WALTER REED MONOGRAPH i OCCUPATIONAL THERAPY APPLIED TO RESTORATION OF FUNCTION OF DISABLED JOINTS BY BIRD T. BALDWIN, Major, S. C, U. S. A. Director of Occupational Therapy and Chief Psychologist Walter Reed General Hospital Takoma Park, Washington, D. C. v;;-* WALTER REED MONOGRAPH OCCUPATIONAL THERAPY APPLIED TO RESTORATION OF FUNCTION OF DISABLED JOINTS BY BIRD T. BALDWIN, Major, S. C, U. S. A. Director of Occupational Therapy and Chief Psychologist Walter Reed General Hospital Takoma Park, Washington, D. C. Printed on the authority of the Surgeon General of the Army Typed by the Occupational Therapy Department APRIL 1919 OUTLINE OF CONTENTS. Introduction. a. Purpose of Monograph. b. Preliminary Case Study. c. Formulation of Problem. -Plate 1. Explanation of Occupational Therapy. Procedure in Assigning Cases in Curative Work.— Piute 2. Typical Assignments in Occupational Therapy (5 Cases). Plate 3. Measurements of a. Range of Voluntary Movement in Stiff Joints.—Plates 4-19. (Progress Curves, Tables 1-2). 1. Individual Illustrations. 2. Summary of Type Cases. b. Strength of Voluntary Movement in Stiff Joints. Plates 20-22. (Type Cases of Strength—3 Cases). Examples of Types of Movements Occuring in Various Occu- pational Activities.—Plates 23-43. Preliminary Type Studies of Movements Involved in a. Planing. b. Engraving.—Plates 44-45. Peripheral Nerve Palsies. Partial List of Tools of Special Curative Value.—Plates 46-48. Type Cases of Occupational Therapy. (3 Cases). Supplementary Comments. Outline of Psychological Service in Hospital. I Introduction This monograph presents in a preliminary and suggestive form the aim, scope and methods of one phase of Occupational Therapy as worked out inductively in the Walter Reed General Hospital. The aim of the monograph is to formulate a program in order that the problem may be further carried out in other hospitals and in order that we may receive suggestions and criticism for work in our laboratories and shops. The writer was assigned to this hospital April 2;>, 1918, as Chief Psychologist, and the first case that he examined was that of Pvt. R. G. P., who was sent here with a disability of chronic osteo-arthritis of meta-phalangeal joints of the 2d, 3d and 4th fingers of the right hand, with cause unrecorded. In addition to the clinical study of the patient's social, educa- tional and vocational history, an intelligence rating and further psy- chological examinations wrere given him, with particular reference to motor coordinations. A detailed study which discussed the vol- untary movement of the affected hand was submitted to the Surgeon General of the Army. A portion of the report read as follows: Movements of Affected Part—Hand (Right). See X-Ray plate, Right hand of Pvt. R. G. P. 1st Finger (thumb) apparently normal movement present. 2d Finger, 1st joint stiff, and cannot be flexed, good power and free movement otherwise. 3d Finger, constantly flexed, cannot be extended to a straight position. No movement in first joint; second joint limited move- ment, and third joint at hand, very little movement. No movement sideways. Painful when struck or when shaking hands. Cannot 4 OCCll'ATIONAI. THER.-I'Y i miji: .tii.nm. smvii-.E WAl.TFR REE1) GENERAL HOSPITAL Tikuma Park. R. C. MEDICAL OFFICERS PRESCRIPTION Nkmr .A-.—-.y.tt.Pv.r.. .... Ward Jfa. , ............ QCLZ-4. . 19/9. Diagnosis 6i-k fane/. U rQC, wetowrpal. .Mnes. Limjfaf/on fioger motion... ..... Probable length of stay in hospital . wi Result to be attained ultimately Increased functx>n fingers and'xraf In ortliopedic cases needing curative work check below: Thumb") Finger I Wrisl J ^\ I Elbow | Shoulder Back To be avoided Abduction Adduction Flexion Extension Pronation Supination .Circumduction Toes Mid-Tarsus Ankle .Knee Hip This man is ready for assignments checked below Jplease include all of which he is capable): ______________________C-r-dw_____Oc.qp.-.doT.al Only______Hours ✓" .....:.&$,«............. Medical Officer's Signature. Name: A----- , H. Pvt Dale. 0ct.30,i9ig ' Wan! .5* WAMT'.H REED I'.F.NERAl. IIOSi'lT.U. tkkomi i'akk, n. c. DIVISION (IK Rf.CONSI'Ki I THIN Building No. 93. lime. Subject. S.OO S:30 !).Uu ■9.30 10:00 1030 Measurements offloremente (Mon, Wed, fn ) nan 10-45 to 1145 Cngroviry (Curative) ll:3u 12:00 _:I5' Academic Jtudies 2:45 " " 3:15. 3:45 4:15 4.45 Want Work.—Tune to be arranged wilh palii-itt ii. r_».....in : * Hex ion of Fingers m grasping and using engraring fool with /eft hand. Pronation - supination m'rrr/gglingl extension of fingers, extension -t'/e*ion and obdect/an - adduction of Wrist by folding plate with /eft hand and engrar- log ui//n right. 3y alternating from right to left Hand engravmy, alt the required moremente are obtained without Fatigue. Assignment Offi, Plate 2 Medical Officer's Prescription and Assignment Program APPLIED TO RESTORATION OF MOVEMENT 5 bend halfway to palm and the hand hurts "like a wire catches." Limitation of motion in full extension. 4th Finger, flexed toward hand. No movement in first joint, lit- tle in third joint. If placed over second finger, cannot be removed voluntarily. Flexed to approximately 45 degrees. 5th Finger, only slightly flexed. Some movement in first joint, little more in second, and more in third. Binds over knuckles. From the standpoint of precision the movements of the arm were com- paratively accurate and those of the fingers inaccurate and slow. X-Ray photograph on file in Psychological Laboratory shows ankylosis and marked deposits at joints. The subject was later placed under an anaesthetic and the fingers extended. A cast was worn for several weeks and a little improve- ment shown. A careful study of this first case showed the possibility of a fertile and practical field in the measurement of the excursion and strength of voluntary movements in partially ankylosed joints, and indicated some of the opportunities for the application of occupational activi- ties for remedial treatment. oince the date of this first fortnightly report, the Department of Occupational Therapy has considered curative work as applied to stiff joints one of its problems. All Departments and lines of activities in the hospital bearing on this problem have been co- ordinated through the cooperation of the Psychological Service, the Curative Shops, the X-Ray Service and the Orthopedic and Medical Service. We are now in a position to present to other hospitals a tenta- tive program continued through several months of development and experiments. This outline of procedure is based on intensive in- dividual studies with progress curves and clinical occupational notes. II Explanation of Occupational Therapy Occupational Therapy is based on the principle that the best type of remedial exercise is that which requires a series of specific volun- tary movements involved in the ordinary trades and occupations, physical training, play, or the daily routine activities of life. Our curative shops are now being organized, and graduated on the prin- ciple which will enable us ultimately to isolate, classify, repeat and to a limited degree, standardize and control the type of movements involved in the particular occupational and recreational operations. The patient's attention is repeatedly called to the particular remedial movements involved; at the same time the movements have the advantage of being initiated by the patient and of forming an in- tegral and necessary part of a larger and more complex series of coordinated movements. The purposive nature of the movements and the end products of the work offer a direct incentive for sus- tained effort; the periodic measurement of the increase in range and strength of movement makes it possible for the patient to watch 6 OCCUPATIONAL THERAPY his recovery from day to day; and frequent comparisons be- tween his progress curve and that of others offers an excellent oppor- tunity to explain and to help him overcome plateau periods or re- gressions which necessarily occur. In addition to evoking an attitude of interest, cheerfulness and optimism in the patient and by showing him that he is really making progress, the records also enable the examiner to determine which mode of treatment leads to the greatest and most consistent gains in a particular case and they directly encourage voluntary effort and personal initiative on the part of the individual. The method of formal mechano-therapy, or formal medical gymnastics, which has been so widely used, consisting of exer- cises of a quasi-passive nature on special apparatus designed to give opportunity for the execution of repeated movements involving spe- cific joints has the advantage of isolating particular joints from the rest of the body, and allowing for the construction of special ap- paratus designed to give repeated exercises under controlled con- ditions for limited periods of time. While these two methods are not materially exclusive the aim of this paper is to set forth, some of the advantages of occupational therapy as applied at Walter Reed Hospital. The disadvantages of the mechano-therapeutic method are that the human body is more than a machine when voluntary movements are concerned and it is very doubtful whether the formal repetition of movement from a mechanical source is of maximum therapeutic value in increasing the amount of movement either in the affected part or as an integral part of the larger co-ordination of movement of which each particular movement must ultimately be an essential part. The application of mechano-therapy does not allow for the personal initiative of the subject, gives little or no opportunity for voluntary effort, and offers little incentive for sustained effort. The second type of mchano-therapy which has some advantages over the traditional method is that formulated and worked out by Captain Bott of the University of Toronto. This type of therapeutic exer- cise is based on the general presuppositions that: "Simple mechanical appliances for bringing specific disabilities into operation are indispensable and the appliances are fitted with metrical devices which record and stimulate daily performance by appealing to the eye and ear. In this way, a patient is brought face to face with his incapacity and is encouraged to use his whole power to overcome it. The psycholgical basis of this treatment differs from that of the curative workshop in requiring the patient to con- centrate upon rather than to forget this injury. The advantage is that he attacks his disability directly, watches his improvement from day to day, and aims at a consistent recovery." The chief disadvantages of the method as stated above, are that this treatment is isolated and no provision is made for the inter-co- ordination with the other movements of which a particular move- ment must ultimately become a part; there is little or no evidence APPLIED TO RESTORATION OF MOVEMENT 7 that either initiative or improvement gained in a formal exercise can be transferred to another occasion or to other types of move- ments. In the curative shops special projects, special machines and special tools are set aside for strictly curative cases, and the instruc- tors check the movements which each man makes in order to see that special joints are not favored or over-fatigued. A distinct ad- vantage possessed by the work-shop type of therapy consists in the fact tnat the patient here is a member of a social group and turns out a tangible product of economic value; he is thus brought to full realization of his social fitness and economic usefulness—a factor which is of inestimable value in encouraging and inspiring the pa- tient. He also notes from day to day in the psychological laboratory and shops the increase in functional restoration and is offered oppor- tunities to try the same type of movement in other allied activities. Ill Procedure in Assigning Cases in Curative Shops When, in the opinion of the surgeon, a patient is ready for work in the curative shops, he is sent with a medical prescription to the interviewing office of the Reconstruction buildings. The prescrip- tion is checked in a manner similar to plate 2 (which precedes) in order that the Reconstruction force may know the functional re- sult to be attained. In a general way the work in Occupational Therapy may be divided into the following classes: Occupational, curative and voca- tional, but no sharp line of demarcation is possible in many cases. It is with one class of curative cases only, that we are dealing in this paper. The above slip shows a typical prescription, and is that made out for Pvt. A. H. In the interviewing office, Form No. 58, Medi- cal Department, U. S. Army, is filled out by the interviewer, and in this, recommendation is made for the immediate training which seems advisable for the man, from the occupational and curative point of view. The patient then goes to the Psychological Labora- tory with the register and medical prescription. Here measure- ments are taken of the extent and strength of voluntary movement in the affected part, and the case is further analyzed from the psy- chological standpoint given by the interview sheet, and from ob- servations and conversations with the man himself. On the basis of these three factors, the man is assigned to definite work in the shops for the prescribed number of hours each day. For the correct selection of work to be given, the following factors are taken into account: First: The work must be one which involves as an essential part the movements required by the prescription, or in which these movements recur from time to time as the work is performed by 8 OCCUPATIONAL THERAPY