special communication
JOSEPH M. BREUER, MA
n January 1974, I left the United States for Japan, partly to familiarize our Japanese partners with American rehabilita tion concepts and instrumentation and partly to learn as much as I could firsthand about physical therapy and rehabilitation in Japan. Since then, I have had occasion to live in, and travel throughout, the main islands and to visit and lecture at physical therapy schools and university-affiliated hospitals and reha bilitation centers. My purpose is to share some of my impres sions with the readers of the Journal. The high degree of industrialization in modern Japan has resulted, at least out wardly, in what is commonly considered "westernization." This westernization defi nitely applies to construction of hospital and rehabilitation centers, but with some signifi cant variations. Many homes, however, are "eastern" style: when one enters the house, shoes are ex changed for slippers; a high (30- to 40-cm) step or stoop has to be ascended and, in the living room area, slippers are removed and one sits on tatami mats and cushions on the floor. Men usually sit with legs crossed and knees close to the ground; women sit on their heels with ankles in maximum plantar flexion and knees in maximum flexion. Toilets are on floor level and require a squatting position. Mr. Breuer is Director, Technical Services, J. A. Preston Corporation, 71 Fifth Ave, New York, NY 1003, and Man ager, Technical Services and Training, Inabata-Preston Co. Ltd, Tokyo, Japan.
564
This style of living, of course, is totally unsuited to the use of wheelchairs, braces, crutches, or even shoes. Rehabilitation units, therefore, have to provide training in activi ties of daily living for western as well as eas tern styles of living. Further, the Japanese traditionally bathe before dinner. To bathe, one squats on a low (10-cm) stool, soaps, and thoroughly rinses oneself. Then one submerges in the tub. Tubs are higher and shorter than ours so knees and hips remain in flexion and water covers the shoulders. For the physically handi capped, bathtub transfer and use present functional problems different from those in the United States. To meet the rehabilitation needs of the Jap anese health-seeking public, Japan today has slightly over 1,000 physical therapists, many of them still under the "grandfather clause," having originally been blind masseurs. Ap proximately 400 to 500 occupational thera pists are now practicing in Japan. Eleven rehabilitation schools now graduate physical therapists, and four of these schools also graduate occupational therapists. The threeyear curriculum is not on the university or college level. The curriculum seems to have been copied fairly faithfully from American and English schools. That does not mean, however, that the teaching and demonstrations are neces sarily equivalent. My impression would be that they are not. The impression I gathered was that many physical and occupational therapists are mainly interested in the techniPHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/5/564/4568248 by Washington University in St. Louis user on 21 February 2019
Comments on Rehabilitation in Japan
Volume 56 / Number 5, May 1976
rists have no equivalent in the Japanese med ical system. Rarely have the orthopedic surgeons who are experts in rehabilitation medicine come into this field entirely by their own choice. They are assigned to rehabilitation medicine by their superiors who are senior professors in the university hospitals. Frequently, when these assignments take place, these physi cians are sent abroad to study for two or more years, or else somebody in the institution who has already been abroad to study may teach rehabilitation concepts in the facility. Not only physicians but also some of the out standing therapists have been sent abroad to study, usually to the United States. Concepts and methods of practice of rehabilitation in Japan today are essentially imported from the United States. In the last few years, many standard textbooks used in the United States have been translated into Japanese, some times in abbreviated versions. In most instances, ample space is provided for rehabilitation services. Most of this space is usually allocated to physical therapy, re search (if any), and occupational therapy, in that order. One-half of all rehabilitation space is customarily allocated to hydrotherapy (as is one-half of the equipment budget). Speech therapy is virtually nonexistent; social service is at a relatively underdeveloped level. Hydrotherapy equipment, in most in stances, consists of a therapeutic pool with some sort of electric or mechanical hoisting device and usually at least one, but more often two, whirlpools such as a Hubbard tank. A different delivery system is used since overhead devices are not suitable because of building construction which is geared to fre quent earthquakes. A standard tank contains a hydraulic or electrical device which lifts the matting from a lower to a higher position so that the patient is placed on top of the under water plinth and is then lowered mechanically or electrically into the water. The patient is transferred to this plinth by a special stretcher having a horizontally mova ble extending surface. This stretcher fits into grooves on the tank, and, after the patient is moved horizontally away from the stretcher and over the plinth which is in the tank, that part of the stretcher on which the patient is
565
Downloaded from https://academic.oup.com/ptj/article-abstract/56/5/564/4568248 by Washington University in St. Louis user on 21 February 2019
