Synapse SPRING 2000 - acpin

JOURNAL AND NEWSLETTER OF THE ASSOCIATION OFCHARTERED PHYSIOTHERAPISTS INTERESTED IN NEUROLOGYSPRING 2000Syn’apseJOURNAL AND NEWSLETTER OF THEASSOCIATION OF CHARTEREDPHYSIOTHERAPISTS INTERESTEDIN NEUROLOGYSPRING 2000ISSN 1369-958X

ContentsFrom the Chair… 2Articles• Botulinum toxin: patterns of usage and outcome measures 3• A simplified balance measure by functional reach 9• The future of national standards for ACPIN 11• Reflex therapy and its use in neurology 13Articles in other Journals 16ACPIN News 18Congress reviews 23Reviews 32Regional reports 39Letters 43Congress 2000 application form 45Guidelines for contributors 47Contact addresses• Regional Secretaries 48JOURNAL AND NEWSLETTER OF THE ASSOCIATION OF CHARTERED PHYSIOTHERAPISTSINTERESTED IN NEUROLOGY SPRING 2000 ISSN 1369-958X

SYNAPSE ● SPRING 2000ARTICLESSENDING YOU ALL BELATED MILLENNIUMGREETINGS! Well, here we are four months intothe year 2000, I cannot say that the ethos ofneurophysiotherapy has changed dramatically since lastyear. However, there are still important issues andplanned events to look forward to, as always inACPIN’s action packed calendar.First, membership. Despite last years problems, wecurrently have 1,100 members, making ACPIN one ofthe largest clinical interest groups. I would like tothank you as members for your support and faith in usas a committee.Secondly, our new Synapse team, co-ordinated byRos Wade have continued to develop Synapse, making ita quality journal. Its high standard can only be maintainedby you as members forwarding articles, reviews,case studies or general queries to the team for inclusion.From the Chair…ACPIN continues to promote sharing of knowledgeby facilitating workshops, conferences and studydays throughout the year. By the time you receive thiscopy of Synapse, our first conference and AGM for theyear entitled ‘Complex Disability, are you managingit?’ will have taken place. A full report will appear inthe November issue.In addition, six regional study days have beenplanned in conjunction with Athena Neuroscience, onthe topic of ‘The management of spasticity in theCommunity’ with an emphasis on Multiple Sclerosis.The Bobath Memorial Study Days will take placethis Spring and representatives from each region willhave been allocated a place. A detailed summary willbe produced by Jackie Newitt for the Novemberedition. The study days will be held in May and Junethis year. Any ACPIN members will be able to attendfree of charge, but places will be limited. Look out forflyers confirming dates and venues, which will be sentdirectly to youThe second CSP Annual Congress and trade exhibition,entitled ‘Expanding Horizons’ will run from20th-22nd October 2000 at the ICC, Birmingham.The ACPIN programme entitled ‘Neurophysiotherapy:the CNS and Beyond’ has been finalised and isenclosed in this edition. Following the success of lastyear, I strongly recommend that you book your placeearly to avoid disappointment.The planning of our second residential conferencewhich will be held from 23rd-24th March 2001, onthe theme of ‘Posture and Balance’ has begun inearnest. Several eminent speakers have beenapproached and have agreed to lecture. The venue willbe the Stakis Hotel in Northampton. Look out forfurther details.Finally, the Events subgroup are proposing to run astudy day on the topic of Medico-legal issues followingcomments and recommendations from severalof our members. This also relates to our motion forARC this year, which was unfortunately rejected.Nicola Hancock’s report will explain the reasoningbehind such a motion.As you are aware the CSP is revising its Standardsof physiotherapy practice. To date, new CoreStandards have been developed and these are currentlybeing piloted. Speciality Standards are to be incorporatedinto the final document so that members haveaccess to all the standards.CIG Liaison Representatives have representedACPIN on the Standards Working Party. Presently, fiveExecutive members convened to review the SpecialityStandards and our comments have been forwarded toMartyn Sumner, Clinical Standards Project Officer. Weawait a response and will keep you informed of theStandards release date, which is planned for later thisyear.ACPIN is currently looking into developing its ownwebsite so that all our news can be disseminatedquickly. Watch this space!As ever, ACPIN strives to promote the educationalneeds of members by promoting Evidence BasedPractice and Clinical Governance and by encouragingneurophysiotherapy.Also, in this issue is an update by Anthea Dendy onthe progress of the complex issue of therapeutic handling.I would like to take this opportunity to