February 1953 JONES: Occupational Therapyfor Long Term Patients in Bed 79

urine sodium and potassium by means of a flamephotometer.

BIBLIOGRAPHYARNOLD, W. P. (195I), New Eng. J. Med., 245, 331.DOCK, W. (1946), Trans. Assoc. Amer. Phys., 59, 282.DOCK, W., and FRANK, N. R. (1950), Amer. Heart J., 40, 638.EMERSON, K., and BECKMAN, W. W. (I945), J. din. Invest.,

24, 564.EMERSON, K., KAHN, S. S., VESTER, J. W., NELSON,

K. D. (I95I), Arch. Int. Med., 88, 605.FRIEDMAN, I. S., ZUCKERMAN, S., and COHN, T. D.

(I95I), Amer. J. Med. Sci., 22I, 672.FRIEDMAN, I. S. (1952), Arch. Int. Med., 89, 99.GREENBLATT, I. J., and GILWOOD, M; E. (1948), quoted by

Emerson et al.GREENMAN, L., PETERS, J. H., MATEER, F. M., WEIGAND,

F. A., WILKINS, D., TARAIL, R., RHODES, G., andDANOWSKI, T. S. (I951), 7. clin. Invest., 30, 995.

IRWIN, L., BERGER, E. Y., ROSENBERG, B., and JACKEN-THAL, R. (I949), J. clin. Invest., 28, I403.

KLINGENSMITH, W. C., and ELKINTON, J. R. (I952),Circulation, 5, 842.

LIPPMAN, R. W. (I95I), Arch. Int. Med., 88, 9.McCHESNEY, E. W., DOCK, W., and TAINTER, M. L. (I95s),

Medicine, 30, I83.MARKS, J. A. (1949), Rev. Gastroenterol., I6, 82.MARTZ, B. L., KOHLSTAEDT, K. G., and HELMER, O. M.

(I952), Circulation, 5, 524.MATEER, F. M., ERHARD, L. H., PRICE, M., WEIGAND,

F. A., PETERS,. J. H., DANOWSKI, T. S., TARAIL, R.,GREENMAN, L. (x95I), J. clin. Invest., 30, ioi8.

NACHOD, F. C. (I949), ' Ion Exchange: Theory and Application,'New York Academic Press.

PAGE, I. H. (I95I), J. Amer. Med. Ass., x47, I3II.PAYNE, W. W., and WILKINSON, R. H. (i95i), Lancet, ii, Iox.SALVESEN, H. A., and LINDER, G. C. (I923), J. biol. Chem.,

58, 617.THOMPSON, H. S. (I850), J. Roy. Agr. Soc., England, II, 68.WAY, J. T. (i850), Ibid., II, 3I3.

OCCUPATIONAL THERAPY FORLONG TERM PATIENTS IN BED

By MARY S. JONES, M.C.S.P., M.A.O.T.Senior Occupational Therapist; Slough Industrial Health Service; Farnham Park Recuperative Home

Aims of TreatmentProlonged rest in bed is sometimes prescribed

for patients as a form of treatment, in the hopethat the condition needing this treatment willeventually be cured or arrested, and that thepatient will return to the outside world with aslittle residual disability as possible. To ensurethis, medical and surgical treatment must beaccompanied by a programme of occupationwhich will maintain the patient's physical capaci-ties as far as may be compatible with the pre-scribed position of decubitus, and which willincrease the mental capacity to the uttermost tomake up for limitations which may be set byphysical disability. The patient must be kepthappy and contented so that as far as possiblenervous strain may be avoided and, at the sametime, ambition fostered so that the patient will beprepared and eager to undertake the responsibilitiesof normal life.

Anxieties for Future EmploymentAnxiety about earning a livelihood in-the future

is often considerable and adds to the nervousstrain of a period of forced inaction, making apatient restless and miserable. In prescribing

occupational therapy for these people the surgeonor physician should indicate the probable periodof incapacity -and give some prognosis of the-degree of physical disability expected. Then, inconsultation with the almoner, some tentativeplans can be considered by the patient for hisfuture employment. If his previous work isobviously not going to be suitable and retrainingfor another will be necessary, the programme ofoccupation should be planned to include somepreparation for the chosen training. If a patientis shown that he can use the period of physicalinaction to good effect and begin at once to pre-pare himself for a new job, he will be more likelyto settle down without excessive fretting and hewill be in a better frame of mind to receive medicalor surgical treatment.

