Recent advances in the field of physical medicine demand that every up-to-date sanitarium or hospital have a department of physical medicine adequate to care for those on its patient list who would benefit by properly administered physical therapy. Physical medicine, either diagnostic or therapeutic, is being employed in most of the medical and surgical specialties. It seems appropriate at this time, to take stock of our present situation in this field and to propose measures which will put us abreast of the march of progress.
In 1940 Sister Elizabeth Kenny arrived in the United States to place before the American medical profession her concept of poliomyelitis and her method for its successful treatment. Whether we agree with her concept of the disease or not, it must be admitted that it has proved a great stimulus to further study, and has modified to a considerable extent our own concept of the disease. There can be no doubt that her method of treatment, with its employment of fomentations and its excellent system of muscle re-education, has revolutionized the care of the polio patient. The establishment of the Elizabeth Kenny Institute and the Elizabeth Kenny Foundation has given permanency to her work. Sister Kenny has made a valuable contribution to the progress of physical medicine in the United States.
DEFINITIONS.—In order that we may all speak -and think in the same terms, let us define a few names commonly used but often misunderstood. The term physical medicine has been adopted by the American Medical Association, the American Congress of Physical Medicine, and the American Society of Physical Medicine. It includes physical therapy, occupational therapy, and rehabilitation. It includes the various therapeutic procedures and such diagnostic procedures as chronaxie muscle testing, functional muscle grading, electromyography, skin temperature study, oscillometry, joint measurements, and rehabilitation grading.
Physical therapy is defined as the use of the physical agents, water, light, electricity, massage, and exercise in the treatment of disease.
Occupational therapy has been defined as "any activity, mental or physical, definitely prescribed and guided for the distinct purpose of contributing to the hastening of recovery from disease or injury, and of assisting in the social and institutional adjustment of individuals requiring long and indefinite periods of hospitalization."
Rehabilitation is defined as the restoration of the handicapped individual to the fullest physical, mental, social, vocational, and economic usefulness of which he is capable. For Seventh-day Adventist medical workers it seems that the term rehabilitation should have even a broader meaning and should include a spiritual phase as well, the restoration of the image of God in man. This, we all too often neglect.
It is apparent, therefore, that the term physical therapy is no longer adequate to cover the fields of physical therapy, occupational therapy, and rehabilitation, which are now grouped under the title of physical medicine.
Physical medicine, to be carried on in the most effective, efficient manner, requires specially trained personnel. The physician who is qualified as a specialist in physical medicine is called a physiatrist. In order to be qualified by the American Board of Physical Medicine, as a physiatrist, the physician must have completed a three-year residency or fellowship in physical medicine, and must have spent two additional years in practice. At the time of the setting up of the board in 1946, a group of approximately fifty men in various parts of the United States were registered without examination.
The registered physical therapy technician or physical therapist is one who has completed a course in physical therapy in an approved school of physical therapy, and who has successfully completed the examination given by the American Registry of Physical Therapy Technicians. Graduate nurses, physical education graduates, and two- or three-year college students are eligible to take the twelve-to-fifteen-month courses given in approved schools of physical therapy, one of which is operated in connection with the College of Medical Evangelists.
Physical Medicine in the United States
Outside our own ranks physical medicine has shown phenomenal development during the past quarter century. The employment of physical measures during and after World War I in the rehabilitation of the wounded demonstrated their great value. In 1922 the American College of Physical Therapy, now called the American Congress of Physical Medicine, was organized. This group has done a great deal for the advancement of physical medicine in the United States. Physical therapy was given official status in medical circles by the appointment by the American Medical Association in 1925 of the Council on Physical Therapy, now the Council on Physical Medicine. The council has promoted physical medicine by the publication of scientific articles, by inspection and approval, or disapproval, of apparatus submitted by Various manufacturers, and by educational' exhibits at medical meetings.
In 1944 the Baruch Committee on Physical Medicine was organized. The work of this committee was financed by a grant of a little over one million dollars from Bernard Baruch, whose father was Dr. Simon Baruch of New York, author of an excellent text on hydrotherapy. The function of the Baruch Committee on Physical Medicine was to survey the field of physical medicine, and to take steps to promote education and research. This the committee has done on a grand scale, with the result that physical medicine has advanced greatly during the past five years. Grants have been made for research, for the hiring of teachers in medical schools, and for the training of young men as specialists in physical medicine. Mr. Baruch's generous donation to the cause of physical medicine has undoubtedly been the greatest single stimulus to the advancement of this branch of the healing art.