cal aspect of their field— how to apply what technique for which condition. Schools of rehabilitation generally employ English-speaking teachers from the United States, Canada, and Australia. These teach ers, as a rule, are good therapists who have had some experience in their field, but only a few of them have actually any teaching expe rience. None of them, when they first come to Japan, have any real concepts or ideas of the special problems which Japanese living con ditions and Japanese traditions impose for rehabilitation. Language difficulties present another problem to the English-speaking teachers. The teachers are told by school directors not to worry about the language difficulties be cause the students' responsibility is to under stand and to learn. The teacher's responsibil ity is merely to teach. Although English is taught in Japanese high schools as a second language, the Japanese student in physical therapy is not prepared to understand enough English to follow sophisticated con cepts and lectures. Although medical schools in the vicinity usually provide some medical staff as instruc tors, the facts that no university degrees are awarded and no university entrance examina tions are required before students are admit ted to the rehabilitation school tend to down grade the entire field in the Japanese educa tional system. The teachers in these schools also encounter problems because the medi cal staff may be unwilling to teach classes of students who will not graduate from universi ties. Japanese hospitals are classified as public (self-defense force, labor accident, national, prefectural, municipal) and proprietary, either owned by individual physicians or groups of physicians. Private practice as we know it is virtually nonexistent, both for physicians and physical therapists. Usually, but not always, rehabilitation de partments in hospitals or rehabilitation hospi tals are under the direction of an orthopedic surgeon. In rare instances, physicians in charge of such departments or hospitals who have studied in the United States or other parts of the western world have become diplomates of rehabilitation medicine. Physiat-
566
patient and helps with his rehabilitation until he is ready to go home as a fully functioning member of the family. This system, so radically different from our concept of getting the patient out of the hos pital and home as soon as possible, becomes logical only when two factors are considered. First, the average Japanese home is totally unsuited to rehabilitation of patients needing such aids as wheelchairs, braces, and crutches because of the tatami mats. Also, in the normal Japanese household, the whole family lives, sleeps, and eats in one room. The presence of a disabled person under these crowded conditions can become difficult. The bathroom presents problems because of the difficulty disabled patients have in squat ting over a toilet instead of sitting on a toilet seat. Also, sitting at a table to eat is difficult because one must sit on the floor with legs crossed. Second, the cost, mostly covered by Na tional Health Insurance, of a patient's stay in the hospital is vastly less than the cost needed to provide the services and perhaps to reconstruct the home and bathroom. Physical therapy in Japan has made great strides since the end of World War II. The Japanese Physical Therapy Association was admitted to the World Confederation for Physical Therapy during 1974. The popula tion/physical therapist ratio is about 10 per cent of the United States ratio. Formal physi cal therapy education is between our physical therapist assistants' curriculum and our cer tificate curriculum. Institutional salaries, con sidering all fringes, range between 50 and 75 percent of ours. In conclusion, I would like to emphasize that the rate of professional growth during the last few years and a projection of further growth during the decade ahead indicate a closing of the existing gap between physical therapy in the United States and in Japan.
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/5/564/4568248 by Washington University in St. Louis user on 21 February 2019
lying is detached and the whole apparatus, on the pressure of a button, sinks down to sub merge the patient. This system is carried to an extreme in the "progressive bathing system" where the pa tient is brought into an area containing over sized tanks, lowered onto the conveyor belt, rolled up to the top of the tank, scrubbed and soaped and washed by four people with longhandle brushes, then extended horizontally over the hot water surface, lowered electri cally into the water, again raised electrically from the tank, again horizontally moved to a drying platform where another four people dry and cover him, and then moved onto a stretcher to be removed from the area. With this system, approximately 20 patients can be handled each hour. This system is used in some of the larger hospitals and has gained increasing acceptance. Hot springs (spa) therapy has deep cultural roots; therefore, hot pools (in addition to tanks and whirl pools) are standard equip ment. Japanese massage (shiatsu) differs greatly from the Swedish style to which we are more accustomed. In the exercise rooms, the first difference that the observer notices is the quantity of traction devices used in the average depart ment. Under the National Health Insurance system, an additional increment is added to the physical therapy fee when traction is pre scribed and used. Rehabilitation procedures are practically never carried on in the patient's home; there fore, equipment which normally would be used for the patient to continue his rehabilita tion at home is not really needed. The system in Japan keeps patients in the institutional hospital until they are fully rehabilitated. Whenever the rehabilitation process will take a considerable length of time, the patient is usually transferred to a specialized rehabilita tion center where the family moves in with the
JOSEPH M. BREUER, MA
n January 1974, I left the United States for Japan, partly to familiarize our Japanese partners with American rehabilita tion concepts and instrumentation and partly to learn as much as I could firsthand about physical therapy and rehabilitation in Japan. Since then, I have had occasion to live in, and travel throughout, the main islands and to visit and lecture at physical therapy schools and university-affiliated hospitals and reha bilitation centers. My purpose is to share some of my impres sions with the readers of the Journal. The high degree of industrialization in modern Japan has resulted, at least out wardly, in what is commonly considered "westernization." This westernization defi nitely applies to construction of hospital and rehabilitation centers, but with some signifi cant variations. Many homes, however, are "eastern" style: when one enters the house, shoes are ex changed for slippers; a high (30- to 40-cm) step or stoop has to be ascended and, in the living room area, slippers are removed and one sits on tatami mats and cushions on the floor. Men usually sit with legs crossed and knees close to the ground; women sit on their heels with ankles in maximum plantar flexion and knees in maximum flexion. Toilets are on floor level and require a squatting position. Mr. Breuer is Director, Technical Services, J. A. Preston Corporation, 71 Fifth Ave, New York, NY 1003, and Man ager, Technical Services and Training, Inabata-Preston Co. Ltd, Tokyo, Japan.
