By this time the contraction will be productive of movement, and the limb can now be held in various positions during the counting, and then the way is open for the prescription of a more advanced form of exercise. It is at this stage that some form of apparatus is of great assistance.
The first principle in the use of the weight and pulley is to devise an exercise that will allow the muscle we hope to strengthen simply to contract and relax without effort - in other words, an assistive movement exercise. For example, in exercising the quadriceps the patient should stand facing the apparatus with the cord attached to the foot (cf. Fig. 54, p. 107). He then flexes the thigh with the knee straight and extends the thigh while the knee is flexed. The same effect can be secured by using the vertical cord and a knee-stool (see Fig. 52, p. 105). Reduction of weight adds to the amount of exercise given, as the pull of the cord tends to support the weight of the leg. Provided the exercise is devised so that the weights tend merely to relieve the muscles of the effect of gravity, the exercise may be prescribed freely almost from the start; but care must be taken lest, by paying too little consideration to this force, we give the antagonists too severe a dose of exercise.
Fig. 98. - To illustrate an exercise for the brachialis anticus with the weight and pulley. No exertion is imposed upon the muscle; the triceps, however, does considerable work.
Fig. 99. - To show the converse of Fig. 98. The brachialis anticus is now called upon to work; the triceps is receiving assistance.
A corresponding exercise for the brachialis anticus may be performed with the back to the apparatus while the horizontal cord passes over the shoulder (see Fig. 98). The weights are gradually reduced to a minimum. Next the patient faces about and then tries to pull the same cord towards him. This should only be done once or twice on the first day, on the next two or three times, while each following day either a weight is added or the patient performs the exercise with increased frequency (see Fig. 99).
So, too, in exercising the quadriceps the patient has only to reverse his position to secure resistive exercise, which is increased daily either by using additional weight, by increased frequency of the movement, or by holding the weights fully supported while he counts during an increasing length of time (see Figs. 53 and 57, pp. 106 and 110).
Presently the patient may be promoted to exercises on the ladder, and in performing these the same gradual increase in severity or in frequency may be made, until the most strenuous of exercises can be performed with freedom. It should be added that, during the early stages, the sound limb does most of the work, next the two limbs share it equally, and then an ever-increasing proportion is thrown on to the unsound limb - now nearly sound once more - until it alone bears the full body-weight throughout the exercise and the patient performs his knee-bending and stretching exercises while the sound limb is held behind, away from all support.
Fig. 100. - First position when utilising a door to re-educate arm movements. The patient crawls up with his fingers as high as he can. Note that the door is fixed by the patient's foot.
The skilful blending and graduation of exercises is a task which would appear to be perfectly simple; in practice it is the rarest possible event to find a masseur who will perform it conscientiously. This is not due to lack of interest, and can rarely be due to lack of intelligence, so the only alternative left is to presume that it is due to lack of comprehension of the importance of re-education and of the wonderful effect of the gradual increase of exercise. Yet herein is the whole secret of success in the treatment of injury, be it recent or of long standing.
Fig.101. - Second position when utilising a door to re-educate arm movements. The body is moved nearer the door, the hand drops slightly, and the elbow bends. The head is dropped forward.
Fig. 102. - Third position when utilising a door to re-educate arm movements. The body rotates slightly, and the elbow remains stationary, while the hand falls naturally to the back of the head, which is then extended.
A few words must suffice to indicate other useful points in re-educating a patient in the use of his arm.
For movements of the shoulder "crawling up the wall" does not suffice. A line must be drawn on the wall, and, having reached the mark, the patient must practise raising the hand from the wall. Thus he should have three marks, one showing the level at which he can raise his hand from the support of the wall while he counts three slowly, the next marks the highest position at which he can raise it momentarily, while the third is placed at the spot beyond which he is unable to reach. All should progress upwards daily, and, when the last has reached the anatomical limit, the others gradually approach it till they coincide. A useful exercise has been devised by Robert Jones. He utilises an ordinary door instead of more elaborate apparatus. The three main positions in the exercise are illustrated in Figs, 100 - 102.
For shoulder and elbow alike various points on the clothing may take the place of the marks on the wall, and exercises with a stick or pole are very valuable. The pole is grasped during the early stages with the hands well apart; as recovery progresses they are approximated.
Exercises for rotation of forearm, of shoulder, or of both together, can be graduated by the use of an umbrella, a heavy stick, and pokers of various weights. The elbow may be held fixed against the side of the body or fully extended (see Figs. 70 and 71, pp. 139 and 140). All "halfway" positions should be prohibited. The weapon is grasped in its centre during the early stages; and, as strength increases the grasp shifts towards one end while the other projects further and further upwards. The exercise can be made more strenuous by slow performance, the duration of each movement from vertical to horizontal being regulated by counting. Where apparatus is available the first stage is to work at roller or rotator when no weight is attached, ever-increasing resistance being graduated by the use of additional weights. When the weight is fully wound up by the roller, an excellent exercise is to release the ratchet and to control the fall of the weight by friction exerted by the grasp.
Fig. 103. - An early exercise with the weight and pulley if the left hand is unable to grasp the handle.
To restore suppleness to the fingers nothing can replace natural use. The simplest way to accomplish this is to pad one of the handles of the weight and pulley with a duster till of sufficient size for the patient to grasp. If necessary the sound hand may assist by being placed over the injured member (see Fig. 103). The weight is then increased daily. As soon as this has assumed fair proportions, the weight is decreased during part of the time, the padding is diminished, and the injured hand works unassisted. As soon as the fingers can make any attempt at grasping the bare handle, ladder exercises are prescribed. It is wonderful at times to see a man, who has been unable to grasp anything for months, gradually tighten his grip on the rung of a ladder as his sound arm tires. Nature seems to prompt his maimed hand to work in order to relieve its fellow. No set exercise can be devised that will replace natural use, and no combination of exercises can equal in curative effect the use of a scythe or grass-shears for one whose grip is enfeebled. Grasping various-sized objects and trying to hide them from view in the palm is an excellent exercise, and reference must be made again to Tait Mackenzie's plan of taking up half a sheet of newspaper by its corner and gradually rolling it up into a ball in the palm of the hand.