VA PAMPHLET 10-29 
REHABILITATION 
OF THE CHRONIC 
NEUROLOGIC PATIENT 
MAY 1949 
VETERANS ADMINISTRATION • WASHINGTON 25, D, C. VA PAMPHLET 10-29 
REHABILITATION 
OF THE CHRONIC 
NEUROLOGIC PATIENT 
MAY 1949 
VETERANS ADMINISTRATION 
WASHINGTON 25, D. C. 
For sale by the Superintendent of Documents, U. S. Government Printing Office, Washington 26, D. C. — Price 30 cents foreword 
This monograph is one of the most encouraging pieces of informa- 
tion ever published by the Veterans Administration. 
It is a principle of modern medical practice that all patients have 
assets as well as liabilities. But what are the assets of a chronic 
neurologic patient who has been hospitalized for 3, 5, 10, or even 
20 years, so paralyzed that he cannot turn over in bed? 
This man, obviously, has a strong will to live and enduring phy- 
sical capacity to survive. Beyond this, he frequently has been looked 
upon as largely helpless and hopeless, a liability to himself, his family, 
and the hospital. 
We now have, however, some methods by which this man’s assets 
can again be mobilized, revitalized, and put into action by profes- 
sionally trained persons willing to join with him in making the effort. 
Perhaps he can turn over in bed? Or feed himself? Or get up? 
Or leave the hospital? Or, yes, even go back to work. 
This volume contains the technical story of how these aims can 
be accomplished by utilizing to the utmost our present knowledge 
and skills. I believe it should be on the desk of every physician. 
l) 
Paul B. Magnuson, M. D., 
Chief Medical Director. 
ii Preface 
A large number of patients with neurologic disa- 
bilities, many of them veterans of World War I, 
occupy beds in Veterans Administration hospitals. 
A similar situation exists in many civilian hospitals 
throughout the country. The problem, in both its 
humanitarian and economic aspects, assumes an in- 
creasing importance in view of the fact that the 
percentage of the population 45 years of age or older 
rose from 17.8 percent in 1900 to 26.5 percent in 
1940. This group, it is estimated, will comprise 
40.3 percent of the population by 1980. The num- 
ber with neurologic disabilities may be expected to 
rise proportionately. This means an increase both 
in human suffering and the costs of bedside care 
for these patients, unless steps can be taken to reverse 
the trend. 
The rehabilitation of patients with neurologic 
disabilities would seem to be an obvious and neces- 
sary procedure. For years, rehabilitation measures 
have been instituted for a few chronic neurologic 
disabilities, such as poliomyelitis and cerebral palsy, 
with good results. In recent years, there has been 
considerable advance in the understanding and 
treatment of other disabling neurologic conditions. 
The initiation of such measures in the general field 
of neurology, nevertheless, frequently meets with 
considerable resistance. This resistance would ap- 
pear to be, in part at least, the result of a lack of 
realization of how much can be accomplished even 
in the most severe involvements. There are other 
factors. The great financial savings that may be 
achieved has not been recognized. Then there is a 
lack of understanding of how retraining techniques 
can be applied to the neurologic patients and, of 
course, there is the natural resistance of individuals 
to any change in standard procedures and methods. 
During the past few years, however, it has been 
possible to demonstrate the possibilities and practical 
gains of this approach in a program of neurologic 
retraining conducted at the Minneapolis, Minn., 
Veterans Administration Hospital. It is the purpose 
of this monograph to describe the essentials of the 
Minneapolis program. 
The program has been made possible by the close 
cooperation and understanding given it by the en- 
tire Veterans Administration and, above all, by the 
enthusiasm, initiative, loyalty, and hard work of the 
various members of the hospital-rehabilitation team, 
all of whom have contributed to the development 
of the program and have supplied specific informa- 
tion for the various sections of this book. 
This text, it is hoped, will serve both as a stimulus 
and guide in the wider application of rehabilitation 
techniques to the neurologic patient. 
A. B. Baker, M. D. 
J. R. Brown, M. D. 
A. B. Baker, M. D., National Consultant for Rehabilitation of Chronic Neurologic Patients. 
J. R. Brown, M. D., Chief, Neurology Section, Veterans Administration Hospital, Minneapolis, Minn. 
iii Contents 
Chapter I THE PROGRAM AND ITS OBJECTIVES 1 
1. The Program 1 
A. Evaluation of the Patient 1 
B. Setting the Goal 1 
C. Treatment Program 2 
2. Objectives 2 
A. Self-Care 2 
B. Ambulation 3 
C. Social Readjustment 3 
Page 
Chapter II THE NEUROLOGIC EXAMINATION 5 
Chapter III THERAPY: PHYSICAL PROCEDURES 8 
1. General Principles 8 
2. Bedside Therapy 8 
3. Continuing Therapy 8 
4. Active Assistive Exercise 11 
5. Active Exercise 11 
6. Muscle Re-education 12 
7. Resistive Exercises 12 
8. Pulley Therapy 13 
9. Ataxia Exercises 13 
10. Reconditioning Exercises 14 
11. Self-Care Methods 14 
12. Ambulation Exercises 15 
13. Rehabilitation Gymnasium 17 
14. Self-Care and Ambulation Chart 18 
15. Occupational Therapy Equipment 20 
IV Page 
Chapter IV THERAPY: SOCIAL PROCEDURES 21 
1. The Role of the Physician 21 
2. The Role of the Nurse ; 22 
3. The Role of the Social Worker 23 
4. The Role of the Physical Therapist 24 
5. The Role of the Corrective Therapist 25 
6. The Role of the Occupational Therapist 26 
7. The Use of Manual Arts Therapy 27 
8. The Use of Vocational Counseling 27 
9. The Use of Educational Therapy 28 
10. The Use of Speech Therapy 28 
11. The Use of Music Therapy 29 
12. The Role of Special Services 29 
13. Rehabilitation Conference 30 
14. Integration and Coordination 30 
Chapter V SPECIFIC DISABILITIES 31 
1. Hemiplegia 31 
2. Ataxias 33 
3. Multiple Sclerosis 35 
4. Parkinsonism 35 
5. Flaccid Paralysis 37 
6. Paraplegia 39 
Chapter VI SPECIAL PROBLEMS 41 
1. Diagnostic Procedures 41 
2. Psychotherapy in Rehabilitation 42 
3. Psychological Testing 43 
4. Care of the Urinary Bladder 43 
5. Nursing Care 44 
6. Orthopedic Appliances 45 
7. Speech 47 
Chapter VII EVALUATION OF RESULTS AND INTERPRETATIONS 48 
V chapter I. the program and its objectives. 
1. THE PROGRAM 
A. Evaluation of the Patient. A program of 
treatment for disabling neurologic disorders, on the 
basis of our present knowledge, consists of three prin- 
cipal parts: First, there is the evaluation of the patient, 
including a general medical, complete neurologic, and 
psychiatric examination as well as a determination of 
the patient’s social and vocational status. 
The neurologic examination includes a determina- 
tion of the type of disability, particularly as to whether 
it is spastic, ataxic, flaccid, rigid, or combined, since 
each of these presents a different therapeutic problem. 
Such an evaluation also includes the cause, the loca- 
tion, and the severity of the illness and an estimation 
of expected progress. It is also necessary to evaluate 
the physical assets of the patient, both present and fu- 
ture, with special reference to what residual function 
he has or may develop. It is these residual functions 
that play a great part in determining the ultimate goal 
of performance which the patient can be expected to 
attain. 
Psychiatric evaluation includes an estimate of the 
patient’s personality, his basic intelligence, and the 
degree of organic mental deterioration that might be 
present. An evaluation of the interests and potential 
motivating forces of the individual is of paramount 
importance. 
The medical examination should emphasize the 
patient’s blood pressure, cardiac reserve, urinary status, 
and orthopedic disabilities, since all these play an im- 
portant part in the ultimate result obtained from the 
treatment of these patients. 
The social evaluation includes the study of the pa- 
tient’s home situation, his attitudes towards his fam- 
ily, and his family’s attitudes towards him. It also 
embraces an evaluation of the resources of the social 
environment. 
Interrelationship of the patient and the family fre- 
quently will determine the ease with which the final 
result is obtained in the treatment of these patients. 
Vocational evaluation consists of study of the patient’s 
aptitudes, abilities, and interests. The information 
thus gained is most helpful and often essential in the 
setting of a vocational and avocational goal for these 
patients. 
B. Setting the Goal. The second phase is a setting 
of a treatment goal in accord with the evaluation of 
the patient. From this point on, all therapeutic pro- 
cedures carried out are directed toward this goal. The 
ultimate goal selected varies greatly from one patient 
to another. For example, in some of the more severe 
hemiplegias, especially in the older age group where 
there is limited cardiac reserve, the maximum goal 
may be one of self-care activities, limited ambulation, 
and a hobby at home. In others, particularly in the 
Fig. I—Many patients on admission to the hospital are seriously 
handicapped and appear hopeless. This is the challenge to the 
rehabilitation program. 
I younger age group, a goal of greater or lesser economic 
independence can often be achieved. It is only in 
individuals who are severely deteriorated, who have a 
severe personality disorder, or who have a widespread 
and rapidly progressing neurologic disorder that some 
goal of treatment cannot be set. 
C. Treatment Program. The methods of achiev- 
ing the goals set make up the final phase of the treat- 
ment program. It is important to emphasize that 
success is not the result of the efforts of a single indi- 
vidual or single skill but requires the coordination of 
all therapeutic influences brought to bear upon the 
patient. Since this accomplishment does require the 
supervision and guidance of a single individual—the 
physician in charge of the patient—he must be ac- 
quainted with all aspects of the patient’s condition and 
of the treatment program. 
Keeping in mind the physical limits of the patient 
and the social and economic possibilities involved, one 
can then proceed on such a coordinated program. 
From a physical standpoint, this consists of physical 
therapy during the acute and subacute stages of the 
illness aimed at preventing contractures and instituting 
early passive and active movements. This is followed 
by corrective therapy which emphasizes recondition- 
ing of the patient and re-education of the use of unin- 
volved parts necessary for substitution problems, 
strengthening of all parts, education in daily self-care 
activities, ambulation, and adapted sports and games. 
Occupational therapy should be both functional and 
diversional. Manual arts therapy is added later and 
is aimed at orienting and testing the patient in the 
type of job which he would be capable of handling in 
view of his residual disability. Adapted sports and 
recreation are used to provide motivation and interest, 
and serve, in some instances, as an easily motivated 
method of corrective exercise. Special speech therapy 
is indicated in the aphasic and dysarthric disorders. 
The nursing staff must be well-informed as to the 
nature of the program so that they can prevent de- 
pendency on the ward and see that the patient’s per- 
formance is kept abreast of his abilities to perform 
during the time he is not occupied with special activi- 
ties. Social service therapy is instituted on the ad- 
mission of the patient to the hospital and continues 
throughout the entire program. 
It is most essential that the physician in charge regu- 
late all of these therapeutic influences which in many 
of these neurologic disabilities are quite specific and 
important in alleviating many of the symptoms. 
Because of the many therapeutic influences being 
brought to bear on the patients and the necessity of 
their supervision, it is most helpful to have some group- 
ing of these patients. In addition to the ease of super- 
vision, the housing of these patients in a separate unit 
also stimulates group spirit and aids motivation. 
2. OBJECTIVES 
A disabled person must be capable of accomplishing 
a large number of activities if he is to make a more or 
less independent adjustment to his environment. 
These activities fall into three large groups: 
A. Self-Care. The disability accompanying a neu- 
rologic disorder produces greater loss of the ability 
to care for one’s daily needs than any other compar- 
able disease. The inability to perform these activities 
creates a burden to the nursing staff, lowers the pa- 
tient’s morale, and many times interferes with the 
patient’s discharge plans. Inability to perform such 
self-care activities is most important in increasing the 
costs for the care of these patients. A number of prin- 
ciples should be followed in outlining the program for 
self-care activities: 
(1) The program should be initiated as soon as 
possible after the patient’s admission to the hos- 
pital. 
(2) In the more severely involved patients, the 
primary aim should be to reduce the necessary 
nursing or attendant care. 
(3) In the less severely involved patients, the 
emphasis should be placed on those activities in 
which the patient is most deficient. 
(4) The self-care activities taught depend upon 
the requirements of the home or domicile to which 
the patient plans to return. 
(5) All personnel coming in contact with the pa- 
tient should be aware of the extent of his self-care 
abilities and cooperate in preventing dependency. 
B. Ambulation. The loss of the ability to walk 
is one of the most common and most distressing dis- 
abilities of neurologic disease. With most patients, 
there is a driving desire to walk again. This motiva- 
tion facilitates the teaching of ambulation. 
As in self-care, the lack of ambulation in many cases 
retards the discharge plans. This is particularly true 
since many domiciliary homes, rest homes, and sol- 
diers’ homes have standards of ambulation perform- 
ance which must be met before patients are acceptable. 
It also plays an important part in the ability of the 
2 patient to make an adequate home adjustment. The 
therapist must be well aware of the goal set for the 
patient and must regulate ambulation activities ac- 
cordingly. It is obvious that the demands made upon 
an individual who intends to pursue an occupation 
will be vastly different from those of an individual 
whose ambulation will be restricted to the home. 
Ambulation must be started as early as possible, both 
from the standpoint of maintaining a high morale and 
also to make a faster recovery in the ability to walk. 
The therapist must remember that teaching a patient 
to walk isn’t enough. Too frequently, the practical 
uses of this activity are forgotten, and the patient will 
fall back on his wheelchair as an easier means of getting 
where he wants to go. He must be progressively 
weaned from the wheelchair by having him walk in- 
creasing distances and carefully eliminating the use of 
the wheelchair in going to meals, the lavatory, to daily 
classes, and finally for any purpose. At the same time, 
the elimination of the wheelchair too soon may have 
detrimental results. These are the general principles 
which must be kept in mind in the successful comple- 
tion of an ambulation program: 
(1) Ambulation must be started as early as pos- 
sible, both from the point of view of maintaining a 
high morale and also of instituting recovery of the 
ability to walk. 
(2) This program should be guided and limited 
by the patient’s ability to walk and the patient’s 
need for this function, with discharge plans for 
the patient always kept in mind. 
(3) The complexity of the activity and the speed 
at which it is performed must be progressively 
graduated. 
(4) It is important to transfer the teaching of the 
ambulation activities in the gymnasium to the 
patient’s actual performance of them in taking 
care of his daily needs. 
(5) The ambulation accomplishments of the pa- 
tient should be encouraged by all individuals 
working with the patient. 
C. Social Readjustment. Any individual who has 
suffered a disabling neurologic disorder must make a 
marked personal readjustment both to his family and 
to his environment. Generally, the family also must 
make a readjustment. This is particularly true when 
the disabilty threatens the financial support and the 
social comforts of the family. It is important that the 
problem be handled in a constructive manner during 
the early stages of a disability. At this time, it is pos- 
siblc to guide the patient and his family in determining 
their future plans in a realistic way. If, on the other 
hand, this critical period is permitted to pass without 
attention, the family will many times work out their 
own plans, rejecting the patient and frequently con- 
signing him to a position of continued dependency. 
Under such circumstances, it later may be difficult to 
persuade the family to readjust their plans to include 
the patient, despite his frequently very adequate phys- 
ical improvement. 
The rapidity and the ease with which the patient 
can accomplish his rehabilitation are dependent to a 
great extent upon proper motivation. This is ob- 
tained by various methods: 
(1) Individual interviews with the patient should 
be held. At the outset, such interviews are the re- 
sponsibility of the doctor. He explains the na- 
ture of the illness to the patient, the general out- 
look and the ultimate prognosis, and the general 
plan of therapy. These contacts with the doctor 
are usually followed by further interviews with 
the social worker. She interprets to the patient 
the attitude of the family toward the illness as 
well as the attitude of society. It is important 
that everyone else who participates in the patient’s 
program carry through a consistently encouraging 
theme, offering the patient a definite hope and 
realistic goal. If, during the course of therapy, 
a patient should fail to make adequate progress, 
then it is important for the doctor to check care- 
fully for any emotional factors which may be 
retarding this patient’s recovery. 
(2) The ultimate emotional adjustment of a 
patient and the speed of his recovery are inti- 
mately dependent upon a satisfying family rela- 
tionship. Hence, it becomes important to en- 
courage the family to participate in the treatment 
program from its beginning. The social worker 
often can play an important role as a liaison be- 
tween the family and the patient in furthering 
treatment. 
(3) Group activities furnish one of the best 
methods of promoting social readjustment. The 
social pressures of the group provide a stimulus 
to the patient and prevent self-preoccupation. 
Exercises, handicrafts, agricultural activities, and 
games all lend themselves to a group setting. 
Friendly and controlled competition in games 
contributes to self-care and ambulation activities. 
Care must be exercised to be certain that the 
829577°—49 2 
3 patient competes with his own progress so he will 
not compare himself unfavorably with others. 
(4) The final step in social readjustment is voca- 
tional placement. The goal to be reached will 
vary with the patient’s age, his disability, and his 
employment assets. An older person with a rela- 
tively mild disability may well accept a hobby in 
his own home. A younger individual with a severe 
disability may be able to hold a job under many 
circumstances. The patient must be encouraged 
and assisted in making plans in keeping with his 
total assets and liabilities. 
In order to evaluate progress in the patient’s ad- 
justment and motivation, there are certain specific 
behavior patterns which can be used as helpful guides. 
