PHYSIOTHERAPY AND THE ORTHOP~DIC PATIENTlBy G. G MCCLOSKEY, F.R.C.S. (Eng.), F.R.A.C.S.,

and MISS CASA N:CLIA

Mr. McClosl<ey comlnenced his lectureby explaIning th~t the title of his addressencompassed a field too vast to cover inthe time at hIs disposal that night, so hehad selected a few cases of interest, inwhich routine physiotherapeutic measureshad played a major part in the treatlnent.

No new procedures were to be demon­strated but the pathological features of thecases were to be discussed and the l11annerin which these can be relieved by routinephysiotherapeutic procedures.

1 A combined lecture-demonstratIon to membersof the VIctorIan Branch of the AustralIan Physio­therapy AssocIation

The first case was a torn medial meniSCUSof the knee joint. Miss Casanelia presentedthe patient and stated that her main reasonfor introducing Mr. R. first was because hewas what she called a "physiotherapIst'sdelight". He was a copy-book example ofthe condition, and his treatment wentexactly according to the book. His progresswas quite uneventful but the speed wasremarkable. Though he had absolutely nopre-operative training he began staticquadriceps exercises immediately post­operatively and soon had full extension andcould take heavy resistance after removalof the sutures. He obtained ahnost full

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flexIon within two days, without anyapparent discomfort, when weight bearingwas begun. This was begun gently but therewas ~tI1~ no sign of pain or swelling, andso wlthln five days the patient could runup and down stairs.

Miss Casanelia then explained that apatIent with either wasted quadriceps or aswollen knee has great difficulty in feelingthe action of trying to lock the knee, sothe exercise given for knock-knees is agood one, as the patient can really feel itwork on the medial side of the joint ..

Mr. McCloskey then commented on theinterval of time that had elapsed betweenthe original injury and the patient's firstattendance. This long delay in receivingeffective treatment is COmITIOn, and duringthis time the tOfn cartilage lies foldedbetween the articular surfaces, slowlyabrading them. As the knee was alreadyosteoarthritic, this trauma aggravated thearthritis, thereby seriously affecting theultilnate prognosis. The future of thisman's knee depends on the nature of thephysiotherapeutic care that he receives. Ifhis quadriceps are kept fully developed, byrepeated courses of physiotherapy, hisprognosis will be reasonably good.

The lay public regard meniscectomy withgrave suspicion, as they associate it withsubsequent weakness and stiffness of theknee. Provided that there are no technicalerrors at operation, the bad results thathave earned this operation its unfortunatereputatIon are due either to dal11age to theknee prIor to the operation, resulting insubsequent osteoarthritis, or to inadequateand lrefficient post-operative physiotherapy.

An example of the type of case thatdrifts into this unsatisfactory result wasdescribed. This patient tore his left medial111eniscus at work, and on the advice of hisworkl11ates he immediately consulted anosteopath. Over the next""' few weeks hislocked knee was manipulated three times,but the locking kept recurring" As thefinal locking occurred on a Saturday after­noon, the services of the osteopath weren01 available, so the advice of a physio­therapIst was sought, who, recognizing thegravIt)T of the condition, referred thepatient for imlnediate medical advice. Theknee vvas glossIy swollen and irritated The

irritation was allowed to subside with bedrest and then the knee was operated upon.The cartilage was found to be torn in thetypical bucket handle luanner with thegreater part of the cartilage displaced intothe centre of the joint, locking it. A largehole was present in the articular cartilageof the medial femoral condyle, caused bythe manipulations.

The next case was one of different path­ology. On December I, I955, the patienttwisted his right knee at work and there­after It slowly became sore, swollen, tense,and warm. A diagnosis of Infective arthritiswas made and the patient admitted to hos­pital for investigation. Although thesynovial fluid was full of pus cells, repeatedcultures failed to grow an organism. Anarthrotomy was performed and the JOIntfound to have the appearances charac­teristic of chronic inflaml11ation.. Micro­scopic examination of the synovial lnem­brane showed the presence of chronic non­specific infective arthritis.

But having Inade thIS diagnosis, thetreatment was still in question. Mr"McCloskey considers that this condition isso like tuberculosis that, for practical pur­poses, one can treat it as such. Thereforethe basic principles of the treatment ofjoint tuberculosis were applied, viz. :(i) chemotherapy for 6-12 months, (ii) resttill quiescent, (iii) progressive mobIlizationthereafter. The chemotherapy consisted ofP.A"S. and isoniazid, streptomycIn beingreserved to cover any possible surgicalinterventIon. Thus the unfortunate patientswallowed 30 tablets a day for six months­SOBle 5500 tablets in all.