the normal individual. In order to discover the activities in which certain specific movements were thus involved, a survey was made of all the shop and ward acivities, and insofar as it was possible by observation and practice, each activity was analyzed into its constituent movements. In Section VI are given two typical an- alyses which were made to meet a practical situation and are in- cluded here merely as suggestive, and in the hope that further and more specific work in this line will be made in other hospitals. From these analyses it has been possible to isolate the activities in which a specific movement is necessary or is recurrently involved. For instance, the adduction and abduction of the left wrist is essen- tially involved in turning the large unmounted plate while making the curves in engraving, where the tool is held with the right hand. Another activity calling for pronounced and continuous adduction and abduction and extension-flexion of the thumb, is in weaving on the Gobelin Tapestry Loom. WTth the possibility of the various ac- tivities in mind, the psychologist in consultation with the surgeon de- cides in which of these the patient should be placed for curative treatment. Second: Where more than one of the activities are equally desirable from the curative standpoint, the one with a vocational outlook is assigned in accordance with the patient's choice and the recommendations of the vocational advisor. Frequently the patient is taken through the shops to observe and to try out the work. Occupational Therapy in work with a vocational outlook is, as a rule, preferable and most desirable from many points of view7, but frequently patients whose stay in the hospital is short, prefer to work along the lines of an avocation rather than to return to vocational experiences. An example of a vocational shifting is illustrated by that of a patient who was a machinist and who, being unable to return to his former heavy work, has been taking light woodworking and mechanical drafting. As an illustration of an avocational interest, a man who has been or intends to be a machinist, and who is not yet able to take up such heavy work, frequently chooses the jewelry shop, in which he is working with metals and with tools. The rug weaving or leather work frequently represents a purely avocational interest. As the curative work is usually limited to one or two hours, the patient frequently takes up as occupational work, a study of allied subjects of an academic nature which do not involve exercise. After the patient has entered upon the work, he returns to the Laboratory at regular intervals for the measurements of the extent and strength of voluntary movement, in order that he may see his progress in a concrete manner as illustrated by progress curves. If there is constant gain, he is encouraged, and the instructors and the surgeons know that the treament is of the proper kind. If there is a drop in the record, the reason is sought. This may be due to absence of occupational or physio-therapeutic treatment, or to the general physical condition of the man. This is also made clearer APPLIED TO RESTORATION OF MOVEMENT 9 to the patient by frequent comparison between his curves and those of other patients with similar plateaus or regressions. IV Typical Assignments in Occupa- tional Therapy Diagnosis: G. S. W. Thumb, left hand. Healed. Limitation thumb. Prescription: Increased thumb motion; adduction-abduction, flexion-extension, circumduction thumb. Assignment: Rug weaving department, work on Gobelin tap- estry loom, where the separating and holding out of the threads of the warp is done by abducting and extending the thumb, with also slight circumduction. The amount of strength required depends on the tightness of the warp. Progress: Worked from the date of assignment, December 29, to January 13, when he was taken ill with the influenza, for one hour or one hour and a half regularly each day. Could not use the tightly drawn threads, so was put on those requiring less strength. In .the beginning had no active movement in the thumb; but was obliged to use the other hand in placing over the thumb the threads which the thumb normally should lift. After a week the thumb it- self did a part of the work, though still assisted by the other hand. In the last few days of the work the thurnb could lift by its own action a few of the threads. Marine C. S. A.—Fingers and Wrist. Diagnosis: (a) Amputation thigh. Right upper middle third healed. (b) Shoulder left, limitation motion. Flesh healed. (c) Forearm left (involving median nerve.) Flesh healed. Prescription: Normal action of fingers of left hand and fore arm with especial reference to wrist, thumb and index. Assignment: Engraving. In "wriggling" with left hand on plate mounted on wooded block, grasping the tool with left hand gives flexion of the fingers, and the desired flexion of all joints of thumb is attained by a specially adapted handle of dental compound. Extension required in releasing it. Steady though slight pronation- supination. This alternated with right hand "wriggling," which gives flexion of metacarpophalangeal joints of fingers of left hand and extension of interphalangeal joints of fingers and thumb in holding the block. Wrist extension-flexion in turning the block. Also typewriting for finger flexion-extension and abduction- adduction. Progress: At first patient could not hold the tool in his left hand in a way to enable him to engrave. After three daily appoint- ments of one hour each, he was able to "wriggle" any ornament and was enthusiastic over the seeming improvement in the function of his left index finger. From November 8, when lie began the work, to December 23, when he dropped it temporarily to go on a furlough, 10 OCCUPATIONAL THERAPY the composition handle was changed three times to adapt it to the constantly increased power of flexion in the thumb and fingers. In typewriting he was able to use all fingers from the first, but tired easily. Function fully restored. See plate No. 3, patient at left, I W-------:----Z----1 Plate 3 Engraving which can be done with tools held in right or left hand asrequired. Tools with especially adapted handle in fore- ground. Pvt. G. N.—Elbow. Diagnosis: Limitation of movement, right elbow.—G. S. W. Prescription: Mobilization right elbow in flexion-extension by work for one hour a day avoiding undue fatigue. Assignment: Carpentry. First project was in making a ciga- rette case for the Red Cross, doing the entire work himself and work- ing at it in all his spare time. After this he made filing boxes. In both these projects the hammering with small hammer and nails required very slight elbow motion, but the sawing and planing of the wood necessitated elbow extension and flexion. The measure- ments of the range of voluntary movement showed a slight but steady increase from October 4 to November 2: Oct. 4, 21.0 degrees; Oct. 11, 24.5 degrees; Oct. 14, 25.3 degrees; Oct. 25, 28 degrees; Oct. 29, 29.8 degrees; Nov. 2, 29 degrees. Pvt. B. G.~Back. Diagnosis: Traumatic acute sacro-iliac strain. Prescription: Free motion of spine; only light spinal exercise advisable in beginning. Assignment: Light greenhouse work, where bending over the APPLIED TO RESTORATION OF MOVEMENT 11 low benches gives flexion-extension of back; work at higher benches requires only slight flexion-extension. Pvt. G. a.—Ankle and Toes. Diagnosis: G. S. W. Perforating right foot. Prescription: Motion of toes mid-tarsus and ankle, with pre- caution that he should not walk far or stand on feet for a long time. Assignment: Woodshop. Work on the small .scroll saw, with treadle action, cutting out picture puzzles. Blocks are placed under the heel on the treadle, an arrangement which requires more exten- sion-flexion of toes and mid-tarsus as well as extension-flexion of ankle. Measurements taken in the laboratory to show range of voluntary extension-flexion are shown in Table Case I (ankle). Those of vol- untary adduction-abduction are the following: Nov. 25, 07 degrees, Nov. 27, 70.2 degrees; Dec. 2, 70.1 degrees; Dec. 1, 80.3 degrees; Dec. 0, 101.3 degrees; Dec. 9, 94 degrees; Dec. 11. 97.1 degrees. Measurements of flexion-extension taken in two cases before and alter the hour's exercise show improvements of 0.3 degrees and 9.2 degrees. \—a. Measurement of Range of Voluntary Movement in Stiff Joints (Psychological Laboratory) As a result of the first case discussed on page 3 it was found ad- visable to have some definite method of letting the patient know the amount of movement which he was able to make in the disabled joint. The surgeon as a rule measures the passive movement of which the joint is capable, and frequently estimates this directly or by some simple apparatus. There is, so far as we know, no stand- ardized apparatus for this measurement. It was eminently desirable to have some measure of movement both for incentive to patient and for information of surgeons and in- structors. Apparatus was therefore devised and made in the shops, which should measure as accurately as possible the range of volun- tary movement possible in any disabled joint in the body. The ac- companying plates 4-14 show the types of apparatus in use at present. Further modifications and improvements ara constantly bing made, and it ;s hoped that this apparatus may be so perfected and so standardized as to form a common basis of measurement for orthopedic cases. The fact that we are dealing with voluntary movements, makes this essentially a psychological problem. In taking these measurements, the laboratory conditions are kept as strictly uniform as is possible in order that measurements may be repeated, controlled and standardized. Certain general principles are followed in all cases: First. The joints adjacent to the joint in question are immobi- lized as far as possible. Since it was not known how far the range 12 OCCUPATIONAL THERAPY of movement in a joint was affected by the position or the movement of adjacent joints, and since it was desirable to keep all factors as constant as possible so that at least the relative readings might be accurate, this principle of immobilization was adopted. It is real- ized that by this method an artificial situation is created, and the actual range of movement may be limited, but if this limitation is constant from day to day, it is possible to obtain the progress of the movement. Second. As far as possible, incentive in the form of an ex- ternal stimulus or suggestion is eliminated during the actual move- ment. In the preliminary sitting, this rule is broken if the patient is not fami.iar with measurements, or does not seem to have grasped the idea of the possibility of noting his gain from day to day, and of breaking his own record. In such cases, the first sitting is devoted to giving the patient this concept of voluntary action. In follow- ing the assignments, the patient is not told what record he is making until after the readings are completed, then he is given full informa- tion and these readings compared wih those of the previous sittings. Though there are undoubtedly advantages in allowing the patient to know exactly what he is doing at the time he is doing it, and even urging him on to make one or two points more, this encouragement formed such a variable factor that it seemed necessary to rule it out in order to obtain a true measure of progress. Third. The recording is made of the maximum of movement in both directions and the difference taken to give the range or ex- tent of movement. Three readings are taken of this range, and the average of these taken as the extent of movement for that sitting. Fourth. The numerical data thus gained are tabulated and curves are plotted from them in order that the patient may have visual evidence of his progress transcribed into graphic form which the patient may see for comparison. Fifth. As far as possible note is made of accompanying irregu- larities in movement and unusual sensation, such as pain or undue pressure, with introspective notes. Sixth. Note should be made of all treatments and activities of the joint in question since last sitting, as well as the general physical condition at the time of the measurement. Plate 4 Illustration of method of measuring amplitude of flexion-exten- sion of finger joints. Plate 5 Preliminary apparatus for measuring the amplitude of flexion and extension of the wrist. (Discarded for type below.) Plate 6 [_-----,4-------„ Sketch of apparatus for measurement of amplitude of flexion and extension of finger joints. Plate 7 Sketch of new apparatus for measuring amplitude of flexion and extension of the wrist. Plate 8 Measurement of adduction—abduction of the wrist. Plate 9 Sketch of apparatus for measuring pronation and supination of forearm. Plate 10 Circumduction of the wrist as used in rake knitting, from below upward. 10 OCCUPATIONAL THERAPY Range of Movement of Fingers in Degrees Extension-Flexion Pvt. C. B. FIRST JOINT SECOND JOINT THIRD JOINT Dates. II. III. IV. V. j II. III. IV. V. j II. III. IV. V. Nov. 17..10.0 43.2 10.8 14.0|................i............... Nov. 27..................| 20.2 01.3 20.0 24.3|............... Dec. 2 ..................|................ Dec. 4 ..25.0 51.0 il.O 11.1|................ Dec. 0 ..................i 03.1 91.3 55.5 31.6 Dec. 9 ..................|................ Dec. 11..37.0 01.1 10.1 20.8j................ Dec. 13..................j 48.0 80.8 50.0 29.3 Dec. 17..................1................ 57.0 78.8 49.0 58.6 08.4 88.3 54.3 62.3 72.0 83.1 54.3 01.3 Pvt. S. F FIRST JOINT SECOND JOINT 70.5 81.7 .... 