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Chapter XIII

Contents

CHAPTER XIII

Reconditioning and Rehabilitation

Dwight E. Harken, M.D., B. Noland Carter, M.D., andMichael E. DeBakey, M.D.

GENERAL CONSIDERATIONS

Policies of hospitalization differ in civilian and military medical practice. A civilian is hospitalized for only part of the time that he is under medical treatment or observation. It is the rule rather than the exception for a surgical patient to be discharged from a civilian hospital early in the postoperative period to complete his convalescence at home. Moreover, he can return to work promptly, at least on a part-time basis, if physical endurance is not a prerequisite.

The military casualty who sustains a wound can be returned to duty promptly within the army area, and occasionally within the division area, if his wound is slight. For psychologic reasons, if for no other reasons, this is the wisest policy. If his wound is of any consequence, he must remain in some hospital until he is physically fit for duty or until he is separated from service after maximum benefits have been obtained from hospitalization. There is no assignment in the army, either on combat duty or limited service, for a soldier who can work only part of the time. This state of affairs necessarily prolongs the period of hospitalization for the wounded soldier.

These generalizations applied to all casualties in World War II. Thoracic casualties originally suffered under an additional handicap, the generally pessimistic outlook of the medical officers and others who cared for them. There was an unfortunate tendency to consider most of them as potential chest cripples, in the same category as the victims of empyema in World War I. As long as they were viewed from this standpoint, the results of treatment were less satisfactory than they should have been, for efforts at reconditioning and rehabilitation were lacking in vigor and enthusiasm if, indeed, any attempts at all were made. When it began to be evident that a wiser concept of chest wounds (p. 198), supplemented by new techniques of resuscitation, anesthesia, and surgery, was producing prompt and excellent results, a spirit of positive optimism began to pervade the thoracic services, involving patients as well as their surgeons and other attendants.

When it was practical, it was an excellent plan to maintain a separate medical thoracic section in close proximity to the surgical section in general


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hospitals on the base or in thoracic surgery centers. When bed space was available and interested internists were willing to assume the responsibility, the patient could be transferred to the medical section as soon as surgical care was no longer necessary, usually within 7 or 8 days. Nutritional deficiencies, anemia, and similar conditions were corrected under the care of the internist, and psychiatric and other care was provided as necessary.

The exercises to be described shortly were begun as soon as possible after operation, often within 24 hours. The program of early ambulation and exercise was correlated with early participation in work details. At the same time, ambulation was expanded into group exercises and then into hikes of increasing length. Bicycle exercises in bed were expanded, as soon as possible, into bicycle rides through the neighboring countryside. A full program of recreation was planned. The idea was to divorce the patient from his wounding and his surgical experience as promptly and completely as possible, so that he would be reconditioned mentally as well as physically for return to duty, preferably in the oversea theater.

Functional Studies

Facilities for bronchospirometric tests of thoracic casualties were not provided in the Mediterranean Theater of Operations, U.S. Army, and were not available in most hospitals in other theaters. Theoretically, these studies would have been desirable. There are, however, time-consuming, and it is doubtful that if facilities had been available, the time could have been taken to make them. They would have provided an objective criterion to indicate when a patient was ready for military duty, particularly if they had been performed serially. Most thoracic surgeons believed that clinical evaluation was quite as satisfactory in determining the activity level or the duty status.

At one chest center, serial fluoroscopic examination proved an efficient and fairly objective method of determining respiratory function. Examination of the normal chest showed that the parenchymal markings followed, in a general way, the ascent and descent of the diaphragm and, to a lesser degree, the upward and outward inspiratory lift of the ribs. The ribs moved in a pattern characteristically out of phase with the parenchymal markings (bronchial and vascular).

After injury, if progress was unsatisfactory and the chest became fused, fluoroscopic examination showed narrowing of the intercostal spaces, poor excursion of the costal cage, and immobility of the diaphragm, with a resulting reduction in respiratory efficiency. Even when such gross abnormalities were not present, pleural adhesions often greatly depressed parenchymal function. Often the only manifestation of the reduction was that the vascular and bronchial markings moved in phase with the movements of the costal cage instead of, as in the normal chest, out of phase with them.