thank all thehard working members of the ACPIN Committee, particularlyJill Hall, Yorkshire Regional Rep and JennyCraig, Merseyside Regional Rep who have bothresigned from the National Committee to pursuefurther opportunities in their respective careers. ACPINcontinues to be one of the strongest of the CIGs,growing from strength to strength, and with your continuedsupport ACPIN can move forward and tackleeven more challenging issues!Linzie Bassett MCSP SRPChairperson ACPINAddress for correspondence:119 Wood End RoadErdingtonBirminghamB24 8BHBotulinum toxin:patterns of usageand outcomemeasuresBrian Durward, Head of Physiotherapy, Queen MargaretCollege, Edinburgh and Sasha Baggaley, JuniorPhysiotherapistIntroductionBotulinum Toxin (BTX) injections are being increasinglyused for the management of spasticity for avariety of neurological conditions, including stroke(Bhakta et al, 1996), brain injury (Elovic, 1996), multiplesclerosis (Borg-Stein et al, 1993) and cerebralpalsy (Cosgrove et al, 1994). The drug exerts its effectat the neuromuscular junction by inhibiting the releaseof acetylcholine from the motor-end plate, causing aflaccid paralysis and reduced muscle spasticity. Itseffects are observed within 24-72 hours, but theblockade is reversed after a few weeks or months(Cosgrove et al, 1994).With the growing requirement in the health servicefor objective evaluation of outcome in rehabilitation(Haas and Crow, 1995), it has become ‘the professionalresponsibility of physiotherapists to strive to identifyand develop appropriate measurements, which preserveobjectivity and that might serve to identify the effectsof intervention.’ (Durward and Baer, 1995).The World Health Organisation (1980) proposed asystem of classifying the consequences of illness intofour levels of pathology, impairment, disability andhandicap. An awareness of these categories when planningtreatment aims and selecting outcome measuresmay encourage both a holistic approach to patient care,and provide a comprehensive evaluation of treatmenteffects, which is necessary when treating the complexityof problems neurology patients can presentwith.Although considerable evidence supports the effectivenessof BTX in reducing spasticity, its influence onspasticity-related disabilities, for which there is noagreement on adequate assessment measures, has yet tobe clarified (Reiter et al, 1996). A study of BTX forstroke patients’ upper limb spasticity (Hesse et al,1996), found improvements in certain self-care activities(eg hand hygiene), but standardised functionalassessments failed to reflect this effect. This demonstratesthe relative insensitivity of global assessments ofmotor impairment and disability to effects secondary tospasticity, or patient reported improvements. Sampaioet al (1996) also found a discrepancy betweenimprovement of spasticity scores and functional status,but attributed it to a possible mismatch betweenmuscles treated and muscles needing treatment, due toprotocol restrictions. They stressed the need fordouble-blind, placebo-controlled trials using homogenouspopulations and treatments.Table 1Aims of Research■ Identify the population receiving treatment with BotulinumToxin for spasticity■ Identify the advantages and disadvantages of using thistreatment, from a physiotherapist‘s perspective■ Identify the measures being used to evaluate treatment effectivenessof patients receiving Botulinum Toxin injections forthe management of spasticity■ Estimate whether the focus of treatment with BotulinumToxin is at the level of impairment, disability or handicap.Methodology■ Study Design A questionnaire was designed tocollect data regarding the current use of BTX in themanagement of spasticity. Postal questionnaires arean effective, time and cost efficient means ofobtaining data from large numbers of people over abroad geographical area, for descriptive or statisticalanalysis (Bork and Francis, 1985).■ Questionnaire To be a useful research tool, thequestionnaire must be reliable, valid and sensitive(Fallowfield, 1995). The questionnaire in this studywas designed to attempt to meet the aims of theresearch (Table 1) using the procedure in Figure A.■ Population Identification Physiotherapists specialisingin the area of neurology are most likely towork with patients treated with BTX for spasticity.A mailing list for Association of CharteredPhysiotherapists Interested in Neurology (ACPIN)members was obtained to target this population.One hundred members were selected (semi-randomly)from the list by the group’s secretary (fulldetails were not provided). Anonymity and confidentialitywere assured and participation wasvoluntary.■ Piloting Procedure To ensure the questionnairewas valid, a pilot test was run on three experts inthe field. They were asked to note how long thequestionnaire took to complete, and any problemswith presentation, clarity or comprehension. An23

