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Chapter 1, Part 1

Medical Science Publication No. 4, Volume II

MONDAY MORNING SESSION
26 April 1954

MODERATOR
COLONEL FRANK E. HAGMAN, MC


PHYSICAL MEDICINE AND REHABILITATION*

LIEUTENANT COLONEL CHARLES D. SHIELDS, MC

Introduction

Physical medicine was established as a service in the Army in 1946 for the purpose of coordinating treatment in physical therapy, occupational therapy and physical reconditioning; and, to render direct medical supervision to therapists engaged in these activities. The specialty combines diagnostic procedures, the use of physical agents and therapeutic exercise, and rehabilitation of the disabled. It was highly developed during World War II and was given its present title shortly after the war.

Physical medicine is an outgrowth of the interest of physicians in the use of physical agents and therapeutic exercise. Dr. Frank Krusen, Head of the Department of Physical Medicine and Rehabilitation at the Mayo Clinic, and the consultant to The Surgeon General of the Army in this specialty, is an outstanding example of medical leadership in this effort. Rehabilitation has been defined at a symposium of the National Council on Physical Rehabilitation in New York, 25 May 1952, as follows: "Restoration of the handicapped to the fullest mental, social, vocational and economic usefulness of which they are capable." Dr. Howard Rusk, Director of the Institute of Physical Medicine and Rehabilitation, New York University, has tirelessly and diligently promoted this cause during and since his military service in World War II. He has popularized the term "The Third Phase of Medical Care." As a result of the efforts of various individuals, the terms physical medicine and rehabilitation have been combined to describe a concept of medical practice and, in a more limited sense, a specialty within medicine.

Physical Reconstruction, World War I

The earliest practitioners of the healing arts made some effort to supervise the period of convalescence, usually with emphasis on rest and inactivity. During World War I there was a concentrated effort to offer purposeful programs of controlled activity to patients to improve


*Presented 26 April 1954, to the course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.


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clinical results and to shorten the period of hospitalization. Volume 13 of the History of the Medical Department of the United States Army in World War (1) covers this subject. The introduction to this work begins with the following statement: "When the United States entered the Great War all the countries actively participating in the conflict, on either side, had evolved more or less elaborate and apparently satisfactory systems by which to restore the wounded to such physical fitness as would warrant their return to the ranks of the fighting forces or to limited military service, or to such condition of partial physical fitness as would make necessary and possible their re-education or vocational rehabilitation for living-making in full or in part. Along with the latter phase, in each country was evolved a system of pensions to supplement or to take the place of restoration to economic capacity."

During World War I an intense effort was made to offer the American soldier the best in physical rehabilitation along with vocational guidance and training. This activity was called physical reconstruction. Following is an extract from a letter of general instructions published during the early part of the First World War:

"Physical reconstruction is the completest form of medical and surgical treatment carried to the point where maximum functional restoration, mental and physical, may be secured. To secure this result, the use of work-mental and manual-will he required during the convalescent period. This therapeutic measure, in addition to aiding in greatly shortening the convalescent period, retains or arouses mental activities preventing hospitalization, and enables the patient to be returned to service or civil life with the full realization that he can work in his handicapped state, and with habits of industry much encouraged if not firmly formed.

"Hereafter no member of the military service should be recommended for discharge from your hospital until he has attained complete recovery or as complete recovery as it is to be expected he will attain when the nature of his disability is considered."

On 22 August 1917, the Division of Special Hospitals and Physical Reconstruction was formed in the office of the Army Surgeon General. Consideration was given at the time to make the Army responsible for vocational training for disabled members of all the services and certain civilians, but this was not favorably considered by the then Secretary of War. This effort in physical rehabilitation and vocational training was becoming fairly well established when on 11 November 1918 the Armistice was signed. Large numbers of disabled were then returned from France. The Medical Department was faced with increased responsibility along with demobilization and the usual shortages of trained personnel. The question of the place of the Army in


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long-range rehabilitation efforts was raised. Patients were gradually transferred to the Bureau of War Risk Insurance. The need for improved long-range medical care and vocational training was one of the factors which resulted in the establishment of the U. S. Veterans' Bureau on 9 August 1921.

Physical Medicine and Rehabilitation, World War II

During World War II numerous hospitals including specialized treatment centers were established in the United States and overseas. Many of the disabled needed the services of various medical specialists and different groups of ancillary personnel. The need for coordination of those efforts and for starting rehabilitation practices early was recognized. Physical medicine services were organized and were assigned this responsibility. After the war the Army continued training programs for ancillary personnel and initiated residency training for physicians in this field.

Korean War

Physical medicine services contributed greatly to the physical rehabilitation of disabled soldiers who were injured in Korea and evacuated to the U. S. Physical medicine services were not established in Korea for the following reasons:

1. There were few physicians in service who had completed residency training (table 1).

2. The specialty is concerned with treatment of disabilities that usually require evacuation of the patient to the Zone of Interior.

