IEEE PULSE presents

Physical Rehabilitation: A Historical Look

Retrospectroscope November/December 2019

Medicine aims toward restoring, maintaining, and improving human health, and engineering aims toward restoring, maintaining and improving human wellness. Both disciplines apply knowledge from science and technology at large to accomplish such objectives. Bioengineering, also called biomedical engineering, is defined as the application of engineering principles and techniques to problems in medicine and biology (always with restoration, maintenance, and improvement in mind), which now also includes veterinary medicine, and the environment in general.
Rehabilitation after any given health event is part of restoration, in human and in veterinary medicine. This article will restrict itself to rehabilitation of patients in medical practice. Several are the origins — the etiology—of the totally or partially incapacitating human events. Without being exhaustive let us try to offer a tentative list:

  • loss of an extremity by a traumatic accident or lack by birth (amputees);
  • loss of an extremity partial function, either by accident or by birth;
  • loss of hearing, vision or speech, either by accident or by birth;
  • brain or spinal injuries, cerebral stroke, cerebral birth defects; and
  • any surgical procedure requires a certain recovering or rehabilitation period.

There are two websites that can be suggested as good sources regarding the last century development of the concept of health rehabilitation in the United States. None the less, they do not deal with developments in other countries nor in previous time periods [1], [2].

Ancient attempts

The evolution of limb prosthetics (from Greek, “addition,” i.e., pros = to, thesis = a placing), perhaps the first and obvious self-evident rehabilitation need, holds a long history, from very primitive beginnings to its sophisticated present, and many promising future visions. The long and difficult road, starting with peg legs and hand hooks (as those frequently pictured pirates) to the myoelectric or neuroelectric extremities, began about in 1500 BC, and has been evolving ever since. To appreciate how far the field has come, we must first look to ancient Egypt. Those, shall we say, physicians-biomechanical engineers, were, no doubt, early pioneers of prosthetic technology, having produced limbs of fiber and also the first prosthetic toe, as found in a mummy. The toe, now at the Cairo Museum, was found in 2000 in a tomb near the ancient city of Thebes. Archaeologists speculated the 50–60-year-old woman the prosthesis came from might have lost her toe due to diabetes complications. The wood and leather prosthesis dates from 1069 to 664 BC. Centuries after, an artificial leg dating to about 300 BC was unearthed at Capua, Italy, in 1858. It was made of bronze and iron with a wooden core, apparently for a below-knee amputee. Later on, the Roman scholar Pliny the Elder (23–79 AD) wrote of a Roman general in the Second Punic War (218–210 BC) who had an iron hand fashioned to hold his shield and was able to return to battle.

Dark ages and thereafter

The Dark Ages (approximately 476–1400 AD) saw little advancement in prosthetics other than the already-mentioned hand hook and peg leg. Most pieces were made to hide deformities or injuries sustained in battle. The next period, the Renaissance (1400–1800 AD), brought about new perspectives in science and arts without forgetting the medical discoveries of the Greeks and Romans, so that a rebirth in the development of prosthetic devices was fostered, which mostly amounted to pieces made of iron, steel, copper, and wood. In 1508, we find for example the German mercenary Gottfried (Götz) von Berlichingen (ca. 1480 1562), nicknamed Iron Hand (in German, eisernen Hand ), after having had a relatively advanced prosthesis, implemented with springs and leather straps, because he had lost his right arm in battle. Those were the years of the French Army surgeon Ambroise Paré (1510–1590), perhaps the father of modern amputation surgery and prosthetic design. He introduced modern amputation procedures in 1529 and made prostheses in 1536 for upper and lower extremities. His contributions showed the first true understanding of how prosthesis should function [3].
In 1696, the Dutch surgeon Pieter Adriaanszoon Verduyn, or Petri Hadriani F. Verduin (ca. 1625–1700), developed the first below-knee prosthetic that allowed for knee movement. He published a monograph which can be freely accessed [4]. Figure 1 displays the front cover of Verduyn’s book; such monograph carries also a picture of his prosthesis (Figure 2). Quite a time span passed until in 1800, James Potts of Chelsea (birth-death dates could not be found), designed a prosthesis made of a wooden shank and socket, a steel knee joint and an articulated foot that was patented as the Anglesey Leg, after the 1st Marquess of Anglesey, Henry William Paget (1768–1854), who lost his leg in the Battle of Waterloo. This leg prosthesis was commercially advertised until 1914. William Selpho of New York brought it to the United States in 1839, where it was known as the “Selpho Leg,” and later patented (U.S. Patent 18021A, 18 August 1857).

