PHYSIOTHERAPY: GENERAL CONSIDERATIONS

Role of physiotherapy--Prineipul body structures and their requirements for hea|th--Nature axid causes of disease--Natural defenoes--lnflammation--Immunity--Effects of inflammation on body structures--Principles of treatment--Methods and effects.

BEFORE considering .the conditions met with in physiotherapy and the various

methods of treatment, it is well to consider what the term implies. Today, with the great advances which have been made in medicine, both in the diagnostic and therapeutic fields, it is essential that all who deal with the patient on his road to recovery should be equipped with a clear understanding of the treatment which they offer. Particularly is this so in physiotherapy. Because of the pressure of modern life and the vast increase in the number of patients referred for treatment, accurate selection from a complex range of methods is necessary if the patient is to receive maximum benefit in the minimum time and with the least disruption of his daily life.

The Role of Physiotherapy.--Physiotherapy--"treatment by physical means". Perhaps too much stress is laid on the various physical means, and insufficient attention paid to what the term 'therapy' implies. The dictionary gives the definition "tending to the cure of disease". In physiotherapy the words 'tending to' are apt. All too often the condition is such that cure, in its true sense of complete restoration of full function, is not possible. It is the job of the physiotherapist to rehabilitate--"Restore to rights, privileges, reputation". In other words, to bring the patient to the point where he can again take his place as an independent member of society. From a patient's point of view his body must obey his will. He must be able to move freely and painlessly. It is largely failure in this that brings him to the Physiotherapy Department, and it is mainly with the re-education of movement that the physiotherapist is co.neerned. It is not within the province of this book to discuss the mechanics of movement; but without a thorough understanding of this field no physiotherapist can play her full part in Therapeutic Medicine. It is, however, relevant to consider briefly what governs efficient functioning of the body. "

Principal Body Structures and their Requirements for Health.--Basically the body consists of fibrous or lymphoid connective tissue, from which the supporting tissues such as bone and cartilage, and the highly specialized muscles, nervous tissue, and skin develop.* For perfect health these tissues depend on the metabolic interchange of fluids, both intracellular and extracellular. The bloodstream is of vital importance, since it constitutes one of the main defences against

2 MASSAGE ANDREMEDIAL EXERCISES

infection, as well as being the medium through which the necessary tissue-fluid interchange is effected, the nutritive and gaseous requirements of the body being supplied and waste products eliminated. Since the gaseous interchange ultimately depends upon external respiration, the respiratory system must also be efficient. For effortless movement joints must be mobile and muscles .strong, but the key to precision movement lies in the accurate reception and interpretation of impulses throughout the central and peripheral nervdus systems. It is to the nervous system that the body looks for smooth co-ordination and control.

The requirements for perfect bodily health and function may be summarized as follows: One must have (1) Efficient circulatory and respiratory systems; (2) Healthy bone and joint structures; (3) Strong but supple soft tissues; (4) Perfect central and peripheral nervous systems.

The adequate maintenance of tissue-fluid interchange keeps the tissues in working order; the nervous system allows them to work. Thus all the major systems and structures of the body are functionally closely interrelated and failure on the part of one may have far-reaching effects.

What then can go wrong? In general terms the answer is disease, i.e.,, a pathological condition of the tissues, of which the causes fall into five main groups :--

1. Infection: Conditions caused by invading micro-organisms known as bacteria, e.g., the common cold; anterior poliomyelitis; tuberculosis. An infective condition may be acute, or chronic, and the organism may be highly virulent or low grade.

2. Trauma: Conditions caused by injury, e.g., violence leading to fracture; or exposure to harmful agents, e.g., extreme temperatures, chemical or radiological substances.

3. Degeneration: Conditions caused by degenerative changes in the tissues. These may be due to "wear and tear", or senility, as in osteo-arthritis; the result of trauma as in hemiplegia; or the result of acute or chronic infection as in anterior poliomyelitis, or tabes dorsalis.