Table 1. Number of Physicians Completing Residency Training by Year

1948-0
1949-1
1950-1
1951-4
1952-3
1953-4

At the beginning of the Korean War physical medicine services were established in all Class II hospitals and later eight services were activated in specialized treatment centers. This expansion raised questions concerning training of personnel and demanded a delineation of the borders and scope of the specialty. Physical medicine was started in the Army as a means of providing supplementary care for patients on other services. A single physician usually established an office in a physical therapy clinic and supervised the work of physical, occupational and reconditioning therapists. The patients were referred from other services and frequently treatment was prescribed by these services. This situation resulted in the rather obvious question as to the need for the services of the physician.

When the eight services were established in Class I specialized treatment centers, young physicians with 12 weeks of concentrated


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training in the specialty were assigned as chiefs of services in the grade of 1st Lieutenant or Captain. The responsibility of the service was not for any type of patient but for the use of physical agents and exercise. As a result, the physicians were soon assigned other duties, often full time, and therapists were left to their own devices. This does not imply criticism of the Commanding Officer who had numerous responsibilities with limited personnel, nor the physician in physical medicine who followed instructions. What was wrong? The training of the physician was not adequate to assume the responsibility and our present concept of physical medicine needs revision. Physical medicine is all too often defined as the use of heat, light, a multitude of other physical agents, and therapeutic exercise. This is partly true but it implies only prescription of these agents and supervision of therapists. It lacks the essential responsibility that physicians must assume for the welfare of patients.

We have learned to define physical medicine as that specialty concerned with the diagnosis, treatment and rehabilitation of patients with neuromuscular diseases and certain musculoskeletal defects. This implies that well trained medical specialists assume responsibility for the coordinated medical care of severely disabled patients. These patients should be housed in physical medicine wards when the major effort is training and physical rehabilitation. Before this period rehabilitation practices are started early on other services.

We have learned, therefore, that physical medicine services must be established in large hospitals where severely disabled patients are concentrated and that the physicians who practice physical medicine must be properly and adequately trained to assume these responsibilities.

Physical Therapy and Occupational Therapy

We have learned some lessons concerning the use of physical and occupational therapists. The duties of these individuals are now better defined and when the medical profession has decided what service is expected for patients from these associated groups it becomes our duty to see that they are properly trained for their jobs.

The Army provides superior training in our own school system for physical and occupational therapists and their technical aides. Selected graduate therapists are eligible for short courses of instruction and for training leading to the Master's degree, in civilian educational institutions.

There are occasions when physical therapists and occupational therapists must be assigned to stations where there is no physical medicine service. We have learned that if such therapists are to render effective service as a part of a complete medical program they must work under the direct supervision of a physician who understands the


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basic fundamentals of these disciplines. These therapists are not trained in diagnosis and indications, and when physical therapy and occupational therapy are used as ends in themselves their value is more than limited.

During World Wars I and II the services of the occupational therapist were widely used throughout our hospitals. There were many purposes, prominent among which were: utilization of free time, relief of boredom and adjustment to hospitalization. Personnel for this broad effort were not available during the Korean War and it also seemed that the mission of these highly trained individuals might be better defined. We now believe that occupational therapy as a medical subspecialty is most effective in treating patients with physical disabilities, psychiatric disorders and tuberculosis, with functional improvement as the goal of therapy.

It has been recommended, therefore, that occupational therapists be assigned only to Class II hospitals and to Class I hospitals that are designated as specialized treatment centers in tuberculosis, neuropsychiatry, orthopedics and/or neurosurgery.

Physical Reconditioning

Physical reconditioning is a type of controlled exercise that is utilized in military hospitals. It is not intended to be used for specific therapeutic purposes or for affected segments of the body. This type of activity has been questioned as duplication of physical therapy. Recently a group of civilian consultants in physical medicine to The Surgeon General met in Washington and recommended the abolition of this special field. In their opinion it is a duplication of physical therapy and it also creates a problem in civilian practice.

Early in World War II physical rehabilitation and training of the disabled became recognized as a need. Physical therapy was concerned with physical agents and therapeutic exercise and occupational therapy with diversional activities. The immediate need resulted in the recruitment and training of a new group to supervise routine exercises for hospitalized patients. After the war some of these individuals desired to continue their service to patients but there were few opportunities. The problem has been partially met by encouraging those with proper educational background to become physical therapists. Physical reconditioning is a valuable contribution to the patient in an Army hospital because a soldier must be ready for duty when he is discharged to his unit. It is most essential in wartime.