SYNAPSE ● SPRING 2000ARTICLESFigure AQuestionnaire design procedureFORMULATE POTENTIAL QUESTIONS• relevant• precise• ethical• unbiased• unambiguousREFINE OR REJECT QUESTIONS• easy to read• easy to understand• elicit appropriate information• suitable for scoring method• maximum of 20-25 words long• maximum of 20 minutes tocomplete questionnaireIDEAREVIEW LITERATUREDISCUSSION WITH COLLEAGUESSELECT SCORING METHOD ANDANALYSIS PROCEDUREPILOT• on target population• identify problems• examine question clarity andreliability• check interpretations ofquestions/responses• test scoring systemFINAL QUESTIONNAIREIDENTIFY POPULATION• accessible• cognitively capable ofresponding• ethical• likely to be able to providerequired informationDEVELOP FORMAT• open-ended or closed-ended• categories of response• sequenceinterview was conducted to establish whether questionsand answers were interpreted appropriately byrespondents and the tester. Following this, problemquestions were removed or adjusted.■ Final Questionnaire Consisted of a cover page(explaining the aims, contents and instructions), andtwo sections. Section A required baseline data onvariables relating to the respondent (area in whichthey work, years of experience, grade of physiotherapist,and number of BTX patients they havetreated). Section B required information about apatient treated with BTX. This section was designedto meet the aims of the study, using both openendedand closed questions. Open-ended responseshad to be categorised for analysis.• Aim I Details were required about the patient whothe respondents had most recently worked with, toincrease accuracy and reliability of responses(French, 1993). These included pathology, duration,age, area injected and the number of times injected,previous treatments and their perceived success.• Aim 2 Questions required respondents to list upto five advantages and disadvantages. These questionswere open-ended because the literature onlyconsidered them from the perspective of drugadministrators or purchasers, rather thantherapists.• Aim 3 Respondents were asked which tool ortechnique was used to establish a baseline measureof spasticity, and which outcome measures wereused to monitor the effects of treatment.Information of variables which might affectoutcome measurements was also required eg whenand how often the measures were made; and anyother therapy the patient received in conjunctionwith the injection.• Aim 4 Since respondents may not have had anunderstanding of the WHO’s definitions for theclassifications of impairment, disability and handicap,the level of focus was estimated byconsidering the aims of treatment and outcomemeasures used.■ Mailing Procedure A copy of the questionnaire,with a cover letter, instructions for its return, and astamped, self-addressed envelope, was sent to 100ACPIN members.■ Data Collection and Analysis Responses wererecorded in Windows SPSS (Statistical Package forthe Social Sciences). Information was convertedfrom descriptive to numerical format to facilitateanalysis of qualitative information. Due to the lowresponse rates, information recording method, andresponse categories used, only response frequenciescould be analysed.Results• Response Rate Fifty eight questionnaires werereturned, of which 27 had been fully completed(‘users’); twenty four respondents had no experiencewith this patient group, but completed Section A (‘nonusers’);seven questionnaires were returned unanswered.Figure BAreas in which respondents worked■ neurorehabilitation■ neuromedicine4%32%7%■ community■ stroke rehabilitation7%21%■ other■ care of the elderly 48%15%13%• Respondent Profile The pie charts (Figure B) illustratethe areas in which respondents worked. Userswere predominantly Senior I Grade, with 2-4 yearsexperience in this field, and had treated between 3-5BTX patients. Eighty five percent had been involved inthe decision to use BTX, as part of a multidisciplinaryteam.• Aim 1 Raw data can be seen in Table 2. The majorityof patients described had been diagnosed as CVA(45%), and were aged between 40-70 years (56%).The onset of pathologies had been within the lastthree years for most patients (74%). The most frequentlyreported criteria for selecting patients was theirdegree of hypertonicity (21 %), followed by a poorresponse to other treatments (15%); age was the leastfrequently reported criteria for selection (2%). Prior totreatment with BTX, 29% of patients had tried otherpharmacological measures to manage their spasticity,and 29% had been treated with splinting or serialcasting, of which 33% of cases were consideredunsuccessful, and 56% were only partially successful.The upper limb and lower limb were being treatedwith similar frequency, but specific muscle groups werenot identified for all patients. Most patients hadreceived only one injection with BTX (67%), althoughthree patients were reported to have received up tothree repeat injections.