An organization which has contributed much to the progress of physical medicine is the National Foundation for Infantile Paralysis. The foundation has established scholarships for the training of physical therapists, and has already paid for the training of several hundred. It has also provided considerable amounts of money for research in physical medicine and allied fields.
The recognition of physical medicine as a definite specialty occurred in 1946, when the American Board of Physical Medicine was established. It is the function of this board, as with all specialty boards, to examine and qualify those who desire and are eligible to be qualified in its field. The establishment of the American Board of Physical Medicine has been a considerable stimulus to the establishment of residency and fellowship training programs throughout the country.
In recent years we have heard a great deal about the rehabilitation of the ill and injured. As already defined, the term rehabilitation means the restoration of the individual, who has been handicapped by disease or injury, to the fullest physical, mental, social, and economic usefulness of which he is capable. For example, a patient may emerge from an attack of rheumatic fever with so much damage to his heart that he is unable to carry on his former occupation, which demanded considerable physical exertion. Instead of sitting idly at home, he may be rehabilitated by the combined efforts of the cardiologist, the physiatrist, the physical therapist, the occupational therapist, the social worker, and such educational personnel as is needed. In spite of his handicap, this team of workers, by coordinated effort, will put him in the best physical condition possible for him, will aid in his adjustment to his handicap, and will direct his retraining in an occupation suited to his physical condition.
This program of rehabilitation should be under the direction of the physiatrist. Many of the chronic invalids in our hospitals and sanitariums, both public and private, could be rehabilitated and made useful citizens again if trained personnel were available to do the job. This is not an idle dream but has been actually demonstrated. It pays economically and infuses new hope and courage into patients who have lost interest in life.
OUR OWN STATUS.—Having placed before you briefly the recent progress and present status of physical medicine in the United States in general, may we now analyze our own situation. From the early days of our health work physical therapy, and more especially hydrotherapy, occupied a prominent place. The system of physical therapy used in our sanitariums today was developed by Dr. J. H. Kellogg in the Battle Creek Sanitarium. Dr. Kellogg carried on a considerable amount of experimental work, which is reported in his book Rational Hydrotherapy. Battle Creek, Sanitarium became known the world over for its treatment program. Dr. G. K. Abbott must also be given credit for his work in hydrotherapy. Dr. Abbott has written several valuable textbooks on this subject, and has promoted hydrotherapy in the medical school and in our sanitariums.
Our present sanitariums, with their unstable staff organizations, have not improved our physical therapy methods materially over those inherited from Battle Creek. Nevertheless, we can say without fear of successful contradiction, that nowhere is hydrotherapy done so well as in Seventh-day Adventist sanitariums. Unfortunately, however, that is the extent of our superiority in the field of physical medicine, and we will not retain that superiority for long unless we are willing to reorganize our departments along up-to-date lines.
Two of the natural methods of healing that we have failed to develop are exercise therapy and occupational therapy. In the preparation of this discussion a brief survey was made of the instruction which has come to us from the Spirit of prophecy on natural methods of healing. It is interesting to observe that there, is much more emphasis placed on exercise therapy than on any of the other physical agencies. Moreover, exercise in the open air in the form of useful work suited to the physical capacity of the patient is especially stressed. This is a form of occupational therapy which is rarely used anywhere today. It seems that we have a unique opportunity in our rural sanitariums to develop this form of treatment. I am aware that it has been tried with but little success in some places. However, with the guidance of a trained therapist and a little more persistence, it is certainly possible to work out such a program. Listen to the following quotation from volume 4, page 94, of the Testimonies:
"Physical exercise and labor combined has a happy influence upon the mind, strengthens the muscles, improves the circulation, and gives the invalid the satisfaction of knowing his own power of endurance ; whereas, if he is restricted from healthful exercise and physical labor, his attention is turned to himself. He is in constant danger of thinking himself worse than he really is, and of having established within him a diseased imagination which causes him to continually fear that he is overtaxing his powers of endurance. As a general thing, if he should engage in some well-directed labor, using his strength and not abusing it, he would find that physical exercise would prove a more powerful and effective agent in his recovery than even the water treatment he is receiving."