These criteria, if evaluated properly, often will indi- 
cate whether the patient requires special help with his 
problems. A determination of the nature of the ad- 
justment problem, however, will require individual 
investigation. The criteria are as follows: 
(a) Cooperation: How does the patient accept 
his treatment program? 
(h) Initiative: Does he attempt to carry on be- 
yond what is actually required of him? 
(c) Personal hygiene: Is he interested in his per- 
sonal appearance? 
(d) Stability: Does he show continuity in action, 
thinking, and planning? 
(e) Adaptiveness: Docs he accept new situations 
readily? 
(/) Consideration: Is he thoughtful and kind 
with others? 
(g) Competitiveness: Does he enthusiastically 
enter into group activities? 
(h) Determination: How sustained are his ef- 
forts in aiding his recovery? 
(i) Enthusiasm: How much interest does the 
patient develop toward his therapy? 
(j) Maturity: How does he handle his emotional 
conflicts? 
Fig. 2—The challenge met. The same patient leaves the hospital 
after about 3 months to return to his home and job. 
4 chapter II. the neurologic examination 
In performing a neurologic examination, it is essen- 
tial to check the function of individual muscles as 
well as to evaluate their combined action in limb mo- 
tion. The muscles listed below have been selected 
as representative of the chief movements of the limbs. 
Frequently, more than one muscle will participate in 
the movement of a limb. For this reason, in testing 
for the selected muscles, one should observe and pal- 
pate the muscle tested in order to detect any substitute 
action of muscles in the presence of paresis of the 
muscle being checked. The following system is 
suggested for recording the state of the muscles: 
N = Normal power. 
— 1 = Inability to maintain position against mod- 
erate resistance. 
— 2= Inability to maintain position against 
slight resistance or gravity. 
— 3 = Active movement with gravity eliminated. 
— 4=Trace of contraction. 
A = Absent. 
In testing for muscle function, it is most convenient 
to have the patient maintain a fixed position against 
force. The examiner is then able to test the various 
muscles by instituting the action of the antagonist. 
This obviates the necessity of giving new directions for 
each muscle tested and simplifies the procedure for 
both patient and examiner. The following fixed posi- 
tions will be used routinely and will be referred to by 
letter: 
(1) Position “A.” The arm is adducted, the 
forearm flexed at the elbow, and the wrist across 
the xiphoid process. 
(2) Position “B.” The patient is on his back 
with the lower extremity flexed at 90° at the hip 
and knee. The examiner should support the 
lower limb at the ankle. 
(3) Position “C.” The patient lies on back with 
the leg and foot in normal extension. 
Using the above fixed positions in testing for muscle 
function will be possible only if no severe paralyses are 
present. Should the weakness of any muscle group 
prevent the use of any of the above positions, then 
substitute positions will have to be improvised. 
(1) Supraspinatus (C4-5). Initiates abduction. 
Holding the patient’s arm at his side, have the 
patient attempt to abduct the limb. 
(2) Deltoid (C5—6). Abduction of arm be- 
tween 15° to 90°. 
Have patient maintain abduction of arm at 45° 
against resistance. 
(3) Lower Trapczius (C2-4). Elevation of arm 
above shoulder. 
Have patient maintain elevation of arm above the 
shoulder against resistance. 
(4) Serratus (C5-7). Fixes the medial border 
of the scapula. Using position “A,” apply pres- 
sure in axis of humerus. 
(5) Infraspinatus (C5). External rotation of 
the arm. Using position “A,” apply downward 
pressure on forearm. 
(6) Subscapularis and teres major (C5-8). In- 
ternal rotation of arm. Using position “A,” pull 
the wrist away from the body. 
(7) Pectoral and latissimus dorsi (C5-8). Ad- 
duction of the arm. Using position “A,” abduct 
the arm in the midaxillary line. 
(8) Brachioradialis (C5-6—radial). Flexion of 
elbow. Using position “A” (be sure forearm is 
pronated), push downward at the wrist. 
(9) Biceps (C5-6—musculocutaneous). Flex- 
ion of elbow. Using position “A” but with fore- 
arm supinated, push downward at the wrist. 
5 (10) Triceps (C7-8—radial). Extends fore- 
arm. Using position “A,” push upward at wrist. 
(11) Pronators (C6-7). Pronates forearm. 
Using position “A,” rotate the forearm so that the 
upper border of the hand turns outward. 
(12) Supinators (C5-6). Supinates forearm. 
Using position “A,” rotate the forearm so that the 
upper border of the hand turns inward. 
(13) Flexors of wrist (C7—median—ulnar). 
Using position “A,” but with hand supinated, 
push down on the palmar surface of the hand. 
(14) Extensors of wrist (C7—radial). Using 
position “A,” but with hand pronated, push down 
on the dorsal surface of the hand. 
(15) Extensors of the digits (C7—radial). 
Using position “A,” but with hand pronated, 
push down on the first phalanx of each digit. 
(16) Flexors of fingers (grip) (C8-T1—me- 
dian—ulnar). Using position “A,” have patient 
squeeze your hand. 
(17) Adductor of thumb (T1—ulnar). Using 
position “A,” with thumb adducted, pull upward 
on the thumb. 
(18) Opponens thumb (T1—median). Using 
position “A” with hand supinated, have the pa- 
tient resist the separation of the tip of the little 
finger from the tip of the extended thumb. 
(19) Interossei (T1—ulnar). Extends fingers. 
Using position “A” but with hand supinated and 
fingers spread apart, attempt to approximate the 
fingers. 
(20) Back muscles. Using position “C,” place 
hand beneath patient’s back and have the patient 
arch his back. 
(21) Abdominals. Using position “C,” place 
hand on patient’s abdomen and have patient at- 
tempt to rise from a recumbent position. 
.(22) Intercostals. Using position “C,” observe 
action of intercostals on deep inspiration. Ob- 
serve excursion and look for asymmetry of excur- 
sion of chest. 
(23) Diaphragm (C4). Have patient cough and 
note the epigastric impulse. 
(24) Iliopsoas (L2—femoral). Flexion of hip 
on abdomen. Using position “B,” place hand 
above knee and push downward. 
(25) Adductors of hip (L2-3—obturator). Us- 
ing position “B,” place hand on the medial surface 
of the thigh and push outward. 
(26) Gluteus med. and min. Abduction of hip. 
Using position “B,” place hand on outer aspect of 
thigh and push inward. 
(27) Quadriceps (femoral). Extension of knee. 
Using position “B,” attempt to further flex the 
leg at knee. 
(28) Hamstrings (S1-2—sciatic). Flexors of the 
knee. Using position “B,” attempt to extend the 
leg at the knee. 
(29 Tibialis anticus (L4—peroneal). Dorso- 
flexion of foot. Using position “C,” place hand 
on the dorsal surface of the foot and push in a 
plantar direction. 
(30) Triceps surae (L5-S2—tibial). Plantar- 
flexion of foot. Using position “C,” place hand 
on the ball of the foot and push in the direction of 
the patient. 
(31) Posterior tibial (L4—tibial). Inverts the 
foot. Using position “C,” grasp the foot at the 
arch and rotate so that the plantar surface of the 
foot turns outward. 
(32) Peroneals (L5—peroneal). Everts the foot. 
Using position “C,” grasp the foot at the arch and 
rotate so that the plantar surface turns inward. 
(33) Dorso-flexors of toes (SI—peroneals). 
Using position “C,” push in a plantar direction 
against the dorsal surface of the toes. 
(34) Plantar-flexors of toes (S2—tibial). Using 
position “C,” place hand on the plantar surface 
of the toes and push in the direction of the patient. 
(35) Gluteus maximus (Sl-2). Dorsi-exten- 
sion of leg at hip with patient lying on his side and 
with the lower limbs maintained in normal ex- 
tension, place hand on back of thigh and push 
forward. (Fig. 2A.) 
6 MOTOR SYSTEM: Paresis Paralysis Atrophy Hypertrophy Tonicity Lim- 
itation of movement Contractures Contractions Dysplasia Dyskenesias 
(chorea, athetosis, tremor, ballismus, dystonia, rigidity) Fibrillation 
Fasiculation Myotonus (If positive record the actual muscle or part involved) 
Strength 
(N, 1, -2, -3, -4, A) Other Alterations 
R L 
1. Neck flexors 
2. Neck extensors 
3. Diaphragm (C4) 
4. Supraspinatus (€4-5) 
5. Deltoid (C5.fi) 
6. Lower trapezius (C2-4) 
7. Serratus (C5-7) 
8. Infraspinatus (C5) 
9. Subscapularis + 
teres major (C5-8) 
10. Pectoral + latis. dorsi (C5-8) 
11. Biceps (Cg.g.MC) 
12. Brachioradialis (C5-6-R) 
13. Triceps (C7_g"R) 
TT. Pronator (Cg-?) 
15. Supinator (C5-6) 
16. Flexion Wrist (C7) 
17. Extension Wrist (C7-R) 
18. Ext. Digits (C7-R) 
19. Grip (Ce-Ti-M-U)' 
20. Add. thumb (U) 
21. Opponens thumb (M) 
22. Spread, fingers 
23. Back 
24. Intercostals 
25. Abdominals 
26. Iliopsoas (L2-F) 
27. Glut, max. (S1-2) 
28. Add, hip (L2-3-O) 
29. Abd. hip (L4) 
30. Quadriceps (1J3-F) 
31. Hamstrings (S1-2-S) 
32. Tibialis ant. (L4-P) 
33. Triceps surae (L5-S2-T) 
34. Post, tibial (L4-T) 
35. Peroneal (L5-P) 
36. Dorsi flexors (Sj-P) 
37. Plantar flexors (S2-T) 
38. Sphincters (S2-4) 
Note: MC—musculocutaneous nerve; R—radial; U--ulnar; M--medial; 
F--femoral; S--sciatic; P--peroneal; T--tibial; ©--obturator. 
Fig. 2A Type of form for neuromuscular examination used by Veterans Administration Hospital at Minneapolis, 
7 chapter III. therapy: physical procedures 
The main details of therapy can be divided into two 
parts—the physical and the social procedures. In 
any one patient, the two categories are integrated into 
a single program. For the sake of simplicity and un- 
derstanding, it is best to discuss them separately. The 
physical procedures, which will be discussed in this 
chapter, in general consist of exercises to retrain the 
patient physically. The social procedures consist of 
(1) the art of applying these physical procedures and 
(2) the methods of promoting the patient’s social 
readjustment. 
1. GENERAL PRINCIPLES 
Bed rest, as is well established, causes marked 
changes in the body’s physiology. Vascular reflexes 
are impaired and visceral functions are disturbed. The 
general musculature becomes flabby and in extreme 
cases will undergo disuse atrophy. Partial fixation 
of joints and contractures occur. Psychologically, the 
patient becomes dependent upon others for his simple 
daily needs. All of these factors have a markedly re- 
tarding effect upon the rehabilitation process. The 
earliest of these retrogressive changes may be noticed 
during the first week of an illness and are accelerated 
in the presence of immobility due to paralysis or pain. 
To combat these retrogressive changes, the rehabili- 
tation process is begun as soon as possible after the 
onset of the acute illness. The chief limiting factor 
is the patient’s general condition. As a general rule, 
the physical procedures should begin within the first 
week or 10 days, if the patient is conscious, afebrile, 
and has passed the stage of serious illness. 
2. BEDSIDE THERAPY 
The neurologically disabled patient, as the first step 
toward his physical rehabilitation, is usually referred 
for physical therapy beginning routinely at the bedside 
during the subacute phase of his illness. Bed posture 
is corrected and supportive measures are instituted to 
maintain good body alignment, to relieve tension on 
weakened or paralyzed muscle groups, and to prevent 
contractures from developing. Hot packs, or radiant 
heat, are used to relieve muscle spasm and pain, 
preparatory to exercise and re-education of weakened 
muscles. The Emerson hot pack and portable infrared 
lamp are useful sources of heat for this early bedside 
treatment. Massage suited to the condition being 
treated is used to improve circulation and to maintain 
the involved parts in the best possible condition for 
function once voluntary function has returned. (Figs. 
3, 4, and 5.) 
Passive motion of all involved parts must be carried 
out daily. It is important to carry the joint through 
its full range of motion. If contractures or muscle 
shortening has occurred, the motion should be carried 
to the point of pain. The shoulder, hand, hip, and 
knee joints are particularly important because of the 
rapidity with which contractures may occur and the 
marked effect such contractures will have on function. 
Weight bearing on a slightly flexed knee requires rela- 
tively great quadriceps strength. This is in marked 
contrast to the knee locked in full extension which can 
bear weight with little or no quadriceps innervation. 
3. CONTINUING THERAPY 
As soon as the patient’s condition permits, he is 
brought to the physical therapy department. If not 
already carried out at the bedside, manual muscle 
tests, joint or girth measurements, and analysis of pos- 
ture and locomotion are made by the physical therapist 
as the need is indicated. These serve as guides in 
determining where efforts should be directed, and as 
records of the patient’s progress. 
Mobilization of joints is continued, preceded by 
the physical agents used at the bedside, as described 
above. In addition, treatment in the reclining posi- 
8 Fig. 3—Massage and passive motion at the bedside is a usual initial step toward rehabilitation. 
tion in the Hubbard tank affords opportunity for pas- 
sive and active underwater exercise, as well as full 
range of motion activities for all body joints. With 
the first sign of returning function, the patient is en- 
couraged to assist actively in all movements. The 
physical therapist will initiate or complete the range 
of motion not within the patient’s capabilities, with- 
out noticeable break in the movement. At the same 
time, the patient is encouraged to “think” and “feel” 
the movement as it is executed. With the first sign of 
returning function, the patient is encouraged to assist 
actively in all movements initiated and completed by 
the physical therapist. A powder-board and counter- 
balanced sling-suspension apparatus are used to elim- 
inate gravitational pull in the patient’s first attempt 
to move the part actively. (Fig. 6). 
4. ACTIVE ASSISTIVE EXERCISE 
Active assistive exercise is effort on part of the pa- 
tient to move his limb (or part), assisted by the phys- 
ical therapist. Assistive movement requires keen 
judgment on the therapist’s part to aid only when the 
muscle is too weak to accomplish its movement. By 
alertness, the physical therapist can eliminate inertia, 
gravity, and friction, and thus allow a feeble and 
weakened muscle to carry the part through an arc of 
motion as completely as possible. Exercise should be 
carried out daily and the muscle should be worked to a 
point short of fatigue. This program of assistance 
in movement is continued until the muscle is capable 
of normal motion and of sufficient strength to carry 
the limb through a range of motion several times. 
The program then develops into one of active or free 
exercise. (Fig. 7.) 
9 Fig. 4—Daily passive motion of involved parts through the full joint range is important in the prevention of contractures. 
Fig. 5—Body alignment and correct limb position is maintained by proper bed posture. 
10 5. ACTIVE EXERCISE 
Active exercise is that type of motion given to a part 
of the body by the volutary contraction and relaxation 
of the muscles controlling the movement of the part. 
The patient makes the entire motion himself without 
assistance. This form of exercise is employed to 
hasten restoration of muscle function. (Fig. 8.) 
Fig. 6—A powder-board is useful in early attempts at active 
movement. 
Fig. 8—Mild resistive exercises may be used to supplement active 
exercises. 
Active exercise should be undertaken at least once 
daily, and the muscles should be worked to a point 
short of fatigue. The exact program will be deter- 
mined by the nature and extent of the disability, but, 
whatever the condition, the amount of effort put forth 
by the patient will largely determine the success of the 
exercises. Consequently, attention to daily effort 
within the full capabilities of the patient is necessary. 
Because many of the patients on a neurologic serv- 
ice have mental impairment, the therapist must con- 
stantly be on the alert for incorrect performance of 
movements. 
Muscle setting is one form of active exercise that 
can be successfully employed with neurologic patients. 
While hard for some patients to learn, the majority of 
the patients can readily be taught this exercise. It 
has value because it is not fatiguing, and can be prac- 
ticed by the patient on the ward. Four such exercises 
Fig. 7—Active assistive exercises may be used in movements of 
the trunk as well as those of the extremities. 
829577°—49 3 of extreme value to the neurologic patients are (1) 
quadriceps setting, (2) gluteal tightening, (3) pelvic 
roll, and (4) deltoid setting. 
6. MUSCLE RE-EDUCATION 
Muscle re-education is a basic procedure employed 
in the restoration of muscle function. The actual pro- 
cedures used in the administration of this form of ther- 
apeutic exercise are described in most standard text- 
books, and discussion here will concern itself with 
adaptations and limitations of standard procedures to 
the ncurologically disabled patients. (Fig. 9.) 
by the co-contraction that occurs during adduction 
and depression of the scapula while in a prone position. 
Varying amounts of mental confusion gravely inter- 
fere with the normal process of muscle re-education. 
Patients with cerebral lesions frequently have difficulty 
learning, which greatly interferes with the normal 
process of muscle re-education. In this circumstance, 
use should be made of the uninvolved limb as an aid 
in relearning muscle function. The patient is in- 
structed in the use of the good limb in order to guide 
the involved extremity through the exercises. For ex- 
ample, in paralysis of the forward flexors of the shoul- 
der, good use may be made of a cane which the patient 
grasps with both hands and carries overhead. The 
principle of using a cane with the good arm guiding 
the poor arm also may be used for other movements. 