564
This style of living, of course, is totally unsuited to the use of wheelchairs, braces, crutches, or even shoes. Rehabilitation units, therefore, have to provide training in activi ties of daily living for western as well as eas tern styles of living. Further, the Japanese traditionally bathe before dinner. To bathe, one squats on a low (10-cm) stool, soaps, and thoroughly rinses oneself. Then one submerges in the tub. Tubs are higher and shorter than ours so knees and hips remain in flexion and water covers the shoulders. For the physically handi capped, bathtub transfer and use present functional problems different from those in the United States. To meet the rehabilitation needs of the Jap anese health-seeking public, Japan today has slightly over 1,000 physical therapists, many of them still under the "grandfather clause," having originally been blind masseurs. Ap proximately 400 to 500 occupational thera pists are now practicing in Japan. Eleven rehabilitation schools now graduate physical therapists, and four of these schools also graduate occupational therapists. The threeyear curriculum is not on the university or college level. The curriculum seems to have been copied fairly faithfully from American and English schools. That does not mean, however, that the teaching and demonstrations are neces sarily equivalent. My impression would be that they are not. The impression I gathered was that many physical and occupational therapists are mainly interested in the techniPHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/5/564/4568248 by Washington University in St. Louis user on 21 February 2019
Comments on Rehabilitation in Japan
Volume 56 / Number 5, May 1976
rists have no equivalent in the Japanese med ical system. Rarely have the orthopedic surgeons who are experts in rehabilitation medicine come into this field entirely by their own choice. They are assigned to rehabilitation medicine by their superiors who are senior professors in the university hospitals. Frequently, when these assignments take place, these physi cians are sent abroad to study for two or more years, or else somebody in the institution who has already been abroad to study may teach rehabilitation concepts in the facility. Not only physicians but also some of the out standing therapists have been sent abroad to study, usually to the United States. Concepts and methods of practice of rehabilitation in Japan today are essentially imported from the United States. In the last few years, many standard textbooks used in the United States have been translated into Japanese, some times in abbreviated versions. In most instances, ample space is provided for rehabilitation services. Most of this space is usually allocated to physical therapy, re search (if any), and occupational therapy, in that order. One-half of all rehabilitation space is customarily allocated to hydrotherapy (as is one-half of the equipment budget). Speech therapy is virtually nonexistent; social service is at a relatively underdeveloped level. Hydrotherapy equipment, in most in stances, consists of a therapeutic pool with some sort of electric or mechanical hoisting device and usually at least one, but more often two, whirlpools such as a Hubbard tank. A different delivery system is used since overhead devices are not suitable because of building construction which is geared to fre quent earthquakes. A standard tank contains a hydraulic or electrical device which lifts the matting from a lower to a higher position so that the patient is placed on top of the under water plinth and is then lowered mechanically or electrically into the water. The patient is transferred to this plinth by a special stretcher having a horizontally mova ble extending surface. This stretcher fits into grooves on the tank, and, after the patient is moved horizontally away from the stretcher and over the plinth which is in the tank, that part of the stretcher on which the patient is
565
Downloaded from https://academic.oup.com/ptj/article-abstract/56/5/564/4568248 by Washington University in St. Louis user on 21 February 2019
cal aspect of their field— how to apply what technique for which condition. Schools of rehabilitation generally employ English-speaking teachers from the United States, Canada, and Australia. These teach ers, as a rule, are good therapists who have had some experience in their field, but only a few of them have actually any teaching expe rience. None of them, when they first come to Japan, have any real concepts or ideas of the special problems which Japanese living con ditions and Japanese traditions impose for rehabilitation. Language difficulties present another problem to the English-speaking teachers. The teachers are told by school directors not to worry about the language difficulties be cause the students' responsibility is to under stand and to learn. The teacher's responsibil ity is merely to teach. Although English is taught in Japanese high schools as a second language, the Japanese student in physical therapy is not prepared