4. Regeneration: Conditions caused by new growths or neoplasms, which may be benign or malignant, e.g., lipoma, carcinoma.

5. Congenital: Conditions caused hy some defective development in utcro, leading to underdevelopment of certain tissues, e.g., congenital deformities such as congenital dislocation of the hip; or spastic conditions such as spastic quadriplegia.

feetion.--In this chapter we will deal only with infection, since bacteria are one of the chief sources of human disease, and since the reaction to infection is the fundamental inflammatory reaction common to all forms of disease..

llactcria.--These are living organisms which exist all rounffus: in the air we breathe; in the soil; in the animate and inanimate objects with which we are in daily contact. They fall into two main groups; pathogenic and nonpathogenic. The pathogenic bacteria are those which cause disease and they sub-divide into four main groups: bacilli; cocci; spirochaetes and protozoa; and viruses.

Bacilli.--These are rod-shaped organisms into which category falls the tubercle bacillus.

Cocci.--These are small spherical organisms such as the streptococcus and staphylococcus.

Spirochaetes and Protozoa.--These are small unicellular organisms responsible for a great range of diseases, amongst which are dysentery, malaria, and syphilis.

Viruses.--These organisms are so minute that they are invisible under normal microscopy. Again they are responsible for a great many infections, amongst which are influenza, the common cold, and anterior poliomyelitis.

There are many differing strains of the various types of bacteria and they exhibit different patterns of life and infection. Some are specific in that they


PHYSIOTI-IERAP: GENERAL CONSIDERATIONS 3

attack a certain type of tissue only (A.P.M. virus). Some require oxygen for the propagation of life. Some are destroyed by heat, others by cold--the vagaries are legion--but all produce a uniform response in human tissues, an inflammatory reaction. Before dealing with inflammation in detail, however, we should briefly consider the ways in which bacteria gain access to the tissues, and the natural defences of the body.

Methods of Entry and Body I)efence.--As has been said, we are in daily contact with bacteria and there are three main methods of entry to the body

1. Direct Contact or Contagion: i.e., by touching an infected body or object. In this ease entry is via the skin, through the pores or hair follicles (we are all familiar with styes and 'pimples'); or through an abrasion.

2. Inhalation: Bacteria are breathed in and gain access to the tissues via the respiratory tract, e.g., the common cold or the tubercle bacillus.

3. Ingestion: Bacteri are taken in with our food and reach the tissues via the digestive tract, e.g., food poisoning or, again, tubercle.

Normally the skin provides an adequate external defence against" infection, being the great protective cover for the tissues, though the pores and hair follicles provide openings for bacterial entry as will any dissolution in the surface. However, the main defence mechanism of the body lies in the reticulo-endothelial system --the leucocytes (white blood corpuscles) found in the blood-stream itself and in the areas of lymphoid tissue found throughout tim body (tonsils and adenoids, lymph glands and areas of lymphoid tissue found in the digestive tract).

Some of the lymphocytes, the neutrophils and monocyles, are phagocytic, i.e., capable of ingesting dead cells and bacteria. They are found in the lymphoid tissue and the blood-stream and are free to migrate. Others, the lymphocytes, are responsible for long-term defence and immunity through the production of antitoxins. It is on the reticulo-endothelial system, therefore, that the body relies once infeclion has occurred.

/ailammation.--Inflammation may be defined as the reaction of body tissues to any irritant, which, as we have seen, may be bacterial, traumatic, degenerative, o.r regenerative. It is important that the student should realize that the response to. any pathological stimulus will be an inflammatory one initially, since this is the body's chief defence and repair mechanism. At times her work will be directed towards producing an inflammatory reaction in order to. promote healing, and at others, and in far the greater number of cases, to mitigating the effects of such a reaction. She should, therefore, be fully conversant with the processes involved. The basic physiological changes are the same whether the reaction is local or general, so we will deal first with an acute local inflammatory reaction of bacterial origin.