7. RESISTIVE EXERCISES 
This type of exercise is carried out by requiring the 
patient to perform muscular movements against in- 
creased resistance. The chief purpose of this type of 
exercise is the development of greater muscle power 
and bulk. The details of this type of exercise are 
standard and well-described in literature on the sub- 
ject. It has two general applications in neurologic 
patients. First, it is used to develop uninvolvcd mus- 
cles in order to compensate for the disability. An 
example of this is the development of the arms in a 
paraplegic to take over the function of crutch waking. 
The second use is to increase the strength in weakened 
muscles. (Fig. 10.) 
Fig. 9—Muscle re-education is of greatest importance in finer move- 
ments and requires the detailed attention of the therapist. 
It is a principle of muscle re-education that a weak- 
ened muscle cannot contract effectively until its an- 
tagonist relaxes. It is possible to assist the muscle that 
is being re-educated by placing the patient in a posi- 
tion where gravity opposes the action of the antagonist. 
A further principle of muscle re-education is that 
muscles may act physiologically as prime movers, as 
synergists, or as fixators. A muscle that has lost the 
ability to function as a prime mover frequently can 
be made to function in a secondary role. For example, 
if a patient is unable to voluntarily contract his lumbar 
erector spinae muscles, he may relearn this function 
Fig. 10—Heavy resistive exercises are applied by the progres- 
sive increasing of the weight of the bell bar which is attached to 
the shoe. 
12 8. PULLEY THERAPY 
In pulley therapy, the intact limb moves the in- 
volved limb by means of a pulley arrangement. This 
type of therapy may be used for producing passive 
movement, for providing active assistive exercises, and 
in reducing contractures. In addition, it provides an 
opportunity for the patient to exercise himself on his 
own initiative. This is an important factor in trans- 
ferring the exercises from the hospital to the home. 
Pulley exercises can be adapted to patients who are 
confined to bed, particularly during the acute and sub- 
acute phases of their illness. (Fig. 11.) 
ing the use of the entire extremity. In the arms, fur- 
ther progression includes such activities as picking up 
blocks. (Fig. 12.) 
Fig. 12—The heel to knee test is one of the standard procedures 
in ataxia exercises of lower extremities. 
Foot-placement exercises are used for improving 
balance and gait. These are carried out by having the 
patient place his feet on painted footprints on the floor. 
These are done at first from a standing position and 
later during walking. (Fig. 13.) 
Fig. 11—Pulley therapy requires that the patient actively partici 
pate in his exercise program. 
9. ATAXIA EXERCISES 
Ataxia exercises are utilized in patients with ataxia 
of either spinal or cerebral origin. The original ex- 
ercises were described by Frenkel, and adaptations of 
these are found in standard texts. The principle of 
their use is the substitution by retraining of cortical, 
optic, and unused spinal pathways for the damaged 
structures. These exercises may be used for improved 
coordination of the upper or lower extremities when 
used independently and also for improving balance 
and gait. In general, they begin with simple flexion 
and extension movements of a single joint and then 
progress to the more complicated movements involv- 
Fig. 13.—The ataxic patient can master the more complicated 
movements by foot placement exercises. 
13 10. RECONDITIONING EXERCISES 
The principle of reconditioning exercises is to aid 
the patient to recover the strength he has lost by in- 
activity. These exercises are directed primarily at 
general physical fitness rather than at paralyzed mus- 
cles. The reconditioning program begins with bed 
exercises including “quadriceps,” back and abdominal 
exercises, and active movement of all joints. When 
the patient can be moved to the gymnasium, an indi- 
vidual program of conditioning exercises is worked out 
for him, including the use of mats, stall bars, chest 
pulleys, etc. (Fig. 14.) 
Fig. 15.—A hemiplegic pafient can master self-care activities 
early. 
Fig. 14—Supervised calisthenics to help strengthen the patient’s 
general musculature. 
11. SELF-CARE METHODS 
The importance of self-care activities has been dis- 
cussed in the previous chapter. It is possible to teach 
self-care by a combination of (1) the direct use of 
the patient’s personal effects and facilities, (2) by the 
use of simulated objects, and (3) by the use of related 
activities in the exercise gymnasium. 
The direct method is probably the best since it 
teaches activity in relation to application. For ex- 
ample, the patient is taught to shave with his own 
razor, to dress with his own clothes, to get into and out 
of his own bed, and to use regular toilet facilities. 
Feeding is actually taught in the dining hall. (Figs. 
15 and 16.) 
When it is not possible for the therapist to teach the 
self-care activities on the ward and in the dining hall, 
it is often necessary to utilize simulated objects and 
facilities. For example, under these conditions, the 
Fig. 1 6—Feeding oneself is of utmost importance to the independ- 
ence of the individual. 
patient sits at a table complete with eating utensils and 
is taught to go through the motions of eating a meal. 
The disadvantage of this method is that the simulated 
activity often must be modified when applied to exist- 
ing facilities. Often a patient may accomplish cer- 
tain self-care activities by transferring skills learned in 
the exercise program. For example, a person who 
has been taught to get on and off an exercise table 
may be able to transfer this skill to getting on and off 
a bed. When this can be accomplished, it is a decided 
short cut both for the patient and the therapist in the 
accomplishment of self-care activities. 
14 12. AMBULATION EXERCISES 
Parallel bars, crutches, and canes comprise the chief 
equipment required in teaching ambulation. Other 
equipment consists of walkers, which are sometimes 
useful, but not essential; footprints marked on the 
floor which regulate the length of the step; eversion 
boards, which are sometimes helpful in eliminating 
inversion; adduction boards which permit patients 
with scissor gaits to walk without crossing their legs; 
wall parallel bars with accompanying footprints used 
for balancing and ataxia exercises. (Fig. 17.) 
B. Parallel Bar Walking 
(1) Assisted. Next, the patient is assisted with 
his walking in the parallel bars. He learns to 
maintain good posture, proper foot placement, 
and balance. 
(2) Unassisted. He now spends a period in- 
side the bars by himself improving his gait, de- 
creasing his support, and gaining confidence. 
(Fig. 18.) 
Fig. 1 8—When the patient can walk unassisted, greater attention 
is paid to the development of a proper gait. 
C. Assisted Ambulation. He is now taken out- 
side the bars and, using whatever aids necessary, he 
is taught the principles of crutch or cane gaits. Dur- 
ing this period, the instructor assists the patient by 
actual physical support. It is impossible to set any 
standard progression in crutch and cane gait for the 
various disabilities since there is too much individual 
variation. Below is a brief description of the various 
crutch and cane gaits used by the neurologic patients: 
(1) Four-Point Crutch or Cane Gait. Left 
crutch, right foot, right crutch, left foot, etc. 
(2) Three-Point Crutch Gait. This gait is 
used by severely disabled hcmiplegics. Right 
crutch, right foot, left foot, etc. 
Fig. ]7—The early stages of ambulation require considerable 
assistance from the therapist. 
Ambulation starts with balancing in parallel bars 
and ends in unassisted walking. A patient may start 
at any stage and progress to any other stage depending 
on his physical condition at the time of referral and 
his ability to learn thereafter. The following are the 
stages in the progression to unassisted walking: 
A. Parallel Bar Balancing. Before the patient 
can walk, he must learn to maintain his balance and 
shift his weight from foot to foot. (3) Two-Point Crutch and Cane Gait. Right 
crutch and left foot advance simultaneously. Left 
crutch and right foot advance simultaneously, etc. 
(Figs. 19 and 20.) 
(4) Shuffle to. Starting from a tripod posi- 
tion, the feet arc brought forward up to the 
crutches. The crutches are then put forward and 
the procedure repeated. The feet are in contact 
with the floor at all times. 
(5) Swing to. Same as shuffle, except feet are 
not in contact with floor. The following chart 
gives the general pattern of progression followed 
by the majority of the different types of neurologic 
disabilities. 
Movement 
.2 
’So 
V 
CL 
| 
X 
Ataxia 
Paraplegia 
Parkinsonism 
Flaccid paral- 
ysis 
“Shuffle to” 
1 
“Swing to” 
2 
“Swing thru” 
3 
4-ot. crutch 
1 2 
1 
4 
] 
3-pt. crutch 1 
i 1 
2-pt. crutch 
1 3 
2 
5 
2 
4-pt. cane 
i 4 
3 
6 
1 
3 
2-pt. cane 
i 5 
4 
7 
2 
4 
No aids 
6 
5 
8 
3 
5 
1 Hemiplegic patients generally use only 1 crutch or 
1 cane. 
Fiq. 19—Two-point crutch walking is an early stage in ambulation. 
This analysis of the most commonly used walking 
gaits for neurologic patients does not necessarily im- 
ply that each patient in each classification follows 
through each of the steps designated. However, it 
does show the earliest stage in which each classification 
needs to start and the intermediate phases leading up 
to walking without aids. 
D. Unassisted Ambulation With Instructor at 
Side. During this stage the instructor walks by the 
patient’s side to give him added confidence and to 
improve his gait, pace, and posture. The instructor 
gradually increases his distance from the patient, and. 
at times, allows him to walk alone for short distances. 
Only after the instructor has observed him for a satis- 
factory period of time, varying with each patient, and 
is confident that no accident will occur, does the cor- 
rective therapist allow the patient to walk unattended. 
(Fig. 21.) 
E. Unattended Ambulation. The emphasis dur- 
ing this period is on increasing the distance the patient 
Fig. 20—A combination of foot placement exercises and cane 
walking will serve to improve the patient’s gait. 
16 13. REHABILITATION GYMNASIUM 
Good results in neurologic rehabilitation are not de- 
pendent upon expensive equipment. In a corrective 
gymnasium, the ambulation section should be about 
50 feet long and the exercise section about 30 feet. 
Parallel bars can be placed on one side wall. Next 
to these parallel bars, a simulated street can be erected 
consisting of two curbs, 8 inches in height, and a stop- 
and-go light. One should also have two stairways 
with railings available, one having a 7-inch and the 
other a 15-inch step leading to a 3-foot platform. This 
latter step is used primarily to teach the patient to 
enter buses and streetcars. The exercise area should 
cover about 30 feet in length and about 10 to 15 feet 
in width. This area should contain exercise tables 
and exercise chairs as well as bar bells, weight shoes, 
and different-sized weight bars ranging from I/4 to 
12/2 pounds. This area should also contain various 
types of corrective apparatus such as shoulder wheels, 
wrist circumductors, supinator pronator machines, 
overhead pulleys, etc. Also, in this area, are placed 
the mats, medicine balls, dumbbells, etc., for general 
body conditioning. Full-length mirrors should be 
used to help the patient observe and maintain correct 
gait. It is important that the equipment used should 
be simply constructed and readily adaptable for use 
in the home so that the program started in the hospital 
in many cases can be continued after the patient is 
discharged. From a practical point of view, the re- 
Fig. 21—Attended ambulation is the final stage before independent 
walking. 
walks, speeding up his pace, improving his gait, and 
applying his walking ability to practical uses. He 
must learn to cross streets, climb curbs, ascend and 
descend stairs, streetcar and bus steps, walk to his 
meals and the lavatory, and get along without his 
wheelchair. (Fig. 22.) 
Fig. 23—Proper organization of a rehabilitation gymnasium en- 
ables the therapist to supervise the corrective therapy of large 
groups of patients. 
Fig. 22—Practice in stair climbing unattended is essential before 
ambulation is complete. 
17 habilitation gymnasium should be located near the hos- 
pital wards. This enables the corrective program to 
be applied directly to the patient’s daily activities. 
(Fig. 23.) 
14. SELF-CARE AND AMBULATION CHART 
The primary puropose of this chart (fig. 25) is to 
provide a comparative means of evaluation of the 
patient’s self-care and ambulation activities. It can 
also be used as a check-list for activities to be practiced, 
as a means of charting progress and as a determining 
factor in the patient’s disposition. 
This chart was designed to include as many impor- 
tant activities as possible and at the same time to 
provide a concise and workable form. A certain 
number of these might require some amplification. 
For example in the self-care chart, item 1, which indi- 
cates the patient’s ability to change his position in bed, 
also requires that he be able to turn completely and 
return to the same position; item 19, which refers 
to the patient’s ability to go to the toilet unassisted, 
also requires that the patient be able to readjust 
his clothing in doing so; item 20, includes open- 
ing and closing the car door, as well as getting in and 
out of the door; finally, item 24, which refers to the 
patient’s ability to take a bath without assistance, also 
gives equal importance to the patient’s ability to take 
a shower. 
In the ambulation chart, item 5 gives the patient 
credit only if he can walk 50 feet unassisted in parallel 
bars; in items 9 and 13, the walking on crutches and 
canes similarly requires the ability to travel at least 50 
feet; and finally, under item 19, the patient is given 
credit for discarding his wheelchair only when he no 
longer uses it for any reason. 
Generally, as soon as the patient is referred to cor- 
rective therapy, his self-care and ambulation efficiency 
is checked and recorded. All activities learned there- 
after are recorded by date. Periodically during the 
program, the patient’s total self-care and ambulation 
scores are checked and compared with his previous 
ratings. In using these charts, it has been found that 
patients whose combined self-care and ambulation 
scores are less than 25 percent present a nursing prob- 
lem and require considerable attendant help. Those 
who score in the 50-percent range are reduced nursing 
problems but still present a formidable problem in the 
home. A patient who scores in the 75-percent range 
requires at most a small amount of help, is a good can- 
didate to return home, and in many cases is capable 
of selected work. The patient who scores near 100 
percent on self-care and ambulation is quite inde- 
pendent and, in many instances, is employable. Again 
it is repeated that a perfect score in ambulation and 
self-care does not represent the 100 percent of a normal 
individual, but rather that the patient would be 
capable of meeting the essential physical requirements 
of daily living. At the same time, he would certainly 
be able to make a most satisfactory physical adjustment 
to his own home. 
In order to be certain that the nursing and attendant 
staff keeps informed as to the progress of the patient, 
a self-care bed tag has been designed. This bed tag 
lists eight of the more significant self-care activities. 
The nursing and attendant personnel consult the tag 
to determine how much help the patient actually needs. 
An example of this tag is illustrated in figure 24. 
CORRECTIVE THERAPY 
BED TAG 
Name < 
In and out of bed alone. 
Use toilet alone. 
Feed self. 
Walk to meals. 
Wheel to meals alone. 
Wash self - brush teeth. 
Discard wheel Qhair. 
Clothe splf 
SPECIAL CONSIDERATIONS: 
Fig. 24—Self-care bed tag. SCORE FOUR POINTS FOR EACH ACTIVITY 
SELF CARE 
AMBULATION 
1. Change position in bed. 
2. Feed sell 
3. Wash hands and face 
4. Brush teeth and comb hair 
5. Write name and address 
6. Use telephone 
7. Sit up for six hours 
8. Get from lying to sitting pos’n. 
9. From sit on bed to stand 
10. Tie pajama bottoms 
11. Put on & take off shoes 
12. From bed to w/chair to bed 
13. Sit and arise from armless chair 
14. Put on & take off pajama bottom 
15. Put on & take off pajama tops 
16. In and out of chair at table 
17. Shave self 
18. Pick object off floor 
19. Use toilet w/o assistance 
20. In and out of car 
21. Tie shoes 
22. Put on and take off braces 
23. Clothe self completely 
24. Take bath w/o assistance 
25. Get from floor to stand 
1. Arise & stand w/aid in par. bars 
2. Arise & stand w /o aid in par, bars 
Shift weight from foot to foot 
3. in parallel bars 
4. Walk in par. bars with assistance 
5. Walk in par. bars w/o assistance 
6. Walk with assistance of Instr. 
7. Walk w/o assistance. Instr. by side 
Arise to stand from w/chair 
8. w/o aid 
9. Walk alone using crutch 
10. Climb stairs with railing 
11. Climb stairs w/rail backwards 
12. Walk sidewards & backwards 
13. Walk alone using cane 
14. Walk on ground & carpeting (rugs) 
15. Open and close door from stand 
16. Climb bus steps 
17. Climb curb 
18. Climb steps w/o hand rail 
19. Discard wheel chair 
20. 1 point for following distances: 
~21. 2sj 50 I 75 I 100 150 200 ~ 
22. 300 400 500 600 700 800 
23. 1 point for following times—48 ft. 
24. 85 80 75 70 65 60 
25. 50| 45 I 40 | 35 30 25 
..Date 
Self Care 
Ambulation 
Date 
Time 
Fig. 25—Self-care and ambulation chart of requirements for daily living. 
829577°—49——4 
19 15. OCCUPATIONAL THERAPY EQUIPMENT 
Occupational therapy plays a part in both the phys- 
ical and social rehabilitation of the neurologic patient. 
The social aspects of occupational therapy will be 
discussed in the subsequent chapter. From the phys- 
ical point of view, this type of therapy can be a means 
of increasing muscle strength, joint motion, and co- 
ordination of movement. In all cases, the therapist 
correlates her program with those of other services. 
When increased muscle strength is indicated by the 
prescribing physician, a course of exercise is planned, 
progressing from active-assistive to graded-resistive 
activities. Wherever a normal extremity can be used 
to aid the affected limb, equipment is adapted to make 
such exercise possible. Suspension slings are used to 
eliminate gravity for upper extremities, and many 
hand tools are constructed for two-hand use. It has 
been found that the most adaptable medium for the 
neurologic patients is weaving in all of its various 
forms. The operation of the loom can be adjusted 
to require the patient to exercise any desired muscle 
group. The exercise can also be graded by the weight 
of hand tools or by the resistance of the hand levers 
on such equipment as a printing press, jigsaw, or sew- 
ing machine. 