to understand enough English to follow sophisticated con cepts and lectures. Although medical schools in the vicinity usually provide some medical staff as instruc tors, the facts that no university degrees are awarded and no university entrance examina tions are required before students are admit ted to the rehabilitation school tend to down grade the entire field in the Japanese educa tional system. The teachers in these schools also encounter problems because the medi cal staff may be unwilling to teach classes of students who will not graduate from universi ties. Japanese hospitals are classified as public (self-defense force, labor accident, national, prefectural, municipal) and proprietary, either owned by individual physicians or groups of physicians. Private practice as we know it is virtually nonexistent, both for physicians and physical therapists. Usually, but not always, rehabilitation de partments in hospitals or rehabilitation hospi tals are under the direction of an orthopedic surgeon. In rare instances, physicians in charge of such departments or hospitals who have studied in the United States or other parts of the western world have become diplomates of rehabilitation medicine. Physiat-
566
patient and helps with his rehabilitation until he is ready to go home as a fully functioning member of the family. This system, so radically different from our concept of getting the patient out of the hos pital and home as soon as possible, becomes logical only when two factors are considered. First, the average Japanese home is totally unsuited to rehabilitation of patients needing such aids as wheelchairs, braces, and crutches because of the tatami mats. Also, in the normal Japanese household, the whole family lives, sleeps, and eats in one room. The presence of a disabled person under these crowded conditions can become difficult. The bathroom presents problems because of the difficulty disabled patients have in squat ting over a toilet instead of sitting on a toilet seat. Also, sitting at a table to eat is difficult because one must sit on the floor with legs crossed. Second, the cost, mostly covered by Na tional Health Insurance, of a patient's stay in the hospital is vastly less than the cost needed to provide the services and perhaps to reconstruct the home and bathroom. Physical therapy in Japan has made great strides since the end of World War II. The Japanese Physical Therapy Association was admitted to the World Confederation for Physical Therapy during 1974. The popula tion/physical therapist ratio is about 10 per cent of the United States ratio. Formal physi cal therapy education is between our physical therapist assistants' curriculum and our cer tificate curriculum. Institutional salaries, con sidering all fringes, range between 50 and 75 percent of ours. In conclusion, I would like to emphasize that the rate of professional growth during the last few years and a projection of further growth during the decade ahead indicate a closing of the existing gap between physical therapy in the United States and in Japan.
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/56/5/564/4568248 by Washington University in St. Louis user on 21 February 2019
lying is detached and the whole apparatus, on the pressure of a button, sinks down to sub merge the patient. This system is carried to an extreme in the "progressive bathing system" where the pa tient is brought into an area containing over sized tanks, lowered onto the conveyor belt, rolled up to the top of the tank, scrubbed and soaped and washed by four people with longhandle brushes, then extended horizontally over the hot water surface, lowered electri cally into the water, again raised electrically from the tank, again horizontally moved to a drying platform where another four people dry and cover him, and then moved onto a stretcher to be removed from the area. With this system, approximately 20 patients can be handled each hour. This system is used in some of the larger hospitals and has gained increasing acceptance. Hot springs (spa) therapy has deep cultural roots; therefore, hot pools (in addition to tanks and whirl pools) are standard equip ment. Japanese massage (shiatsu) differs greatly from the Swedish style to which we are more accustomed. In the exercise rooms, the first difference that the observer notices is the quantity of traction devices used in the average depart ment. Under the National Health Insurance system, an additional increment is added to the physical therapy fee when traction is pre scribed and used. Rehabilitation procedures are practically never carried on in the patient's home; there fore, equipment which normally would be used for the patient to continue his rehabilita tion at home is not really needed. The system in Japan keeps patients in the institutional hospital until they are fully rehabilitated. Whenever the rehabilitation process will take a considerable length of time, the patient is usually transferred to a specialized rehabilita tion center where the family moves in with the
