to active duty status at about the time they reached the point of inactivity by National Tuberculosis Association Standards, with chemotherapy being continued under medical supervision for several months afterwards.
At Fitzsimons General Hospital, assignment to the work therapy program was made by the occupational therapist.35 At Valley Forge General Hospital, work assignments were made by the supervisory personnel of the Medical Holding Detachment. In both hospitals, the calisthenics and sports programs were conducted by physical reconditioning specialists under the administrative supervision of the occupational therapist.
In addition to following a rehabilitation program very similar in concept to that of Fitzsimons General Hospital, the occupational therapists at Valley Forge General Hospital from 1958 to 1960 stressed the use of group activities as a means of meeting the adjustment problems of the tuberculous men and women patients (fig. 161).36 These group activities were planned not only to develop group cohesion through experiences in working and learning together, but also to have the group assume the myriad responsibilities involved in the conduct of the activities. Thus, if it were a style show or an exhibit of patient-made articles or a program of craft demonstrations by individual patients, the patients organized and conducted the programs. The occupational therapist was either directive or nondirective as needed for the particular situation, but in all instances, provided a receptive, flexible environment in which social interaction could take place. It was repeatedly demonstrated that the group activity approach was exceedingly beneficial to tuberculous patients as it encouraged interest and concern in others, thus negating depression and introspection and
35Nachod, E. M., and Viesko, B. J.: Rehabilitation of the Tuberculosis Patient in an Army Hospital. In Proceedings of the 1960 Annual Conference, American Occupational Therapy Association, New York, N.Y., p. 59.
36Knickerbocker, B. M.: Group Activities for Tuberculous Patients. In Proceedings of the 1960 Annual Conference, American Occupational Therapy Association, New York, N.Y., pp. 25-28.
aided the patients in regaining self-confidence and assurance in themselves and their abilities.37
In order to assure the highest caliber of medical care for patients, it is essential that the professional staff be exposed to continuous education in their own specialty area and in the areas of medicine with which they are allied. A survey of Army occupational therapy inservice educational programs from 1947 to 1961 revealed that in general a wide variety of learning experiences was made available to both officer and enlisted personnel.38 These experiences included both formal and informal clinic staff meetings at which new trends in medicine or technical procedures were discussed by physicians, members of allied professional fields, or staff members who had recently attended workshops or special courses of study. Staff meetings as a rule were reported as being a medium for the relay of information concerning hospital or
37Ibid., pp. 26-28.
38Survey conducted by the author and directed to chiefs of occupational therapy clinics during 1947-61.
department policies and procedures. Some departments rotated the responsibility for staff meetings among the occupational therapy staff who were free to present a program of their choice and invite guest speakers if they so desired.
One particular kind of meeting-reported by several hospitals-was one in which the occupational therapist and enlisted specialists in a clinic would participate in a daily review of the patients` treatment progress. The occupational therapist in charge of the particular clinic program usually led the discussion. This review covered the purpose of the treatment, the physical and emotional status of the patient, the type of activity, and anticipated changes which might have to be made. It not only provided learning opportunities for the staff, but it also afforded experience in organizing and presenting succinct capsulated information and opportunity to point up the similarities in concepts and procedures in the treatment programs. During these review periods, discussion of ideas and procedures learned from treatment of other patients added depth to the learning experience.
Two programs differed from the general type of inservice training programs: the use-of-self program at Walter Reed General Hospital and the emergency medical care program at Valley Forge General Hospital.
The purpose of the use-of-self program was two-fold: `to investigate the kinds of knowledge most useful to the occupational therapist in his relationship with patients` and `how best to help the occupational therapist become more aware of and better able to use this knowledge.`39 A 1-hour weekly period was allotted to the program which all of the occupational therapists attended. Following several periods in which little progress was visible, a psychiatrist was asked to join the group (9 to 13 members) and act as leader. Later, an anthropologist, an enlisted technician, was invited to join the group and act as observer. At first, the psychiatrist gave formal presentations on patient relationships which were followed by group discussion. This was unsuccessful as the group appeared unwilling to orally relate his presentation with incidences of their own interactions with patients. Case presentations were then tried. These, too, were unsuccessful as they resulted in a one-to-one communication between the psychiatrist and the occupational therapist presenting the case. Role playing was used during one session and while it was considered enjoyable (by those observing), it was thought not to provide the kind of learning experience needed by members of the group.