Preparatory Training for EmploymentIt may be obvious that a carpenter or brick-

layer with spinal caries will not be able to go backto'his' old job. But this man will appreciate thata sound knowledge of woodwork or bricklayingwould be useful to a builder's clerk. He maytherefore be persuaded to embark on a corres-pondence course in bookkeeping which will be

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February 1953 JONES: Occupational Therapy for Long Term Patients in Bed

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FIG. I.-A man of 50, a gardener, making parts for' Walkie Talkie' wireless sets.

a valuable foundation for his future training. Hisanxieties will be allayed and his mind occupiedwith plans for the future rather than regrets forthe past. In some courses provided at Govern-ment Training Centres a considerable amount oftime has to be spent in teaching the traineessimple mathematics and mechanical drawing.One; patient, who had been a window cleanerbefore a fall had left him paraplegic, said that thisstudy was the most trying part-of his training inwatch and clock repairing. He was naturally aneat-fingered man, who found practical work easy.If he had started doing some of the study whilsthe was a patient in bed he would have savedmuch time both for himself and other trainees.Some start in training can be made in hospital(Guttman, I946).The British Council of Rehabilitation set up

a Preparatory Training Bureau in 1947 to giveadvice and assistance in arranging correspondencecourses for patients requiring the basic educationneeded for various types of retraining, or to enablestudents to pursue studies interrupted by illness.It is a great help if some personal coaching canbe arranged in conjunction with the corres-pondence course. This will keep up the earlyinterest and enthusiasm which without encourage-ment may easily flag, and will give opportunityfor discussion and explanation of a knotty point.Children kept in hospital for a long time haveschool teachers who are trained to cope with their

educational needs (Education Act, I944, I948).But unless special arrangements are made withthe local education authorities, for which thereare permissive powers, the adult long-term patientis dependent on the correspondence course alone(Ministry of Health, I945; Ministry of Education,i945; Ministry of Labour, I949).For the patient who has not the intellectual

capacity to undertake a study course, some othertypes of occupation must be found which willreassure him about his future. For these peoplesome form of industrial work will be more satis-factory (Ministry of Health, I943). The agricul-tural labourer who has had rheumatoid arthritis,or a severe pulmonary affection, may not be ableto return to heavy work, out of doors in allweathers. Some factory assembly work may bethe only thing that he will be able to do. If simplework of this kind can be given him whilst he isin bed he gets into the habit of doing repetitionwork and if, at the same time, he can earn even asmall amount, he learns the value of accuracy andregularity of production. He will gain con-fidence in his capacity to earn his living in thisway when he is again fit to go out to work. Duringthe last war, work of this sort was easily obtainable(Jones, I95I). The accompanying photograph(Fig. I) shows a patient, a man of 50, who hadbeen a gardener until he got a tubercular hip.He assembled 4,500 small units of different typesfor army wireless sets. He never had a single one

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82 POSTGRADUATE MEDICAL JOURNAL February I953

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rejected by the factory. Other bed patients doingthis type of work were employed by the samefactory when they were up and fit enough totravel to work.

Recreations and HobbiesAs well as preparation for employment, some

provision must be made for leisure hours of thefuture, to replace previous activities which willno longer be possible. Handicrafts such- asmodelling, leatherwork, basketry, weaving, em-broidery, jewellery or flytying can be as easilycarried on in the recumbent position as in theupright, if suitable bed-tables with vices, and armsupports are provided. Hobbies such as photo-graphy can be continued by patients. Onepatient who spent eighteen months in a plasterboat made a superb collection of cloud photo-graphs. Painting and designing have beendeveloped for patients with pulmonary tuber-culosis (Hill, 1946). Many people will discover,with a little encouragement and teaching, thatthey have latent talents which will provide themwith much pleasure.Bed-Tables

Small movable vices can easily be fixed on toordinary bed-tables for patients who are allowedto sit up. In Fig. 2 the overhead bed-tables shownwere originally planned for the use of patientswith spinal caries treated in plaster boats (Jones,

I944). These bed-tables enabled patients to carry-through all the processes of their work, handicraft,reading or writing, without interfering with theprescribed position of the spine. Their handi-crafts and work provided them with a reasonableamount of activity, especially in the use of thelong back muscles to stabilize the shoulder-girdle. Also, by keeping their work or book atnormal eye level, the use of these bed-tablesprevented the eye strain which so commonlytroubles patients who are kept completely recum-bent for a long time.

Arm SupportsVarious spring arm supports which can be

adapted for patients in bed have also been evolved(Warren, I950; Jones, I950). The buoyancy ofthe spring seems to encourage the patient to startusing the deltoid, and to lift the arm from theside. It prevents trick movements such as usingtrapixius to shrug up the shoulder-girdle and thelumbar flexors of the opposite side to move thetrunk, and so get the hand into a useful position.The power of the support can gradually be re-duced from the 45 to 50 lb. spring needed by theheavy adult with little muscular power to the ioto 5 lb. spring which provides only moral support.Work with gradually increasing physical strain willbe valuable in toning up patients with cardiacconditions and ;nfantile paralysis, or after thoracicoperations when they may be unwilling to lift the

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February 1953 JONES: Occupational Therapyfor Long Term Patients in Bed 83

arm from the side for fear of pain when the scaris stretched. Apprehension of pain and the feelingof insecurity are often the cause of inco-ordinationof movement.