Complete bed rest, With the right kneeIn a plaster cast, was given till the jointwas quiescent; then the plaster was replacedby a caliper, permitting progressive mobi­lization of the knee.

Miss Casaneha then descrIbed Mr. C., aUlan to whon1 exercises were entirelyforeign, and stated that the good result hehas today was entirely due to his own hardwork. After the long period of immobiliza­tion the right quadriceps was very wasted,so, for the first two months, treatment con­sisted of hard work to the right quadricepsmuscle until its strength was almost equalto that of the left leg The patient was

PHYSIOTHERAPY AND THE ORTHOP~DIC PATIENT 99

then allowed up in a caliper and mobiliza­tion began. This was begun gently, watch­ing carefully for any sign of actIvation ofthe dIsease. The first 70° came quicklyand progress then continued at the rate of2-3 0 per week. Unhke the mobihzation ofa fracture where care has to be taken notto apply pressure over weakened areas,gentle even pressure was used to advantagein this case, care being taken to keep withinthe limit of pain. FaIrly strong assistancewas given by the left leg in sIttIng andprone lying. When discharged the patIenthad a strong knee, with I I I 0 flexion, whichwas useful enough for him to return to thenot so easy task of driving a bus.

The next case was presented for tworeasons: firstly, because it was by patIent,painstaking physiotherapy that the patienthad been rendered fit for operatIon, andsecondly, as an exal11ple of Sudeck's atrophy.

X-ray films were shown demonstratingosteoarthritis of the ankle joint, with per­sistent subluxation, and the decalcificationcharacterIstic of Sudeck's atrophy.

With these lesions an arthrodesis of theankle was inevitable, but could not be donewhIlst the foot and tarsus were so stiff. Sothe patient was referred to Miss Casaneliafor mobilization of hIS rigid foot andstrengthening of the fallen longitudinaland transverse arches. The dropping ofthe longitudinal arch was due to outwardrotation of the foot, a habit developed bythe patient to relieve his pain and to enablehim to walk more quickly, as his weightwas thus taken off the heads of the meta­tarsals, which, due to the fallen transversearch, were resting on the ground. Mobi­lizing exerCises and foot manipulationswere given untIl there was good movementat the tala-calcaneal Joint, the lnid-tarsalJoints, and JOInts of the toes.. Thus, whenthe arthrodesis is performed, the patientwill have a fairly moblie foot, to simulatethe movements lost at the ankle joint.Intensive exercise for the intrinsic musclesof the feet and the muscles producinginversion of the foot were practised forsome months..

Sudeck's post-traumatic bone atrophyoccurs in the hands and feet. It may com­plicate trivial as well as severe jointinjuries. There is pain, complete loss of

function, swelling, marked decalcrficationof the bones, atrophy of the subcutaneoustissues, and tropIC changes In the skInHowever, thIS syndrome differs in degreeonly froill the ordindry dIsuse changes fol­lowing injury If exerCIses are neglected. ItIS believed that this condItIon occurs onlyas a result of neglected dIsuse changes. Itis therefore a direct challenge to the physIo­therapist, both to prevent It and to cure It.

Then followed two cases IllustratingSOine of the manIfestatIons of intervertebraldisc degeneration in the cervical spine.

During recent years, cervical disc lesionsand degenerative spondylosis have come tobe recognIzed as frequent causes of cer­vical and brachial neuralgia. These respondwell to either neck immobilization orstretching. Although the condition is veryCOlnman, the underlying cause is very fre­quently overlooked and the appropriatetreatment is not gIven.

The patient whose trouble is localtzedto the upper cervical spine complains ofattacks of excruciating pain in the back ofthe head, of sudden onset and aggravatedby movement of the neck. The pain isoften incapacItating.

When the trouble is localized in the lowercervical spine, pain, parcesthesia, pins andneedles, and tinglIng, are experienced III theshoulder, arm, or hand. Mild cases of thisare very comnlon indeed, occurring at night,during the winter months, and disappearingduring the day and during the warmweather. These cases respond most satis­factorily to cervical traction, manipulation,and exercises.

Occasionally one sees a severe brachialneuralgia, causing severe incapacity. Thesecond case presented was such a case. Thefirst case was one of cervical neuralgia dueto a cervical spondylosis, and treatmentconsisted of physiotherapy, i.e., heat, mas­sage, and remedial exercise, plus cervicaltraction. Heat and massage were givenmainly to lull the patient into a "false senseof security" before applying the cervicaltraction, which can be given in severalways. A Sayers sling can be used but isnot always practical; or the patient can beplaced with his head over the side of a bed,someone holding his shoulders and applyingcounteraction; or the patient can sit in a

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chair, an upward pull being exerted on hishead, using the weight of his body ascountertraction. Manipulation of the neckand remedial exercises usually produce agood result in this condition.