Finally, tapes were made of the initial interviews of patients by the occupational therapists. These provided the most useful approach to the study of the therapeutic use of self because they afforded a focus for general discussion and could be replayed for verification of `hearing` or clarification of points under discussion. Tapes were made on medical and surgical patient interviews only. The program terminated
39Robinson, R. A., Aronson, J. A., and Polgar, S.: The Use of Self in Occupational Therapy; An On-the-Job Training Program. Am. J. Occup. Therapy 14: 288-291, November-December 1960.
in 1959 (the psychiatrist and anthropologist left the Army) before neuropsychiatric patient interviews were taped. The tapes were limited in number because of the occupational therapists` reluctance to record.
As time went on, the goals of the group became more explicit. These were that the occupational therapist should be more perceptive of what the patient is communicating both verbally and non-verbally and of his own feelings and attitudes and their effect on his relationship with the patient. This involves a greater awareness of the reasons behind both the patient`s behavior and the therapist`s responses.40
The use-of-self program was successful in that the group achieved a better understanding of themselves and their relationships with patients.
Many Army occupational therapists participated in programs on emergency medical care but the most intensive one was that reported for 1958 and 1959 from Valley Forge General Hospital by Maj. Mabel E. Hampton,41 chief occupational therapist. The 1958 program totaled 120 hours of which 80 hours were in the applicatory training phase in the operating room, recovery ward, obstetrical ward, central materiel, and in the cast room. In the event a delivery was not observed during training in the obstetrical ward, the occupational therapist was placed on call until this deficit was made up. The 1959 course, in essence a refresher course, totaled 58 hours with 18 hours of lecture and 40 hours of practical training.
The purpose of emergency medical care training was to prepare the occupational therapist to serve in the role of nursing assistant in disaster situations.42 Attainment of proficiency in this role was the goal. The occupational therapists had already had lectures and demonstrations in first aid and in the short 12-hour course on `Essentials of Emergency Medical Care,` but it was firmly believed by Army Medical Specialist Corps Officers in the Surgeon General`s Office that lectures and demonstrations were ineffective unless adequate practical training was included. The Valley Forge General Hospital programs proved that it was possible to obtain an acceptable minimal proficiency preparation through an inservice educational program.
1st Lt. (later Capt.) Mary A. Reilly and Maj. Pauline Bettinger, in addition to their other duties in the Surgeon General`s Office, served as technical advisers for professional films on occupational therapy. Lieutenant Reilly`s specific responsibility centered on three films `Time Out,` `Problems of Motion,` and `Journey to Reality` which were
40Ibid., p. 291.
41Formerly Maj. Mabel Eisele.
42McDaniel, M. L.: The Role of the Occupational Therapist in Natural Disaster Situations. Am. J. Occup. Therapy 14: 195-198, July-August 1960.
released in 1950.43 `Time Out` was selected for exhibit in the Realistic Documentary Experimental Class at the Fourth International Film Festival held in Edinburgh, Scotland, in 1950, and a certificate was received by the Signal Corps in evidence of this recognition. In 1952, Major Bettinger was adviser on the production of the film `Introduction to Occupational Therapy.` Footage was taken from the other three films to make a 28-minute film.44 A filmstrip entitled `Spontaneous Drawings and Paintings by Neuropsychiatric Patients` was completed in March 1954.45
The films and filmstrip served many useful purposes. They were used not only in the Army program to orient occupational therapy students and enlisted technicians to practice and procedure in three of the major fields in the profession but were frequently borrowed by civilian schools, affiliated centers, and state occupational therapy associations to augment lectures and demonstrations to their groups. Whether these films were an aid to procurement of students or occupational therapists is unknown, but they did publicize the role and function of occupational therapy in the Army Medical Service.
`Journey to Reality` was used to orient each class of neuropsychiatric technicians in their course of instruction at the Medical Field Service School, Fort Sam Houston, Tex. It was of particular value as it assisted in giving them a more complete understanding of the total treatment program in which their patients would be involved. `Time Out,` which depicted the occupational therapy program of tuberculous patients, was also used to inform patients of the purpose and restrictions of the program.
The technical manual on occupational therapy, originally published in December 1944, was revised and reissued in September 1951.46 The early edition contained the organization and administration of occupational therapy under the reconditioning service, whereas the later edition reflects the organizational pattern under the physical medicine service. These manuals are a permanent record of the doctrine and practice of the period in which they were written and a comparison of the contents of the manuals shows the changes in trends and philosophy of treatment in Army occupational therapy.
43PMF 5116-A, Time Out (treatment of tuberculosis patients); PMF 5116-B, Problems of Motion (treatment of physical disability patients); and PMF 5116-C, Journey to Reality (treatment of psychiatric patients).
44PMF 5227, Introduction to Occupational Therapy.
45FS 8-172, Spontaneous Drawings and Paintings by Neuropsychiatric Patients.
46War Department Technical Manual (TM) 8-291, September 1951. The third revision was issued in May 1962.