50.3 Dates. II. III. I\. V. j II. III. IV. V. Nov. 18..39.7 50.0 38.0 15.0|............... Nov. 20.................. Nov. 22.................. Nov. 25. .00.5 79.1 50.0 20.0 Nov. 27.................. Dec. 3 .................. Dec. 4 . .01.8 70.8 59.0 32.8 Dec. 0 .................. Dec. 9 .................. Dec. 10. .84.3 85.0 45.0 31.0 60.0 78.0 .... 44.1 101.3 113.1 . .. 58.5 THIRD JOINT II. 111. IV. V. 69.7 69.3 65.0 60.3 85.1 85.5 78.8 70.5 78.0 84.5 76.0 53.3 Table 1 APPLIED TO RESTORATION OF MOVEMENT 17 Type Cases in Extension-Flexion Range of Movement in Fourth Finger, Third Joint, in Terms of Degrees, Also Wrist, Elbow, Knee and Ankle FOURTH FINCER. THIRD JOINT. Measurement. Increment. Percent. Days. '- •_ - ° *_ '- — c — 1 S 2 245. 74 36. 42 38.6 30 56.0 28 206.5 5 62.9 98 25.4 53 44.9 15 I. (Left) ...13.4 24.4 40.2 11. 21.8 82. 103. II. (Left) ...34.7 41. 47.2 0.3 0.2 18.2 17.8 III. (Left) ...53. 00.8 73.5 13.8 0.7 20. 12.0 IV. (Right) ..38. 54.8 61.3 10.8 0.5 44.2 11.8 WRIST. I. (Left) . . 47.2 144.7 97.5 200. II. (Left) .. 52.0 73.0 85.7 21. 12.1 39.9 23. HI. (Left) . .117.8 137.3 147.7 19.5 10.4 10.5 8.8 IV. (Right) .131.5 153.2 190.5 21.7 37.3 16.5 28.4 ELROW. I. (Right) ..75. 83.9 91.5 8.9 8. 11.8 10.6 22.5 11 II. (Right) .22.7 20.7 2!).4 5. 2.7 17.0 11.8 29.5 29 III. (Left) ...18.3 35.3 33. 17. 2.3 92.9 12.5 80.3 21 IV. (Left) ...00.7 74.3 70. 7.0 1.7 11.4 2.5 13.9 51 KNEE. I. (Left) ...17.8 08.8 72. 51. 3.2 287. 18. 305. 34 II. (Righl) ..88.2 90.5 100.0 8.3 10.1 9.4 11.4 20.8 5 III. (Left) ...19.2 21.1 22.4 1.9 1.3 9.9 0.7 10.6 39 IV. (Left) ...55.2 S3.2 89.3 28. 0.1507. 11. 61.7 23 ANKLE. I. (Right) .43.9 52.0 57.3 8.7 4.7 19.8 10.7 30.5 64 II. (Left) ...32.2 13.5 72.7 11.3 29.2 35. 90.0 125.6 17 Table 2 _____ W^______P"^ ^*^__i. __■ y It— v^W u 1 ___lil_. ^^B__ J " ~^^^ ____^_hPv Tt^Sm^ Plate 11 Apparatus for measurement of elbow extension and flex- ion cases. Plate 12 Measuring the range of voluntary inversion-eversion of the ankle. Plate 13 A / V Sketch of apparatus for the mea- surement of the adduction- abduction of the ankle. Plate 14 Sketch of apparatus for measur- ing the amplitude of ever- sion and inversion of ankle. APPLIED TO RESTORATION OF MOVEMENT 19 Wn 'fl 1 Drtrw nf Mnvi7m_7n in Finne "i T!m 1 1 Q V r ■* ? e o g I '/" * i s lA 7^ i s » > 'xi\ -* T __; i /' A 1 " / 1" ?m 3" ■* ' /\ ¥ iv § i , ' 5 /jA i a- s- i /.i f | ■s. 9- " * * 3 \ ■ < r 7, — .()•< { 5" I" « : j J 01 r CO 1- »> o J S 1 \ ' ^ "~ ! J ■ f S ?l } «T A/^ - £ If* ' =-, *" In >* * : * / S S ^ 4 r < '. < 1 < r * -^i «o t i 5 J 1 r > ;_ /i\ l/l 1 ^ A : 5 £ A i 1 A V *[2 rl«-i Dap A < ? PI? , r i | njw _ < t F ^ Plate 15 Progress curves of extension and flexion of fingers. 20 OCCl PATIONAl. THERAPY §s fVt Ward 5 Vnnae of 111111 111 1 11 n In 11 i 1 [ ill 1 1' IhiLLLL1 iffiWffiitiin Vl^l f 44+ :H 11 Ft 11111 111 1111 11 Trt i jjji 11111 TJ~" ll^^^l^p m ii-j-i- iHtHHHH' ?_j UJ^4Ji>fflitT^A^P-^^P^^^^^¥" -'- +: +ff At" H fit H S&. H M Plate 16 Progress curves of flexion and extension and adduction and iib- duction of wrist. lYnnl ■> ?.'!. ,.■ , f M.T. in W nr f. ._^_ -I 1 - 1 ----------S_-----------. 2 -- un * /! ■ — 110 /'^i/ /} ^ g -■-- 3 i \ 21ST 1 i i r r _ i i is > i i i ____J, 1 ; 1 __.. ^ 1 i { ', CO 70 60 50" s. Li— | X. < ! S C / z tS 5 _: i*t-«n 5ion- fl«xion 1/ \ TT WPI 5T - £.d4->-norJ- Abd JCllon 1 Vn "fU° .l"-Z Days i 1 Plate 17 Progress curves of extension and flexion, adduction and abduc- tion of wrist and extension and flexion of elbow. \ Nurd AnkU \ r ! ■ i 1 ! A j ^ o 2 £ a^g I? / fv" "t\ LJ. A 5-* i !, 5 3 o_^ * ;Ss' A i\y , W i * N *^ '* J A ^-U"|Ui' _> mA—', */. rr- i* l/l i. b . ! t? / rf-! E Z 5» 1 fe? 'I r <* £ .__ i Udducr on-Ab Jucho i 5 5 *_ 1 t3 Invzr 5ion- -.verji pn | 5ca t\* l"-Z Days —■■ l" Platp 18 Progress curves of extension and flexion, inversion and eversion, and adduction and abduction of ankle. OCCUPATIONAL THERAPY ' too '*> /So 'To /CO f4i '30 'to t/0 Progress course of improvement in flexion-extension of wrist. Plate 19 b. Strength of Voluntary Movements in Stiff Joints (Psychological Laboratory) Measurements of muscular strength in cases of partially stiffen- ed joints are made, first, in order to determine the initial degree of disability in the limb involved, by comparing the strength of the weakened joint muscles with the strength of like muscles in the un- injured limb. With a knowledge of the amount of strength in a par- tially disabled limb, the patient can intelligently be assigned to cura- tive work which he will be able to perform, and which will not be too strenuous. By subsequent measurements check can be made on rate and extent of improvement. If work is not showing results which seem to be sufficiently beneficial, the patient may be re-as- signed to more suitable work. By continuing the measurements it is possible to determine when complete recovery has been attained. The muscle testing is done with spring-balance scales by the Martin method. Commercial scales such as can be bought in any hardware store are used, a few modifications being made to render them more suitable. The most important modification is the inser- tion on the dial of a small runner, which slides with the minimum amount of friction necessary to keep it in any position against the APPLIED TO RESTORATION OF MOVEMENT 23 force of gravity. When a pull against resistance is made with the scales the pointer on the dial carries the runner with it. Upon ces- sation of the pull, the pointer returns to the zero reading while the runner remains at the point reached in the maximum pull, thus making the scales self-registering. The runner is then pushed back to the zero point by hand. The Martin method* has a double advantage in that it makes possible testing under constant conditions of both leverage and posi- tion. The pull of the scales is made against a fixed position assumed by the patient. Two persons are required in making the tests, an operator and an assistant who co-ordinate the pull of the scales with the resistance of the muscle and attend carefully to the maintenance of correct positions of the limb and of the relationships of leverage. The command "hold back" by the operator is the signal for the pa- tient to innervate the muscle being measured and for the assistant to commence pulling. The pull is made along accurately determined lines in opposition to the pull of the muscle. A steady increasing pull is maintained until resistance of the muscle has been overcome, as shown by the movement in the direction of the pull of the scales of the limb or part of the limb being measured. The reading of the scales is then taken in pounds or fractions of a pound. Three read- ings are taken for each muscle, and the average taken. To avoid con- ditions of fatigue the three measurements of the same muscle are not taken in direct sequence. For the lower extremity the muscles which govern the following movements can be measured: Hip flexion, extension, adduction and abduction; knee flexion and extension; plantar flexion, dorsiflexion, inversion and eversion. All of these measurements are taken with the patient lying on a table, and the pull of the scales is in a hori- zontal plane. In measuring the elbow flexor and extensor muscles the subject lies on the back with the forearm perpendicular to the table. In measuring the muscle moving the shoulder the subject stands square- ly against a post or similar firm support and braces with the opposite arm. For the wrist muscles the arm is held in a horizontal plane and properly braced. The subject is in a standing position. The Smedley hand dynamometer is used for the hand. In all cases, the part of the extremity proximal to the joint moved by the muscle being measured is braced so that the pull of the scales will always be against only the particular muscle involved. To ob- tain accurate results it is most important to preclude the use of any *For a more complete description of the Martin method of muscle testing see R. W. Lovett: "The Treatment of Infantile Paralysis," 2nd Ed. 1917, Chap. VII, also R. W. Lovett and E. G. Mar- tin : "The Muscle Test for Infantile Paralysis—a Description of the Technique," Amer. Jour. Orth. Surg., July, 1916. Plate 20 Illustration of method of measuring strength of muscles involved in flexion of wrist. Plate 21 Illustration of method of measuring strength of muscles involved in flexion of elbow. APPLIED TO RESTORATION OF MOVEMENT 25 but the muscle to be measured, and the utmost care must be exercised in keeping conditions of position and leverage constant. Tests on patients of this hospital were begun on December 18, 1918. In practically all cases of men given curative occupational as- signment, measurements are taken at the time of assignment and three times a week thereafter. The results in a few typical cases are given below: Case I. J. S. Gunshot wound through forearm just below the elbow, with a slight wound just above the wrist. Resultant loss of strength in flexion and extension of elbow and fingers, and thumb abduction and adduction. Measurements of the muscles moving the elbow and metacarpophalangeal joints were as follows: (Readings in pounds.) Plate 22 Measuring strength of muscles controlling elbow flexion. Note scar at elbow. 26 OCCUPATIONAL THERAPY Left arm Right arm (normal) Per cent of normal Elbow strength in left arm Flexion .... . 38.0 66.0 57.5 Extension . . 32.0 47.0 68.0 Thumb Adduction . . 14.3 20.5 69.7 Abduction . . 7.0 6.3 111.1 I Flexion .... . 11.0 12.2 90.1 Extension . 4.0 6.7 59.7 II Flexion . . . . 11.0 12.7 86.6 Extension . 4.7 5.5 85.5 III Flexion .... . 11.0 11.5 95.7 Extension . . 5.5 5.7 96.5 IV Flexion___ . 9.0 . 8.5 105.8 Extension . 4.5 4.3 104.0 Average of 85.9 percent normal strength in left arm. In this case almost complete recovery had been attained when the measurements were begun. Measurements of the weakened muscles of the left arm taken more than two weeks apart were as follows: Elbow Dec. 20 Jan. 0 Percent of gain in strength Flexion ........ 38.0 Extension ...... 32.0 Thumb Adduction ...... 14.3 Abduction ...... 7.0 Fingers I Flexion ........ 11.0 Extension ...... 4.0 II Flexion ........ 11.0 Extension ...... 4.7 III Flexion ........ 11.0 Extension ...... 5.5 IV Flexion ........ 9.0 Extension ...... 4.1 Average percent of gain in strength 2.4 percent. Case II. J. K. Gunshot wound through right shoulder. Well healed, but limited motion of shoulder and elbow remains. Measure- ments in pounds were as follows: Muscle Right Arm Dec. 19 Jan. 9 Pectoral...................29.0 Anterior deltoid .............30.0 Posterior deltoid ............23.5 Elbow flexor ................21.0 Elbow extensor ..............27.0 Here the measurements for January 9th show an average gain of 58.6 per cent over the measurements made on December 19. On 38.0 0.0 33.5 4.7 17.0 18.8 6.2 -11.4 12.5 13.0 4.5 12.5 13.2 20.0 4.3 — 8.5 11.3 2.7 4.7 -14.5 8.8 __ 2.2 4.2 0.6 Left Arm (normal) 47.7 75.3 54.3 84.3 39.7 51.7 33.3 76.3 35.7 68.3 APPLIED TO RESTORATION OF MOVEMENT 27 December 19 the right arm was found to have 37.3 per cent normal strength as shown by measurement of the left arm, while on Janu- ary 9 it had improvecMo 56.1 per cent normal strength. In this case recovery is not nearly so complete as in Case I, and the gain in strength is much more marked. Case III. J. D. S. Gunshot wound through upper third of right fore arm. Well healed, but muscles still weak and motion somewhat limfced. Measurements in pounds were as follows: Muscle Right Arm Left Arm (normal) Dec. 30 Jan. 7 Jan. 9 Elbow flexor .........25.7 28.3 28.0 09.7 Elbow extensor ......19.0 20.0 20.7 44.0 On December 30, the muscles moving the right forearm are shown to have 40 per cent normal strength. By January 7, the gain in strength is within 43 per cent of normal, while the measurements on January 9 show the muscles to average 50.8 per cent normal strength. The tests which were begun on stiff joint cases are now be- ing modified so as to be adaptable to amputation cases as well. VI Examples of Types of Movements Occurring in Various Occupational Activities Definition* and Illustration. Extension is the straightening of a joint. Opening the hand is an example of extension of the finger joints. Straightening the wrist and elbow as in reaching for something, movement of the shoulder as in bringing the arm forward and downward from a raised position in front of the body (given by Morris Beevor et al„ not given by Piersol and Gray), movement of the neck, back, hip and knee, as in coming to "attention," ankle (plantar flexion) and mid-larsus as in walking on the tip-toe, toes as in bending them to- ward the upper side of the foot, are other examples of extension. An attempt has been made in the following specific examples of occupational therapy to give a detailed analysis for the specific joints involved. Since, as stated above, one of the advantages of oc- cupational therapy consists in the fact that movements are not iso- lated, but consist of a series of co-ordinated movements with other joints, it should be noted that as a rule the movements are never lim- ited to one joint. The detailed outline may seem too specific for the average instructor, who may prefer to deal simply with grosser movements. The movements outlined refer to joints and not to special muscles. 'Definitions selected and adopted for standardizing the proced- ure for instructors in the various curative activities. 