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Personnel

In whatever hospital chest casualties were treated, whether overseas or in the Zone of Interior, trained and interested personnel were essential to the success of the reconditioning program. Members of the Army Nurse Corps, male and female physiotherapists, and trained technicians were responsible for the constant attention to minute details and for the individual handling which these patients required. Their attitude was in large measure a reflection of the importance that medical officers who cared for the patients attached to the program.

Individual attention was mandatory, particularly after wounding, to assure the proper frame of mind on the part of the casualty. During wartime, the normal desire to recover completely and promptly was not always strong in the wounded soldier. Unless this negativistic tendency was counteracted promptly, the chest disability could easily become fixed, the more prolonged the fixation, the more refractory it was to treatment. For this reason, individual attention by trained and enthusiastic personnel was necessary to institute and supervise check exercises from the earliest feasible moment.

Some chest centers made a practice of using as assistants in the program certain carefully selected chest casualties who had recovered. It was a stimulating and encouraging object lesson for newly admitted patients to see another patient, with the same wounds they had suffered, looking fit and well and performing without difficulty the exercises they were being required to undertake.

Whatever the method, it was imperative that some member of the staff of the unit to which the casualty was admitted or transferred be aware of the importance of these exercises. It was the responsibility of whoever was in charge of the program to see that all patients were performing the exercises and that all were performing them correctly. It was also imperative that someone stand guard against the patient's fixation on his wound when he began to suffer from the dyspnea and tachycardia inevitable at the beginning of a rigorous training program. If specific remedial breathing exercises were not instituted and continued as indicated, the classical thoracic deformity would either occur or recur in serious chest wounds, and the casualty would be well on the way to becoming a chest cripple like his predecessors of World War I.

GENERAL POLICIES

Chest exercises were of two kinds:

1. The basic calisthenic program which eventually became part of the reconditioning of all wounded patients, regardless of the nature of their wounds (fig. 47), supplemented, for chest casualties, by special breathing exercises and exercises for the shoulder girdle.

2. The special exercises necessary to correct chest deformities that had already occurred.


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FIGURE 47.-Convalescent reconditioning exercises for bed patients. These exercises were devised in the European theater and published by the Office of the Chief Surgeon. They are presented as typical of the exercises generally used for this purpose. A. Breathing exercise. B. Neck exercise. C. Chin-neck exercise. D. Arm and hand exercise. E. Shoulder exercise. F. Arm and shoulder exercise. G. Abdominal exercise.


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FIGURE 47.-Continued. H. Foot and ankle exercise. I. Leg exercise. J. Abdomen and leg exercise. K. Thigh-trunk exercise. L. Trunk exercise. M. Leg-back exercise. N. Leg-cycle exercise.


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General (Preventive) Exercises

Whenever it was practical, it was a wise plan to train chest patients in breathing exercises and in special exercises for the shoulder girdle before operation. This eliminated the difficulty of instructing them in the required movements when postoperative discomfort might limit their cooperation.

As a rule, breathing exercises were started as soon after operation as the patient was oriented. In some chest centers, all patients, in addition to the special exercises required for their special injuries, practiced breathing exercises for 5 or 10 minutes of every hour during the day and until bedtime. The nurse and the wardmaster were responsible for seeing that the schedule was followed.

More vigorous exercises were usually possible by the second or third postoperative day. When this program was enforced, the respiratory excursion was frequently full and unimpaired by the time the soft-tissue wound was healed. Whether or not results were entirely satisfactory, the classical chest deformity was seldom part of the picture.

Corrective Exercises

Corrective chest exercises were designed to undo the sequelae of chest injuries in which deformity had been permitted to become established. Their rationale was as follows:

1. At the time of injury (operation), the chest wall becomes painful on motion, and the patient splints it voluntarily. Normally, both the voluntary and involuntary breathing mechanisms are symmetrical. When, however, the wounded side is splinted to avoid discomfort, it is divorced from the respiratory act. After a short time, the automatic neuromuscular mechanism is interrupted, and it frequently does not return spontaneously. In many injuries, immobilization that is first of voluntary, and then of neuromuscular, origin is mechanically reinforced and maintained by adhesions that have formed between the parietal and visceral pleura. The parietes and the lung are sometimes solidly incarcerated by the dense fibrous cortices.