Signs and Symptoms.--Everyone is familiar with the signs and symptoms of an acute local inflammation, such as an infected scratch or a cold, and they can be summarized as follows :--

1. Redness: Or in lay terms, the area is 'inflamed'.

2. Heat: This will vary with the type and degree of inflammation. In the ease of an infected scratch, .the surrounding area will feel holaad may throba In the case of a cold there wall be a general rase m temperature..

8. Swelling: In the case of the scratch this may, or ma'ot, be visible. In the case of a cold it manifests itself in a feeling of congestion in the throat and nose,

4. Pain: This is edused by pressure on nerve-endings in the area.

5. Loss of Function: Again this will vary with the type and degree of infection and may, or may not, be appreciated by the patient. In the case of the scratcJh there will probably be little or no effect. In the case of the cold, respiration impeded.


MASSAGE AND REMEDIAL EXERCISES

Physiological Ehanges.--Once bacteria have gained access to the tissues, the following changes take place :--

1. Capillary Dilatation (Redness and Heat): This leads to an increased blood- supply to the area and to increased permeability of the vessel walls.

2. Extravasation of Tissue luid (Swelling): Tissue fluid seeps out into the surrounding tissues. The nature of the exudate varies according to the condition

but it frequently contains a high degree of fibrinogen.

3. Clustering of Leucocytes on Vessel Walls.

4. Migration of Leucocytes from the Vessels into the Tissues.

This increased metabolic activity gives rise to a general rise in temperature if the infection is fairly widespread, or ff the organism is a virulent one. At the same time activity in the lymphoid tissue will be manifest in swollen glands near the focus of infection, e.g., the cervical glands in the case of a cold.

Termination of Inflammatian.--These events having taken place, a 'battle' ensues between the reticulo-endothelial cells and the invading organism, and the inflammatory reaction ends in one of two ways :--

1. Resolution: In this method the invading organisms are completely destroyed and ingested by the reticulo-endothelial cells. The tissues then return to normal. In some cases, e.g., the infectious diseases of childhood such as measles, the lymphocytes, together with the plasma proteins build up substances called antibodies, which are reabsorbed into the blood-stream and render the patient immune, or partially immune, to subsequent attack.

2. Suppuration: In certain types of infection the invading organism is a pyogenic one, i.e., the resulting debris of inflammatory exudate and dead cells liquefies and turns to pus, e.g., a stye. The pus has to discharge before healing occurs by resolution.

General Inflammation.--If either, or both, the general health and circulation of the patient is poor, and particularly if the organism is a virulent one, it may gain access to the blood-stream. Travelling via the lymphatic system, it then gives rise to general septicamia. If the organism is a pyogenic one, or if pus gains access to the blood-stream, boils or abscesses will occur in other parts of the body. The condition is then known as pycemia.

In both cases the signs and symptoms are the same as those of local inflammation but of greater intensity, and tlm patient feels and is very ill, though antibiotics have done much to lessen the gravity of these conditions.

Chrnle Inflammatin.--Tbis may be the result of an acute inflammatory reaction, in which the patient's resistance is poor and the reticuloendothelial system is unable to control the invading organism effectively, e.g., infection by the

tubercle bacillus. On the other hand, it may be the result of a low-grade infection from the beginning, e.g., rheumatoid arthritis or syphilis. Chronic inflammatory

conditions generally follow a progressive course and may be characterized by periods of sudden acute flare-up, followed by periods of relative quiescencf

Immunlty.--Before closing this section on disease and inflammation, a word should be said about immunity. It has already been mentioned that once contact has been made with certain infections, a degree of immunity can be built up through the production of antibodies. Such immunity is called acquired immunity. Nor is it necessary that disease should actually occur before such immunity is gained. We are probably all in contact with the tubercle bacillus at some time in our lives, but we do not all become victims of tuberculosis. A newborn child gains a certain amount of immunity from its mother during foetal life, which is designed to protect it through its first few months until it can begin to build up its own resistance.

. 'Besides natural immunity, it is now possible to give immunity by artificial ,leans, either passively by immunization or actively by vaccination.

