An injured limb can be made to work again by a programme of graded exercises to increase the range of joint movement and muscle power using weights, springs and other devices in the ward or gymnasium. Rehabilitation and the supervision of day-to-day progress are essential parts of orthopaedic treatment, but only part of the physiotherapist’s role; a good physiotherapist will also build up the patient’s morale to achieve goals previously thought impossible.

Muscles can be made to contract by applying an intermittent current (faradic stimulation or ‘faradism’) if the patient is unable to contract the muscle voluntarily. Faradism will not work if muscle is denervated, although interrupted direct current and other types of electrotherapy are effective.

Physiotherapists also manipulate the spine and other joints when necessary.

Remedial gymnastics, which once required a separate qualification from physiotherapy, takes the physical rehabilitation of the patient further than routine physiotherapy and is helpful to the young patient with physical or sporting ambitions.

The popular concept of occupational therapy is centred on handicrafts such as raffia and wickerwork, but this has little in common with modern occupational therapy, which concentrates on rehabilitating the patient through tasks relevant to work and everyday activities.

Occupational therapy departments include a small kitchen, a bath and a lavatory so that problems can be overcome before the patient leaves hospital, rather than after discharge when there is no help available. The department may also include a small printing press, so that patients can regain fine finger movement while they set type, and a treadle-operated woodworking machine to improve the coordination and strength of the legs, as well as the manual skills of carpentry. Apart from encouraging physical coordination, to produce something useful is tangible evidence of recovery and excellent for morale.

Occupational therapists also provide special cutlery for patients with hand deformities, ‘pickups’ for those who cannot bend and simple gadgets to help with dressing and other activities of daily living (Fig. 6.1).

Chiropractors and osteopaths practise manipulation with great skill but do very little else, and generally work outside the hospital system. ‘Manipulative medicine’ is only one component of physiotherapy and is best conducted where there is access to other forms of treatment.

Surgical appliances include splints and braces to support limbs, prostheses to replace absent parts of the body, surgical shoes and spinal supports. Appliances are expensive, although economical by comparison with hospital admission.

Many patients have been helped more by social services or modifications to their home than by hospital treatment. Elderly patients unable to fend for themselves may need a home help to assist with housework and shopping rather than a total hip replacement, and the insuperable problem of climbing stairs can sometimes be solved by fitting a stout handrail.

These aspects of patient care cannot be ignored just because they happen outside hospital.

Warden-controlled accommodation is suitable for many elderly or infirm patients and allows them to live an independent existence in a home of their own. As the age of the population increases, small developments of single-storey accommodation designed specifically for the elderly are seen more often.

Those who cannot cope with warden-controlled accommodation need long-term residential care. Such accommodation may be provided either by local authorities or by private individuals but is under great pressure and the level of care offered is very variable.

If a patient is to be cared for by the family it is important to consider before discharge the impact such arrangements will have upon the rest of the family. Home visits from social workers, occupational therapists and the local health visitor are very helpful.

Patients who cannot be restored to their former work need to be resettled or retrained. A man engaged in heavy manual work and unable to lift after a back injury must find another job; a builder’s labourer with a stiff foot needs work that does not involve walking over rough ground. These problems commonly occur in patients with little academic aptitude and the selection of a new job can be difficult.

Advising a patient to give up his or her work and undergo retraining involves a great deal of thought and sympathetic assessment to determine the patient’s own particular skills (Fig. 6.13). This is best done in a resettlement or retraining centre, contacted through the local Disablement Resettlement Officer. It is not uncommon to find that a resettled patient can earn more in the new job and enjoys it better. On the other hand, ‘outdoor people’ are always unhappy at the prospect of working indoors, seated at a bench doing repetitive manual tasks, and need much encouragement.

Rehabilitation of the severely injured patient requires a coordinated approach and a sense of direction, which is missing when the patient is an outpatient receiving a little physiotherapy here and some occupational therapy there while they wait their turn for industrial retraining. Combining all these facilities under one roof, where patients receive more concentrated and continuous treatment than an ordinary hospital can offer, makes the task of rehabilitation a full-time occupation. This can achieve results not possible if patients are at home dwelling on their problems.

Non-steroidal anti-inflammatory drugs are used for the conservative management of joint disease. Many such drugs are available and there is little to choose between them, but patients often do not react predictably. One patient may be completely relieved by a drug that has no effect on a patient with the same condition, and several may have to be tried before finding one that ‘suits’ the individual.