• Aim 2 The ability to target specific muscles for alocal effect, and the perceived effectiveness of the drugwere the most frequently reported advantages of usingBTX. Eighteen more advantages than disadvantageswere reported, and eight respondents stated that therewere no disadvantages of using BTX in their opinion.The transient nature of the drug was considered bothan advantage (eight respondents) and a disadvantage‘Users’19% 13%13% 8%Figure CAdvantages (n=54) and disadvantages (n=36) of using BTXAdvantages‘ Non-users’0 2 4 6 8 10 12 14 16 18 20DisdvantagesLong lastingDose controlEasy to administerRapid effectTransientNo side effectsEffectiveSpecifityPainfuldevelopment of antibodiesIdentify siteUnknown outcomeCostAssociated risksTransientNone0 1 2 3 4 5 6 7 8Response frequenciesResponse frequencies45

SYNAPSE ● SPRING 2000ARTICLESSUBJECT PATHOLOGY DURATION AGE (YRS) MUSCLES INJECTED FREQUENCY SUCCESS1 Spasmodic Torticolis 27yrs 41 Sternocleidomastoid 3 short termlevator scapulae2 Head injury 15yrs 27 Hamstrings 1 yes3 Spasmodic Torticolis 9mth 45 Sternocleidomastoid 2 short termsplenius; upper trapezius4 CVA 2yrs 56 Biceps brachii; sartorius 3 yes5 CVA 18mth 83 Flexor carpi radialis; 2 short termflexor digitorum longus6 CVA 3yrs 65 Wrist and finger flexors 1 short term7 Head injury 6mth 27 Hamstrings 1 yes8 CVA 6mth 67 Hamstrings 1 yes9 Multiple sclerosis 10yrs 37 Hamstrings; hip flexors 1 yes10 CVA 2yrs 23 Gastrocnemius; soleus 1 partially11 CVA 4mth 70 Hamstrings; hip adductors 1 yes12 Head injury 14mth 35 Pectoralis; biceps; 1 short termbrachioradialis13 CVA 5mth 49 Medial hamstring 2 short term14 RSD type pain 2yrs 15 Tibialis anterior; 2 short termtibialis posterior15 Spinal cord lesion 6wks 36 Forearm flexors; biceps 1 don’t knowtransferred16 CVA 5yrs 54 ?Biceps or forearm flexors 2 partially17 Cerebral palsy 10yrs 10 Gastrocnemius; rectus 1 yesfemoris18 Head injury 18mth 25 Wrist flexors; gastrocnemius 1 yes19 CVA 10mth 69 Wrist flexors; finger flexors 1 yes20 Multiple sclerosis 2yrs 22 Gastrocnemius; radial arch of 2 yesfoot21 CVA 8mth 65 Hamstrings 1 yes22 Head injury 3yrs 18 Biceps; brachialis; 1 yesbrachioradialis23 Encephalitis 7mth 53 Finger flexors; triceps 1 no24 CVA 6mth 55 Forearm flexors 1 short term25 CVA 7yrs 61 Pronator teres; biceps; 3 yes26 CVA 18mth 65 Long finger flexors 1 don’t know died27 Intramedullary cyst 18yrs 37 Hamstrings 1 don’t knowtransferredTable 2Raw data of patient profile(also eight respondents). These response frequenciescan be seen in Figure 3.• Aim 3 Most respondents used the Ashworth GradingScale (37%) or goniometry (33%) to obtain a baselinemeasure of spasticity. Conversely, outcome of treatmentwas predominantly measured using goniometry(56%), with the Ashworth being used by only 22% ofrespondents (Table 3). Despite reduction of painreported as an aim of treatment by ten respondents,only five used a pain measure for a baseline or outcomemeasure.• Aim 4 Response categories used for the aims andoutcome measures were assigned to the most appropriatelevel. Figure 3 shows both aims and outcomemeasures were predominantly focused at the impairmentand disability levels, with minimal focus onhandicap.DiscussionFrom the questionnaire it was found, in relation to thestudy aims, that:■ 1. Various neurological pathologies are beingtreated with BTX, predominantly stroke patientsbetween the age of 40-70 years. This may reflectFigure CAims and outcome measures focused atthe impairment, disability and handicaplevelsAims28%69%■ impairment■ disability■ handicapOutcome measures44%3%56%the high incidence of stroke, which rises rapidlywith age and is the most common cause of neurologicaldisability in the adult population (Downie,1986). However, the target population is not necessarilyrepresentative of all physiotherapists workingin neurology (eg few paediatric members), therefore,the findings may lack reliability.■ 2. Ability to target specific muscles is recognised asa major advantage of the drug, whilst its transientnature is considered both a disadvantage and anadvantage. The style of questioning did not facilitateranking responses or determining whetheradvantages outweighed disadvantages.