28 OCCUPATIONAL THERAPY Examples : I. Thumb. Carpentry: Forcible straightening of the thumb in holding boards in wood working, especially in sawing (see cut), holding and guiding wood in cutting out figures on the scroll saw. Machine shop: Holding sheet metal while marking design for cutting. En- graving: Extension of interphalangeal and metacarpophalangeal joints in guiding tools, in making curves and in "wriggling;" exten- sion of interphalangeal joints of fingers and thumb, the amount of extension depending upon the size of the block used. Rug weaving: Separating alternate threads of warp of the Gobelin tapestry loom; in pulling rags through while weaving rag rugs on Lane loom. Jew- elry: In holding metal for polishing and sawing, holding articles for polishing on the electric buffer, holding jewelry while filing and polishing with emeries, or in finishing work, holding pliers and twisting wires for chains. Drafting: In holding T-square. Type- writing: In grasping handle to turn roller. Modeling: In pressing the clay on the board for the background in bas relief work. Ward work: Forcible extension of joint (interphalangeal joint) in using large handled pliers or punches, active extension (and flexion) of metacarpophalangeal joint in using scissors, pliers or punches. Gym- nasium: In gymnastics, in using medicine and volley and hand ball. Miscellaneous: In piano playing. Note: Active extension of thumb in releasing all tools and implements in farm or other work. II. Fingers. Carpentry: Forcible straightening of fingers as in use of whet- stone, cabinet scraper, in wood working, painting, sand-paper or wax polishing, holding and guiding wood in cutting out figures on the scroll saw. Machine shop: In holding sheet metal while marking design for cutting. In the guiding hand in scraping. Engraving (left hand) : Extension of all joints of all fingers in working on large unmounted plate; of inter-phalangeal joints in using wooden block with mounted plate (see cut); of inter-phalangeal joints of finger and thumb, amount of extension depending on size of block used. Rug weaving: Reaching through shed on Lane loom for pull- ing rags through, pulling threads and changing sheds on Gobelin tap- estry loom. Jewelry : In polishing, buffing and holding of flat metals while working on them; metacarpophalangeal joints are extended while holding the block while soldering; in all polishing and finish- ing; extension (and flexion) in chasing and using planishing ham- mer. Drafting: In holding T-square and triangles. Typewriting: Extension of index finger of left hand in throwing carriage of type- writer. Burroughs Adding and Listing Machine: Extension (and flexion) of fingers. Modeling: In pressing clay on background in bas relief work, extension of fingers and thumb in manipulating clay. Ward work: Forcible extension in bookbinding, in spreading the paste, in pressing the cloth or paper on back of book; leather APPLIED TO RESTORATION OF MOVEMENT 29 work, in holding leather flat with one hand; in tooling with other, extension of 2d and 3d fingers in holding tool; basketry, in keeping reeds in proper position and in raking reeds into place, cord belt- ing, in reaching for cords to tie the knots and in holding leaders on which the knot is tied; weaving; gymnastic exercises, including the pulling of weights, bearing weight of body on fingers, basket ball, hand ball, use of rackets with large handles in tennis and tether ball. Gymnastics: Medicine, volley and hand ball, gymnastics. Farm: Holding cultivator and light plow handles; active extension of fingers in releasing all tools and implements from the grasp. Leveling and preparing soil in seed beds in green-houses. Miscellaneous: Piano playing. III. Wrist. Carpentry: Straightening and bending back of wrist in planing, in wood-carving, in use of post drill press. Machine shop: In turn- ing hand-power drills and grinders, in turning portable crane hoist. Engraving: In returning to initial position when turning block in using block with mounted plate; in dotting, slight flexion (and ex- tension). Rug weaving: Changing sheds on Lane loom by use of over-head bar, throwing shuttle on Lane loom, use of syeater ma- chine (both wrists). Jewelry: In holding articles for buffing with Plato 23 Jewelry work as illustrated by patient at left offers many of the required movements of the hand and wrist. 30 OCCUPATIONAL THERAPY the electric buffer, in pulling of wire with tongs. Drafting: Slight extended position in holding ruling pen. Telegraphy: Extended position of wrist in telegraphing and slight movement of same. In Burroughs Adding and Listing Machine: In using lever. Modeling: Extension (and flexion) in constructing armatures in building up figures, heads, etc. Ward work: Flexion (and extension) in mak- ing Colonial mats, in weaving, painting, and book-binding. Gym- nastics, boxing, pulley weights, horizontal bars. Farm: In using farm tools, including hoe, rake, fork and spade. Miscellaneous: Plastering with trowel. Plate 24 Typical movements in rug weaving. IV. Elbow. Carpentry: Straightening of arm as required in planing, sawing, hanTmering with a heavy hammer and spikes, turning the handle in the post drill press. Machine shop: Shifting of lathe clutch lever, using card belt shifter. Engraving: S'ight extension (and flexion) Plate 25 Modelling, which offers varied movements of the thumb, fingers and wrist. Plate 26 Illusliation showing the finger movements in rug weaving. Plate 27 Two Curative Cases with marked left hand disabilities working at Gobelin Tapestry loom. Plate 28 Exercise in sawing the sandpapering involving the extension of the thumb and little finger of the left hand. APPLIED TO RESTORATION OF MOVEMENT 33 of left hand in making curves, of right, in dotting. Rug weaving: Use of beater on Lane loom, throwing shuttle through shed on Lane loom, tying of knots on Oriental Rugs, the amount of extension de- pending on the length of thread; use of sweater machine (both el- bows), winding of yarn, reaching up in changing sheds on Gobelin tapestry loom. Jewelry: Extension (and flexion) of elbow in pull- ing wire in hammering, slight extension (and flexion) in buffing with the electric buffer, in sawing. Drafting: In drawing lines up to ap- proximately three inches, in use of pantograph, machine sketching in general. Telegraphy: Slight, quick extension-flexion. Burroughs Adding and Listing Machine: Slight extension of right elbow in Plate 29 Orthopedic Cases at Work in the Greenhouses. manipulating lever. Modeling: Extension (and flexion) in model- ing, the amount of extension depending upon size and nature of work. Ward work: Turning the lever in the sock machine, pulling out long cords in making the Macrame belt, working with long reeds in basketry, winding the frame in a Colonial mat. Gymnasium: Gymnastics, boxing, wrestling, bag punching, ball games, horizontal bar, rowing machine, pulley weight. Farm: Garden work, such as separating and hand scuffling, shoveling, spading, raking, hoeing, using hand power horse rake. Miscellaneous: Writing with arm movement. 34 OCCl' RATION AL TH ERAPY V. Shoulder. Machine shop: Shifting of lathe clutch lever, using cord belt shifter, using hack saw, filing. Carpentry: Use of levers in post drill press. Rug weaving: Reaching to pull down thread in Gobe- lin tapestry loom. Jewelry: Slight extension (and flexion) in pull- ing wire and in hammering". Modeling: Slight shoulder movements in ordinary modeling, the amount varying with size and heaviness of work. Gymnasium: Climbing rope, horizontal bar, playing bas- ket ball, bowling. Farm: Hoeing, raking, sifting soil for green houses, cutting with axe. VI. Back. Carpentry: Movement from bending to vertical position as in planing, cross-cut sawing. Farm: Light farm work. Miscellane- ous: Rowing, gymnastics. VII. Hip. Carpentry: Work wThich requires use of foot lathes, jig saw or grindstone with foot power—all these adjusted for long and short strokes to increase the range of hip extension, long edge planing. Machine shop: In using foot power metal lathe, in using foot power grinder. Rug weaving: Slight extension in use of treadles in shift- ing sheds on Lane loom. Farm: Use of scythe. Miscellaneous: Walking, running, riding bicycle, pressing the foot lever of the print- ing press; use of nailing machine in shoe shop. VIII. Knee. Carpentry: In using all kinds of foot power machines, lathes, jig saw, grindstone, treadle machines where leg is forced to a straightened position. Machine shop: In using foot power metal lathe, and grinder. Rug weaving: In use of treadles in shifting sheds on Lane loom, use of foot treadle in machine for winding yarn, slight extension in use of sweater machine. Gymnasium: Gymnastics, dancing, various ball games, rowing machine. Farm: Use of horse rake. Miscellaneous: Using the potter's wheel with disc drive, in bicycle riding, walking or running. IX. Ankle. Carpentry: Bending foot downward as in use of treadle ma- chine. Machine shop: In using foot power metal lathe and grinder. Rug weaving: Use of treadle on Lane loom and shifting the sheds, use of treadle in machine for winding yarn, slight use of ankle in moving from side to side with sweater machine. Typewriting: Extension (and flexion) in using foot shift key in arm amputation cases. Miscellaneous: Bicycle riding, piano playing, walking over rough ground and down hill. X. Mid Tarsus and Toes. Same as ankle. Carpentry and machine shop: Special adjust- ments on the treadle machines, in garden work involving weeding, APPLIED TO RESTORATION OF MOVEMENT 35 transplanting or picking vegetables from bushes where a squatting position is required, work requiring standing on tiptoes. Gymna- sium: Games and exercises involving standing on tiptoes. Miscel- laneous: Dancing. Flexion. Definition and Illustration. Flexion is the bending of a joint. Closing the hand as in grasp- ing an object is an example of flexion of the finger joints. Move- ment of the wrist as in touching the inside of the forearm with the fingers, elbow as in bringing the hand to the face, shoulder as in raising the arm forward and upward (see note above), neck, back hip and knee as in picking up something from the ground, ankle (dorsal flexion) as in walking on the heels, toes and mid-tarsus as in bringing the toes toward the sole of the foot, are other examples of flexion. Examples, Shops : I. Thumb. Carpentry: Bending the thumb as in grasping any tool, the amount of flexion depending upon the size of the tool handle. Ma- chine shop: Grasping wrenches, hack saw, files, breast and hand drills and other tools as hammer and cold chisel. Strength of grip can be graded by size of tool, proportioned to the work. Gripping of tongs or rod in blacksmith work. Engraving: In using wooden block with mounted plate, small b'ock requiring flexion of all joints, of the right hand in using regular graver's block in dotting. Rug weaving: Reaching to pull down shed in Gobelin tapestry loom, holding of needle in weaving rugs, ho'ding comb for beating down knots, holding yarn in winding machine. Jewelry: In gripping all the tools (and extension in releasing them). A varied amount of extension in grasping tools with handles of various sizes down to the fine bits of stones, metals, etc., in holding block for soldering, in holding mouth blow pipe, in twisting wires, etc. Drafting: In grasping any drafting instrument. Telegraphy: In holding key. Modeling: In grasping tools and manipu'ating material. Gym- nasium: Gymnastics, boxing, baseball (batting), horizontal bars, pulley weights, rowing machine, fencing. Farm: Grasping any tool in garden or greenhouse work. II. Fingers. Carpentry: Bending fingers as in grasping all kinds of tools, the amount of flexion depending upon the size of the handle. Ma- chine shop: Grasping wrenches, hack saw, files, breast and hand drills and other tools as hammer, cold chisel, strength of grip be- ing graded by size of tool, proportioned to the work; gripping of tongs or rod in blacksmith work. Engraving: In making curves flexion of all joints in fingers of right hand, in using wooden block with mounted plate (see cut), flexion of metacarpo-phalangeal joints, small blocks requiring flexion of all joints; flexion of all fingers 36 OCCUPATIONAL THERAPY in using regular graver's block, flexion of right hand in firm grasp of tool in dotting. Rug weaving: Catching and pulling down thread in the Gobelin tapestry loom, holding of needle in weaving rugs, holding comb for beating down knots, holding yarn in winding machine. Jewelry: In gripping all the tools (and extension in releasing them). A varied amount of extension in grasping tools with handles of various sizes down to the fine bits of stones, metals, etc., in holding block for soldering, in holding mouth blow pipe, twisting wrires, etc. Drafting: In grasping any drafting instrument. Telegraphy: Flexion of third finger in hold- ing key. Typewriting: In grasping handle to turn roller, in strik- ing keys. Burroughs Adding and Listing Machine: Extension (and flexion) of fingers. Modeling: In grasping tools and manipulating material. Ward work: In practically all the hand crafts, the amount of flexion varying with the size of the object grasped, from the large handled pliers, punches, baskets, mat frames, to fine reeds, beads, needles, etc. Gymnasium: Gymnastics, boxing, wrestling, fenc- ing, baseball, rowing, pulley weights, wrist machine, dynometer (tests), squash (tennis). Farm: In grasping all kinds of tools. Practically all movements occurring in farm work. III. Wrist. Carpentry: Bending wrist toward inner side of arm as required iin wood carving, use of hand drill. Machine shop: Using breast drill, grinders, hand powrer drills. Engraving: In making curves (left hand), in working on large unmounted plate, flexed position of wrist, in using wooden block with mounted plate, flexion in turn- ing