When the pathologic process has progressed to this point, the classical chest deformity is likely to be present (appendix A, p. 341). The head is held laterally toward the injured side. The shoulder on the involved side slides downward and inward and moves medial to the vertical line from the anterior superior iliac spine. The chest wall is held in a position of full expiration. At the same time, the spine assumes a position of scoliosis and the pelvis is tilted toward the unaffected side.

When a casualty with a chest wound had been permitted to reach the state described, his condition could be corrected only by special exercises in which he received personal instruction.

Both in the European Theater of Operations, U.S. Army, and in the Zone of Interior, great stress was put upon elaborate special respiratory exercises.


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The programs employed at the chest centers at the 160th General Hospital, Stowell Park, England, and at Baxter General Hospital, Spokane, Wash., were highly developed and extremely effective.

DEVELOPMENT OF PROGRAM, MEDITERRANEAN THEATER

In the Mediterranean theater, even in the early days of the fighting, the importance of deep breathing was emphasized to all patients. Practically all bed patients were able to participate in breathing exercises led by a corpsman especially trained in calling out orders.

Intelligent physiotherapy was also employed to great advantage in the early recovery phase. It was directed primarily toward early restoration of shoulder motion (fig. 48) and reestablishment of normal posture. It was found, however, that unless both medical officer and physiotherapist were alert to the progress of the individual patients, there was a tendency to continue this type of treatment far beyond the period of actual benefit. This overloaded the physical therapy department, needlessly prolonged hospitalization, and had an extremely bad psychologic effect on the soldier himself.

Shoulder girdle exercises were instituted in all patients with wounds or surgical incisions involving the muscles in this region. Patients without abdominal extension of their injuries also were trained in exercises tensing the abdominal wall. Flexing the leg and thigh muscles was added to the exercises after one or two instances of femoral thrombophlebitis had occurred.

With the single exception of those with cardiac wounds, patients who had had major chest surgery could be safely and comfortably out of bed within 24 hours after operation. Early ambulation had both physiologic and psychologic advantages. The wasting and atrophy of disuse were avoided. The dangers of pulmonary emboli were greatly reduced. The nutritional state often improved dramatically because the appetite improved and food intake increased. Empyema cavities which had remained stationary in size as long as the patients remained bedridden decreased in size when they became ambulatory.

Chest wounds were peculiarly well adapted to the program of early ambulation. With pain controlled by intercostal nerve block with procaine hydrochloride, the patient had no temptation to fight against movement or to practice protective splinting on the injured side (immobilizing it in total expiration and relaxing the accessory muscles of respiration).

Ambulatory patients were sent on daily walks, and were encouraged to participate in recreational activities. Some of them worked about the wards.

In the Mediterranean theater, blow bottles were found of little value, and no special attempts were made to teach the differential breathing exercises popular in the European theater. They were not thought necessary when a proper routine was followed immediately after surgery. In refractory cases, in which patients were received on the service with the shoulder girdle frozen, treatment consisted of heat, massage, and active and passive motion instituted under the direction of physiotherapists.


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FIGURE 48.-Exercises to restore function of shoulder in chest casualties. A. Assisted horizontal adduction. B. Active flexion.


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FIGURE 48.-Continued. C. Bilateral abduction with outward rotation. D. Extension. E. Circumduction.


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THE PROGRAM IN THE EUROPEAN THEATER1

The reconditioning program employed at the 160th General Hospital chest center was under the direction of Maj. (later Lt.. Col.) Dwight E. Harken, MC, and Capt. Joseph P. Lynch, MC. It was modified from the voluntary respiratory exercises which British thoracic surgeons had been employing for a number of years. The program at this center was chiefly based upon the routine employed by Mr. A. Tudor Edwards, under whom Major Harken had received part of his training (p. 115), and his physical therapy staff, particularly Miss Winifred Linton and Miss Jocelyn M. W. Reed (1).