PHYSIOTHERAPY: GENERAL CONSIDERATIONS 5

1. Immunization : This is passive, in that scrum containingthe required antibodies is injected into the human body, e.g., anti-tetantus, diphtheria, and whooping- cough (the 'triple' injection now given to babies in the first few months of life).

2. Vaccination: This is active, in that bacteria of an allied disease, e.g., cowpox for small-pox, are introduced into the body to allow the natural processes of imnunity to be triggered off.

The Effects of Inflammation on Body Structures.--It was stated at the beginning of the section on inflammation that, besides being a defence mechanism, inflammation was also the main repair mechanism. The daily processes of metabolism are designed to maintain the integrity of the tissues but, following major traumatic or pathological intervention, the tissues are capable of only limited regeneration. There are two methods of repair, by homogenous tissue or by scar tissue.

1. Repair by Homogenous Tissue: The inflammatory reaction leads to the formation of new cells and the tissues are again restored to normal, e.g., superficial cuts. Tlmre may or may not be suppuration. Homogenous repair will occur in bone, fibrous tissue, and epidermal structures. The more highly specialized tissues such as muscles and nervous tissue degenerate, in that they repair by scar tissue.

2. Repair by Scar Tissue: The inflamnmtory reaction leads to From formation of fibrous tissue which takes the place of the original tissue, e.g., deep cuts which reach the dermis. Because of this area of scarring, function is lost to some extent. Again, there may or may not be suppuration.

Let us now consider the effects of inflammation on the main body structures bnt first let it be said that wherever a lesion occurs there must be a local hypercemia, since the inflammatory reaction leading to repair springs from the bloodstream: Failure in this leads to delay in healing.

The Structural System.--As stated above, bone repairs by homogenous tissue. The Cardiovascular System.--If an inflammatory reaction occurs in any part of this system degenerative changes result. The overall effect of these changes is a diminution in circulation which may be local or general. Tissues deprived of blood become devitalized and this may bare serious and far-reaching effects. Not only do waste products accumulate as a result of decreased metabolism, but any or all of the following trophic changes may occur :--

1. The skin becomes dry and papery. It breaks easily and provides an entry for micro-organisms. Since the blood-supply is poor, infection can set in and, once established, healing will be slow and prolonged. If the organism is a virulent one there is grave danger of a rapid spread of infection.

2. Fibrous tissue thickens and coutracts, restricting movement.

3. Muscle power is diminished since the extra oxygen required for activity is not available. In addition waste products accumulate and have a further deleterious effect. If the ischemia is prolonged the fibres will atrophy in time, and the special properties of muscle will be lost.

. Nervous tissue atrophies. In time the cells die and the fibres fibrose. Eventually both become necrotic.

Since the cardiovascular system is the life-line of the body it i essential, ,,for health or healing, that an adequa'e circulation is maintained.

The Respiratory System.--An inflammatory reaction in any part of the respra. tory system leads to a certain degree of hypoventilation. Although the cardiovascular system may be normal, metabolic processes cannot be carrie'd out adequately if ventilation is poor, for oxygenation 'ill be inadequate and carbon dioxide will accumulate: It is therefore useless to have an effective cardiovascular system if ventilation is defective and vice versa.

Fibrous Soft Tissues.--Fibrous tissue being the basic body structure, it is also the principal repair tissue. Its response to inflammation is prolific regeneration.


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The danger inlmrent in this natural repair lies in the fact that fibrin is required for it, and excess fibrin leads to the formation of adhesions. Adhesions are thin strong fibrous strands which stretch between structures and bind them to neighbouring structures. This leads to considerable restriction in movement, and to painful movement. Once adhesions form, contractures and deformities can ensue. In all cases of inflammation in the fibrous tissues, it is essential that the fibrinous exudate is kept within limits compatible with health.

lusculature.--Since muscles are basically soft tissues and siuce they are encased in fibrous tissue, an inflammatory reaction in muscles can also give rise to adhesions. If the fibres are cut or ruptured scarring follows. Either of these results leads to restricted activity and diminished power.