block, slight flexion (and extension) of right hand in dotting. Rug weaving: In turning bar in changing sheds on the Lane loom, use of handle on sweater machine, throwing shuttle on loom. Draft- ing: Sketching. Burroughs Adding and Listing Machine: In using lever. Gymnasium: Gymnastics, wrist machine, boxing, baseball, volley ball, medicine ball, horizontal bar, squash. Farm: Using sickle, sowing seeds, preparing soil by hand in greenhouses. Mis- cellaneous: Turning moving picture machine, painting. IV. Elbow. Carpentry: Raising forearm as in hammering large spikes with a heavy hammer, planing, filing, painting, sand papering, scrap- ing. Machine shop: Hack sawing, filing, hammering metal. En- graving: Slight extension (and flexion) in making curves with left hand, slight in dotting with right hand. Rug weaving: Use of beater in packing the rags on Lane loom, pulling reeds to change sheds on Lane loom, pulling down threads which open sheds in Gobelin tap- estry loom, use of sweater machine, guiding thread on spool ma- chine, untying knots in rug weaving, packing knots on small Ori- ental rugs. Jewelry: Hammering and sawing. Drafting: Use of pantograph, machine sketching. Telegraphy: Slight, quick flexion (and extension) in sending. Burroughs Adding and Listing Machine: Flexion (and extension) of right elbow in using lever. Ward w*)rk: APPLIED TO RESTORATION OF MOVEMENT 37 The hand crafts involving extension of elbow, involves flexion as well, tiymnasiu'm: Gymnastics, boxing, dumb bells, Indian clubs, hand ball, volley ball, medicine ball, pulley weights, fencing. Farm: In using scythe, rake, hoe, shovel, spraying with hand pump. Mis- cellaneous: In using hand pump, turning moving picture machine, writing with arm movement, piano playing. V. Shoulder. (Involves also forward and backward extension ab- duction-adduction.) Carpentry: Planing long boards, use of large hammer or axe, cross cut sawing. Machine shop: Working under automobile (reaching up), hack saw filing. Rug weaving: Reaching to pull down thread in Gobelin tapestry loom. Gymnasium: Gymnastics, volley ball, tennis, squash, pulley weights. Farm: Hoeing and rak- ing, digging with mattock, using flail, any work in raising the arm, such as picking fruit from over head. Plate 30 Telegraphy offers light exercise in the extension and flexion of partially ankylosed joints of the wrist. The first patient has an artificial right arm and a stiff wrist in the left. VI. Hip and Back. Carpentry: Flexion of back in planing long boards, in cross cut sawing. Of the hip in using foot lathes adjusted for long or short strokes to increase the range of hip flexion, use of foot lathes, jig saw or grindstone with foot power—all these adjusted for long and short strokes to increase the range of hip flexion, long edge planing. Machine shop: Of the back in automobile work in general. Note: Only slight flexion of back required in general ma- chine work. Of the hip in foot power machines, foot power at- _______________ ngRU- r^^B fc T T'i— ■mil ,< * m'. ">'*WI____a___fe_____95f HB ___*« i • ■§2l5ph nj ■■ -. 'Z5£k Btt^te____ "_B* •■■113 ■'■' ;-A e_r:i>e^J'--iL.- ■£ ■ i_V 11 ^ «A V 5^ ^-A^-:■." \^m'^ * ' "U f'A" ^H "SB 1 I Plate 31 M. G. at work on Lane Loom showing extension of wrist and elbow and flexion of fingers in grasping the beater. Plate 32 Curative exercise in planing fo? injury to the left wrist. Plate 33 Curative work requiring flexion, extension of stiffened elbow. Plate 34 There is little movement in this patient's left arm and fingers. Wood carving gives light exercise. Plate 35 Work requiring pronation and supination of fore arm of right arm and flexion of fin- gers of left hand as illustrated by case at left of picture. 40 OCCUPATIONAL THERAPY tachments to emery grinder, lathe. Rug weaving: Slight flexion of the back in fitting loom on table. Of the hip, slight, in use of treadles in shifting sheds on Lane loom. Gymnasium: Of the hip in gymnastics, walking and dancing, and any active game. Farm: Light farm work which requires stooping of the back. Picking flowers and vegetables or any work which requires squatting; of rtie hip, use of horse rake. Miscellaneous: Back, rowing; hip, walk- ing, running bicycle riding. VII. Knee. Carpentry: Use of all kinds of foot power machines, lathes, jigsaw, grindstone, treadle machines where leg is forced to a straightened position. Machine shop: Use of emery grindstone with foot power attachments, (any foot power machinery, such as lathe or grindstone). Rug weaving: Use of treadles in shifting sheds on Lane loom, use of foot treadle in machine for winding yarn, Plate 36 Left hand planing for flexion-extension of «lbow. APPLIED TO RESTORATION OF MOVEMENT 41 slight extension in use of sweater machine. Gymnasium: Gymnas- tics, walking, dancing, almost any game. Farm: Weeding, pick- ing low-growing flowers and vegetables. Miscellaneous: Using the sewing machine, foot power printing press, bicycle riding, walk- ing, running, using the potter's wheel with the disc drive. VIII. Ankle. Carpenter Shop and Machine Shop: Use of all foot power machines. Rug weaving: Ankle and toe in sweater machine (movement from side to side). Gymnasium: Gymnastics, almost any game which requires foot work, dancing. Farm: Garden work which involves weeding, transplanting, or picking vegetables from low bushes. Miscellaneous: Bicycle riding, piano or pianola playing, sewing machine. IX. Toes and Mid-Tarsus. Carpentry: Treadle machine with especially blocked or hinged treadle, somewhat involved in all movements. Listed under ankle flexion. Abduction, Definition and Illustration. Abduction is movement away from the body as the outward movement of the fingers or wrist with the palm up and thumb out, Plate 37 Light treadle work with specially prepared treadle for extension of the right ankle. Plate 38 nalient with disabled knee working on a specially adapted grindstone. Plate 39 Light treadle work with specially prepared treadle for extension of the right ankle. APPLIED TO RESTORATION OF MOVEMENT 43 shoulder movement as in raising the arm sidewise or in moving the arm back of the body (lateral abduction backward extension or "backward" movement by Piersol), hip movement in sidewise out- ward movement of the leg. Abduction of the ankle as in walking on the inside edge of the foot is sometimes called eversion. Examples, Shops : I. Thumb. (Also involves extension.) Carpentry: Abducted position of the thumb in guiding wood on the scroll saw. Machine shop: Holding sheet metal while trac- Plaie 40 Special work in planing for a case with sacroiliac sprain. ing design for cutting. Engraving: Holding mounted plate, Rug weaving: Turning thumb outward as required in separating alternate threads of the woof and warp of the Gobelin tapestry loom. Jewelry: Abducted position of thumb in holding soldering block, abduction (and adduction) of thumb in placing metal on pitch for shaving and repousse work. Typewriting: Of right thumb in use of space bar: Gymnastics: Abduction ( and adduction) of thumb in gymnastics, calisthenics, medicine ball, volley ball, hand ball. Farm: Potting plants. Miscel'aneous: Setting glass. 44 OCCUPATIONAL THERAPY II. Fingers. Carpentry: Abducted position in guiding wood on scroll saw, holding board in sawing (see cut). Machine shop: Holding sheet met- al while tracing design for cutting. Engraving: Abducted position of fingers in holding unmounted plate. Jewelry: Holding flat piece of metal in cutting and in planishing. Drafting: Holding sheet of paper while erasing. Typewriting: Use of fifth finger to operate shift key, very slight abduction (and adduction) of other fingers. Burroughs Adding and Listing Machine: Slight abduction, especially of second and third fingers. Gymnasium: Gymnastics, hand ball, volley ball, medicine ball. Farm: Preparing soil in greenhouses. Plate 41 Specially adapted machine for long or short stroke for flexion-extension of knee and ankle. Pvt. L. has little movement and is using short stroke. _ APPLIED TO RESTORATION OF MOVEMENT 45 III. Wrist. Carpentry: Abduction (and adduction) in hammering with light hammer, using lathe. Machine shop: No special machine, but variety of tools. Engraving: Abduction in turning plate, and ad- duction in returning to initial posiion in making curves in work- ing on large unmounted plate, slight abduction in dotting. Rug weav- tea*- Plate 42 J. H. at work on SQroll-saw for extension-flexion of knee. This machine can be used in cases where there is too little knee motion to allow the work to be done in a sitting position. ing: Slight abduction in flattening rags for rugs, in combing rugs. Jewelry: Abduction (aid adduction) of wrist in polishing by hand with emery and rouge papers, turning wire around a mandril to make links for chains, in using mandril for burnished work. Draft- ing: Cartooning, sketching, illustrating. Gymnasium: Gymnas- 40 OCCUPATIONAL THERAPY tics, dumb bells, Indian clubs, punching bag, boxing, pool, fencing. Miscellanous: Writing on blackboard. Ward hand crafts: Holding of rake in rake knitfing, punching in brass work. IV. Shoulder. Machine shop: Lateral abduction (and adduction) with hand bellows, in the lever forge, slight in valve grinding in raising to draw abrasive substance in place. Engraving: Making curves, in work- ing on large unmounted plate, abduction of left shoulder, slight in extent, but with a good deal of strength demanded, if the elbow is held away from the table and the movement controlled from the shoulder, in making curves slightly abducted position of right shoul- der, in "wriggling" slight abduction of right shoulder. Dotting, slight abduction-adduction of right shoulder, movement quick, snap- Plate 43 Specially adapted machine for long or short stroke for flexion-extension of knee and ankle. An example of use of long stroke. APPLIED TO RESTORATION OF MOVEMENT 47 py, but not as strong as in other movements. Rug weaving: Lateral abduction (and adduction) throwing shuttle of sweater machine, in passing rags through sheds on Lane loom. Typewriting: Gym- nasium: Gymnastics, ^Indian club, dumb bells, punching bag, medicine ball. Ward hand crafts: Pulling out cords in macrame belt, pulling reeds through basket. V. Hip. Rug weaving: Standing before and using the hand lever of sweater machine. Gymnasium: Gymnastics, volley ball, hand ball. VI. Ankle. Use of all kinds of foot pwer machines, especially those with velocipede treadles, or of specially tipped pedals to throw the foot upon the inner edge. Adduction, Definition and Illustration. Adduction is movement toward the body. Inclining the right or left hand toward body with palm up, thumb out is wrist adduction (ulner flexion.) Spreading fingers or toes when the movement is to ward the body, moving the shoulder in lowering the arm sidewise or in bringing the arm across the breast (lateral adduction, "forward movement" by Piersol); with hip sidewise moving the leg toward the median line of the body, are examples of adduction. Adduc- tion of the ankle as in walking on the outside edge of the foot is sometimes called inversion. Examples, Shops : I. Thumb. (Involves flexion.) Shops: Adducted position of thumb in grasping tools, amount of adduction varying with the size of the tool. Typewriting: Right thumb in return from using the space bar. Gymnastics: Adduc- tion (and abduction) of thumb in gymnastics, calisthenics, medi- cine ball, volley ball, hand ball, II. Fingers. In shops: Bringing fingers together as in use of tools with small handles. Farm: Preparing soil in greenhouses. III. Wrist. Carpentry: Adduction (and abduction) in hammering with light hammer and in use of lathe. Machine shop: No special ma- chine, but in general use of tools. Engraving: In return to initial position in making curves in working on large unmounted plate. Rug weaving: S'ight adduction (and abduction) in flattening rags for Colonial rugs. Jewelry: Adduction (and abduction) of wrist in polishing by hand with emery and rouge papers, turning a wire around a mandril to make links for chains, using mandril for burnished work. Drafting: Cartooning, sketching, illustrating. Gymnastics: Dumb bells, Indian clubs, punching bag, boxing, pool, 48 OCCUPATIONAL THERAPY fencing. Miscellaneous: Writing on blackboard. Ward hand crafts: Brass punching. IV. Shoulder. (Adduction rare.) 0 Carpentry: Slight adduction in planing. Machine shop: Lat- eral adduction (and abduction) in use of hand bellows in the lever forge, slight in valve grinding, in reaching to draw abrasive sub- stance in place. Engraving: In "dotting," slight adduction-abduc- tion of right shoulder. Rug weaving: Lateral adduction (and ab- duction) throwing shuttle in use of sweater machine, passing rags through sheds on the Lane loom. Farm: Using scythe. Gym- nasium: Indian clubs, dumb bells, punching bag, medicine ball. Miscellaneous: Wigwag signalling. Ward hand crafts. V. Hip. Rug weaving: Standing before and using the hand lever of the sweater machine. Gymnasium: Gymnastics, volley ball, hand ball. Miscellaneous: Dancing, covering seed with foot. VI. Ankle, Toes and Mid-Tarsus. Use of all kinds of foot power machines, especially those with velocipede treadles, or specially tipped pedals to throw the foot upon the outer edge. Pronation and Supination, Definition and Illustration. Pronation is the movement of the forearm in turning the palm of the hand down, to the rear in the erect position. Supination is the movement of theforearm in turning the palm up, to the front in the erect position. Examples, Shops: Carpentry: Using screw driver with the screw horizontal, us- ing turning tools, such as gimlet, awl. Machine shop: Use of screw driver and reamer, grinding valves. Engraving: Slight in working on large unmounted plate making curves, in "wriggling," prona- tion-supination of wrist-elbow, not of wide amplitude, but requiring regular steady movement. May be done quickly or slowly. Rug weaving: Separating alternate threads of the warp of the Gobe- lin tapestry loom, tying knots in Oriental rug making, throwing shuttle (slight), pulling rag through in hooked rug. Jewelry: polishing and finishing jewelry by hand (jewelry being held in the other hand), in pulling and twisting wires filing concave surfaces, in the finishing process with polishing powrder. Modeling: Us- ing horizontal movements. Gymnasium: Gymnastics, boxyig, bag punching, various ball games, tennis, tether ball. Farming: Spad- ing, troweling. Circumduction, Definition and Illustration. Circumduction is a circular swinging movement as in twirling the thumbs or fingers, revolving the wrist or ankle, moving the APPLIED TO RESTORATION OF MOVEMENT 49 shoulder as in the full arm swing, or swing the leg and hip. (A combination of flexion, abduction adduction.) Examples, Shops: I. Thumb. Shops: Work on the Gobelin tapestry loom. Turning small carrier wheel on lathe. II. Fingers. Jewelry: Movement of fingers and thumb in polishing and burnishing. III. Wrist. Machine shop: Valve grinding with special valve grinding tools. Jewelry: Twisting wire around a mandril to make links, wiring jewelry for soldering, in grinding of enamel in mortar and pestle. Ward hand crafts: Especially rake knitting and basketry. IV. Shoulder. (Adduction, rare.) Machine shop: Turning cranks with large handles. Rug weav- ing: Use of sweater machine. Drafting: Sketching in large free hand drawing, movements as in cartooning. Gymnasium: Gym- nastics, tennis, volley ball, hand ball, boxing, bag punching. Farm: Use of fork, scythe and shovel. Blackboard writing. V. Hip. Gymnastics, ball games, soccer, foot ball, dancing. VI. Ankle. Use of special foot levers, games and dancing. Rotation, Definition and Illustration. Rotation is turning or twisting around an axis as in twisting the shoulder in turning a door knob with the elbow and wrist relatively rigid, twisting the neck, or the hip in moving the toes outward or inward with the knee and ankle relatively rigid. Rotation is some- times not distinguished from circumduction. Note: Rotation involved in practically all the occupational ac- tivities in which circumduction is present. General Note: In the majority of tools in the machine shop, strong gripping is required. In the process of jig sawing, die and tool making, a delicate touch is applied. Oxy-acctylene welding, involves practically all movements of fingers, wrist, elbow and slight movements of shoulder in lowered position. Back, hip, knee, ankle, toes and mid-tarsus movements are involved only in standing and moving around. Lever forge, in- cludes extension-flexion of elbow, extension-flexion of back, adduc- tion and abduction of shoulder. In rug weaving, there are involved practically all movements of the thumb, fingers, wrist and elbow, with slight shoulder movements in the making of the Oriental rugs. 50 OCCUPATIONAL THERAPY Examples taken from jewelry are from the finer bench work. Larger and stronger movements would be taken up in a shop equipped with gas are, hip, knee, ankle, mid-tarsus and toe move- ments would be involved in doing all the larger work, especially with the foot bellows, foot rheostat and enameling furnace. In modeling, are brought in all of the movements of thumb, fin- gers, wrist and elbow in a non-intensive form, the amount of exertion varying according to the size and heaviness of the material. Move- ments of shoulder come in very slightly in moderate sized work, but but these can be extended in margin or increased in strength by the size and heaviness of the work. Back, hip, knee and ankle move- ments are incidental only, except in large figures where it is neces- sary to stand and move about in the work. In farm and automobile work, there are involved practically all movements of all parts of the body. In these two departments, it is more difficult to assign the patient to a limited and special move- ment, but in the course of time, the desired movement is bound to recur, and the desired exercise is eventually obtained. The general nature of these, both from the orthopedic and the mental point of view, must be considered in making the assignment, whether to the more monotonous and specific curative work, or to the more general type. VII. A Preliminary Type Study of Joint Movements in- volved in Planing on Long Board, Jack Plane. (Bight-handed Worker. See Plate 40, Page 43.) Hand. The fingers of the right hand, which grasps the handle of the plane, are all flexed and rigid; little movement in these fingers. The amount of flexion may be changed by varying the size of the knob. A few workers grasp the handle of the plane in a way which involves the extending of the index finger and the thumb. The fin- gers of the left hand, which aids in guiding the plane, are all flexed, but the amount may be modified by changing the size of the knob. Wrist. One of the most conspicuous movements of the wrist is the abduction in the right wrist—the amplitude and intensity of the abduction varying with the length of the path of the plane, i. e., with the length of the board planed or with the type of plane used; there is also a slight extension of the right wrist. There is an abduc- tion and an extension of the left wrist, but of less degree than in the right. Elrow. The right elbow is very active, its movements consist- ing of extension-flexion, with a slight supination. The movements of the left elbow are primarily extension-flexion. Shoulder. Both shoulders are actively involved in planing; the movements are extension-flexion, adduction and a slight rotation— these movements being of greater amplitude and intensity in the right shoulder than in the left. APPLIED TO RESTORATION OF MOVEMENT 51 Back. There is a marked extension-flexion of the back which is particularly conspicuous in the lumbar region and the shoulder region. These movements are more extended when the path of the plane is long, as in planing a board four feet or more in length. Hips. A slight extension-flexion in both hips, increasing in amplitude with the increase in length of the board planed. Knee. Extension-flexion in the left knee, little or none in the right. Feet and Ankles. Marked extension-flexion in left ankle, es- pecially when the board is long; relatively slight in right. Exten- sion-flexion in ball of left foot; slight extension-flexion in ball of right foot when path is short, very great when path is long. In planing a very short board—six inches or less—the move- ments may be confined to the arms. When the board is lengthened to two feet, the shoulders and back are more involved in the move- ments. And when the board is lengthened to three feet or upwards, intensive movements of the legs and feet are involved. These move- ments may vary with the characteristic types of motor coordinations of different individuals and the type of planes used. Preliminary Type Study of Joint Movements Involved in Engraving. (Right Hand). (Study made from one subject, engraver by trade.) I. In Making Curves. A. Right. 1. Fingers. (In holding tool). Flexion of all joints. 2. Thumb. Extension of interphalangeal and meta-carpo-phalan- geal joints; used in guiding tool. 3. Wrist, elbow, shoulder rigid. Slightly abducted position of shoulder. B. Left. 1. In working on large unmounted plate. Plate 44 Sketch showing position of thumb and fingers of right hand in holding tool in engraving. <>- OCCUPATIONAL THERAPY a. Fingers. Extension of all joints of all lingers; abduction of fingers. b. Thumb. Abducted. c. Wrist. Flexed position, with abduction in turning plate, and adduction in returning to initial position; steady, slow, con- trolled movement. d. Elbow. Slight extension-flexion; slight pronation-supina- tion.* * e. Shoulder. Abduction slight in extent but with a good deal of strength demanded, if the elbow is held away from the table and the movement controlled from the shoulder. (See right hand worker in cut.)** 2. In using wooden block with mounted p'ate. (See cut). a. Fingers. b. Thumb. Flexion of metacarpophalangeal joints; extension of inter-phalangeal joints of fingers and thumb, the amount of extension depending upon the size of the block used, small blocks requiring flexion of all joints. c. Wrist. Flexion in turning block, extension in returning to initial position. d. As above. (No pronation-supination.) (B. I. d.) e. As above. (B. I. e.) 3. In using regular graver's block. a. Fingers. Flexion of all fingers and thumb. b. As above. (B. I. b.) d. As above. (B. I. d.) e. As above. (B. I. a.) II. In "Wriggling." A. Right. 1. Fingers. Flexion in holding too!. Sketch showing extension of fin- gers and thumb and flexion and abduction of wrist of left hand in engraving. See section VII. B, I, a, b, c. APPLIED TO RESTORATION OF MOVEMENT 53 2. Thumb. Extension of interphalangeal and metacarpo-phalangeal joint, adducted position of thumb in guiding tool. 3. Wrist-Elbow. Pronation-supination, not of wide amplitude, but requiring regular steady movement. May be done quickly or slowly. 4. Shoulder. Position of slight abduction. B. As above, in use of the three types of holder. III. Dotting. A. Right. 1. ringers and thumb. Flexion in firm grasp of tool. 2. Wrist. Slight flexion-extension; adduction-abduction. 3. Elbow. Slight extension-flexion. 4. Shoulder. Slight abduction-adduction; movement quick, snappy, but not as strong as in other movements. * "Example of adaptation to disability by making shorter curves with wrist movement only, and elbow and forearm resting on table. VIII. Peripheral Nerve Palsies CAUTION—The principles of curative therapy, as outlined for stiff joints are not applicable to peripheral nerve palsies without distinct modifications, since in all palsy the muscles are paralysed and can be over-stretched easily by wrong exercise. The over- stretching of a paralysed muscle invariably results in irreparable damage. Care should be taken that all cases taking curative therapy wear splints, so constructed as to prevent over-stretching of muscles, but no splint can be made strong enough absolutely to prevent ex- treme force from causing damage. In nerve lesions only the gentler forms of exercise should be used, and all heavy work avoided. A few general types of occupational activities to be used in peripheral nerve palsies, may be cited here: MUSCLES. 1. Muscle-Spiral. Typewriting, typesetting, rug-weaving, piano-playing, adding ma- chine, mechanical drafting. 2. Ulnar. Flexion of metacarpophalangeal joints of all fingers, extension of the two inter-phalangeal joints. Scroll saw, etc. (with mtacarpophalangeal joints safeguarded by splint). Carving, engraving, etc., which gives gripping of light tools. 3. Median. Flexion of thumb and index finger, with care not to over-stretch. Grasping of light tools in light jewelry, basketry, etc. 4. Sciatic. No specific curative work. Avoid active treadle work and long standing. 54 OCCUPATIONAL THERAPY 5. External popliteal (foot drop). Foot treadle work, safeguarded by right angle stop splint. Pvt. W. C. E.—Fingers, Wrist and Elbow. Diagnosis: G. S. W. (a) Amputation arm, right middle lower third. Healed. (b) Elbow left limited motion, (c) Forearm left, fractured ulna, involving musculo-spiral and ulna nerves. Prescription: Flexion—extension of thumb, fingers, elbow. Assignment: To rug weaving. The left arm was confined in a lock-up splint which made the tying of the knots in the actual rug weaving impossible. He was therefore given the spooling of yarn upon a machine where the heavy work was in the treadle and the hand was used only for starting the wheel and guiding the thread. Progress: At first, he could not hold the thread, which was therefore passed around a large spool which he could grasp and use for guiding. The holding and releasing of this gave flexion-exten- sion of the fingers and the movements backward and forward in guiding the winding on the large spindle gave flexion-extension of the elbow. In addition to the regular curative exercise which he did for one-half hour each day, he spent two or three hours a day in the shops reading and studying rugs, as he intends to take up the business as a salesman. The arrangement of the splint made it im- possible to take accurate measurements of his improvement, but he was able, after two or three weeks, to use his hand sufficiently to hold his fork; and whereas, when he began the work, he could not bend the elbow enough to get the hand less than six inches below the chin, he was able at the later time to get his hand to his head. IX a.