In a similar manner, graded force is applied for 
stretching contractures and increasing joint motion. 
In patients with impaired coordinations or dexterity, 
activities are graded from gross to fine movements or 
from simple to complex muscle action. Weaving, 
gardening, beadwork, jigsaw puzzles, various board 
games, and printing are excellent activities to promote 
increased coordination. 
Throughout the course of treatment, the therapy is 
constantly guided by the suggestions of the physician 
in charge of the patient’s condition, and necessary 
changes are made when indicated in order to further 
total rehabilitation. 
20 chapter IV. therapy= social procedures. 
1. THE ROLE OF THE PHYSICIAN 
The program of neurologic rehabilitation is carried 
out under direct supervision of the neurologist who 
assumes the over-all care of the patient from the time 
of admission. He directs the evaluation of the patient 
and the speed at which therapeutic procedures are 
instituted, working in close cooperation and consul- 
tation with the physiatrist and all members of the 
rehabilitation team. 
Detailed history and examination of the patient are 
carried out on admission. (Fig. 26.) Complicating 
illnesses, such as hypertention, gastrointestinal disease, 
urinary tract difficulties, cardiac complaints, and or- 
thopedic disabilities are carefully investigated by ap- 
propriate tests and consultations. The physician must 
be schooled to carry out his own psychiatric evalua- 
tion, calling for more experienced help when needed. 
This psychiatric evaluation is of the utmost value and 
cannot be overemphasized. 
The neurological examination and diagnosis in- 
cludes detailed studies to determine the location, na- 
ture, and extent of the lesion. Corrective medical or 
surgical procedures may be instituted. These may, for 
example, include measures to control pain, reduce 
spasticity, or decrease rigidity. 
It is essential to evaluate the patient with the atti- 
tude of searching for what functions are remaining 
rather than what have been destroyed. These assets 
are the building stones of rehabilitation. Many pa- 
tients considered hopeless when viewed from the stand- 
point of disability are found to have resources for 
rehabilitation when approached from the point of view 
of assets rather than liabilities. 
After the evaluation of the patient, a tentative goal 
and procedure is often set after consulting with the 
various other members of the rehabilitation team. It 
is the physician’s responsibility to keep track of the 
patient’s progress. If it is slow, the physician must 
avoid permitting himself to become discouraged, but 
rather investigate its cause. It is easy to reject the 
patient who fails to make progress but is far more 
gratifying to motivate him to improved function. 
An outstanding problem is that of emotional read- 
justment of the patient. In disabilities of short dura- 
tion, the outstanding feature is that of a depressive 
reaction to the illness. This can be combated by early 
planning and working toward the goal. It is im- 
portant that all personnel in contact with the patient 
be aware of this reaction and guard against it. The 
patient is generally given support early, and later is 
encouraged to take over more and more activities. 
Among many patients, there is emotional lability 
due to the organic damage early in the disease. 
Patience and a calm attitude will encourage the patient 
to gain more control. A similar attitude is advisable 
when aphasia complicates the picture. 
Fig. 26—A detailed knowledge of the nature of the physical ill- 
ness and any complicating diseases is required before rehabilita- 
tion can be started. An examination of the eyes is part of this 
examination. 
21 When the disability has been present 6 months or 
more, the problem of emotional readjustment is more 
difficult. Many of such patients develop a marked 
dependency reaction. An occasional patient will show 
considerable stubbornness and some hostility. It has 
been possible in our experience to convert these feelings 
into stronge, stubborn motivations to walk again. A 
fair percentage of patients make their readjustment 
with a minimum of guidance. 
Drug therapy may be described briefly here, but 
it is important to note that sedative drugs are usually 
unnecessary in patients on the rehabilitation program. 
Anticonvulsants are required in some patients. 
Specific and supportive drugs are used as indicated 
in individual cases for treatment of pernicious anemia, 
diabetes, cardiac decompensation, lues, urinary infec- 
tions, etc. For care of the urinary bladder, decubitus 
ulcers, skin grafting, and similar problems, one must 
refer to the literature on these subjects. 
There are certain special medications which have 
received considerable attention within recent years, 
particularly in the rehabilitation of neurologic dis- 
orders. The use of most of these drugs in nontoxic 
doses has been based on the theory that they will effec- 
tively reduce muscle tone in the presence of spasm or 
spasticity. Controlled experiments, however, still 
leave considerable doubts as to whether any of these 
drugs have any such specific action in the dosage as 
recommended. Further experimentation would be 
required to either confirm or deny their effectiveness 
before specific credit can be given these drugs for the 
results obtained. The use of such drugs, however, 
sometimes seems to be of definite psychotherapeutic 
value and tends to make the patient more willing to 
accept the physical modalities. 
Tubo-curare in oil has been used subcutaneously in 
an attempt to secure prolonged effectiveness in the 
reduction of muscle shortening and spasticity. This 
drug in too great a dosage may produce respiratory 
difficulties and hence, if used, must be administered 
carefully. For details of its use, one should refer to 
the specific literature on the subject. 
Myanesin is a newer drug. Its action is somewhat 
similar to that of tubo-curare. It may be taken by 
mouth and may exert toxic action, particularly upon 
the kidneys. 
Prostigmine is taken by mouth and has been pop- 
ularized within recent years for the treatment of 
muscle spasticity and shortening. Most investigators 
agree, at the present time, that if adequate patient 
controls are used this drug has little or no value in 
such cases. 
Dihydro-beta-erythroidine is an oral product with 
a curare-like effect. It seems to have some beneficial 
effect in the rigidity of parkinsonism but has little 
usefulness in the treatment of muscle spasticity. Ob- 
jective experiments on this drug are not yet available. 
2. THE ROLE OF THE NURSE 
Care of physical being. When the patient begins 
his rehabilitation he has already passed the acute stage 
of his illness and, being handicapped, is generally faced 
with a formidable problem of readjustment. This re- 
adjustment, both physical and emotional, can be 
greatly eased by a nurse who participates actively and 
intelligently as part of the treatment team. There are 
a number of specific contributions which the nurse can 
make. First and foremost, she must direct her atten- 
tion toward the physical welfare of the patient, such 
as the care of the skin, the care of the bowel and blad- 
der, prevention of deformities, nutritional needs, and 
sleep requirements. (Fig. 27.) In confused or 
aphasic patients, it may be necessary for the nurse to 
be particularly attentive to these needs since the pa- 
tients themselves will have difficulty in cooperating. 
Care of emotional readjustment. The emotional re- 
adjustment of the patient to his disability can be greatly 
facilitated by an understanding nurse. It is most im- 
portant for her to understand the patient’s likes and 
dislikes. This can be obtained by an early interview 
with the relatives, who can provide a great deal of in- 
formation concerning the patient’s habits before his 
illness, such as his food preferences, smoking habits, 
Fig. 27—A daily bed bath is very important not only for the 
morale of the patient but for the protection of the skin against 
break-down. 
22 his toilet habits, amount of ventilation during sleep, 
etc. A little attention to these preferences can go a 
long way in obtaining better cooperation of the patient 
with the program and with the staff. As the patient 
improves, he should be encouraged by the nurse to 
enter into group and recreational activities. 
Coordination with other parts of the program. In 
the rehabilitation program, principles of self-care and 
ambulation activities are taught during specific pe- 
riods; but the nurse on the ward must encourage and 
supervise their constant application to the practical 
needs of the patient. For example, as soon as the 
patient is able to turn from side to side, it is the nurse’s 
responsibility to see that he does so at regular intervals; 
if the patient is able to walk on crutches, the nurse does 
not permit him to resort to his wheelchair. The self- 
care bed tag, in this respect, proves a valuable adjunct, 
indicating to the nurse what activities the patient is 
able to perform. In certain instances, the nurse can 
aid greatly in teaching the patient certain self-care 
activities. Probably the most common of these are 
feeding and toilet activities. The nurse’s activities in 
these respects naturally should depend upon the pa- 
tient’s disability. 
3. THE ROLE OF THE SOCIAL WORKER 
The role of the social worker is to assist the doctor in 
the emotional, social, and economic readjustment of 
the patient and the family. The evaluation of the 
patient’s social setting, which includes his family sit- 
uation, his past work record, and his economic status, 
becomes one of her first responsibilities in rehabilita- 
tion. This information is most essential in determining 
the goal and in developing the treatment program. 
(Fig. 28.) 
By continuing conthct with the patient throughout 
the course of treatment, the social worker assists in 
interpreting the treatment program and goals and in 
laying the groundwork for a healthy philosophy of 
readjustment and a willingness to accept a state of in- 
dependent although modified usefulness. The social 
worker often can help provide a patient with a favor- 
able mental attitude and a sustaining incentive and 
can keep the doctor informed of the patient’s emo- 
tional status. 
As the patient’s adjustment progresses, the social 
worker plays a very important role in helping guide 
and orient the family in their participation in the 
patient’s problems and recovery. An understanding 
family can be most helpful to the patient and the 
Fig. 28—Cooperation with the family obtained by an early inter- 
view with the social worker goes far in encouraging the patient 
in his participation in the program. 
physician. Lack of cooperation on the part of the 
family often is a result of lack of understanding of 
their role rather than their unwillingness to help. 
Finally, as progress is made both physically and emo- 
tionally toward recovery, the social worker plays an 
essential role in arranging for proper occupational 
situations outside the hospital or within the home. 
Such occupational situations must fit the patient’s limi- 
tations. These final plans are of utmost importance 
because they often enable the patient, in spite of 
certain physical limitations, to assume a position of at 
least partial economic independence. Many of the 
necessary skills can be developed in the hospital or the 
home, but it is a great step to transfer from the pro- 
tected environment of a hospital to the harsh competi- 
tive atmosphere of society. The social worker again 
can play on important role in helping the patient bridge 
this gap and make the adequate outside adjustment 
which ultimately leads to a complete recovery. 
In order to advise the patient and the family ade- 
quately and to help both plan correctly, the social 
worker must have a complete understanding of the 
nature of the patient’s illness, the limitations of recov- 
ery, and the ultimate physical and economic adjust- 
ment that will be possible. Such guidance can only 
come from the doctors and others in the rehabilitation 
team who are aiding toward the patient’s physical 
recovery. 
The social worker, in carrying out her function, must 
develop and utilize various community resources which 
are available both within and outside the Veterans 
23 Administration. It is of importance to be acquainted 
with the following resources and to use them to their 
utmost: 
OFFICIAL VA SERVICES 
1. Special services. 
2. The voluntary services advisory committee (in- 
cludes all veterans organizations). 
3. Regional office social service. 
4. Outpatient clinics. 
5. Clothing committee. 
6. Medical rehabilitation board. 
7. Veterans Administration domiciliary homes. 
8. Contact representative. 
9. Chaplains. 
10. Chief attorney, regional office. 
COMMUNITY RESOURCES 
1. The American Red Gross (field director, home 
service department, gray ladies, motor corps). 
2. Department of veterans’ affairs (State). 
3. The public welfare agencies. 
4. Community Chest agencies. 
5. United States Employment Office. 
6. State rehabilitation program. 
7. County service officers. 
8. Special housing listings (houses within the hospi- 
tal vicinity which rent rooms at a nominal fee 
to patients’ families who come from out of 
town). 
9. Central index (social service exchange). 
10. Clergymen. 
11. Private convalescent homes. 
12. Soldiers’ homes. 
13. Public Health nursing services. 
4. THE ROLE OF THE PHYSICAL THERAPIST 
The physical therapist makes an early contact with 
the neurologic patient and therefore shares in the re- 
sponsibility for a favorable beginning in the process of 
rehabilitation. Much depends upon this initial ap- 
proach. The physical therapist, therefore, may go a 
long way toward allaying apprehension, quieting re- 
sentments, and creating a desire to join wholeheartedly 
in the therapy. 
Ideally, the rehabilitation process begins at the bed- 
side, where the therapist instructs the patient as to 
the purpose of the various procedures as they are intro- 
duced. The patient is instructed in proper bed pos- 
ture and proper exercises necessary to avoid the de- 
teriorating effects of inactivity. Close affiliation of 
the therapist with the nursing staff contributes materi- 
ally to the effectiveness of supportive measures and the 
regular performance of simple movements which the 
therapist has taught the patient. Any gains made by 
the patient which can be carried over into his daily 
activities are made known to those in charge of his 
program so that they may be incorporated in the 
routine activites of the patient. 
The physical therapist periodically makes and re- 
cords an evaluation of the patient’s muscular weak- 
ness, body mechanics, etc. (Fig. 29.) 
Fig. 29—Detailed and repeated muscle examinations are carried 
out by the physical therapist. 
By calling attention to each gain, however slight, 
the therapist can contribute to the morale of the pa- 
tient. The physical therapists, because of their early 
and frequent contact with the patient, are in a favor- 
able position to detect physical defects and emotional 
problems that might arise early in the treatment 
process. Evidence of skin lesions, threatening decubiti, 
or early contractures can be immediately called to the 
attention of the doctor and thus eradicated. Fam- 
ily and personal problems that are troubling the patient 
and perhaps slowing recovery often are discussed with 
the therapist during treatment. An alert and under- 
standing therapist can many times help the patient 
with the simpler difficulties and can inform the 
physician concerning some of the more complicated 
problems. 
24 5. THE ROLE OF THE CORRECTIVE THERAPIST 
The corrective therapist plays a dominant role from 
the time the patient is able to leave his bed until the 
patient leaves the hospital. The early activities con- 
sist of individual instruction of the patient. As soon 
as possible, this individual therapy is replaced by group 
activities in which the patient assumes more and more 
responsibility for his own rehabilitation. 
Individual instruction.—Individual instruction of 
the patient is primarily a means of physical rehabilita- 
tion; it serves, however, as a social procedure because 
it enables the corrective therapist to develop rapport 
with the patient and prepares the patient for group 
activities. The corrective therapist works with rather 
than on the patient and has a role somewhat similar 
to a coach. 
Group exercise therapy.—One of corrective ther- 
apy’s greatest contributions to the physical, mental, 
social, and economic rehabilitation of neurologic 
patients occurs through its group activities. They are 
the most effective means of providing motivation, cre- 
ating high morale, and encouraging voluntary partici- 
pation. In the exercise room the patient has the 
opportunity of observing and working with men of 
like disabilities in all stages of recovery. He is en- 
couraged to compete with and to try to excel other 
patients in the various activities which they do to- 
gether. Records are kept on charts, which are con- 
spicuously displayed, so that he might see at a glance 
how he compares with others as well as with his own 
record. Activities which readily motivate him through 
controlled competition are speed in walking, distance 
in walking, upper and lower extremity weight lifting, 
and increases in range of motion. (Fig. 30.) 
Group recreational therapy.—The recreational pe- 
riod is a means of continuing socialization of the pa- 
tient at times other than those spent in doing definite 
prescribed exercises. Patients who are often lukewarm 
in regard to exercise become enthusiastic in competing 
with others during the game period. This enthusiasm 
is often then carried over to the exercise period. In 
addition to its socializing value, the recreational period 
can be utilized for retraining the left hand in right 
hemiplegics, for developing dexterity by throwing darts 
and balls, and increasing the patient’s tolerance for 
exercise. 
The exercise room, when not occupied, can be used 
for recreational therapy. During these periods, pa- 
tients should be grouped according to their disabilities 
Fig. 30—In teaching activities such as ambulation, it is possible 
for the patients to work in small groups. 
and proficiency in games. Great care should be taken 
to eliminate the domination of a group by any one 
individual. As soon as a player shows a tendency in 
this direction, he should be moved to a higher group. 
In this manner, all patients have the opportunity of 
gaining the satisfaction of winning. At the conclusion 
of the recreational period it is helpful to serve light 
refreshments which furthers the spirit of camaraderie. 
There are a number of simple games which are adapt- 
able for even severely disabled patients which arc 
listed on the next page. 
1. Darts and dart boards. 
2. Various-sized balls and various-sized pails or 
boxes into which the ball is cast. 
3. Quoits. 
4. Putter golf. 
5. Rubber rings and pegs. 
6. Shuffleboard. 
7. Wheelchair basketball. 
Volunteer workers.—Volunteer workers may play 
an important role in the social readjustment of dis- 
abled patients by assisting with the activities which do 
not require supervision by a corrective therapist. Be- 
fore taking an active part in the program, the volun- 
teers should be thoroughly indoctrinated and briefed 
in the activities in which they are expected to partici- 
pate. Patients frequently develop attachments to cer- 
tain volunteers which acts as an added stimulus for 
their participation in the program. 
25 For older patients, whose posthospital goal is self- 
care and limited ambulation, it has been found helpful 
to provide an avocational interest. This may develop 
into a remunerative hobby, or it may be a means of 
maintaining morale by constructive use of time. 
Previous to their discharge, these patients are en- 
couraged to make the simpler equipment while volun- 
teer organizations are encouraged to donate the more 
complicated occupational tools for use at home. 
7. THE USE OF MANUAL ARTS THERAPY 
This activity is generally more applicable to the 
younger patient for whom an employment goal has 
been set. By simulating the demands of various 
types of work in industry or trade, objective data is 
made available to medical staffs so they may advise 
whether or not posthospital vocational goals arc com- 
Fig. 31—Sports adapted to the patient’s ability furnish motiva- 
tion and group spirit as well as exercise. This can be supervised 
by volunteers. 