The 19th and early 20th century

As the United States Civil War (1861–1865) progressed, the number of amputations rose enormously, leading many people in the country to get into the field of prosthetics. For example, James Edward Hanger (1843–1919), a very young engineering student and one of the first amputees of the War, developed what he later patented as the “Hanger Limb” (U.S. Patent N 155, 23 March 1863), and founded a still-existing prosthesis enterprise. An amazing and moving example of how a dreadful event may spur a human mind to overcome it and even to make something useful from it [5].

Figure 1. Front cover of Verduin’s Monograph where his leg prosthesis was described.
(With permission from info@europeana.eu.)

Other improvements were introduced in the prosthetic field during the second half of the 19th century, but nothing really significant or revolutionary, until in 1912 André Marcel Desoutter (1894–1952), a well-known English aviator, lost his leg in an airplane accident, and made the first aluminum prosthesis with the help of his brother Charles, an engineer.
Unlike the Civil War, World War I did not foster much advancement in the field. Despite the lack of technological advances, the Surgeon General of the Army at the time realized the importance of the discussion of technology and development of prostheses; this eventually led to the formation of the American Orthotic & Prosthetic Association (AOPA).

Figure 2. Verduin’s leg prosthesis, as shown in his 1696 monograph.
(see https://www.hathitrust.org/access_use#pdgoogle).

In addition to lighter and better devices, the advent of microprocessors, computer chips, and robotics in the second half of the 20th century and beginning of the 21st brought significant advances to the amputees’ lifestyles [6]–[9].

The 20th century

The first and second references [1], [2] concentrate on the contributions to physical medicine and rehabilitation within the United States, fields that were heavily promoted by the tremendous needs of wounded soldiers from the World Wars (1914–1918; 1939–1945). Physiatrist derives from Greek physis, related to physical phenomena, and iatreia, referring to healer. Thus, the physiatrist is a physician who employs physical agents.
In 1917 Major Frank B. Granger, of the Medical Corps, was appointed the Director of the army physiotherapy service. Reconstruction units were set up in several hospitals throughout the United States. In them, graded exercises were prescribed aiming at rehabilitating injured soldiers. Physicians who practiced physical therapy in the 1920s fostered the field, which strangely enough, was much helped by radiologists. By 1938, the Archives of Physical Therapy were separated from a journal shared with the radiology group; in 1945, the journal became Archives of Physical Medicine, and later, it became the Archives of Physical Medicine and Rehabilitation. The field of physiatry developed rapidly in response to social and medical needs.
During World War II several events plus the drive of a philanthropist, Bernard Baruch, pushed forward physical medicine through awarding funds to develop programs at selected universities. During this time, in 1945, a section on Physical Medicine and Rehabilitation was established in the American Medical Association (AMA).
Another institution from the U.S. is the Burke Rehabilitation Center in New York City [2]. It opened its doors in April of 1915, through the support of John Masterson Burke. Its influence on the field of medical rehabilitation was significant and long lasting. The vast number and variety of injuries suffered led to increased emphasis on physical and occupational therapies, improvements to prosthetic limbs and wheelchairs, and the development of community services. In 1951, it formally became a hospital [10].