—A Partial List of Selected Tools of Special Curative Value, Arranged in Order of Joints Concerned The aim is to use standard tools and machinery and to fit spe- cial appliances necessary to obtain the desired movement. The size of the handles of all hand tools may be readily changed by the use of ordinary dental modelling composition. Each type of case pre- sents a new or modified problem. I. Fingers and Thumb. a. Ward Occupations Department. Clippers, pliers, scissors, eyelet punch, leather tools, typewriter, carving tools, rake, knitting needles, braid mat frame, bead loom, belt loom, Persian rug loom, tapestry loom, braid loom, crotchet hook. b. Oriental Rug and Textile Department. Hand looms, combs of various sizes and shapes; needles, long, short, straight and curved; paddles and sheds fitted with handles of dif- ferent sizes and shapes, spherical, oblate, spade, curved, twisted; tapestry looms, sweater machines. APPLIED TO RESTORATION OF MOVEMENT 05 c. Engraving Department. Gravers with handles ranging in diameter from seven-eighths of an inch to one and a half inches; engraving blocks ranging from one inch to three inches in length; practice plates involving a span of the worker's hand ranging from one inch to live inches; hand vises; compasses and dividers, handles enlarged and fitted to hand by use of dental modelling composition. d. Jewelry and Metal Work Department. Hammers and mallets of various sizes and weights, with handles whose diameters range from one half inch to one and a quarter inches; pliers and tweezers of various forms ranging in span from one-eighth of an inch to two and one quarter inches; chasing tools, hand vises; snips; burnishing tools. e. Mechanical and Electrical Department. Hand wrenches of various sizes, shapes and weights, (four to twelve inches in length, eight to thirteen ounces in weight) bolts and nuts of a wide variety of size; cold chisels of various sizes; hammers from eight to thirteen ounces in weight; screw drivers; auto jacks; vises; soldering irons; tap wrenches, pliers and nippers, elec- tric wiring tools. f. Woodworking Department. Hammers of various weights and with handles of various sizes rang- ing in diameter from three-quarters of an inch to two inches; chisels with handles varying from three-quarters of an inch in diameter to two inches and a half; mallets of different weights; screw drivers of various sizes; carving tools of numerous sizes and forms; saws; planes; oil stones; draw knives, special knobs and grips for planes, made by enlarging regular handles by use of dental modelling com- position, compasses; gauges and vises. II. Wrist and Elbow. Most of the tools and appliances already listed under the several departments involve movements which are not limited to the hand and fingers, but also involve movements of the wrist, elbow and other joints of the body. The present list attempts to mention under each heading only those tools and appliances which are most appropriate for curative wrork with each joint under our main heading. a. Ward Occupation Work. Cardboard cutter; colonial mat frame; sock machine; sand paper; rug hook; harness needles; wonder weaver loom; block print tools. b. Oriental Rug and Textile Department. Reeds provided with hinged, swinging and frictional devices for push and pull; sheds adapted for various corrective motions; pad- dles, combs; spinning wheel and distaff equipped with various spe- cial appliances, looms, winding machines. c. Engraving Department. Gravers tools, hand vises, oil stones, compasses and dividers. d. Jewelry and Metal Work Department. Hammers and mallets, chasing tools, hand vises, pliers, tweezers, snips, scissors, files, burnishing tools, soldering outfit, oil stone. 50 OCCUPATIONAL THERAPV e. Mechanical and Electrical Department. Wrenches; hammers, files, vise, breast drill, auto jack, hack saw, auto chassis; hand auto pump, soldering outfit, tap wrenches, ma- chine tools with handles, hack saws, sensitive drill, hand shears, punching machine. f. Wood Working Department. Hammers, saws, planes, drawing knife, hatchet, brads awl, spoke shave, screwdriver, brace and bit, hand drill, whetstone, saws, plane, carving tools, chisels, compasses and dividers, hand emery wheels, mitre box, wood clamps and metal clamps, gauge, vises, wood turn- ing lathes, mallets, sand paper, rasps, hand power post drill presses. III. Shoulder. a. Ward Occupational Department. Clothes wringer, block printing, saw, cardboard cutter, wonder weaver loom, braid loom, Slovd knife, colonial mat frame, carving tools. b. Oriental Rug and Textile Department. Paddles, reeds, sheds, looms, spinning wheel, distaff. c. Engraving Department. Gravers, engraving blocks, oil stones, dividers and compasses. d. Jewelry and Metal Work Department. Hammers and mallets, hack saw, files, chasing tools, burnishing tools, vises, pliers, tweezers, snips, soldering outfit, burnishing tools. e. Mechanical and Electrical Department. Wrenches, hamers, files, hack saws, breast drills, auto jacks, hand auto pumps, vises, tap wrenches, belt shippers, hand drill, electric wiring, hand-blown forge. f. Woodworking Department. Hammers, saws, planes, drawing knives, hatchets, screw drivers, brad awls, chisels, wood carving tools, brace and bit, hand drills, hand emery wheels, clamps, vises, rasps, sand paper, vertical hand drill- ing machines, for crank and lever motion. IV. Back. b. Oriental Rug and Textile Department. Looms, spinning wheels, distaff. e. Mechanical and Electrical Department. Hand auto pump. f. Wood Working Department. Planes, draw knife, with shaving bench, brace and bit, saws, sand paper. V. Hips. b. Oriental Rug and Textile Department. Treadle looms, spinning wheel, distaff, winding machines, sweater machines. e. Mechanical and Electrical Department. Auto jacks, hand auto pumps, lifting machines and materials. f. Wood Working Department. APPLIED TO RESTORATION OF MOVEMENT 57 Planes, saws, shaving benches, treadle lathes, with varying strokes, treadle grindstones, jig saws and scroll saws, planer. VI. Knee. a. Ward Occupation Department. Treadle looms, jig saws. b. Oriental Rug and Textile Department. Treadle looms, treadle spool winding, sewing machines. e. Mechanical and Electrical Department. Auto Jack; foot power lathes. f. Wood Working Department. Planes (long boards) shaving benches, foot lathes of varying strokes, jig saws, scroll saws, grindstones, foot mortising machines. VII. Ankle, Mid-Tarsus and Toes. a. Ward Occupation Department. Treadle looms, jig saws. b. Oriental Rug and Textile Department. Treadle loom, spinning wheel, distaff, sewing machines. e. Mechanical and Electrical Department. Auto Jack, foot power lathes. ' f. Wood Working Department. Foot lathes of varying strokes, shaving benches, grindstones with adjustable connecting rods, (foot power) jig saws, scroll saws, foot mortising machines, power mortising machines. Plate 46 Specially adapted handles made from dental modeling wax. > B___ *wl!____! mM^V^W 'Qj__L&A!______ ■B llSi r> i 5i Itt f£>* a*. ___ ^^a. jjr.m, — .,!, Plate 47 Specially adapted foot power machines for exer- cise of ankle, knee or hip. Plate 48 A project representing varied light movements made by patient with disabled right hand and forearm. APPLIED TO RESTORATION OF MOVEMENT 59 X Type. Cases Pvt. C. B. I. Personal and Educational History. Supply Company 100. Age 20. Eighth grade. Left at the age of 10 years. Unskilled laborer. Cabinet making. Brakeman on railroad. Future occupation, railroad inspector. Personal history, good. No venereal disease. Enlisted May 30, 1917. II. History of Disability. July 17, 1918, while in action on Lorraine front was hit by rifle bullet in left hand. July 17. Evac. Hosp. No. 2. Operation debriement of wound. Suture tendon sheaths. Removal of spiculae bone. August 1, fingers partially flexed. August 3, surface wound healing, unable to flex ring and little finger of left hand. Unable to extend middle and index finger. August 10, surface wound healed. Unable to use fin- gers. Pyroderma developed, condition of fingers not improved. Pyroderma improved August 25. August 30, Base No. 0. Surface wound healed with limitation of movement of hand. September 22, Base No. 8. Hand still in splint, though wound is healed. Condition on admission to this hospital: Left hand healed at base of all fingers on outer surface. Fingers cannot be made to form a first and are stiff. Diagnosis: Healed gunshot wound, left hand, palmar surface with little contraction. Massage, hydro-therapy and exercise daily. X-Ray report: O-Fracture, proximal end of proximal phalanges of 2, 3, 4, 5 fingers. October 29. Union is present with deformity of 2, 4, 5 proximal phalanges. November 20. Finger shows some improvement, but stiff. December 1. Since admission finger has improved. Present treatment continued. III. Occupational Therapy. Prescription for work in curative shops for flexion of fingers sent in October 24th. Assigned the same day to carpentry, where his first project was edge planing and sawing in making a file box, the handling of tools requiring flexion and extension of the fingers. At his own request, he was also assigned to one hour a day of type- writing as supplementary curative exercise. In this work there is finger extension and flexion, the exercise fostering dexterity rather than the strength given by the carpentry. An hour massage daily completed the curative program. His attitude throughout has been one of keen interest in his improvement. At first specially adapted tools were used in the carpentry to increase the flexion and extension of the fingers. In the planing work, the patient used diif- with the left hand. An enlarged hammer handle with fingers ferent sized knobs, ranging from 1% to 3M> inches, holding the knobs 00 OCCUPATIONAL THERAPY strapped made it possible for him to grip the hammer firmlv and do the nailing with the left hand. These special devices were soon dropped, and the saw, hammer, mallet and chisel of ordinary sizes were used in the making of a large filing cabinet. The week before Christmas, toy airplanes and a set of doll's furniture which he made required the handling of finer tools. All of his spare time was spent in the woodshop. In typewriting, he was gaining in strength and endurance in the use of his left hand. He could reach every key with proper fingering, and one day worked 90 minutes without tir- ing. In addition to this he has done curative work in his ward. The measurements of voluntary movements taken in the psycho- logical laboratory from November 27 to December 19 show a gain in range of flexion-extension in degrees as follows: 3rd Joint 2nd Joint 1st Joint (Distal) (Interphalangeal) (Metacarpophalangeal) II Finger.......18.0 22.4 15.6 III Finger.......24.5 25.8 7.3 IV Finger....... 3.2 29.3 7.3 V Finger....... 0.4 5.0 2.7 The third joints of the fourth and fifth fingers were still in- capable of complete extension when the patient was transferred to a convalescent camp. Pvt. J. S., Co. B, 166th Inf. I. Personal and Educational History. Third grade school, completed schooling at 10 years of age. Main occupation, farming. Future occupation, farming. II. History of Disability. July 21, 1918, while fighting at Chateau Thierry, wounded by high explosive on forearm. Admitted to dressing station, then to Field Hospital No. 4, then to No. 7. Then to Paris, then to Vichy, then to New York. General health good. Field Hospital No. 108. Compound fracture left elbow, gunshot wound penetrating left el- bow. Base Hospital, F. C. C. Ulnar left on junction of lower mid- dle third. Field 168, July 28. Redressing. Gunshot wound multiple, large wound on left forearm inner side. C. C. F. left ulnar three inches above wrist. Debriement Base 19. Gunshot wound, possible fracture. August 13. X-Ray. Base 155. F. C. C. Junction lower and middle thirds. U. S. A. Debarkation on Ellis Island. Arrived October 2 for No. 2, Saten Island. Departed October 21 for Walter Reed. Admitted October 21. Nov. 3. Massage, hydro-therapy, exercise daily. X-Ray. Fracture through lower and middle third of ulnar. Small metallic fragment is present. Bones of wrist show consider- able lime and salt absorption. APPLIED TO RESTORATION OF MOVEMENT 61 III. Occupational Therapy. Diagnosis, Oct. 24: Gunshot wound, left elbow and forearm. Compound fracture ulna. Unhealed. Slight limitation motion. Sent to the curative workshops for flexion-extension of thumb, finger, wrist, elbow, with the caution that over use of elbow was to be avoided. He was assigned to the rug weaving department, where the tying of the Turkish knot would involve finger and wrist move- ments, with the avoidance of strong elbow movements. He was also assigned to typewriting at his own request, and because in this he would gain dexterity of finger movement. He was from the first, regular in his attendance at his daily appointment and soon asked for an extra hour in the afternoon. Shortly after this, he asked that he be allowed to drop the typewriting in order to devote all his time to the rug work, which he believed was the best exercise for his hand, and in which he had become so much interested that he was considering taking it up as a vocation. He completed one small rug made with the Turkish knot and has begun his second with the more intricate Persian knot, while the healing of the wound made it possible for him to bring in the elbow motion which he had form- erly avoided. Worked constantly until the time of his trans- fer to convalescent camp on Jan. 9, 1919. Measurements of the range of voluntary extension-flexion of the finger joints showed im- provement, typified by the figures for the distal joint of his fourth finger, given in Table Case III. Private S. F., Co. C, 7th Inf. I. Personal and Educational History. Twenty-six years of age. Seven grades. Left at the age of 17 years. Main occupation, farming and tool factory. Future occupation, probably will return to farm. General health, good. II. History of Disability. In action in Chateau Thierry, received shrapnel wound right forearm and right lower chest wall. July 14, 1918. Admitted July 16, American Red Cross Hospital, France. Gun shot wound, multiple, right side. General wounds right, with gun shot wound right fore arm. Gas gangrene chest and fore arm. Radio artery cut. X-Ray negative. July 26, Base No. 6, multiple perforating wound right up- per forearm. Daykns tubes in situ. Possible nerve injury, weak- ness of right wrist and hand. Some numbness. Right side of chest wall, dirty, lacerating, granulating wound. Aug. 1. Operation. Base No. 114. Aug. 24. Wounds practically healed. Requires mas- sage. Sept. 11, all wounds healed. Dropped splint to hold forearm. Base No. 8, Sept. 28. All wounds healed. Wrist drop, right forearm stiff and patient unable to supinate it. Oct. 9, left for port of em- barkation. Base No. 8. Sept. 28. Arrived Walter Beed Hospital Oct. 24. 