Editor’s Note: Flashback is a new recurring feature in the newsletter that will take a quick look into the last century with a focus on rehabilitation developments from a MossRehab perspective.
Physical Medicine and Rehabilitation is a fast-growing specialty that is well respected in the medical community. It was not always viewed in that light and prior to the late 1940s; it was dismissed by most of the professional medical establishment.
Today, MossRehab treats more than 160,000 patients each year for injuries to the brain and spinal cord, and other neurological problems. It was nearly 80 years ago that the specialty of Physical Medicine and Rehabilitation (PM&R) began to treat musculoskeletal and neurological problems. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) was founded on September 12, 1938, as the Society of Physical Therapy Physicians, during the annual meeting of the American Congress of Physical Medicine at the Palmer House in Chicago. But it would take nearly a decade for the American Medical Association to recognize PM&R as a medical specialty.
One of the specialty’s true pioneers was Frank H. Krusen, MD. Having undergone treatment at a sanitarium after being diagnosed with tuberculosis, Dr. Krusen began studying the medical uses of a variety of physical agents used during his healing. Following that fork in the road soon led him to an exciting discipline that would develop into a notable career.
Widely regarded as the “father” of PM&R, Dr. Krusen helped establish the first department of PM&R at the Mayo Clinic in 1936. He served as the president of the AAPM&R from 1941 through 1942. He also founded a physical medicine department at Temple University in Philadelphia in 1928 and returned there in 1963 to expand the facilities.
Dr. Krusen went on to become professor of physical medicine at Tufts University Medical School. While he was there, the Association of Academic Physiatrists (AAP) came into existence in 1967. Dr. Krusen retired in 1969 after receiving the Eisenhower Medal for outstanding contributions to international understanding. He died in September of 1973. At about the time of his death, MossRehab, in collaboration with Temple University Hospital, began a comprehensive program to train physiatrists in Philadelphia. Today, the Temple/MossRehab Residency Training Program continues to produce many respected practitioners.
A champion for people with disabilities
During the 1960s and 1970s, MossRehab became a champion for people with disabilities and an active supporter of community outreach programs. MossRehab also introduced its Driving Program for disabled individuals in the 1970s. It remains one the longest running programs of its kind in the country, serving more than 1,000 people each year.
In the early 1970s, two programs located at MossRehab and funded by federal grants were introduced: the Rehabilitation Engineering Center and the Rehabilitation Education Center. These two programs introduced a wide variety of progressive ideas.
The Rehabilitation Engineering Center was a collaborative effort between Temple University, Drexel University and MossRehab. It was based within the MossRehab facilities for ten years until 1982. The Center promoted the idea of interdisciplinary teams. Scientists worked with engineers and clinicians to solve problems for people with physical disabilities.
There were many new ideas and developments to come out of the centers during those years. The Engineering Center brought the study of walking into a laboratory. Two of the earliest clinical research gait labs were located in the United States. Rancho Los Amigos Hospital in California focused on orthopedics and the MossRehab laboratory concentrated on rehabilitation. The scientists at MossRehab began research on human gait in an effort to understand pathological walking.
Although today there may be more than 200 gait labs worldwide, the MossRehab gait lab was a pioneer in research and understanding how a person walks. A variety of breakthroughs and inventions came out of this dynamic lab: the force-line visualization system, the electronic gait mat, and a variety of assessment tools for measuring muscle activity (dynamic EMG) and the limb load monitor.
One of the early examples of rehabilitation ingenuity to come out of the gait lab was centered on a design to monitor weight bearing and function. Known as the Limb Load Monitor, this device allowed a therapist to gauge how much weight a patient exerted on their leg. This technology soon became accepted as an ideal tool for clinical use worldwide.
Scientists at the lab during this period also developed a variety of biofeedback devices, such as the electrogoniometer, which measures the amount of movement in a particular joint, and the electromyography box, which provides auditory feedback of muscles during activity.
Ahead of the Field
What may be viewed as very simple devices and standards of care today were years ahead of their time when developed by MossRehab in the 1960s and 1970s. Another example of this type of technology is the force-line visualization system that was first introduced at MossRehab in the late 1970s by T.M. Cook.
This real-time system featured a force plate and a laser beam, in conjunction with a video camera and a beam splitter. It provided the clinician with an image that offered, for the first time, reliable- quantitative data for aligning braces and prostheses. It allowed a clinician to see changes in a patient's walking and to analyze the performance at each stage of the stance phase of gait. Gait abnormalities became easier to spot and adjustments to braces and prostheses could be made and evaluated more quickly.
Wooden Limbs to Ultra-Light Plastics
Until the mid-1970s, nearly all of the available lower limb prosthetic devices were made from wood. MossRehab scientists A. Bennett Wilson and Melvin Stills led a group of colleagues on a project that advanced the idea of an ultra-lightweight, below-the-knee prosthesis using thermo-plastics. They began working with polypropylene, which came in sheets that became malleable when heated. They used these sheets to create an outer shell of strong, but light material.
Their original design featured a hollow polypropylene foot with a heel wedge. This reduced the weight of the prosthesis significantly. Although a major development, the process was later eclipsed by lightweight metal alloy limbs that were much simpler to fabricate.
In addition to being the first place to use thermoplastic materials to develop an ultra light prosthesis, the MossRehab Engineering Center also reengineered leg braces traditionally made of stainless steel or aluminum and leather to incorporate plastics. Not only lighter, plastic made the braces more comfortable, easier to wear, and more cosmetic without sacrificing strength.
Capitalizing on Collaboration
A partnership between MossRehab scientists and Philco/Ford engineers resulted in the development of the first upper limb prosthesis that used multiple electrodes in the amputated arm to control a multi-jointed limb with an elbow, wrist and hook.
This development has paved the way for subsequent advances in myoelectric prosthesis and current developments funded by the Defense Advanced Research Projects Agency (DARPA) in centers across the country.
In collaboration with Drexel University engineers, MossRehab scientists Gordon Moskowitz, PhD and William Freedman, PhD introduced the first powered knee joint for people who had lost a leg above the knee. Myoelectric controls use signals from the muscles in the leg to determine movement. This innovation triggered the development of all the subsequent active knees in the market today.
MossRehab scientists discovered how to use the least number of muscle sensors around the thigh to predict which direction the artificial leg would move—either into extension or flexion. This process, now commonly known as “pattern recognition,” was a very innovative technique in the 1970s and has become widely used and accepted today.