6. THE ROLE OF THE OCCUPATIONAL THERAPIST 
The occupational therapist plays an even more im- 
portant role in the social than the physical adjustment 
of the patient by encouraging group activities, by pre- 
vocational exploring, and by developing avocations. 
Although all of the treatment in occupational therapy 
is on an individual prescription basis, the activities 
which bring patients together in the clinic are a defi- 
nite aid to socialization. The clinic resembles a nor- 
mal working situation in many respects, and the 
friendly competition which arises in comparing proj- 
ects is encouraged. The patients often help each 
other with craft techniques and contribute to the de- 
partment by constructing tool cabinets, flower boxes, 
shuttle racks, etc. Good work habits arc encouraged 
at every opportunity. 
A common problem is the concern of the men about 
their finances and their means of earning an income. 
By the use of certain activities, specific diagnostic data 
for personality evaluation may be provided and voca- 
tional (work) interests determined, indicating what 
the patient may be trained to do to develop his pre- 
vocational or avocational abilities. Information on 
the patient in the form of progress notes for his med- 
ical record may be used by manual arts therapy and 
vocational advisement. Some of the activities which 
may lend themselves in prevocational exploration are 
woodworking, gardening, sign painting, model con- 
struction, leatherwork, weaving, and jewelry. (Fig. 
Fig. 32—Plastic projects serve as an excellent form of occupational 
therapy for parkinsonism. 
mensurate with disabilities. It is particularly well 
adapted to patients with flaccid paralysis, paraplegia, 
hemiplegia, and similar illnesses resulting in residual 
disabilities that may affect a person’s capacity for 
work. (Fig. 33.) 
2 6 altitude, or using power machinery. Because of cer- 
tain social prejudices and compensation restrictions, 
certain vocations are not open at present to patients 
with convulsions and must be taken into consideration 
in the vocational guidance of these individuals. (Fig. 
34.) 
Fig. 33—Manual arts is of special interest to the younger men 
where they can do prevocational exploring. It is adaptable to 
group activities. 
8. THE USE OF VOCATIONAL COUNSELING 
The main function of vocational counseling is to 
advise the disabled individual as to the best means 
for him to earn a living. Since most people earn 
their livelihood by the use of their hands or their 
voice—functions which are often severely involved in 
neurologic disabilities—counseling this group of 
patients presents certain special problems. Here are 
some of the more important of these problems: 
Manual dexterity.-—With the exception of the 
paraplegics, this is one of the most constantly and 
severely involved functions. It is possible to evaluate 
the patient’s dexterity as compared to the general 
population by means of the Minnesota rate-of-manipu- 
lation test, the Purdue peg-board test, or similar 
tests. 
Speech involvement.—-Speech involvement, al- 
though important, plays a less prominent part in the 
patient’s disability if there is reasonable manual 
dexterity. The procedures of handling the speech 
difficulty will be discussed in a future paragraph. 
Convulsions.—Symptomatic convulsions, if evalu- 
ated and treated properly, generally can be fairly 
well controlled in most patients. Even the best of 
control, however, leaves the possibility of occasional 
seizures and hence creates certain vocational problems. 
It is important to see that the patient does not plan 
for an occupation that will be dangerous to himself 
or others, such as driving a vehicle, working at high 
Fig. 34—Detailed testing of the patient's abilities is one of the 
functions of vocational counseling. 
Nature and course of the illness.—In involvements 
of the nervous system, there is a considerable varia- 
bility as to the degree and course of the illness. These 
factors require careful consideration in every case for 
adequate counseling. Although the approach in an 
arrested disease will be different from that in a 
progressive disease, one can, even in the latter, con- 
tinue to make limited vocational plans. Even in 
patients with organic brain deterioration, a vocational 
adjustment at a lower level may be possible. Within 
the limits imposed by the factors described above, voca- 
tional counseling consists of four steps: 
(1) Evaluation of the patient by means of indi- 
vidual interviews and special tests. 
(2) Following this evaluation and in consulta- 
tion with the physician, specific vocational sugges- 
tions are made to the patient. 
(3) After the patient has shown an interest and 
aptitude in an appropriate vocation, his vocational 
training is begun. 
(4) Before the patient’s discharge from the hos- 
pital, contacts are made with various agencies in 
order to accomplish job placement. 
27 9. THE USE OF EDUCATIONAL THERAPY 
Often after a proper vocation has been selected for 
a patient, it is found that certain educational require- 
ments must be met. It is here that educational ther- 
apy plays its most important role. In carrying out 
this function, educational therapy generally institutes 
the following steps: 
(1) A study of the patient’s educational back- 
ground—If the patient does not have a high 
school diploma, he is given a battery of five tests, 
known as the high school general educational de- 
velopment tests, to see if he is eligible for a high 
school diploma. This is particularly important if 
his vocational goal is to include further college 
training. 
(2) The selection of the appropriate courses to 
be taken—In light of the patient’s educational ac- 
complishments and the vocation which has been 
recommended, an educational program is out- 
lined. There are various facilities which are 
available to the educational therapist in carrying 
through such a preparatory program. These in- 
clude USAFI or Armed Forces Institute courses, 
individual tutoring, and university extension 
courses. 
(3) Supervision of the training—It Is the respon- 
sibility of the therapist to offer continuing guid- 
ance to the patient during this work and to arrange 
for proper examinations in the courses so that, if 
possible, college credit can be obtained for them. 
10. THE USE OF SPEECH THERAPY 
Speech is the most important single means of com- 
munication, and without it, the socialization of a pa- 
tient is very difficult. Formal speech training and the 
correction of speech defects should be carried out only 
by a qualified individual. All members of the rehabili- 
tation team, however, can stimulate the patient to 
utilize his speech more effectively by following a few 
simple rules. 
(1) The patient needs the stimulation of hearing 
normal language. For this reason, he should 
be spoken to in a natural manner. Overarticula- 
tion, loud talking, or slow talking embarrasses and 
confuses the patient. 
(2) If the patient appears to have difficulty in 
understanding, use short, direct, natural sentences. 
(3) Wait for the patient to answer, giving him 
your full attention and all the time he needs. 
Trying to hurry him will create more tension and 
increase his difficulty. 
(4) It is reassuring to the patient to have a lis- 
tener recognize his disability and show interest 
in his accomplishment. 
(5) When the patient is relaxed and at ease, it 
is all right to try to get a few specific responses 
regarding familiar objects with which he is work- 
ing. The patient should be encouraged in an easy 
and friendly manner to use the best speech of 
which he is capable and should not be allowed to 
get away with a gesture if he can use a word, a 
word if he can use a phrase or sentence, or mum- 
ble a response if he can talk clearly. 
The hospital librarian can contribute to the speech 
program, first by careful selection of reading material 
according to the patient’s interest, and secondly, by 
forming reading groups in which selections of general 
interest are read and discussed. Naturally, the group 
must be a selected one for this function. The librarian 
similarly can increase the morale of patients without 
speech disabilities. 
11. THE USE OF MUSIC THERAPY 
It is becoming apparent that music therapy can 
play a very important role in the social rehabilitation 
of the disabled patient. There are many ways in 
which this function can act: 
Music appreciation.—Since music appreciation re- 
quires no physical participation on the part of the 
patient, it is one of the best means of introducing the 
patient to this therapeutic measure. This is accom- 
plished through playing appropriate music during the 
exercise and dining periods, by having special recorded 
and radio programs, and through the sendees of skilled 
entertainers. 
Group participation.—As soon as possible, the pa- 
tient is encouraged to participate actively in musical 
projects. Such projects include community singing, 
group chorus, and small instrumental groups. 
Individual instruction.—Individual instruction is 
generally reserved for patients evidencing particular 
interest or skills. Patients can be taught to use simple 
musical instruments despite rather severe disabilities. 
The accomplishment of this skill offers the patient an 
additional means of entertainment. Practice on mu- 
sical instruments may have the added advantage of 
furthering functional recovery. 
28 Improvement of speech.—Because the basic factors 
involved in good singing are similar to those involved 
in good speech, individual singing instructions can 
augment the speech therapy program. Special em- 
phasis is given to the development of breath control, 
resonance, pitch control, rhythm, and articulation. 
(Fig. 35.) 
Chaplaincy service.—By means of church services 
and individual conferences, the chaplain makes relig- 
ious experiences available for the patients. In certain 
cases, the chaplain, by his influence, may aid consid- 
erably in obtaining the patient’s cooperation in the 
total program and working out certain of the family 
problems. 
Library service.—Selected reading materials, books, 
and periodicals can furnish a great comfort, particu- 
larly to a bedridden patient. Such reading material 
can furnish amusement and entertainment as well as 
educational experiences. The success of such a service 
naturally will depend upon the skill with which the 
librarian interweaves it with the rest of the program. 
Recreation and sports.—Recreation and sports ac- 
tivities, particularly in this country, have become one 
of the most important aspects of special services. Such 
a program, to be a satisfactory complement of the 
rehabilitation regime, must have variety and must meet 
the needs but not exceed the capabilities of the patients 
for whom it is planned. It must be carefully sched- 
uled to avoid conflict with the definitive treatment of 
the patient and with the programs of the other sup- 
porting services. Recreation and adapted sports pro- 
gram includes a great variety of activities such as 
wheel-chair archery, fly casting or plug casting from a 
wheelchair, instrumentation, chess, bridge, and 
photography. Where the disability precludes the full 
participation in recreational activities formerly en- 
joyed by the patient, adaptations of such activities 
can be offered as substitutes. (Fig. 36.) 
Fig. 35—Singing and vocalizing are helpful adjuncts to speech 
therapy. 
12. THE ROLE OF SPECIAL SERVICES 
During the retraining process, which may require a 
considerable period of hospitalization, the patient is 
faced with many conflicting emotions precipitated by 
his need to adjust to the problems facing him. If it 
were possible to keep these individuals occupied with 
a medical regime throughout the day, this problem 
would be largely resolved; but, it is neither practical 
nor wise to attempt so extensive an exercise program. 
For this reason and because it more closely resembles 
the normal routine, an adequate social recreation pro- 
gram is essential. This need is filled by special services 
and includes such activities as religious, musical, 
sports, games, and parties. 
Fig. 36—Contacts between patients are furthered during unsuper- 
vised recreation periods. The card holder was made by the patient 
to assist him in playing cards. 
29 Canteen service.—The canteen service provides the 
patient with opportunities for self-expression and for 
normal social experience “over a cup of coffee” or by 
means of making gift purchases for his family and 
friends. It is equally important that a canteen ward 
cart be available for bedfast patients, and that the 
canteen store be located in a place that is accessible 
to semiambulant patients. 
13. REHABILITATION CONFERENCE 
It is apparent from the above discussion that there 
are numerous therapeutic influences being brought to 
bear on the patient. In order to coordinate and to 
follow the progress of the individual patients, it is 
helpful to have a periodic patient conference. This 
conference is conducted by the Chief of the Neurology 
Service in consultation with the chief, Physical Medi- 
cine Rehabilitation, and is participated in by all mem- 
bers of the entire rehabilitation team. This can be 
done either informally or when indicated, by utilizing 
the official Veterans Administration Rehabilitation 
Board. 
The patient, as a rule, is presented at this conference 
a few days after he is started on the program. At this 
time, the total physical and social evaluation is pre- 
sented in order to orient the entire personnel with the 
therapeutic problem. The patient is re-evaluated at 
subsequent conferences, and his progress as well as 
his problems are discussed. Reports are given by all 
the members of the therapeutic team described above. 
Each member of the therapeutic team is encouraged 
to participate with questions or suggestions. Each 
patient, immediately prior to discharge, is again 
presented to set his course after discharge from the 
hospital. (Fig. 37.) 
14. INTEGRATION AND COORDINATION 
In addition to the periodic patient conferences, it is 
essential to maintain a more intimate integration by 
Fig. 37—A weekly conference of the rehabilitation team reviews 
the patient's progress and coordinates the program. 
day-to-day supervision of the various activities. The 
over-all direction of the therapeutic influences is car- 
ried out by the patient’s physician. The success of 
the progress of any single patient will necessarily de- 
pend upon the energy and interest of his physician. 
Since it is apparent there is no sharp line of demarca- 
tion between the activities of the various therapists, it 
frequently becomes the duty of the physician to appor- 
tion the work in accordance with the individual 
patient’s needs. 
In practice, it becomes necessary to schedule the 
activities of each patient. For such a schedule to 
become workable, at least some portions of the pro- 
gram must be flexible. For example, because of the 
individual nature of the treatments in physical 
therapy, these usually must be scheduled rather rigidly. 
Corrective and occupational therapy, through group 
work, permit greater flexibility. It becomes the re- 
sponsibility of the coordinator to be sure there is no 
conflict between these various activities and to see 
that the patient’s day is as full as compatible with his 
general physical condition. 
30 chapter V. specific disabilities 
1. HEMIPLEGIA 
The syndrome of hemiplegia is due to a lesion in 
that part of the brain that controls voluntary move- 
ment. The centers for the control of movement of 
the right side of the body are located on the left side 
of the brain. In right-handed individuals, the speech 
centers are generally located on the left side of the 
brain. Therefore, when a person has a disease involv- 
ing the left side of the brain, he frequently will have a 
paralysis (hemiplegia) of the right arm and leg and 
difficulty with speech. On the other hand, if he has 
a lesion on the right side of his brain, he will show 
only a paralysis of the left arm and leg with no trouble 
in speech. This can vary from a mild weakness of 
the arm or leg to a complete paralysis of one-half of 
the body, depending upon the size and location of the 
lesion in the brain. Frequently, the arm is more se- 
verely involved than the leg and the distal parts more 
severely involved than the proximal parts. 
There are many causes for hemiplegia, varying with 
the age of the patient. In young individuals, one 
most frequently encounters infections and tumors; in 
older individuals, the most common cause is a hemor- 
rhage or a thrombosis, referred to as a stroke. In ad- 
dition to the above, there are numerous other lesser 
known causes of hemiplegia. Owing to the multiplicity 
of causes, it is imperative that each patient receive a 
careful neurologic examination to determine the spe- 
cific etiology in each case and the effect it might have 
on the patient’s rehabilitation program. 
Following recovery from a stroke, the average pa- 
tient will have a severe weakness of the arm, leg, or 
both. Early, this is frequently flaccid but later it be- 
comes spastic. Because of the immobility and spas- 
ticity, contractures are a common development, par- 
ticularly in the shoulder, wrist, hip, and knee. A spas- 
tic, inverted foot is an additional common compli- 
cation. 
Due to the brain damage, many patients with 
hemiplegia show marked emotional instability with 
frequent tendency to cry in an uncontrolled fashion. 
This behavior generally improves with the passage of 
time and intelligent handling, but, in the early phases 
of the illness, may hinder the treatment of the patient. 
The outlook for functional recovery is variable from 
patient to patient and can be determined only by care- 
ful neurologic evaluation from time to time. Long 
continued flaccidity, the loss of reflexes, and the early 
onset of contractures are unfavorable signs. The early 
return of reflexes and function implies rapid and com- 
plete recovery. All patients with hemiplegia, regard- 
less of the degree of recovery, are capable of ambula- 
tion if given adequate rehabilitation therapy. 
Because these patients are frequently in the older 
age group, many are subject to high blood pressure, 
heart disease, kidney disease, or diabetes. These as- 
sociated conditions must receive careful attention from 
the physician at the onset; it is seldom necessary, how- 
ever, to deny the patient the benefits of rehabilitation 
because of these conditions. 
Immediate care of the hemiplegic patient is thus 
seen to be chiefly good nursing care and general med- 
ical treatment. During the period of flaccidity, it is 
important to prevent the occurrence of contractures. 
This is done by passive motion daily through full joint 
range and proper positioning in bed. Generally, the 
patient is kept quiet in bed; careful attention is given 
to the skin, mouth, bladder, and bowel. Medical pro- 
cedures and therapy for underlying disease, if not 
started on arrival at the hospital, are now begun. 
The nursing care of these patients is of utmost im- 
portance. They must be carefully watched for evi- 
dence of exacerbations of their condition. The pa- 
ralysis of the extremities leaves the patient quite help- 
31 less for a time, and he must be fed and encouraged to 
begin feeding himself as soon as possible. Decubiti are 
avoided by close attention to maintenance of skin hy- 
giene, chiefly through preventing the patient from soil- 
ing himself while incontinent. During this early 
period, he is placed on a schedule for eating, bowel 
habits, waking, and sleeping. The nurse’s encourage- 
ment of the patient to help himself in her initial con- 
tact with him is the first step in rehabilitation. 
Social service is notified as soon as possible after ad- 
mission, and then interviews the patient’s family. At 
this time, the general aims of the program are outlined 
to the family, and an estimate is given as to how long 
it might be until the patient is ready to return home. 
Any financial or social problems resulting from the 
patient’s illness are discussed, and the family is en- 
couraged to use Social Service facilities to the fullest 
extent. The social worker also begins her attempts to 
orient the patient as soon as his condition permits. 
Her contacts with both the patient and the family con- 
tinue through the entire hospital stay. 