Rationale of Exercises

These exercises were designed to teach the patient voluntary, unilateral, segmental, controlled breathing, on the theory that breathing is an activity that the human race has permitted to become almost entirely automatic, voluntary, and bilateral. By recapturing the ability to expand the affected side, it was possible to restore it to the functional level of the unaffected side. Calisthenics and the breathing exercises usually practiced, in the opinion of British chest surgeons, simply developed the unaffected side, to the further detriment of the injured side. They considered it neither practical nor desirable for the patient to undertake such activities until the lung on the affected side was fully expanded and the vital capacity correspondingly increased.

The purpose of these exercises was twofold:

1. To reestablish the lost neuromuscular arc from the motor cortex to the chest wall and diaphragm. Until this had been accomplished, it was futile to urge the patient to use the injured side of his chest.

2. To mobilize the chest wall and diaphragm, which were restricted locally by incarcerating cortices and adhesions. Accomplishment of this objective ultimately freed the pleura and allowed normal air and vascular exchange in the lung.

Procedure

As soon as possible after he reached the center, the patient was seen by a member of the thoracic reconditioning staff. Special records were made of his weight, chest expansion, function of thoracic cage, chest deformities, general status, and similar data. These records were used later for comparative purposes.

The patient was given a mimeographed sheet of instructions, which described the thoracic deformity, stated the principles of its correction, and detailed the manner of performing the specific remedial breathing exercises (appendix A, p. 341). At the same time, all of these matters were clearly explained to him in the simplest possible words. If he was ambulatory, the

1 The reconditioning program at the 160th General Hospital chest center is presented as perhaps the most carefully worked out and supervised in the European theater.


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nature of his deformity was demonstrated to him in the large mirror with which each ward was provided.

After the patient had been familiarized with his disability and deformity, he was shown how to lie correctly in bed. The tilted pelvis was returned to normal position, so that the weight was distributed equally on both buttocks. The shoulders were squared, and the head was shifted to the midline.

The next undertaking was the restoration of motor cortex control over the muscles of respiration. As already pointed out, man does not normally exercise voluntary control over the independent respiratory activity of separate sides of the chest, much less control particular segments within one hemithorax or the other. Yet, this was precisely what was necessary for the recovery of chest casualties, to prevent their becoming permanent chest cripples. The establishment of voluntary motor control over the injured hemithorax and its fused, sunken segments was the foundation of success in remedial breathing exercises. Equally important was voluntary motor control over the excursions of the diaphragm, in order to accomplish its remobilization.

The problem was essentially the education of the motor cortex, or, more properly, the education of the whole neuromuscular mechanism, in order to achieve voluntary control of areas that are not normally under the voluntary domain and that in the fused chest had also been dropped from the normal involuntary sphere.

Restoration of the mobility of the diaphragm was more difficult than restoration of the mobility of the chest wall, for three reasons:

1. It was impossible for the patient to see the results he was achieving.

2. The costophrenic adhesions, or, more correctly, the parietophrenic adhesions were often very dense and were slow to yield to the diaphragmatic pull.

3. The patient sometimes had great difficulty in comprehending the concept of abdominal breathing and more often than not would move the abdominal wall in a manner precisely opposite to the proper pattern.

The first step in the patient's reeducation in voluntary breathing was to make him find, or become aware of, the involved and immobile portion of his chest.2 This was accomplished by having him place his hand over the affected area, institute gentle pressure, and exaggerate any existing respiratory excursions or initiate them if none were present. It usually required intense concentration for the patient to become conscious of specific areas of his chest.

The manner in which the pressure was delivered was also important. During the inspiratory effort, the pressure from the hand was just firm enough to establish an afferent pathway whereby he could become conscious of the area. During the expiratory phase, the pressure was much firmer, representing an exaggerated substitute for normal. When expiration was deepest, a gentle extra thrust, sharply released, would give the chest wall a spring or recoil that initiated the inspiratory phase of the act. Most often, it was this recoil that

2 Illustrations for these exercises are in the material given to each patient (appendix A, p. 341).


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the patient picked up and continued in his conscious effort to move the lagging area of the chest wall.