62 OCCUPATIONAL THERAPY Diagnosis: Wound on chest healed, elbow motion good. Sup- ination of forearm normal. Three healed scars on outer and inner aspects, upper third right forearm. Can make fist and fully extend fingers. Gun shot wound, multiple, penetrating right forearm. X-Ray report: No signs of any injury to bones of forearm. Bones of wrist show some salt absorption. III. Occupational Therapy. On November 2, patient was assigned to curative shops for flexion-extension of thumb, fingers and wrist. An hour's work each day was to be taken in the jewelry shop for curative purposes, while the afternoon was to be spent at the farm where the vocational would be united with the curative. In the metal work, he was given the pulling of copper wire which requires strength and flexion in the fingers, and extension in the releasing and changing of the tool. In the hammering out of rings from French coins, elbow extension- flexion was acquired. At first, work was changed every fifteen min- utes to avoid fatigue. As his grip improved, he was able to handle the small saw, and in sawing out a silver ring with open work pat- tern and his initial in it, he gained in flexion of fingers by grasping the handle, in wrist extension-flexion and elbow extension. The filing required holding very small tools and in this it was at first necesary to utilize the left hand as aid. The patient asked to be allowed to give up the farm work, as he felt that the metal work wras more curative and that all his time should be devoted to it. He now spends afternoon as well as morning at the shop. Measurements of the voluntary movements taken in the laboratory have given to the patient from day to day the actual figures of his improvement. For example, in one month he gained 44.2 per cent in the movement of the third joint of the 4th finger over the initial measurement. (See Case IV Table.) XI. Supplementary Comments. The preceding section of this Monograph indicates the pro- cedure in the treatment of stiffened joints, followed in the Cura- tive Shops in the Walter Reed General Hospital. The method has been worked out inductively to meet situations as they arose; but the system as presented here offers a program attained in many, but does not include all cases. Physical and mental reconstruction work is a new feature in Army Hospital organization, and this Mono- graph is issued for our convenience and to assist others who are at- tempting work in a similar field. It is therefore advisable to state the difficulties and obstacles which have been encountered. These can be classified into two general groups—one of a psychological nature and the other, administrative. The psychological difficulty lies mainly in the mental attitude of the patients, and a consequent reluctance of many to begin occupa- APPLIED TO RESTORATION OF MOVEMENT 63 tional therapeutic work. The basis of this obstacle depends mainly on the following conditions: 1. Frequently, there is a misunderstanding as to the real'object of the work. To some patients it presents merely a means to keep occupied, and unless they can see the direct vocational bearing and curative value, they are unwilling to undertake this work. The in- terviewing and assigning officers must see that the patients fully realize the significance of the work for curative purposes which forms as important a part of modern therapeutic treatment, as medi- cine, massage or electro-therapy. 2. Many patients believe that the Reconstruction Work will lengthen their stay at the Hospital, and it is the desire of all to get home as soon as possible—especially since the signing of the Armis- tice. Some patients have expressed the belief that as long as they were found to be improving, they might be detained until this im- provement was completed, while if they were given up as hopeless cases, they might be discharged or transferred at once, and the com- pensation would be greater than if they were cured. These ideas, though often not exprssed openly, are frequently at the basis of their reluctance, and must be recognized, met, and dispelled, where pos- sible. 3. The patients in many instances are in a fatigued condition from their experiences in France. This physical disability is aug- mented by a constant shifting from hospital to hospital, from ward to ward, and in meeting the new7 situations, both military and social. Patients have not yet attained their mental alertness and normal health. 4. Patients also find it difficult after becoming accustomed to hospital and army life, to regain their point of view of civil life, in which initiative, self-interest and self-responsibility are such im- portant factors. Often when asked what they expect to do after leaving the army, the men are nonplussed at the situation facing them. This attitude is enhanced by the relief associations and the attitude of misdirected sympathy on the part of the public, which may become the disabled man's worst enemy. In other cases, work undertaken for its curative value only, has been continued from a vocational interest and the man has been placed in the same kind of work as a trade, on leaving the hospital. Administrative—A limited number of unavoidable administrative conditions in this hospital have interfered with the practice and the carrying out of the occupational program. These may be summar- ized as follows: 1. The proximity of the hospital to the city of Washington presents a difficult problem, since the outside interests continually encroach upon the time of the men, which might be given to Recon- struction work. The men are constantly invited to the city, and the pleasures from the city come to the hospital. These interests un- doubtedly have value, but are exceedingly difficult to control and standardize. 04 OCCUPATIONAL THERAPY 2. The distance of the Reconstruction Shops from the wards, and the great distances to be covered in the hospital grounds, afford difliculties, especially in rainy weather, for leg amputation cases, of which we have a large number. 3. Theoretically, the surgeon sends the man to the shop im- mediately on his arrival at the hospital, but in many instances, this does not occur for days, weeks, and in some cases, months afterward. The work has been on a voluntary basis, and occasionally men do not report although repeatedly notified by the nurse, surgeon or a representative of the Reconstruction Department. The work is now- being made complsory, where possible. For the past five months we have had from 1,000 to 1,300 patients enrolled monthly in the work. 4. The occupational work is subsidiary to the regular hos- pital routine and must give way to ward inspection, medical attend- ance, transfer from ward to ward, furloughs, passes and other types of medical and other administrative regulations. 5. The hospital having been largely a training scheel, the shifting nature of the staff has caused certain courses to be dropped or modified, after the patient has started the work. This has been particularly true in the physical training department, and has been beyond the control of the hospital. 0. Following the signing of the armistice, the morale on the part of the instructors has been lowered, since all are anxious to return to civilian life, and this has reflected on the patients, although it is remarkable how well both the patients and men have overcome the inanitions accompanying this great morale readjustment which has been going on throughout the country at large. At present, March, 1919, the morale is greatly improved. XII Appendix Outline of Psychological Service It has been found that the psychologist can be of direct service to the medical officer and the educational instructor: 1. By giving to each the results of a personal, social and in- tellectual survey of the disabled man in the form of a synoptic pic- ture of his mental capacity, his special aptitudes, his temperament and his ability to learn. 2. By analyzing, evaluating and directing the mental attitude of the patient toward himself, his wound, his future and toward others, and, also by directing the attitude of others toward him, by helping to develop a good morale in the hospital. 3. By helping the patient to find himself, helping him to see what others have done and what he can do, and by helping him to act again as a whole man physically, socially, and vocationally. By adapting the work to medical or surgical needs of the patient. 4. By working with amputation cases in co-operation with the APPLIED TO RESTORATION' OF MOVEMENT 65 surgeon, the officer in charge of artificial limbs and the teacher on the learning problem of using the remaining member for fundamental movements, the artificial member for auxiliary movements, the trans- fer of former finer movements to the remaining member. o. By the study of methods of teaching employed in the cura- tive workshop schedule with a view to suggesting improvements. 0. By co-operating with the psychiatrist in the study of men- tal deficiency and the study of nervous cases. The psychological work in the hospital has been organized with the aim of enabling the patient to act again as a normal man, physi- cally, socially, vocationally and economically. The following lines of work are being carried out: I. Surveys to obtain information regarding the patient's a. Personal, social, educational and vocational history. b. Special interests, aptitudes and abilities. II. Examinations to determine intellectual capacities and analyze mental abnormalities. a. Group and individual examinations of general intelligence to be used as additional evidence of patient's fitness for a given curative occupational assignment or for permanent vocational training. 1. Alpha examination for high grade literates. 2. Stani'ord-Binet and Point Scale examinations for low grade literates. 3. Army performance test for illiterates. b. Individual psychological examination for patients exhibit- ing special mental abilities or disabilities. 1. Examinations requested by the neuro-psychiatrists to aid in diagnosis and disposition of their patients. 2. Examinations of psychiatric cases who cannot be inter- viewed and assigned to curative work through the usual methods owing to their special defects and susceptibili- ties. Assignment of such cases either to ward gardens, to shops, typewriting, etc., follows directly upon exam- ination. 3. Investigation of psychological causes of special cases of maladjustment, with counsel to patient and general re- commendation. III. Examinations to determine skill in the various occupations, by means of trade tests. a. In order that the patient may be assigned to curative work which may at the same time furnish vocational training, whenever such is possible. b. For the Information of the Federal Board for Vocational Education. 66 OCCl RATIONAL THERAPY IV. Measurements of Voluntary Movement and Muscular Strength. a. Procedure: 1. Measurement in degrees of the range of voluntary move- ments of various joints in isolation. 2. Measurement in pounds of the strength of muscles gov- erning the various movements in upper and lower ex- tremities. b. Purpose: 1. To obtain necessary information for proper assignment to curative work, a. Adapted to limited powers of the patient. a. As required for sufficient exercise to develop in- creased function of the partially disabled limb. 2. To obtain in numerical and graphical form, reports which may be used: a. To encourage and stimulate the patient to persist in the prescribed curative work by showing him defi- nitely the progress of improvement. b. To furnish to the surgeon definite information as to the patient's progress. c. To keep the instructor informed as to the patient's progress that he may adapt the work to changing needs. V. Work on the learning problem with a view to determining and applying the most effective methods of teaching: a. In developing greater use of the remaining or uninjured limb by transfering its functions to the other. b. In training for effective use of the artificial limb, or a par- tially disabled limb. c. In applying psycho-educational measurements. VI. Development of Morale: a. By inducing a proper mental attitude on the part of the pa- tient in regard to his disability and his future by— 1. Showing him what others similiarly handicapped have done. 2. Showing him that the hospital treatment is really pro- ducing beneficial results. 3. By making clear what steps the government has taken to provide for his future in the way of compensation, in- surance and vocational re-habilitation. b. By providing opportunities for the patient's recreation and amusement while in the hospital: 1. Through the agencies of the Red Cross, Y. M. C. A., K. of C. and J. W. B. 2. Through use of the gymnasium for athletics, dancing, etc. * APPLIED TO RESTORATION OF MOVEMENT 07 3. Through educational excursions to Mt. Vernon, Capitol, etc. Need of further psychological work along the lines specified below is clearly indicated by: 1. An extension of work on the learning problem: a. To apply the most eftective methods of teaching in aca- demic work. 2. Measurements of sensitivity in cases of injured nerves, or sutured nerves. 3. Measurements (I speed and accuracy of movement and mo- or co-ordination. WZii- m,.