Since most hcmiplegics are kept in bed for a period 
of 3 to 6 weeks depending upon the severity and cause 
of their involvement, it is necessary to begin physical 
therapy on the affected limb as soon as the acute symp- 
toms have subsided and while the patient is still bed- 
ridden. At this stage, physical therapy consists of pre- 
vention of deformity by the use of passive movement 
through the full joint range. Between therapy pe- 
riods, footboards and sandbags may be used to hold the 
foot at a right angle and to prevent external rotation 
of the thigh. In selected cases, posterior splints may 
be substituted. Light cock-up splints may be indi- 
cated for the hand and wrist. As he improves, he is 
taken to the physical therapy department where active 
assistive exercises and muscle training are begun. The 
patient is encouraged to use the affected extremity as 
much as possible and to care for his own bedside needs. 
In physical therapy, heat, massage, and hydrotherapy 
may be used for painful extremities and joints. These 
procedures prepare the patient for corrective therapy. 
In corrective therapy, the patient is exposed to more 
vigorous exercise and group activities. Since the chief 
goal is ambulation, resistive exercises and pulley 
therapy are begun early. (Fig. 38.) Ambulation is 
started when the patient is strong eough to bear weight 
on the affected limb. He usually starts by balancing 
within the parallel bars and progresses through the 
normal stages of ambulation described in previous 
Fig. 38—Resistive exercises for strengthening the quadriceps are 
frequently helpful in hemiplegics, particularly if any contracture 
has developed. 
chapters. During this period, he is taught the neces- 
sary self-care activities. 
When the patient is not at physical or corrective 
therapy, he is encouraged to participate in occupa- 
tional therapy. Woodworking, braiding, finger paint- 
ing, and clay modeling offer excellent exercises for the 
development of the hemiplegic hand and wrist while 
the bicycle, jigsaw, sewing machine, and similar treadle 
apparatus are used for the development of the foot 
and ankle. (Fig. 39.) 
The speech therapist is requested to see the patient 
when speech difficulty (aphasia) is present. The pa- 
tient is encouraged to use his language residual as 
much as possible. Materials are provided by the 
therapist for retraining and expansion of the limited 
function. The course of speech therapy is often much 
more prolonged than any of the other rehabilitation 
procedures and frequently must be continued after 
the patient has left the hospital. 
Because of their disability, many patients have to 
learn new vocations which will enable them to con- 
tribute to the support of the family. In younger indi- 
viduals, this prevocational training is begun in the 
hospital, and contacts are made for him to continue 
his training after discharge. In the older individuals, 
it is frequently necessary to be satisfed with home craft 
or an avocation. (Fig. 40.) 
In every patient, prior to discharge, the minimum 
goal should be self-care and moderate ambulation. 
32 mcnt manifests itself upon the arm and leg of the 
same side. In such a patient, there develops an inco- 
ordination of the involved limbs resulting in awkward- 
ness in gait, clumsiness in the hands, and, in many 
cases, slurred speech. Tremor may be an associated 
finding. Many of the ataxic patients also have vary- 
ing complements of spasticity. 
The spinal types of ataxia are due to such diseases as 
pernicious anemia, tabes dorsalis, and multiple scle- 
rosis. Cerebellar ataxia may be due to tumors, in- 
juries, thromboses, and degenerations. Most of these 
diseases tend to be progressive, but many of them 
have prolonged periods of remission. Therefore, it 
is very important to get a careful evaluation of the 
patient and the cause of disturbance prior to the insti- 
tution of therapy. In spite of the general unfavorable 
outlook in this group of conditions, many patients 
show considerable improvement under a retraining 
program. 
In contrast to the hemiplegic patients, the ataxias 
are much more chronic disabilities and rehabilitation 
can be instituted as soon as the evaluation of the pa- 
tient is completed. The general principles of retraining 
of these patients consist of substitution activities. Be- 
cause of the loss of the coordinating mechanism, the 
patients have to compensate by substituting other 
senses, such as sight. Such a substitution requires 
the conscious concentration of the patient and there- 
fore necessitates a prolonged period of retraining. 
Even after such retraining, slight emotional upsets 
may temporarily disturb the newly acquired com- 
pensations and again precipitate the incoordination. 
Such emotional overreactions may appear to be very 
insignificant such as being amongst company, board- 
ing a streetcar, or undertaking a new activity. 
The nursing care of these patients consists chiefly 
in protecting the patient against bodily injury, from 
falls, cutting himself, etc. The nurses must also ex- 
pend considerable effort in teaching these patients 
self-care activities. 
These illnesses, because they are chronic and pro- 
gressive, generally have been present some time before 
the patient applies for rehabilitation. As a result, the 
patient and the family have already made certain and 
often unhealthy psychological adjustments. It is the 
primary duty of the social worker, once a medical 
evaluation and goal has been set, to attempt to develop 
a healthier family relationship. 
Since hypotonia is a common accompaniment of 
these disorders, contractures are uncommon and 
Fig. 39—Supports can be used in occupational therapy to elimi- 
nate the effect of gravity and friction on the weak muscles. 
Fig. 40—Photography is an excellent vocation or hobby for a 
hemiplegic patient. 
2. ATAXIAS 
The syndrome of ataxia may be due to involvement 
of the cerebellum or to involvement of some of the 
special tracts in the spinal cord. Such an involve- 
33 passive movements arc generally not required. The 
chief purposes of the exercise program are to develop 
muscle power, coordination, and endurance. The 
development of muscle power is accomplished by 
resistive exercises and general reconditioning exer- 
cises. Retraining in coordination is carried out by 
modification of Frenkel’s ataxia exercises. Stabiliza- 
tion of the elbows against the body is a useful com- 
pensation in reducing incoordination of hand move- 
ments. Endurance is built up by constant repetition 
and perseverance in the exercises and activities. 
Since, in these patients, the bulk of the physical exer- 
cises can be carried out on a group basis, they generally 
fall into the realm of the corrective therapist. Muscle 
testing and muscle re-education are likewise important 
for this type of patient, and, as each is usually different 
in extent of involvement, individual treatment is 
indicated as prescribed. (Figs. 41 & 42.) 
Fig. 42—Handrails installed in the home make it possible for the 
severely ataxic patient to go up and down stairs, making him more 
independent in his own home. 
The purpose of speech therapy in the ataxic patient 
is to make the speech as intelligible as possible and to 
reassure the patient that it is understandable. This 
can be accomplished by training the patient to speak 
slowly and to pronounce his words as carefully as pos- 
sible. It is frequently helpful to have the patient pause 
after every word or every phrase. Specific speech 
drills arc indicated in selected patients. The patient 
must be taught to understand and accept the changes 
which have occurred in his speech and to develop an 
objective attitude toward his speech problems. Un- 
derstanding and tolerance on the part of the listener 
often goes a long way in the development of speech 
confidence in the ataxic patient. 
Vocational training follows the same general princi- 
ples as for any other chronic neurologic disorder and 
will be limited only by the severity of the disability and 
the progressions of the illness. 
3. MULTIPLE SCLEROSIS 
Multiple sclerosis affects scattered and multiple por- 
tions of the nervous system. Some of the cases are spe- 
Fig. 41—Block placement exercises develop coordination in the 
upper extremities. 
Occupational therapy generally supplements the 
general exercise program. One usually should start 
with group activities and proceed to those requiring 
finer movements. The patient should be protected 
against frustration and personal injury. Activities 
which may result in tearing, spilling, breaking, etc., 
should be avoided. One may employ braid weaving 
and the use of floor looms. Woodworking is excellent 
for the rhythmic repetitive motions involved. Finally, 
one can progress to the use of plastic and leatherwork. 
Gardening is a very excellent exercise for these patients 
and has the additional asset of getting the patient 
outdoors. 
34 cifically hemiplegic; others closely resemble paraple- 
gias. The majority of them, however, have a com- 
bined ataxia with spasticity. The treatment problem 
will depend upon the predominant involvement, be it 
ataxia or hemiplegia. Their treatment has been de- 
tailed in the two previous sections. 
Multiple sclerosis, however, does present a special 
problem because this disease has a tendency in many 
cases to exacerbations and remissions and is most fre- 
quently seen in the younger age groups. Because of 
the remissions and exacerbations, the course of the 
disease is extremely variable and unpredictable from 
patient to patient. This requires repeated re-evalua- 
tions of the patient in order to fit his rehabilitation pro- 
gram with his needs, and to keep the plan fluid so that 
it can be readily changed. There are certain general 
rules in the handling of multiple sclerosis. 
During the acute relapse, it is probably advisable to 
avoid an intensive exercise program. Even though 
such a program may not be deleterious from a physical 
point of view, it is better psychologically to begin the 
exercises after the patient has leveled off. It is im- 
portant, however, to prevent deformities and to carry 
out at least diversional occupational therapy during 
this acute stage. 
As soon as the patient’s condition has leveled off, it is 
important to begin the appropriate exercises with as 
little delay as possible. At the same time, the occupa- 
tional therapy should be converted from diversional to 
functional activities. 
One must keep in mind, however, that even in the 
most unfavorable type of case where the disease tends 
to take a fairly progressive course, this progression is 
usually slow and a great deal can be done to improve 
the function and adjustment in the majority of these 
patients. 
A large number of drugs have been used in the treat- 
ment of this disorder. These include quinine, fever 
therapy, vitamins and liver, vasodilators, and anticoag- 
ulants. The remissions and relapses characteristic of 
this disease make their evaluation difficult. Controlled 
studies seem to show no significant difference between 
the effects of any of these drugs and of placebos. How- 
ever, many individual patients feel that one specific 
drug has been of benefit to them and, for psycho- 
therapeutic reasons, it is often important to supplement 
the exercise program with the drug. Under these cir- 
cumstances, until a proven effective drug is found, the 
use of a simple, nontoxic medication is advisable. 
4. PARKINSONISM 
Parkinsonism, or shaking palsy, is a disease which 
manifests itself primarily by muscular rigidity which 
often is associated with a tremor. Because of the 
muscular rigidity, these patients may demonstrate 
marked slowness of movements and a hesitant speech. 
Generally, this is a slowly progressive disease lasting 
over an extended period of years and more commonly 
affecting the older age groups. If not handled prop- 
erly, this illness frequently will lead to complete in- 
validism. The two main causes for this illness are 
arteriosclerosis and encephalitis, the latter generally 
affecting the younger age groups. 
The treatment of these patients is a combination of 
the intelligent use of drugs, exercise, and emotional 
readjustment. Since there are, at the present time, 
many drugs which greatly aid in reducing the rigidity 
of these patients, drug therapy must be the first con- 
sideration. (Fig. 43.) 
Fig. 43—Because of the large number of drugs available and their 
varying effects in parkinsonism, each patient must be individually 
evaluated. 
The principal drugs are hyoscine, rabcllon, vinobcl, 
and bella bulgara. Drugs such as benzedrine, prostig- 
mine, dial, and quinine may be uSed as adjuncts. As 
a general rule, these drugs are much more effective 
against the rigidity than against tremor. The patients 
vary tremendously in their tolerance to those drugs 
and, therefore, the therapy must be highly individual- 
ized to obtain the maximum results. 
While the patient is being regulated on his medica- 
tion, one proceeds with the other forms or treatment, 
such as retraining and emotional readjustment. The 
latter requires considerable attention from the phy- 
sician throughout the entire course of therapy. These 
35 patients tend to follow a set routine and are resistant 
to change. They tend to become dependent upon 
others and are commonly subject to mild depressions. 
These personality traits are of great importance in the 
treatment of the patient and must be modified before 
adequate results can be obtained. 
Such results are obtained through the combined 
efforts of the physician with the help of the social 
worker. Because this disorder is of long duration, 
there is a marked tendency for families to reject the 
patient while the patient, on the other hand, becomes 
more and more dependent upon others for his care. 
Both these difficulties can be greatly improved by 
constructive social work. 
Because the upper limbs are more frequently in- 
volved than the lower extremities, the condition affects 
self-care activities much more than ambulation. For 
this reason, the chief nursing problem is daily training 
in self-care activities. It is important that the nurse 
follow closely the medical regime prescribed by the 
physician but, since the patients may be resistant to 
changes in their medication, it taxes the ingenuity of 
the nurses to carry out the doctor’s orders. (Fig. 44.) 
The chief role of physical therapy in the treatment 
of parkinsonism is to attempt to break down contrac- 
tures and increase joint mobility. In the more chronic 
cases, in which swollen, painful joints and extensive 
edema have developed, heat and passive movement 
may prove of definite benefit. 
Most of these patients score well on ambulation; 
however, they do have considerable difficulty in get- 
ting in and out of chairs, up and down stairs, and roll- 
ing over in bed. For this reason, truncal exercises on 
the mat, sit-ups, and calisthenics in cadence are given. 
(Fig. 45.) 
Work in occupational therapy is impaired by these 
patients’ postural difficulties and stiffness of the hands. 
One of the first therapeutic aims is that of achieving 
good working fists. This can be accomplished by 
weaving, woodworking, and especially hammer- 
ing. Leatherwork forms a more advanced project. 
(Fig. 46.) 
The statements made concerning speech therapy in 
ataxic patients are directly applicable to patients with 
Parkinson’s disease. The actual type of speech defect 
is somewhat different but the method of handling is 
essentially the same. 
Very mild parkinsonisms under adequate therapy 
may achieve, for a time, a full vocational adjustment. 
Since this illness is a progressive one, however, eventu- 
Fig. 44—Even in the presence of severe tremor, an electric shaver 
will make it possible for the parkinsonism patient to shave himself. 
Fig. 45—Exercises for truncal rigidity can be carried out in a group 
by mat calisthenics. 
ally most of these patients have to resort to avocations 
or hobbies. Craftwork and gardening are excellent in 
this respect. 
5. FLACCID PARALYSIS 
Flaccid paralysis, in contrast to the previously de- 
scribed conditions, is characterized by weakness or 
paralysis of individual muscles or muscle groups fre- 
36 dislocations which are pressing upon the peripheral 
nerves. If the disease is infectious in nature, the im- 
mediate care consists of bed rest, good nursing care, 
and daily passive movement through full range of 
motion. 
Nursing care is of primary importance both for the 
protection of the involved limb and for the comfort 
of the patient. Freedom from pressure can be accom- 
plished by use of footboards, a cradle over the limbs, 
pillows placed in the proper position, or the use of 
splints correctly fitted for the patient’s disability. In 
involvement of the feet or hands, elastic or spring 
splints are of value. 
The nurses should be alert to prevent contractures, 
and should not allow the patient to assume or main- 
tain improper positions in bed. If trained therapists 
are not available, the nurse should carry the joints 
through the full range of motion at least once daily. 
The patient should be encouraged to change position 
often. Those who are unable to do so themselves 
should be moved frequently and gently. 
The nurse should also pay particular attention to 
the patient’s skin to prevent its break-down, particu- 
larly over the bony prominences. Early in the course, 
the patient must be discouraged from too great activity 
and too many visitors. His surroundings should be 
kept quiet and cheerful. 
When the paralysis involves the upper extremities, 
it is necessary to observe the patient carefully for any 
signs of possible paralysis of the throat or chest muscles 
manifesting itself in difficulty in breathing or swallow- 
ing. In such cases, emergency equipment such as 
suction machine, tracheotomy trays, and respirator 
should be conveniently available. Oral medication 
should be avoided, and the diet should be liquid or soft. 
At all times, the nurse’s approach to the patient should 
be one which will build confidence and allay anxieties. 
Physical therapy should be started early when the 
patient is still confined in bed. The object is to pre- 
vent contractures and maintain the paralyzed muscles 
in the best possible position. Denervated muscles are 
protected against the constant pull of gravity or of 
their antagonists. The effects of immobilization are 
combatted by daily passive movement through full 
joint range. Where pain is present, some form of 
mild heat provides relaxation and facilitates passive 
movement. Heat may be applied by any of the 
standard means. Massage, when used, should be 
gentle. (Fig. 47.) 
Fig. 46—Occupational therapy for parkinsonism frequently in- 
cludes the use of the loom. 
quently resulting in a flail limb. This condition us- 
ually is associated with a rapid and severe degenera- 
tion, resulting in marked atrophy of the involved 
muscles often associated with severe tenderness and 
skin changes. 
A flaccid paralysis is found in a large number of 
conditions such as cord injuries, peripheral nerve in- 
juries, poliomyelitis, Guillain-Barre’s syndrome, mus- 
cular atrophies and dystrophies and multiple neuritis. 
The distribution of the paralyzed muscles will vary 
greatly according to the cause of the disorder, the 
severity of the illness, and the location of the involve- 
ment. The amount of involvement may vary from 
an isolated paralysis of one or two muscles to involve- 
ment of an entire limb or even to the paralysis of all 
four limbs. 
The requirements for rehabilitation vary according 
to the nature of the muscular involvement; for ex- 
ample, lower extremity involvement severely impairs 
ambulation while upper extremity involvement more 
severely impairs self-care and vocational activities. 
The outlook for recovery in a flaccid paralysis will 
vary from patient to patient and can only be deter- 
mined by careful neurologic examination from time 
to time. 
Acute stage.—During the acute stage, the immediate 
treatment of the patient will depend upon the 
cause of the illness. If the lesion is due to an injury, 
bed rest is not usually necessary for the paral- 
ysis, but surgical consultation or treatment may be 
required. Indicated surgical treatment might be the 
repair of cut nerves or the reduction of fractures or 
37 is taken to the corrective gymnasium for light mat exer- 
cises. About this time, progressive resistive exer- 
cises of the lower and upper extremities are cautiously 
applied to a point just short of fatigue. The patient 
then progresses to standing and weight shifting in the 
parallel bars, concentrating on good posture. From 
this stage, he progresses through the usual stages of 
ambulation which have already been discussed in 
detail. 