The key to the solution of problems connected with the diaphragm was to explain to the patient that on inspiration the chest wall increases the volume of the thoracic cavity, and therefore of the lungs, by opening like bellows, while the floor of the thoracic cavity (that is, the diaphragm) similarly increases the thoracic volume by dropping downward like a piston. After many trials, it was found that the comparison with a piston was the most effective description. When it was used, the patients quickly realized that the abdominal muscles must relax and be forced out by the descending piston and that, conversely, these muscles could force the piston upward into the thoracic cavity if they were contracted and the abdomen was pushed in. Progress in diaphragmatic breathing could best be assessed by fluoroscopic examination at 5-day intervals.

THE PROGRAM IN THE ZONE OF INTERIOR

Development of Program

At the Baxter General Hospital chest center, the program of reconditioning of thoracic casualties was developed to meet a specific need.3 Many patients were admitted to the hospital who were in good condition after adequate and appropriate medical and surgical treatment overseas. Some patients, however, were found to have a persistent disability, which took the form of a constant complaint of inordinate dyspnea upon even moderate exertion. They simply had to drop out of whatever activity they were engaged in, sit down, and puff.

Physical examination of these patients showed that the side of the chest involved in the previous injury (or occasionally the previous disease) was restricted in its movement or fixed in the position of expiration. The ribs were in close approximation in the dependent position, and the diaphragm was elevated. On fluoroscopic examination, there was little movement of the affected rib cage or the diaphragm, even during an episode of dyspnea.

The explanation of these findings was that in the course of prolonged bed rest after wounding (or illness), with voluntary or involuntary limitation of thoracic motion on the affected side, a number of pathologic changes had occurred. The muscles of respiration had become markedly atrophic. Fibrous thickening had developed in the parietal pleura, intrathoracic fascia, and intercostal structures, with considerable fibrous obliteration of the pleural space. The diaphragm on the affected side had become seriously involved in the process, and as a result, the respiratory muscles motivating the mechanism of breathing had lost their strength. In addition to this handicap, these muscles had another burden imposed upon them, that of moving the ribs and the diaphragm (the bellows of the respiratory apparatus), which were fixed by fibrous adhesions.

3 The reconditioning program at the Baxter General Hospital chest center is presented as perhaps the most carefully worked out and supervised in the Zone of Interior.


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Casual inspection of these patients, and even careful study of their roentgenograms, gave no hint of the severity of their disability. That became apparent only when the severe dyspnea produced by moderate exertion was observed. Apparently, the increased metabolism caused by exercise resulted in an accumulation of carbon dioxide in sufficient amounts to activate the respiratory center. The oxygen levels remained adequate, as indicated by the absence of cyanosis and the normal coloration of the peripheral circulating blood.

A number of studies would have been desirable, including determination of the vital capacity; determination of the oxygen and carbon dioxide blood levels; selective spirometry of the tracheobronchial tree; and studies of samples of tidal air for comparison of the relative nitrogen, oxygen, and carbon dioxide levels of the affected and unaffected hemithoraces. Facilities for these investigations were not available.

In the absence of this fundamental information, the best plan seemed to be to devise a program of exercises which, by specific direction toward that end, would rapidly redevelop the muscles of respiration without imposing a total physical contribution upon the entire body. It also seemed important that these exercises be so planned that they could be continued for long periods without the development of dyspnea, which would discourage further activity; it had been observed that the breathlessness or sense of breathlessness associated with the false dyspnea of carbon dioxide accumulation discouraged further activity and thus helped to maintain the process which was causing it.

The program at Baxter General Hospital was under the general direction of Maj. Thomas B. Wiper, MC, assisted by Maj. James T. Lang, CAC, Capt. Leslie T. Wood, Inf., Capt. David Blair McClosky, AC, and T. Sgt. Renold Cook (2). An important collaborator was Captain McClosky, a former concert singer, who had suffered a loss of respiratory capacity and experienced a sense of breathlessness after surgical treatment of postpneumonic empyema.

