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CHAPTER 33
the chest more fully from the lower lobes. In this connection the Stoke Mandeville-
Egerton turning and tilting bed greatly facilitates the work of the physiotherapist.
In order to improve the function of the diaphragm in cervical lesions, the physio
therapist must fix the diaphragm with her hands by applying pressure during expiration,
in order to compensate for the loss of abdominal muscles which normally, by their resist
ance, facilitate the action of the diaphragm. As the physiotherapist places her hands over
the lower lobe and on the lower chest wall, the patient takes a deep breath in, and, as he
breathes out with forced expiration, the physiotherapist vibrates the chest wall, giving
maximal pressure at the end of each expiration. After this has been repeated several times,
the physiotherapist then tells the patient to breathe out as far as possible and then to
cough, trying at the same time to expectorate the loose mucus from his chest. As he
coughs, she slides her hands down from the lower rib cage, so that she can give pressure
over the upper part of the abdomen, in order to replace the function of the paralysed
abdominal muscles. It may be noted that, in transverse lesions of the cervical and upper
thoracic cord, although the intercostal muscles are completely paralysed, their tone
recovers to some extent, in later stages, and, once the spinal cord below the level of the
lesion regains its automatic function, these muscles may become active by reflex action
and participate in the act of respiration (see Chapter on Respiratory Complications).
In addition to the technique of facilitating expiration and preventing congestion of
the lung, the physiotherapist's important task is to mobilize, exercise and overdevelop
the auxiliary respiratory muscles, in particular sternomastoid, trapezius, levator scapulae,
platysma and scaleni to improve the upward movement of the chest and thus increase
the antero-posterior diameter of the chest. The patient has to be encouraged to carry
out these exercises as often as possible during the day.
Glossopharyngeal breathing, also called 'frog' breathing or 'gulping' has been used
as a substitute for breathing in high cervical lesions due to poliomyelitis, in which there
is a paralysis or weakness not only of intercostals and diaphragm but also of the levator
scapulae and trapezius. It makes use of the function of the mouth and throat muscles to
act as a pump, to force air into the lungs. A special technique of this type of breathing
has been described by Clarence W.Dail (1951). However, this technique is now rarely
used, as it is replaced in these high lesions by tracheostomy.
The physiotherapist has also important functions in the management of the tetra-
plegic after a tracheostomy has been performed and, like the nursing staff, must, there
fore, be familiar with the technique of the respirator and the suction technique through
the tracheostomy tube. The danger of vigorous and excessive suction causing adverse
vagal and vasomotor reflexes resulting even in heart arrest has already been mentioned
(see Chapter on Respiratory Complications).
Sudden respiratory and heart arrest may occur during the execution of passive
movements of the paralysed legs or during the turning procedure of the patient, caused
by an embolus. Therefore, the physiotherapist, like the nursing staff, must be familiar
with the technique of artificial respiration, which she must commence without delay and
continue until members of the nursing and medical staff arrive on the scene. It has been
the vigilance and immediate action of some of our physiotherapists which saved the
life of such patients (see page 179).