The Nervous Systems.--An inflammatory reaction in any part of the central nervous system results in irrevocable degenerative changes. Since the central nervous system controls all muscle and joint activity the results are serious and often diffuse. Any or all of the following symptoms may exist :--

1. Paralysis: This may be flaccid or spastic. From it contractures and deformity may result.

2. Incordinatlon: This can range from slight clumsiness to complete ataxia.

3. Altered Sensation: This may range from hypo-csthcsia to complete anaesthesia, or it may take the form of hypcrmsthesia.

The effect of an inflammatory reaction in the peripheral nervous system depends on the site and degree of damage. The peripheral nerves are capable of limited regeneration, but a peripheral nerve lesion results in a period of muscular paralysis. If the lesion lies in the anterior horn cells, the cells of origin of the nerve- fibres and therefore of muscle action, the result is degeneration. The muscle-

fibres supplied by the affected cells are denervated and their function is lost. The autonomic nervous system is capable of regeneration.

The Skin.--Epidermal structures will regenerate following inflammation. If the dermal structures are involved and the epidermis is destroyed, scarring will result. With other vital organs the physiotherapist is not directly concerned.

IRINCIPLES OF TREATMENT

The ultimate aim of physiotherapy is the restoration of the fullest functioal activity possible."

From the preceding consideration of the requirements for health and function, certain principles emerge of vital importance in the rehabilitation of a patient. These may be summarized as follows.

Circulation and Tissue-fluid Interchange must be Maintained or Increased.--This will be necessary in the interests of healing, in order to alleviate symptoms, or in the interests of general tissue health. By stimulating circulation and metabolic interchange locally it is possible to promote healing in cases where this is required, and at the same time ninimize the risk of adhesions by the absorption of excess inflammatory exudate; to disperse metabolic waste products, or cedema, thereby reducing pain and limitation of movement due to pressure or to'ns; to combat the effects of inactivity and thereby reduce the risk of trophic changes or disuse atrophy; to prepare muscles for work and to maintain uninflected tissues in a healthy, functional state. Whatever may be the underlying reason, this principle is of paramount importance in physiotherapy.

Joint Mobility must be Maintained or Increased.--For ease of movement joints must be as mobile as possible. When joints are affected attempts must be made to relieve the condition and to gain a wider range of movement. This may involve the use of splints and appliances, or even operative treatment in severe cases. It should be remembered that any interference in joint mobility will throw strain on unaffected joints and this endangers their health and function. It may therefore be

PHYSIOTHERAPY: GENERAL CONSIDERATIONS 7

necessary to treat unaffected as well as affected areas and muscle power must
not be neglected.
Muscle Power must be Maintained and Increased.-Joint mobility and muscle
power are closely interrelated, joint range depending on muscle power to a
large extent. If the muscle is weak it cannot move the joint through its
full range. If the joint is allowed to fall into disuse changes may occur in its
structure which further limit its range. If this happens extra effort is required
to produce joint movement which, in its weakened state, the muscle cannot
give. In any case of weak musculature joint range mast be maintained whilst
muscle power is being built up. It may be necessary to train muscles to ta.ke
over from -ffected muscles, o-r to share their work. In some cases it is necessary
to give specific muscle training in order to enable the patient to use mechanical
aids or appliance.s. In any form of mtscle re-education the importance of the anterior

horn cells must never be forgotten. Respiration

must he Adequate.--Tissue ventilation being of such importance it may be necessary to assist respiration, not only in specific chest conditions, but in the interests of the patient's general health.

Specific Symptoms must be Relleved as far as Posslble.--Symptoms vary with the condition. Such things as pain, cede---ma, and s]asticity must be relieved where possible since, besides graYeqy fficapacitating the patient,'they can reduce metabolism and restrict muscle and joint activity.