In view of the dangers of overfatiguc of the in- 
volved muscles in flaccid paralysis, the occupational 
therapist must regulate the program very carefully in 
this type of disorder. The beginning activities gener- 
ally are adapted for the elimination of gravity, be- 
ginning with suspension slings or powder-boards. As 
the patient’s tolerance increases, the problem then is 
one of building up increased muscle power by graded 
exercise. Activities must be chosen which will pro- 
vide exercise only to the affected muscles while 
avoiding strengthening unaffected muscles. 
It is important to watch for compensation or sub- 
stitution of an unaffected muscle group on the part 
of the patient. It is only in the chronic stage that 
such substitution activities arc encouraged. Various 
forms of hand weaving, cord knotting, clay modeling, 
drawing, and finger painting can be used as first 
projects in the treatment of the upper extremities 
while the bicycle, jigsaw, looms, and other treadle 
Fig. 47—An infrared lamp furnishes a good source of heat in 
cases of flaccid paralyses. 
Subacute stage.—In the subacute stage, the patient 
has recovered from the immediate effects of his acute 
illness and should be ready for more active measures. 
As voluntary muscle power returns, active assistive 
exercises replace the passive movement. The patient 
is permitted to assume mild active or free exercise as 
he is able to tolerate it. Too early or too intensive 
active exercise may retard the patient’s recovery. 
During the period of active exercise, muscle re-educa- 
tion begins, and is continued until the muscle power 
is sufficient to carry the affected limb through complete 
range of motion with gravity eliminated. In some 
muscle groups, adequate voluntary power is never re- 
gained. If there is severe paralysis which does not 
recover, it is useless to continue with muscle 
re-education indefinitely; the patient must be taught 
substitution methods similar to the training of the 
paraplegics. 
Concomitantly with the muscle re-education (fig. 
48) the patient is referred to the corrective therapist, 
who teaches him self-care and preambulation activi- 
ties. Sitting posture and balance are taught, increas- 
ing the sitting time to over 1 hour before the patient 
Fig. 48—In flaccid paralysis, active assistive exercises require con- 
siderable individual attention by the therapist. 
38 equipment are used for strengthening of the lower 
limbs. 
Chronic stage.—Generally, the chronic stage in a 
flaccid paralysis can be considered to begin about 9 
months after the onset of the disease. By the utiliza- 
tion of modern diagnostic means, it is possible by this 
time to estimate with reasonable accuracy the amount 
of recovery from paralysis which can be expected. 
The exercise program for those parts which promise 
further recovery continues along the lines indicated 
above. The required substitution for self-care and 
ambulation are usually well started by this time, and 
one can now' make plans for the social and economic 
readjustment of the patient. 
At this stage, the social worker plays an increasingly 
important role by preparing the patient for the 
transition from the hospital environment to society. 
Vocational guidance, prevocational testing, and edu- 
cational retraining must all be brought into play at 
this point if the patient is going to make an adequate 
social and economic adjustment after being in the 
hospital. 
6. PARAPLEGIA 
Paraplegia customarily refers to a paralysis of the 
lower limbs associated with impaired control of the 
bladder and bowel. The classical cases are the result 
of a widespread destruction of the lower part of the 
spinal cord, usually from injury and less commonly 
from tumors or infections. 
Since the problems involved in the rehabilitation of 
the paraplegic are special ones and since special centers 
have been established for their care in the Veterans 
Administration, the present discussion will be limited 
to immediate care prior to the transfer to such cen- 
ters. Such immediate care consists of the carrying 
out of indicated surgery, the care of the skin, bladder, 
and bowels, prevention of contractures, and the. 
preliminary strengthening of the upper extremities as 
a prcrccjuisite to ambulation. (Fig. 49.) 
Indicated surgery.—Great difference of opinion ex- 
ists among neurologists and neurosurgeons regarding 
indications for operative interference and the time 
when operation should be done in the traumatic 
paraplegics. Many believe laminectomy is indicated 
as soon as primary' surgical shock has disappeared; 
others believe in waiting 4 to 5 weeks. Most surgeons 
agree that if symptoms indicate a partial cord lesion, 
if X-rays reveal dislocated bone fragments or presence 
Fig. 49—An evaluation by the doctor of the cause, severity, and 
outlook of the paraplegic is essential before rehabilitation pro- 
cedures can be applied intelligently. 
of a foreign body causing pressure on the cord, and if 
spinal tap reveals a block, an open operation is indi- 
cated. Operations in which symptoms and signs of a 
complete transverse lesion exist rarely prove of any 
benefit. Occasionally surgery will cause an incomplete 
lesion to become complete. 
Care of the skin.—When the lower part of the cord 
is damaged in paraplegics, there is a greater tendency 
toward development of bedsores. The skin will macer- 
ate quickly when wet and, therefore, should be kept 
scrupulously clean and dry. Bed linen should be 
changed at once in case of soiling. The tissues around 
bony prominences, such as the feet and knees, should 
be protected by large pads securely but loosely wrapped 
with Ace bandages. When the patient is lying on his 
back, large pads and small pillows should be placed 
beneath him to relieve pressure. The bedpan should 
be padded and under no circumstances should a 
chipped bedpan be used for this type of patient. 
The decubiti are preventable in most cases; should 
they occur, they must be kept scrupulously clean and 
free from contamination. These patients must be 
turned at least every hour in order to avoid pressure 
on the bony prominences and pulmonary congestion. 
This may be accomplished by various methods. A 
draw-sheet may be used, thereby eliminating any pos- 
sible abrasion or bruising to the skin by dragging or 
from pressure. Some patients may be placed on a 
Stryker or a Bradford frame to facilitate their turning 
and handling. As soon as possible, the patient must 
39 be taught how to turn himself without producing 
injury to his skin. 
Care of the bladder.—All severe lesions of the lower 
cord will cause acute urinary retention and necessitate 
immediate catheterization, preferably with constant 
drainage. Details of special bladder care will be dis- 
cussed in detail in chapter VI, section 4. 
Care of the bowel.—During the acute stage, the 
patient frequently develops paralysis of the bowels 
which will manifest itself in abdominal distention and 
obstinate constipation. This requires the use of re- 
peated enemas and of various drugs such as pitressin, 
prostigmine, and the like. Bowel habits can be re- 
established by the use of daily enemas given at the 
same hour each day. 
Many spinal cord injuries develop marked nutri- 
tional deficits, especially in the presence of bedsores 
and urinary infections. These patients generally re- 
quire a daily minimum of 3,000 calorics and 150 grams 
of protein. High doses of vitamin supplements are 
indicated. Transfusions should be given if anemia 
exists. Infections are treated by appropriate chemo- 
therapy. 
Prevention of contractures.—Contractures may be 
prevented by placing the patient’s extremities in good 
anatomical position. Sandbags, pillows, and splints 
are useful to maintain position. Footboards will help 
prevent foot drop. The nurse, in giving general bed 
care to these patients, usually can continue passive ex- 
ercises to supplement the treatment given by the phys- 
ical therapist. 
Strengthening of the upper extremities.—Strength- 
ening of the upper extremities is essential to the re- 
habilitation of the paraplegic patient. It is begun 
early and continued until his transfer. The exercise 
program includes a limited number of movements, all 
of which are calculated to improve the strength of 
those muscles necessary for crutch walking. Resist- 
ance is added progressively to obtain the maximum 
possible muscle power. (Fig. 50.) 
Fig. 50—Short crutches are used to strengthen the upper extremi- 
ties preparatory to ambulation for the paraplegic. 
40 chapter VI. special problems. 
1. DIAGNOSTIC PROCEDURES 
In following the course of the neurologic patient 
on rehabilitation, certain supplementary diagnostic 
procedures are required. They are, with some excep- 
tions, the same as used in examining and evaluating 
the acute neurologist patient. Aside from the gen- 
eral neurologic examination, some of the procedures 
follow: 
Cranial roentgenography.—X-rays of the skull are 
almost routine in any neurologic patient showing brain 
symptoms such as the hemiplegias, the ataxias, and the 
parkinsonisms. In some patients tending to show pro- 
gressive symptomatology or seemingly not responding 
properly to a program of rehabilitation, however, it is 
frequently necessary to recheck the X-ray of the skull 
and to augment such rechecks with special X-ray pro- 
cedures. Ventriculography and pneumoencephalog- 
raphy consist of injecting air so that the brain itself 
rather than the skull can be visualized by X-ray. This 
procedure is particularly valuable in differentiating be- 
tween cases of tumors and progressive degenerations. 
Angiography is a procedure or method in which the 
blood vessels of the brain can be visualized by X-ray 
after they have been injected by an opaque dye. This 
procedure is of particular value in cases of vascular 
abnormalities affecting the brain. 
Spinal roentgenography.—X-rays of the spine are 
particularly useful in cases of flaccid paralysis, para- 
plegia, and in patients in the older age group who, 
during the course of the retraining program, complain 
of pains in the back. Under these circumstances, 
standard X-rays of the spine may show fractures, dis- 
locations, tumors, or arthritis. If the standard pro- 
cedures do not offer adequate information, myelog- 
raphy with opaque oil may be indicated. This me- 
dium fills the spinal canal and brings into view abnor- 
malities, such as adhensions or tumors. 
Spinal fluid.—The repeated examination of the 
spinal fluid is of value in all forms of neurological dis- 
abilities. It is of particular importance, however, in 
following the course of neurosyphilis and spinal cord 
tumors. (Fig. 51.) 
Electroencephalography. — Electroencephalography 
is a relatively recent procedure for study of the elec- 
trical activity of the brain. This procedure is 
particuarly useful in establishing the presence of con- 
vulsive disorders and tumors. In following the course 
of patients suffering from injuries, infections, and vas- 
Fig. 51—A spinal puncture by the doctor frequently yields im- 
portant information as to the underlying illness. cular disorders, the electroencephalogram will often 
indicate whether the disease is progressing or returning 
toward normal. 
Miscellaneous laboratory procedures.—There are a 
number of laboratory procedures which are useful in 
following the patients undergoing a prolonged hos- 
pitalization : (1) Hemoglobin, plasma protein, and 
blood urea nitrogen should be done at regular inter- 
vals, particularly in the presence of edema, in bed 
patients, or patients who are deteriorating physically; 
(2) repeated urinalysis should be routine for all 
patients. 
2. PSYCHOTHERAPY IN REHABILITATION 
The value of suggestion, reassurance, and encour- 
agement from the physician in the treatment of physi- 
cal disorders long has been known. The value is so 
unquestionable that discussion is hardly necessary. In 
any well-planned and active therapeutic program the 
patient’s ability to respond to increased hope and 
optimism is a valuable adjunct. (Fig. 52.) 
Group influence.—When a patient enters a rehabili- 
tation hospital, he should be impressed by its efficiency, 
friendliness, and optimism. There should be little de- 
lay in outlining the treatment program for him, in 
starting his pretreatment work-up, and in his actual 
participation in the program. The value of being 
able to place this patient with others who have been 
under treatment for some time is important; from his 
fellow patients, he is able to derive encouragement and 
hope. To see others who have troubles similar to his 
own will help him overcome one of the most difficult 
and discouraging features of severe invalidism. Group 
morale is a motivating factor. 
Individual and family influence.—A complete anal- 
ysis of features of the illness is a necessity, as often 
problems not related to the actual physical incapacity 
may make it impossible for the patient to feel eager- 
ness to improve. Interviews with adequately trained 
social-service workers, preferably those with training 
in psychiatric social work, is a necessity. The social 
worker should contact the relatives of the patient 
whenever possible. Adequate plans for the future are 
important. The situational anxiety accompanying 
any illness is frequently most severe with neuorologic 
handicaps. This can be attributed to the attitudes 
of all of us toward our bodies, and the things which 
these bodies have always done for us before. To be 
an obvious cripple is difficult to accept. The obvious- 
ness of the illness makes one much more aware of the 
attitudes of others, and gives one the feeling that he 
cannot now be accepted into the same social groups as 
before. Hospitalization helps the patient to adopt a 
new attitude toward his handicap. 
Patient’s reactions.—In a patient having difficulty 
adjusting to his neurologic disability, there are two 
fundamental types of reactions—defeatism and hos- 
tility. In both cases, the illness is utilized to assist the 
patient solve long-standing personality problems. In 
defeatism, the patient uses his disability to fulfill a 
long-standing desire to cease competing in his environ- 
ment. Under such circumstances, the patient becomes 
dependent upon others, lacks initiative in the program, 
and is slow in making discharge plans. 
Many patients will respond to the routine proce- 
dures described above. The social and family aspects 
are very important in that it is frequently necessary 
to manipulate the environment through the patient’s 
relatives. On occasions, individual psychotherapy 
interviews are required. As a final resort, it may be 
necessary to adopt a firm attitude toward the patients. 
In the hostility reaction, the patient becomes very 
resentful at having become disabled. Many times, 
this resentment becomes fixed upon the paralyzed part 
itself and thus interfers with any progress the patient 
may make toward improvement. Therapy is directed 
at getting the patient to accept his disability in a re- 
alistic manner and therefore must be highly individual- 
Fig. 52—Every disabled person has emotional problems which 
must be worked out on an individual basis. 
42 ized. The realization that other people are suffering 
from the same disabilities helps some with these pa- 
tients. Individual interviews usually are required and 
frequently must be carried out by a trained psychia- 
trist. Once these patients have directed their aggres- 
siveness into getting well, they many times apply them- 
selves with greater than average energy and therefore 
progress very rapidly. 
Other emotional problems, such as conversion re- 
actions, post-traumatic reactions, and compensation 
reactions, require individual attention and usually 
specific psychiatric management. 
3. PSYCHOLOGICAL TESTING 
In the psychological examination of patients on the 
rehabilitation program, there are three general areas 
which must be investigated: (a) the level of intellec- 
tual efficiency; (b) the amount and type of deteriora- 
tion; and (c) the emotional and personality make-up 
of the individual. In addition, it is important to con- 
sider the effects that blindness, aphasia, or paralysis 
of the preferred arm may have in evaluating the 
psychometric tests. Examination of such patients 
should never be a matter of a routine battery of tests; 
therefore, it seldom can be accomplished satsfactorily 
by a disinterested and uninformed psychologist. If 
the results of these psychological tests are to be useful 
in facilitating the work with the patient, they must 
be reported in terms understood by all members of the 
rehabilitation team. In general, psychological testing 
is desirable in the original evaluation of the patient; 
however, it achieves its greatest usefulness in uncov- 
ering factors which are interfering with the recovery 
of the patient and slowing down the progress of his 
rehabilitation. 
The intellectual sphere.—The intellectual sphere is 
examined by well-standardized tests such as the Belle- 
vue-Wcchsler scale and Stanford-Binet 1937 scale. 
The former is an excellent scale for the upper levels of 
mental ability while the latter is standardized at lower 
levels; hence, the two tests are not directly comparable. 
There are, in addition, paper and pencil tests, such as 
the Otis test, which are seldom satisfactory for use with 
handicapped patients. 
Deterioration.—It is extremely difficult to estimate 
clinically the degree and type of intellectual damage 
without the use of psychometric tests. The chief rea- 
son for this difficulty lies in the fact that ordinary 
clinical judgment is based upon such functions as com- 
prehension, vocabulary, and range of information 
which may be relatively unimpaired. Psychometric 
evaluation will give information concerning the follow- 
ing: Abstraction, relearning ability, calculations, and 
ability to shift quickly from one concept to another; 
these are frequently severely impaired in patients with 
brain damage. At the present time, there are a num- 
ber of specific tests for organic brain damage, such as 
the Hunt test, the Weigl-Goldstein-Schcerer test, and 
the use of the subtests of the Wechsler-Bellevue. 
Personality.—The Minnesota Multiphasic Person- 
ality Inventory offers a simple and effective evaluation 
of the patient’s emotional adjustment. In addition, 
there are a number of other tests which may be applied 
to selected cases, such as the Thematic Apperception 
test, Stein’s Sentence Completion test, and the 
Rorschach test. (Fig. 53.) 
Fig. 53—Special psychologic tests, such as the Minnesota Multi- 
phasic Personality Inventory, are helpful in uncovering emotional 
problems and assisting vocational guidance. 
4. CARE OF THE URINARY BLADDER 
Because of the type of disabilities encountered and 
the age of the patients, the care of the urinary bladder 
is of extreme importance in the treatment of neurologic 
disabilities. The objectives sought in the care of the 
urinary bladder are (1) the ability of the patient to 
void through an intact urethra, (2) the maintenance 
of a bladder capacity of 200 to 400 cubic centimeters, 
(3) the ability of the bladder to empty itself completely, 
and (4) sufficient bladder control to avoid incon- 
tinence. The methods of obtaining these objectives 
can be broken down into several stages. 
Immediate care.—Immediate care, particularly in 
traumatic cases, generally involves the use of a 
43 none of which are without certain disadvantages. 
Methods in common use include a condom or penrose 
drain fitted over the penis, the use of metal or rubber 
urinals in place, and the use of a penile incontinence 
clamp. In all of these, the problem of infection and 
decubitus ulcerations must be carefully guarded 
against. 