A letter of greeting from the commanding officer of Baxter General Hospital to all thoracic casualties (appendix B, p. 345) made them cognizant at once of the importance attached to the exercise program.

Indications for Exercises

The exercises that were part of the reconditioning program for chest casualties were taught to the following groups of patients:

1. Those with dyspnea on exertion, as just described.

2. Those with stabilized empyema in which there was delay in reexpansion of the lung after adequate drainage.

3. Those with stabilized lung abscesses in which there was delayed obliteration of the space left after adequate drainage.

4. Those with small residual hemothoraces in which the space did not provide sufficient room for surgical decortication.


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5. Those with structural deformities of the thoracic cage resulting from multiple rib fractures caused by crushing injuries.

6. Those to be submitted to elective thoracotomy, so that they would be prepared to begin these remedial exercises immediately after recovery from anesthesia. This group of patients was transferred to the convalescent ward as soon as possible, so that they might take part in the additional exercises instituted for all casualties who had advanced to this status.

Routine of Exercises

The exercises employed at this chest center were devised to strengthen all the muscles of respiration and to mobilize the ribs, lung, adherent pleural surfaces, and diaphragm. Mobilization of these fixed structures was accomplished by the pull of selective muscle groups upon the rib cage and by exercises which utilized the principle of Valsalva's maneuver.

The exercises were graded and phased as follows:

1. For the first 8 to 10 days after operation, exercises consisted of deep breathing; active movements of abduction, adduction, flexion, and extension of the arms; and active abduction and adduction of the scapula (figs. 49 and 50). The physiotherapist, in addition to supervising these active movements of the respiratory muscles and muscles of the shoulder girdle, which were designed to prevent atrophy and fixation, also worked to improve the posture of the patient in bed. Selected patients also received diathermy, radiant heat, and massage according to their special needs.

It was found at this center that the immediate postoperative reconditioning of chest casualties could be most satisfactorily conducted under the direction of female physiotherapists who had been indoctrinated with the basic philosophy of the reconditioning program and who understood the anatomy of the muscles which participate in the respiratory act.

At the end of this period, the patients were reclassified and moved to a preconvalescent ward. Here they came under the direction of male instructors in the physical reconditioning section.

2. Between the 10th and 15th days after operation, 11 basic thoracic exercises were conducted twice daily, for 15 minutes at a time (figs. 51-61).

3. Between the 15th and 20th days after operation, the exercise periods were increased to 20 minutes twice daily, and each exercise was repeated 8 times.

4. Between the 20th and 23d days after operation, the exercises were conducted for 25 minutes twice daily and "Tarzan" exercises were added to the list (fig. 62).

5. Between the 23d and 26th days after operation, the exercises listed were conducted for 30 minutes twice daily.

6. Between the 26th and 30th days after operation, the exercises were carried out for 40 minutes twice daily, and supplementary exercises (figs. 63, 64, and 65) were added for warmup purposes. Other exercises, including woodchopping and swimming, were added at the discretion of the instructor. All exercises were carried out with emphasis on deep breathing.


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FIGURE 49.-Individually prescribed exercises for early postoperative period, Baxter General Hospital chest center (2).

FIGURE 50.-Mild thoracic exercises 7-14 days after operation (2).


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FIGURE 51.-Basic thoracic exercises. 1. Breaking chains (2).


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FIGURE 52.-Basic thoracic exercises. 2. Elbow exercise (2).


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FIGURE 53.-Basic thoracic exercises. 3. Arm exercise (2).


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FIGURE 54.-Basic thoracic exercises. 4. Rib stretcher  (2).


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FIGURE 54.-Continued


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FIGURE 55.-Basic thoracic exercises. 5. Against the wall (2).


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FIGURE 56.-Basic thoracic exercises. 6. Clasped hands (2).


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FIGURE 57.-Basic thoracic exercises. 7. Hand on chest (2).


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FIGURE 58.-Basic thoracic exercises. 8. Hand on knee (2).


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FIGURE 59.-Basic thoracic exercises. 9. Hand on foot (2).


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FIGURE 60.-Basic thoracic exercises. 10. Full chest (2).