Our medical institutions suffer from a lack of trained personnel in the field of physical medicine. Trained personnel is of much more importance than facilities and equipment. Much good physical therapy can be carried on by well-qualified personnel with relatively meager equipment; and, conversely, the finest facilities and equipment are of little value without qualified personnel. The time has passed when it is possible to teach more than the mere elements of physical medicine during the undergraduate training of our medical men. The field has become so broad that no physician can become proficient in it without special graduate training.
We have in the whole denomination only four or five qualified physiatrists. Upon the establishment of an approved residency program at the White Memorial Hospital three years ago, a letter was written to the medical director of each of our sanitariums announcing the fact. There were two responses: One man thanked us for the letter ; the other desired to take a residency in physical medicine, but his local board of trustees would not permit him to do so. To develop a satisfactory program of physical medicine in a sanitarium or hospital, there must be a physician in charge who has had at least a minimum of special training in the field.
In 1941 an approved school for the training of physical therapists was established in the College of Medical Evangelists. The school has prospered in spite of the fact that it has excited much more interest outside our ranks than within them. The primary purpose in starting the school was to furnish trained physical therapists for our own work. In this we have been only partially successful, although we are making progress. The ideal plan is for the sanitarium to send graduate nurses for training in physical therapy. Washington Sanitarium, upon Dr. Wayne McFarland's recommendation, sent three students three years ago. This year we have one student from Paradise Valley Sanitarium. We also have graduates at Saint Helena, Boulder, Riverside, Florida, and Portland sanitariums. Four of these seven institutions are asking for more physical therapists.
A situation which has retarded the development of physical medicine in our sanitariums is the separation of electrotherapy and light therapy from hydrotherapy and massage. These should be so integrated and organized that any type or combination of physical procedures can be ordered at will by the physician.
The practice of giving physical therapy on a flat rate with board and room is not conducive to good treatment. Physical therapy should be prescribed according to the indications in the individual case. There may even be some patients who do not need physical therapy. The tendency when treatment is lumped with board and room is to treat every patient without regard to specific indications.
IMMEDIATE NEEDS.—The physical-medicine departments in most of our sanitariums need to be reorganized for greater efficiency and more effective service to our patients. The sanitarium should have one department of physical medicine with a division for men and a division for women. The electrotherapy department, as such, should be abolished. Equipment for hydrotherapy, electrotherapy, light therapy, exercise, and massage should all be available in the same department. This makes for greater efficiency and better treatment. Such an arrangement would require little or no alteration in some of our sanitariums. In fact, the space devoted at present to the electrotherapy department could be devoted to some other use.
The department of physical medicine should have a physician in charge as medical director. If a fully qualified physiatrist is not available, some member of the staff should take at least a three-month-intensive course of training in physical medicine. This is by no means adequate, but will serve as a temporary expedient.
Working under the direction of the medical director, there should be a chief physical therapist in charge of all physical treatment for both men and women. The chief physical therapist should preferably be a graduate nurse who has finished the course in an approved school of physical therapy.
In addition to the chief physical therapist, there should be an adequate number of fully qualified male and female therapists to staff the men's and women's divisions. The department should continue to instruct student nurses in physical therapy, most emphasis being placed on hydrotherapy and massage.
Each department of physical medicine should have on its staff a registered occupational therapist. Unfortunately, we do not have within our own organization a training school for occupational therapists. However, a graduate physical therapist can obtain some credit on the course in occupational therapy for the work done in the physical therapy course, and can thus shorten somewhat the length of training in occupational therapy.
An important consideration in the maintenance of an efficient department of physical medicine is an adequate postgraduate program for the permanent personnel of the department. This is a rapidly developing field, and frequent periods of graduate training for key workers are essential.
We are happy that some of our 'sanitariums have made excellent beginnings in the reorganization of their physical therapy departments. Until each institution has a complete staff of qualified personnel, the ideal has not been reached. The results of such a setup will amaze those who have not followed the recent progress in the field of physical medicine.