Bladder retraining.—Bladder retraining works best 
in patients with intact abdominal musculature such as 
occurs in lesions of the lower portion of the spinal cord. 
These patients are taught to assist the emptying of the 
bladder at regular intervals by abdominal straining 
which may be augmented by manual pressure over the 
lower abdomen. In lesions of the upper cord, auto- 
matic reflex bladder emptying frequently develops but 
tends to be inefficient. Surgical intervention should 
be considered in all cases which do not respond ade- 
quately to retraining methods. Such cases require 
study by a qualified urologist. 
5. NURSING CARE 
The nursing care in patients with neurologic dis- 
abilities presents certain problems which differ from 
those of other types. This is true because neurologic 
patients may be comatose, paralyzed, have areas of 
anesthesia, lack control of bowel and bladder, or may 
have convulsions. The above factors produce a prob- 
lem in the care of the skin. 
The care of the unconscious or irrational patient 
first requires measures to prevent self-injury. Many 
of these patients need sideboards on the beds and some 
will require restraints. During this stage, it is neces- 
sary to change the position of the patient every 1 to 2 
hours to prevent the development of pneumonia, con- 
tractures, and decubiti. Determinations of blood 
pressure, pulse rate, respiration, temperature, and 
state of consciousness are taken at regular intervals, 
varying from every half hour to every 4 hours. An 
adequate airway is maintained by using postural drain- 
age or mechanical suction for the nasal and oral secre- 
tions. Intake and output are recorded accurately 
during this stage. 
The problem of paralysis makes it difficult for the 
patient to take care of his daily needs, including turn- 
ing himself in bed. Because of the paralysis and 
numbness, special attention must be paid to the care 
of the skin and the prevention of decubiti. Proper 
bed posture must be maintained as discussed in an 
earlier chapter. Footboards are routine on such pa- 
tients to prevent pressure from the bedclothes. 
Fig. 54—A dependent loop in the tubing may interfere with the 
proper functioning of continuous-flow bladder irrigation. 
catheter to prevent overdistension of the bladder and 
to avoid incontinence, resulting in a wet bed. Inter- 
mittent catheterization is generally unsatisfactory in 
these patients. For continuous drainage, an indwell- 
ing catheter, preferably of the Foley type, should be 
connected with a sterile closed drainage system. The 
catheter should be removed once weekly and should 
be left out for several hours to permit the drainage of 
urethral secretions. At this time, any progress in 
voiding can be observed. For irrigation of an in- 
dwelling catheter, one may use the tidal method, the 
continuous drip, or intermittent irrigation. The lat- 
ter has the advantage of allowing the patient himself 
to participate in his bladder retraining during the 
initial stages. Complications encountered are chiefly 
infections and calculus formations. These may be 
combatted by the use of chemotherapy, special irrigat- 
ing solutions, and by early ambulation. Fluids should 
be forced to at least 2,000 to 3,000 cubic centimeters 
daily. (Fig. 54.) 
Incontinence.—When the patient is being taken off 
catheter care, incontinence may become an important 
problem. There are several methods of handling this, 
44 Patients with areas of anesthesia require special at- 
tention because they are unable to recognize when 
undue pressures to the skin are occurring. The areas 
of anesthesia often are associated with changes in 
circulation which make these patients more susceptible 
to burns. For these reasons, special attention is paid 
to be certain that any heat applied to anesthetic pa- 
tients is mild and runs no risk of burning the patient. 
Care of the bladder is discussed in section 4 of this 
chapter. The care of the bowels is discussed in chap- 
ter V, section 6. 
The care of the skin requires attention to all of the 
features described in the preceding paragraphs. The 
general principles to be followed are frequent turning 
of the patient, the avoidance of wrinkled bed linens, 
and scrupulous cleanliness in the care of the bowels 
and bladder. A daily bath with light massage and an 
alcohol mineral oil rub stimulates the circulation and 
tends to harden the skin. Ventilation of the skin of 
the patient prevents maceration from sweating. In 
most of the cases, decubiti can be prevented; how- 
ever, if they do occur, the above measures are intensi- 
fied and the patient is placed on a diet which is high 
in protein, vitamins, and caloric intake. Numerous 
topical applications have been recommended but seem 
of less value than exacting nursing care. A daily bath 
in a warm, continuous-flow tub cleanses a decubitus 
ulcer, appears to stimulate circulation, and reduces the 
pressure by tending to float the patient. In severe 
cases, plastic surgery is indicated even in the presence 
of mildly infected granulation tissue. Such plastic 
procedures may markedly reduce the time required for 
healing. 
The immediate care of the patient with a convul- 
sion is directed toward prevention of injury. This 
includes the placing of a tongue blade between the 
teeth and the general protective measures for an un- 
conscious patient. In addition, it is important to 
observe and record in detail the onset and various 
manifestations observed during the convulsion. 
6. ORTHOPEDIC APPLIANCES 
In general, the application of orthopedic appliances 
to the neurologic patient is based on a few funda- 
mental designs modified to support, actively or pas- 
sively to splint, or to prevent deformity of the involved 
part of the patient. Personnel actively engaged in re- 
habilitation need to understand the basic principles of 
splinting and their modifications so that they may 
instruct the brace maker as to construction of the de- 
sired appliances. Often a physician or surgeon can 
greatly improve the chances for rehabilitation of a 
neurologic patient by including the brace maker as 
a part of the team in rehabilitation. Details of specific 
construction of various types of orthopedic appliances 
can be found in the literature. The indications and 
types of surgical procedures which can be utilized are 
too varied and numerous for discussion within this 
monograph, and evaluation for this type of therapy 
can best be determined by orthopedic consultation as 
indicated for each specific case. 
Knowledge of conservative orthopedic methods, 
however, is of definite value for personnel actively 
engaged in rehabilitation programs. Application of 
well-constructed and properly fitted appliances is es- 
sential for the following purposes: 
(1) To prevent skeletal deformities. Appliances 
of this type must be used for prolonged periods 
of time. 
(2) To supply rest for an extremity or back, pre- 
venting pain and muscle spasm. 
(3) To correct a deformity becoming fixed. Ap- 
pliances must be constructed so as to apply cor- 
rective forces. 
(4) To restore locomotive function of the skele- 
tal system by continued motion of joints and main- 
tenance of available muscle tone and other func- 
tional factors in motion. 
(5) To improve skeletal function by application 
of a brace or splint, substituting for loss of muscle 
power across a joint, giving stability, and en- 
hancing remaining muscle function. 
Some of the more important appliances used on the 
neurologic rehabilitation service consist of casts, 
splints, traction devices, and braces. 
Casts.—Casts are used most commonly in neurologic 
disabilities when there is a complicating fracture. 
Splints.-—Splints may be plaster, plastic, or metal 
and are used to provide rest to joints and to prevent 
deformity. They are constructed so that the part 
may be removed readily to permit the application of 
massage, passive movement, and other types of therapy. 
They are used chiefly during the prcambulatory stage 
but may be applied at night to an ambulatory patient 
to help prevent deformity. 
Traction devices.—Traction devices are used on 
neurologic patients largely to reduce or prevent con- 
tractures. (1) Skin traction is of limited use in such 
patients because of the danger of skin changes. (2) 
45 Skeletal traction is very satisfactory, particularly in 
correcting contractures of the larger joints, such as the 
knee joint. (3) Active spring or rubber splints are 
utilized chiefly to give traction to the smaller joints, 
such as fingers or wrists. 
Braces.—Braces are used primarily to permit early 
ambulation of neurologic patients. In general, they 
should conform to the contour of the body and be 
individually fitted. They should be durable and as 
light as is compatible with adequate strength. Full 
correction should be attained by the completed 
appliance. (Figs. 55 and 56.) 
(1) Spine braces.—The spine braces in common 
use are generally variations of the Taylor type 
brace. The general purpose is to give support to 
the lumbar and lower dorsal spine. Modifica- 
tions of the upper portion include support for the 
cervical spine and auxiliary crutch attachments. 
Lower extremity braces may be attached to the 
pelvic frame of the brace for stabilization at the 
hips. Spine braces are used chiefly in paraplegics, 
but will find some use in severely involved 
postpoliomyelitis patients. 
(2) Lower extremity braces.—Lower extremity 
braces are designed to stabilize and support joints 
of the lower extremities and to overcome foot de- 
formities. In patients with instability of the hip, 
long leg braces with a pelvic-band attachment 
may be required. With weakness of the thigh re- 
sulting in instability of the knee joint, long leg 
braces alone are required. Ankle or foot instabil- 
ity requires only short leg braces with an attach- 
ment to prevent foot drop. With simple inver- 
sion or eversion, a single-bar lower-leg brace with 
T-strap attachment is adequate. Whenever 
possible, braces should be avoided in the interest 
of developing adequate muscle function. When 
braces are required, they should be as simple and 
light as possible. 
(3) Upper extremity braces.—Upper extremity 
braces can be made of lighter construction because 
weight bearing is not a factor. Active functional 
splints of the spring variety are particularly use- 
ful in hand and wrist deformities. These may be 
adapted for use at the fingers, wrist, or elbow, the 
most common application being for extension of 
the fingers and wrist, and flexion of the elbow. 
Fig. 55 and Fig. 56—Genu recurvatum and drop foot are corrected 
by properly fitted braces. 
46 7. SPEECH 
There are two common types of speech problems en- 
countered in patients with neurologic disabilities— 
dysarthria and aphasia. (Fig. 57.) 
It is generally possible to improve the speech of such 
patients by retraining. The methods of retraining in- 
clude phonation exercises, controlled breathing, speak- 
ing in short phrases, and emphasis upon clarity of 
speech. Although some improvement may be ob- 
tained by personnel in daily contact with the patient, 
the greatest benefits and improvements are seen when 
formal speech training is available from qualified 
therapists. 
Aphasia.—Because of their varied manifestations, it 
is impossible to adequately describe the aphasia dis- 
orders. It might be well to list, however, some of the 
outstanding symptoms encountered: (1) Inability to 
understand spoken language, (2) inability to under- 
stand written language, (3) inability to find the proper 
words in speaking, (4) inability to formulate words 
into sentences and phrases, (5) inability to speak, and 
(6) inability to write. 
In addition to the above symptoms, one may see 
substitutions of incorrect words, repetition of a word 
which has been used previously, and jargon speech. 
These symptoms which have been described above 
have been given various technical names which are 
not within the scope of this booklet. It is obvious that 
the treatment of a patient with aphasia will depend 
upon the specific nature of his speech loss and can only 
be carried out by a trained therapist. General rules 
for approaching a person with a speech disorder have 
been outlined in chapter III on social procedures. 
Fig. 57—A sound recorder gives the aphosic patient the opportu- 
nity of rehearsing his own speech. 
Dysarthria.—This is a difficulty in articulation, most 
commonly seen in ataxias, Parkinson’s disease, mul- 
tiple sclerosis, and diseases of the base of the brain. 
The speech may be slow, slurred, explosive, high- 
pitched, monotonous, hoarse, or nasal. 
47 chapter VII. evaluation of results and interpretations 
Two and a half years ago, the Neurologic Rehabili- 
tation Service was organized under the direction of the 
Neurology Section at the Veterans Hospital at Min- 
neapolis. During this period (ending December 
1948), 289 patients with chronic neurologic disorders, 
most of them bedridden for years and considered hope- 
less, were referred to this Service for study and treat- 
ment. As of December 1948, 20 had left the hospital 
or were transferred to other hospitals, 7 had died due 
to intercurrent disease or to fatal progression of neu- 
rologic lesions, and 226, or 74.7 percent of these pa- 
tients, had been discharged from the hospital as having 
completed their treatment. Among the discharged 
patients 89.4 percent attained varying degrees of re- 
habilitation, while only 10.6 percent were considered 
as failures, since they were unable to show significant 
improvement above their admission abilities. 
The conclusive demonstration that many of these 
previously neglected patients could attain some level 
of self-care and ambulation, or even economic inde- 
pendence, resulted in an expansion of the program and 
a consequent increase in number of patients discharged 
from the hospital. The increase in the number of 
patients discharged from the hospital is illustrated in 
the following table; 
from the standpoint of their capacity to perform the 
ordinary requirements for daily living. The determi- 
nation of the capacity of each patient to meet exi- 
gencies of daily living was based upon the score of his 
performance (daily activities score) on the self-care 
and ambulation chart (fig. 25 on page 19). 
Upon discharge from the hospital, each of the 175 
severely disabled patients received a final rating on 
their ability to perform the activities listed on the 
self-care and ambulation chart. Expressed in terms 
of the percentage of the activities reauired for dailv 
living, as listed on the chart, the patients were able to 
perform as follows: 
66.0 percent capable of performing 85-100 percent 
of activities. 
13.7 percent (24) capable of performing 60-85 
percent of activities. 
6.6 percent (12) capable of performing 33-60 
percent of activities. 
13.7 percent (24) capable of performing less than 
33 percent of activities. 
Patients capable of less than 33 percent of the 
activities required for daily living are considered as 
failures. Of these failures, seven were considered to 
be due to severe personality disorders and the re- 
mainder the result of progressive organic deterioration. 
A statistical analysis is being made of the chronic 
patients at Veterans Administration Hospital, Min- 
neapolis. Although the results of this study are not 
as yet complete, nevertheless, they have progressed 
sufficiently to report some pertinent observations. 
These are: 
(1) A program of total neurologic and rehabili- 
tative treatment will result in the discharge to 
their homes of about 75 percent of veteran pa- 
tients on a chronic neurologic ward. 
Number of 
patients 
Year 
discharged 
1946 (6 months) 
19 
1947 
70 
1948 
164 
Since the seriously disabled neurologic patients con- 
stitute the heaviest burden on hospital resources, a 
special study was made of this group. These patients 
have widespread, irreversible neurologic lesions, and 
many, upon admission, were incapable of any form of 
self-care or of ambulation. One hundred and seventy- 
five patients from this group were frequently evaluated (2) Only about 10 percent of such patients do 
not benefit at all from the program. 
(3) The amount of time required for rehabilita- 
tion is greater in older patients and in patients 
with prolonged disability. 
(4) The achievement of maximum benefit from 
treatment is more dependent upon the duration 
of the disability than upon the age of the patient, 
indicating the need for beginning treatment 
early. 
(5) Among the various groups of patients, the 
hemiplegias show the greatest gains relative to 
the severity of disability at time of admission. 
They are followed by the paraplegias, the ataxias, 
the parkinsonisms, and flaccid paralyses, in the 
order named. The group of flaccid paralyses, 
however, improve most within the limits possible 
for them. 
Although the program as described in this booklet 
has been based primarily on the work carried out at 
the Veterans Administration Hospital in Minneapolis 
to meet the great need for treatment of this type of 
patient, there is an even greater necessity for such a 
program in the civilian population. It has been esti- 
mated that during the first year alone such a program 
in one hospital saved more than $1,000,000. From 
this, it is easy to visualize the total savings to the people 
of this country if similar treatment were available 
universally. 
Obviously, because of the limited number of trained 
neurologists and physiatrists, it would be impossible 
for them to direct the rehabilitation of all such indi- 
viduals. A share of this problem will have to he, and 
rightly should he, handled by the general practitioner, 
who should assume such responsibility as a part of the 
practice of good medicine. 
At the Veterans Administration hospital, the pro- 
gram has become quite elaborate. Such rehabilitation 
procedures can be carried out on the less complicated 
cases in the home, however, providing the doctor 
understands his goal, is sympathetic toward it, and is 
willing to spend a little time with the family and the 
patient in outlining and directing the course of 
therapy. 
Members of the family can be taught to carry out 
passive movement in appropriate cases. Pulley exer- 
cises can be simply adapted for home use. Self-care 
and ambulation activities, particularly in the milder 
cases, may not need a trained therapist and can be 
carried on by the family under the supervision of the 
physician. Even in more severely involved cases, such 
activities can be continued by the family after a pre- 
liminary period under a trained therapist. (Fig. 58.) 
Fig. 58—Various appliances installed in the home make it pos- 
sible for the patient to continue his improvement after discharge. 
There are State resources available for the voca- 
tional retraining of patients in their homes. (See list 
of community resources on page 24.) 
Since part of the ultimate burden necessarily must 
fall upon the general practitioner, it seems essential 
that we begin teaching and indoctrinating our medical 
students and young physicians in the principles of this 
rehabilitation program. It is only through their un- 
derstanding as doctors and their willingness to instruct 
the family and work with the patient that the maxi- 
mum number of patients can be successfully handled. 
It probably will be necessary, ultimately, to have 
established centers for neurologic retraining with all 
the ancillary aids which are now being used to such 
great advantage at the veterans hospitals. Such a 
center would serve not only as a part of the educa- 
tional program for physicians and therapists but would 
be available for the treatment of the more severe cases 
49 which require intensive care. It would also act as an 
aid to the practitioner in the diagnosing and evaluating 
of the more difficult neurologic problems and in out- 
lining the treatment procedures to be carried out at 
home in these cases. 
The savings in hospital beds and actual money are 
readily measured. Even more important is the im- 
measurable saving in human suffering. It is hoped 
that this booklet will stimulate the increasing applica- 
tion of this approach to the problem of the neu- 
rologically distabled patients throughout the country. 
(Fig. 59.) 
Fig. 59—The fruits of rehabilitation add years of happy home life to elderly individuals. 
50 
II. S. GOVERNMENT PRlNTl N\OFF|CE : 1949