The consultant group is fully aware of this fact and does not recommend abolition of the service to patients, but of the special group that performs these duties. The physical and occupational therapists are already highly trained in the theory and practice of therapeutic ex-


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ercise. It is proposed that general reconditioning exercises be given to patients by physical therapy technicians under the supervision of the physical therapist, and that reconditioning for the psychiatric patient be done by the occupational therapy technician under the supervision of the occupational therapist. This recommendation has great merit and in our opinion could be further extended by combining all enlisted training to produce one enlisted aide (physical medicine aide) who would be available to assist the physical therapist and/or the occupational therapist.

These recommendations will probably be followed but because of the intrinsic value of reconditioning exercises and because of their particular value in military hospitals, a preliminary pilot study will be made in a large Army hospital. In this study physical and occupational therapists will become responsible for all reconditioning activities for a 3-month period.

This also raises the question of the convalescent center Table of Organization and Equipment 8-590, to which large numbers of reconditioning officers are assigned. This unit was not requested for use in the Korean Theater by the Surgeon of the Far East Forces; therefore, its particular value cannot be evaluated in relation to the Korean War. This does present an opportunity to mention convalescence. A new emphasis has been placed on purposeful medical management to shorten the convalescent period and to provide the patient with as complete functional capacity as is possible. Convalescent patients frequently profit by training and therapy rendered by the physical medicine service. They also need other specialized medical services. All convalescent patients should receive reconditioning exercises. It is my opinion that acceptance of the responsibility of medical supervision in the third phase of medical care merits special planning and consideration for the period of convalescence rather than segregation into special installations for exercise and recreation.

The importance of exercise to maintain or improve physical fitness is obvious, but it must not be overemphasized. It is an individual responsibility and a responsibility of command. Reconditioning for hospitalized patients is a function of the Army Medical Service and proper facilities for this purpose should be established in all of our hospitals and this will eliminate the need for specialized hospitals devoted to exercise and recreation.

Transfer of Patients with Chronic Diseases to Veterans Administration

Executive Order No. 10400, dated 27 September 1952, vests in the Administrator of Veterans' Affairs all duties, powers, and functions incident to the hospitalization of members or former members of the uniformed services who require hospitalization for chronic diseases.


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The Order states in part: "that chronic diseases shall be construed to include chronic arthritis, malignancy, psychiatric or neuropsychiatric disorder, neurological disabilities, poliomyelitis with disability residuals and degenerative disease of the nervous system, severe injuries to the nervous system including quadriplegics, hemiplegics, and paraplegics, tuberculosis, blindness and deafness requiring definitive rehabilitation, major amputees, and such other diseases as may be so defined jointly by the Secretary of Defense, the Administrator of Veterans' Affairs, and the Federal Security Administrator and so described in appropriate regulations of the respective departments and agencies concerned."

This directive, issued during the Korean War, obviously affects the magnitude of our efforts but does not alter the need for our services. It is not always possible to determine immediately that certain patients may not return to duty and there are classes of patients not eligible for transfer to the Veterans Administration.

The Medical Statistics Division, Office of The Surgeon General, was asked to supply the number of patients who developed major amputations and paraplegia for a period during the Korean War. They have furnished provisional data for the period January 1952 through June 1953. The number of permanent disability retirements by cause of separation is shown in table 2.

Table 2. Provisional Data, January 1952-June 1953, Permanent Disability Retirements

Cause of separation

Total

Permanently retired

Major amputations1

988

969

One upper extremity

233

228

Both upper extremities

4

4

One lower extremity

692

678

Both lower extremities

59

59

Paraplegia2

258

247

1Includes only amputations at the wrist and ankle, or above.
2 Includes quadriplegia.

The number of these patients transferred to the Veterans Administration during this same period is shown in table 3.

Table 3. Provisional Data-January 1952-June 1953-Patients Transferred to Veterans Administration

 

Total

To Veterans Administration

Amputations

988

177

Paraplegia

258

355


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Conclusions

1. The Korean War has affected the practice of physical medicine.

2. Physical medicine must be defined in terms of medical practice and must assume responsibility for specific service to selected patients.

3. Physical medicine services must be established where groups of severely disabled patients are concentrated.

4. Occupational therapists should be assigned only to Class II hospitals and to Class I hospitals that are designated as specialized treatment centers in psychiatry, tuberculosis, orthopedics and/or neurosurgery.

5. It has been recommended that physical reconditioning be eliminated as a special branch because it is a duplication of a segment of physical therapy. General reconditioning could become the responsibility of physical therapy and reconditioning for psychiatric patients could be made the responsibility of occupational therapy. A pilot study along these lines is being made.

6. Executive Order No. 10400, dated 27 September 1952, has diminished the volume of our efforts in physical medicine but has not eliminated the need for these services.

Reference

1. The Medical Department of the United States Army in The World War, Volume XIII, 1927.