Complications must he Prevented.--Again, these vary with the condition but the possibility of trophic change, the formation of adhesiops, contractures, seps.is, thrombos.is, and chest conditions should be taken into account and steps taken to reduce their risk.

6eneral Health may need Improvement.--This applies particularly in chronic conditions, in infective conditions, and in the case of elderly patients. In all cases, however, the gneral condition of the patient should be considered when a treatment scheme is being prepared. Where it is considered beneficial, steps should be taken to improve the general health.

The Use and Care of Aids and Applianees.--Where any-f-o-.rm of aid or- appiance is to be used it is the province of the physiotherapist to instruct the patient in its use and maintenance. It may also be herob to make apair them.

"--n general the pri'nciples of maintaining circulation and ssue-fluid interchange, and maintaini.ng joint mobility and muscle power apply in almost every case treated by physiotherapy. They are in fact the guiding principles of physiotherapy. The other principles are applicable or not, depending on the condition.

MfETHODS OF TREATMENT AND THEIR EFFECTS

Before concluding this chapter it seems appropriate to give a brief r6sum6 of the various methods of treatment and their effects.

Massage.--Although the various techniques produce slightly different effects, the overall effects only need be considered here, since a massage treatment would rarely, if ever, be confined to the use of one technique. Firstly, the senspry aerve-:-e-adngs in the skin may be stulat, ed or sedated, the latter assisting both local and general relaxation. Secondly, a local hyperemic effect may be produced, either directly through the stimulation of sensory nerve-endings, or indirect.!y through slight cellular damage leading to the liberation of H-substa.nce. Both these effects result in arteriole dilatation. Thirdly, ve,,p.p.d lymphatic return is given mechanical assistance by alternate pressure and relaxation. Fourthly, the skin and subcutkneous tissues are moved. This hks a stretching and softening effect, p-aricularl); bn fibrous tissue.

Exercise.--The movement of muscles and joints has a mechanical pu.mping effect which assists venous and lymphatic return. Also by keeping cortical

8 MASSAGE AND REMEDIAL EXERCISES

pathways open the patt,..er-n-oo-.f- movement is not forgotten. Mobility and range

of movement can be increased by all forms of movement. Passive movements
can stretch, and therefore soften, fibrous structures. Resisted movement will
build up muscle power. Balance and co-ordination can be improved. I general
ized and of sufficient vigour, the general circulatory rate can be raised through
the effect of exercise on the heart.
Electrical Treatment.--By means of electrical equipment heat is administered,
ultra-violet radiation given, artificial exercis induced, and drugs driven in.
The administration of heat has a sedatory eff'ct on nerve-endings, thereby
inducing local and general relaxation. A local hyperemia can be induced and
a general increase in circulation and metabolism may sometimes be produced.
Ultra-violet radiation can be used locally for its effect on the ski.--n, or generally
for its effect on me.-t--bolism.
Artificial exercise, having the effects of joint and muscle activation, can be
given by the use of the faradic current. Interrupted cirect'current can be used
to prevent disnse atrophy in denervated tissue, and the sinusoidal current
stimulates circulation through its effect on sensory nerve-endings and also
through the mechanical effect of muscle contraction and relaxation.
In addition to its use for the ionization of specific drugs the direct current may
be used to sedate or stimulate .sensory nerve-endings, and through the latter to
produce an increa-s.e in circulati'ffn.-lmay also be used for its phoretic effect,
general ionic interchange in the tissues being brought about in the area treated.
For detailed effects of electrotherapy the student should refer to a standard
text-book on electrotherapy.
In this chapter an attempt has been made to provide a background for more
detailed study of diseases and their various methods of treatment. It is important
that every physiotherapist should be fully aware of the interdependence of all the
body structures and appreciate the danger to otter structures inherent in failure on
the part of one. By drawing attention to this it is hoped that the student will more
clearly understand that, although physiotherapy covers such a wide field, and
individual cases create individual problems, certain factors are common to all.
The main basic principles apply to all cases, and the varying methods of treat/ ment lead to one end. /