Social ActivitiesSo far the occupations suggested have stressed

the individuality of the patient and his interests.General sociability and communal interests shouldalso be encouraged if the patient is not to becomeself-centred and selfish. Concerts, gramophonerecitals, lectures, discussion groups and playreadings are of great value in getting patients in-bed to meet others than their immediate neigh-bours. Film shows and, in particular, newsreelswill help to keep them in touch with what is goingon in the outside world. Patients may be in-terested in making marionettes or puppets toform a hospital ' repertory theatre,' and in writingplays for them. Naturally the puppets wouldhave to be played by ambulant patients or mem-bers of the staff, but the making of the puppets,their dresses and stage properties give a verystrong communal interest to the project.Red Cross picture and book libraries have done

much to keep patients happy and contented.Red Cross workers have also been very helpful inservicing the travelling shop which is taken roundthe wards periodically. A trolley stocked withsuch things as toothpaste, hair shampoos, hairnets and combs, stamps, writing paper and so ongives the patients opportunity to buy things forthemselves instead of depending on the kindlynurse or visiting friend. Actually handling theirown money and being able to exercise somepower of personal choice helps to keep the patientsin contact with the outside world and its changingconditions.

Conditions of WorkIn children's wards of hospitals taking long-

term patients, there are not only teachers pro-vided but the ward routine is so arranged that theteachers can have the children's undisturbedattention for a reasonable period of time bothmorning and afternoon. This is, of course,requisite for their proper education. Similararrangements in all adult wards taking long-termpatients are essential. It is easy enough to arousea patient's interest in some form of study, indus-trial or handicraft work, but this interest will soonflag if he cannot count on adequate help andtuition, or if his attention is continually dis-tracted. Dressings, physiotherapy, visits fromthe doctor provide constant diversions, and it is

a strong-minded patient who can resist the gossipsubsequent to each and every incident of his ownor another patient's treatment. He soon beginsto make the plea that it is not worth starting to doanything because another interruption is im-minent and time is frittered away in waiting forsomething else to happen. The patient soonbecomes discouraged by the little he has to showfor a week's work.

It is ideal if wards taking long-term patients areprovided with a day room where patients aremoved for whatever period of time the medicalofficer in charge considers they are fit for work.Failing this, it is possible to screen off one end ofthe ward and move the long-term patients therefor a couple of hours in the morning, and thosewho do not need an afternoon sleep can stay therefor the afternoon session as well. Then thepatient can expect to do some undisturbed studyin the morning, and do their handicrafts in theafternoon, whilst the more sociable occupationsare arranged for the period after tea.

Such an arrangement gives the patient oppor-tunity to carry on the chosen work or study fora period of time sufficient not only to give resultsimmediately satisfying, but to maintain anddevelop the power of concentration which willbe an important factor in his future success inlife. The experience of some years working ina hospital taking long-term patients, and morerecently in a recuperative centre, has shown thatthe habit of keeping the mind on the job is easilylost and not so easily regained. For a long-termpatient the return to a full eight-hour day in office,shop or factory is a great test. The complaints offatigue have mostly come from those patientswho have shown little capacity for concentration.In hospital or reablement centre this side oftraining is much hampered by the customaryroutine and the many types of treatment whichcompete for the patient's attention.

It is now accepted as a truism that reablementshould begin as soon as possible after injury orthe onset of illness. It is also accepted that re-ablement should include both physical and mentaltraining. Not enough is known of the factorsthat affect the powers of concentration in adultlong-term patients. If we are to develop thesepowers, further study ought to be undertaken ofnecessary processes of training. Such researchmight prove rew:arding. If the patient can learnto keep his mind on the job in hand, whatever itmay be, the tirrte needed for reablement andretraining will be shortened, and he will moreeasily and more successfully find employment inthe competitive world to which he must return.

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84 POSTGRADUATE MEDICAL JOURNAL February I9

BIBLIOGRAPHYEducation Ac t, 194 e 48 (x95i), Summary of legislation and direc-

tory of ocganit. ions for the care of the physically handicapped,p. 42, Central Council for Care of Cripples. Hernemann,London.

GUTTMANN, L 1946), Brit. J. Phys. Med., 9, 6.HILL, A. (I946), 'Jirt versus Illness,' Williams & Norgate, London.JONES, M. S. (1944), Brit. J. Phys. Med., 7, I.JONES, M. S. (1950), Ibid., 13, II.JONES, M. S. (i95I), Lancet, ii, 7.Ministry of Education Circular 15 (I945), Educational provision

for civilian patients in hospitals and sanatoria.

Ministry of Health Circular EMS 34/344 (1943), Hospital patientsengaged in productive work.

Ministry of Health Circular 5/45 (I945), Educational provision forcivilian patients in hospitals and sanatoria.

Ministry of Labour ( 949), Second report of the Standing Committeeon the rehabilitation and resettlement of disabled persons,p. Io, D.37. H.M. Stationery Office. 36/176.

Preparatory Training Bureau, British Council for Rehabilitation,Tavistock House, Tavistock Square, London, W.C. I.

WARREN, M. W. (i95o), 'Geriatrics. Recent Advances inPhysical Medicine,' p. 321. Churchill London.

CLINICAL SECTION

GOITRE PLONGEANTBy J. N. HARRIS-JONES, M.D., M.R.C.P.

Senior Medical Registrar, Royal Hospital, Sheffeld

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