The next subject discussed was that oflow back pain, one of the commonest andmost perplexing symptolTIS encountered inmedical practice. Because it is dnly in asmall proportion of the patients so afflictedthat any pathological basIs can be found,<etiology is largely speculative and treat­Inent IS ernpirica1. The majority of patientswIth low back pain are characterized byhaving little variety in their symptoms, nospecific physical signs, equivocal X-rayappearances, and negligible pathologicalfindings.

Mr. McCloskey said that he had nodesire to add to the depressing complexityof this subject but, on the contrary, believedthat the patient's interests were best servedby taking as simple a view of the conditionas possible. It is a well-known fact thatour parents suffered from lumbago, that itwas a subject of music hall jokes, and thatthey recovered without undue incapacita­tion. But today we diagnose a "slippeddisc" and the patient resigns himself to alife of painful incapacitation. This pessi­nlistic attitude, common not only alTIOngstpatIents but among their medical attendantstoo, causes this incapacity and distracts thepatIents from receiving the treatment thatcan relieve their incapacitation"

Therefore, after excluding the presenceof organic disease of the spine, it isexplained to the patient that his pain is notdue to disea~e or to "discs being out ofplace" but simply to weakness of his back.The patient can appreciate that discs, liga­Inents, and lTIuscles can become weak,resulting in chronic c;train, which is painful,If thi" is explained to him. He then loseshIs fear of the unknown and can under­stand the rationale of the various physio­therapeutic procedures he is asked toundergo. Thus it is at once obvious to himthat active extension exercises will be thefundamental factor in restoring strengthto his baclc Also he can understand thenecessityT for wearing a spinal brace tosupport his back until the exercisesstrengthen it sufficiently to discard the

brace; and he can understand the necessityof manipulation to break down adhesionsthat have forilled in chronically strainedjoints. The importance of posture and thebad effects of poor posture in producIng achronic strain of his weak back are easIlyaccepted by the patient. And, V\Then it IS

explained that in the absence of severe orprogressive damage to nerves, surgery isnot necessary) the patient is muchencouraged, for most patients rightly dreadan operation upon the back.

Recently a new syndrome, the hypo­plastic back, has been described. It is dueto disuse atrophy aggravated by faultyposture and occurs in the so-called execu­tive types, i.e., those who spend their tilnesitting at a desk or at the wheel of a carand never have time to do any real work~doctors, for example.

If one can catch up with these people forlong enough to persuade them to have treat­ment, they respond very well to manipula­tion and exercises. Unfortunately, theynever seem to find time for any treatmentexcept to wear a spinal brace, upon whichthey become increasingly dependent.

Post-traumatic adhesion formation result­ing from direct injury of the back IS acondition which also responds readily tomanipulation and exercises Miss Casaheliathen presented such a case.

Miss S. was a good example of a backsuitable for treatment by manipulationunder general anresthesia followed byintensive physiotherapy. Before the mani­pulation she was treated for a month with­out any degree of success, her back beingrigid, and it derived no benefit {rOln exer­cise. One month after manipulation shewas free of pain and more mobile than shehad ever been in her life" The Inain diffi­culty had been to convince her to keeptTIoving immediately after the manipulationeven though she was sore, so that she wouldnot tighten up again. Massage was a greatencouragement here.

The final case was one of acute prolapseof an intervertebral disc. Jlist as a joint thatis injured or twisted becomes swollen andpainful and has to be rested until the acutestage subsides and thereafter protectedfrom subsequent injury by developlnent ofthe TIluscles controlIing the joint, so it is

PHYSIOTHERAPY AND THE ORTHOP£DIC PATIENT rOI

with an injured I.V. disc. The disc isrested by ordering the patient to bed untilthe acute symptoms subside. It is thenprotected from further injury by developingthe controlling muscles of the spine wIthactive extension exercises, and by wearinga spinal brace until the erector spinalmuscles are strong enough to make thisbrace unnecessary.

This patient, although appearing to be avery lTIUSCttlar type, had actually a weakback, which, together with the arduoustimber lugging job, had caused his con­dition. Although the most important treat­ment was hyperextension exercises, heat

and Il1assage were of great value also,because these patients are In pain, and thesehelp relieve it, even if only tetnporarily. Ifthe patient feels that somethtng is beingdone for his pain, he will try harder withhis exercises and one will get far more outof the patient. If one simply says that exer­cise is the cure for the backache and makesthe patIent perform for half an hour, hethen feels exhausted and probably moresore. M nch exercise must be given, byuSIng tnany exercises, even as many astwenty done a few times each so thatpatients do not lose interest and then per­form them carelessly.