Discussion

We have mostly referred to amputees and the prostheses developed in the rehabilitation saga. With new devices, such as exoskeletons and artificial hands, arms and legs driven by voluntary action potentials are bringing back almost to a rather normal life a growing number of people that have experienced accidents. However, the rehabilitation concept, as briefly outlined at the beginning, much exceeds the biomechanical area.
Very recently, significant reports have opened new hopes for a better life in cases of severe spinal injury. Electrochemical neuromodulation therapies, robot assisted rehabilitation and willpower-based training paradigms restored supraspinal control of locomotion in rodent models of severe spinal cord injury. This treatment promoted extensive and ubiquitous remodeling of spared circuits and residual neural pathways. In four chronic paraplegic individuals, electrical neuromodulation of the spinal cord resulted in the immediate recovery of voluntary leg movements, suggesting that the therapeutic concepts developed in rodent models may also apply to humans. The referred to paper briefly reviews previous work, summarizes current developments, and highlights impediments to translate these interventions into medical practice to improve functional recovery of this kind of patients [11].
While this article offers an incomplete and rather biased historical account of the rehabilitation concept, current research is diving deeper into multiple aspects of rehabilitation. Out of the list suggested at the beginning of the article, an example of the second disability (partial function loss either by accident or by birth), we can mention a relatively recent contribution by López et al. [12]. The rehabilitation area is full of possibilities reaching the psychological field, too. New therapies have the potential to offer patients the opportunity to significantly contribute to society and to themselves, building on the historical framework of attempts to restore, maintain, and improve human wellness.

References

  1. Medical College of Wisconsin, “History of physical medicine and rehabilitation.” Dec. 12, 2014. [Online]. Available: https://www.mcw.edu/departments/physicalmedicine- and-rehabilitation/about-us
  2. Burke Rehabilitation Center, “The history of Burke.” [Online]. Available: http://www.burke.org/rehab/ about/history
  3. J. Goldberg, “On Paré and prosthetics,” nyamhistorymed, Dec. 19, 2014. [Online]. Available: http://nyamcenterforhistory.org/tag/pieteradriaanszoon-
    verduyn/
  4. P. A. Verduyn, “Dissertatio epistolaris de nova artuum decurtandorum ratione,” Amsterdam, The Netherlands: Joannem Wolters, 1696. [Online]. Available: http://babel.hathitrust.org/cgi/pt?id=ucm.5309453529;view=1up;seq=1
  5. “The J.E. Hanger story,” 2015. [Online]. Available: http://www.hanger.com/history/Pages/The-J.E.- Hanger-Story.aspx
  6. K. M. Norton, “A brief history of prosthetics,” In Motion, vol. 17, no. 7, Nov./Dec. 2007. [Online]. Available: http://www.amputee-coalition.org/inmotion/nov_
    dec_07/history_prosthetics.html
  7. C. Q. Choi, “World’s first prosthetic: Egyptian mummy’s fake toe,” Live Sci., Jul. 27, 2007. [Online]. Available: http://www.livescience.com/4555-world prostheticegyptian-mummy-fake-toe.html
  8. [Online]. Available: www.univie.ac.at/cga/history/prosthetics.html
  9. [Online]. Available: www.uihealthcare.com/depts/medmuseum/wallexhibits/body/histofpros/histofpros.html
  10. J. L. Opitz et al., “The history of physical medicine and rehabilitation as recorded in the diary of Dr. Frank Krusen: Part 1. Gathering momentum (the years before 1942),” Arch. Phys. Med. Rehabil., vol. 78, no. 4, pp. 442–445, 1997.
  11. R. van den Brand et al., “Neuroprosthetic technologies to augment the impact of neurorehabilitation after spinal cord injury,” Ann. Phys. Rehabil. Med., vol. 58, no. 4, pp. 232–237, Sep. 2015. [Online]. Available: http://dx.doi.org/10.1016/j.rehab.2015.04.003
  12. N. M. López et al., “Customized device for pediatric upper limb rehabilitation in obstetric brachial palsy,”
    Amer. J. Phys. Med. Rehabil., vol. 92, pp. 1–4, 2013.

Related Articles