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FIGURE 61.-Basic thoracic exercises. 11. Disappearing stomach (2).


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FIGURE 62.-Basic thoracic exercises. 12. Tarzan exercise (2).


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FIGURE 63.-Supplementary exercises. High jumper (2).


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FIGURE 64.-Supplementary exercises. Shoulder swing (2).


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FIGURE 65.-Supplementary exercises. Bobbing movements to each side (2).


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FIGURE 66.-Page used by patients to record their own progress (2).

7. After the 30th postoperative day, the reconditioning program lasted for an hour and a half twice a day. The first 45 minutes were devoted to the 12 thoracic exercises and the supplementary warmup exercises. The second 45 minutes were devoted to sports and games and were entirely recreational, though in the selection of activities those were stressed that would encourage continued stretching of the thoracic cage.

While the program outlined was the routine generally followed, the patient's progress from one phase to another depended entirely upon his individual performance, of which he kept his own records (fig. 66). All activities were conducted in small groups and were closely supervised by physical instructors (fig. 67).

About 45 days after operation, most patients were in suitable condition to be transferred to the Army Air Forces Reconditioning and Convalescent Regional Hospital, Fort George Wright, Wash. Here the remedial thoracic exercises were continued under supervision while the patients participated in the general physical reconditioning program directed by The Surgeon General.


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FIGURE 67.-Group exercises under supervision (2).


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Results of Program

At the Baxter General Hospital chest center, it was noted that occasional patients who had made what seemed to be a complete surgical recovery from posttraumatic or postpneumonic empyema presented manifestations indicative of reactivation of the inflammatory disease when they began their reconditioning routine. The residual status of the disease had not been revealed by either physical or roentgenologic examination. The patients had arrived from other hospitals in apparently good condition, with their wounds well healed and no physical evidence of disability. When recurrent empyema manifested itself in this fashion, patients were referred to the surgical ward for operation, after proper preparation for it.

Another group of patients who had sustained some loss of substance of the thoracic wall as the result of either initial trauma or the extensive debridement required by it reacted to the exercise program by herniation of the lung through the defect. Those patients were also referred to the surgical section, for plastic reconstruction of the chest wall.

The exercise program thus unwittingly served as a valuable method of detecting physical fitness and of bringing to light promptly any residual defect or disability which might require further surgery.

It needed no more than simple clinical observation of the comparative progress of patients given breathing and other exercises with those not given them to prove that this program was one of the most valuable additions to the care of thoracic casualties. Patients not given these exercises complained of chest pain, dyspnea, and other disabilities, and also presented deformities of the chest wall. Early ambulation and the early use of these exercises generally eliminated this sequence. Patients consistently found that their exercise and activity tolerances increased as their respiratory function improved. It was exceptional, unless there were complications, that a patient submitted to thoracotomy for the removal of foreign bodies or for decortication was not able to participate in all but the most rigorous physical exertion within a month after operation. Gain in weight and strength and response to therapy for anemia, as well as the general well-being, always paralleled the increase in respiratory function.

The condition of thoracic casualties on discharge from the chest center was generally gratifying. Once it was explained to them, they readily realized the importance of their cooperation in these exercises in their own immediate rehabilitation and future health. As a result, these patients, like most other thoracic casualties of World War II, faced the world well and fit, and not as chest cripples.

References

1. Reed, J. M. W.: Post-Operative Breathing and Other Exercises. In Pye's Surgical Handicraft: A Manual of Surgical Manipulations, Minor Surgery, and Other Matters Connected with the Work of Surgical Dressers, House Surgeons, and Practitioners, edited by H. Bailey. Ed. 14. Bristol: John Wright & Sons, Ltd., 1944.


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2. Thoracic Remedial Exercises as Developed and Presented at Baxter General Hospital, Spokane, Wash. Medical Research and Development, Thomas B. Wiper, Major, MC; Physical Reconditioning Research and Development, James T. Lang, Major, CAC; Leslie T. Wood, Captain, Inf.; David B. McClosky, Captain, AC; and Renold Cook, Technical Sergeant; 1945.

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