■ 3. The Ashworth Scale was mainly used to recordbaseline measures of spasticity, which is the onlyreliable and valid test of spasticity available in theclinical setting (Bohannon and Smith, 1987); rangeof movement was used most frequently to measureoutcome, even though it is not a direct measure ofTable 3Baseline and outcome measuresBASELINE MEASURESResponse category Frequency Percentage Percentage ofof response of frequency respondents (n=27)Ashworth scale 10 22 37Goniometry 9 20 33Functional assessment 7 16 26Don’t know/none 6 13 22Video analysis 4 9 15Other tone grading 4 9 15Pain scale 3 6.5 11Other 2 4.5 7OUTCOME MEASURESResponse category Frequency Percentage Percentage ofof response of frequency respondents (n=27)Goniometer 15 32 56Functional ability measure 10 21 37Ashworth grading scale 6 13 22Gait analysis measure 4 8.5 15Video analysis 4 8.5 15None 3 6.5 11Don’t know 3 6.5 11Pain measure 2 4 7Table 4Suggested categories for aims and outcome measuresWHO CATEGORY AIM OUTCOME MEASUREImpairment Reduce spasticity Ashworth grading scaleReduce painPain measurement scalesPrevent secondaryNone suggestedcomplicationsIncrease range ofGoniometrymovementDisability Improve function Functional measures/video analysisImprove gaitImprove hygienespasticity. This highlights a problem that exists inneurology with finding appropriate measurementsthat will reflect the aims of treatment, are easy touse, and are reliable and valid. Poor questiondesign resulted in difficulties in analysing whichmeasures were used and when they were used.■ 4. Impairment and disability were the main focus oftreatment, based on reported aims and outcomemeasures. The absence of handicap measurementreflects the lack of suitable measures availableGait analysis/video analysisFunctional measuresHandicap Improve comfort None suggested67

SYNAPSE ● SPRING 2000ARTICLES(Wade, 1992); a lack of outcome measures relativeto aims may reflect the paucity of reliable and validmeasures in neurology.When drawing conclusions from these findings,limitations of small sample size and population usedmust be considered. Also, poorly worded questioningand the use of open-ended response formats createdproblems with analysing information due to ambiguities,vague responses, and possible misinterpretation ofquestions, restricting its reliability.ConclusionThe transient nature of BTX, coupled with its highfinancial cost (Jordan and Bames, 1994) and the potentialto develop antibodies with long term use(Hambleton et al, 1996) raises concern over thecost/benefit ratio of using this treatment (Reiter et al,1996). It is therefore important that guidelines aredeveloped for optimum dosages and patient selectioncriteria, by conducting research using randomised, controlledtrials, long term analysis of patients receivingtreatment, and precise documentation of outcome measuresin both a clinical and research setting.Physiotherapists are responsible for finding andusing ‘the most appropriate, reliable and sensitive toolsavailable in order to evaluate and justify physiotherapyintervention’ (Crow, 1995). Therefore, goals of BTXtreatment should be carefully identified according tothe patient’s clinical features, and measures used shouldreflect these, in order to determine the effects of BTXat more than just the level of impairment.REFERENCESBhakta B, Cozens J, Bamford J, Chamberlain M (1996) Useof botulinum toxin in stroke patients with severe upperlimb spasticity. Journal of Neurology, Neurosurgery andPsychiatry Vol 61(1):30-35Bohannon R, Smith M (1987) Inter-rater reliability of amodified Ashworth Scale of muscle spasticity. PhysicalTherapy Vol 67(2):206-207Borg-Stein J, Pine Z, Miller J, Brin M (1993) BotulinumToxin for the treatment of spasticity in multiple sclerosis.American Journal of Physical Medicine andRehabilitation Vol 72(6):364-368Bork C, Francis J, (1985) Developing effective quesionnaires.Physical Therapy Vol 65(6):907-911Cosgrove A, Corry I, Graham H (1994) Botulinum Toxin inthe management of the lower limb in cerebral palsy.Developmental Medical Child Neurology Vol 35:379-385Crow JL (1995) Aspects of neurology: Abnormal tone andmeasurement. Physiotherapy Vol 81(8):419-420 (editorial)Downie P (1986) Cash’s Textbook of Neurology forPhysiotherapists 4th Edition Faber & Faber, LondonDurward B, Baer G, (1995) Physiotherapy and neurology:towards research based practice. Physiotherapy Vol81(8):436-437Elovic E (1996) The use of botulinum toxin for the treatmentof spasticity in post-traumatic brain injury. [Online]JFK online articles Available from:http://www.jfkhs.org/arehab2.html (accessed 29.10.97)Fallowfield L (1995) Questionnaire design. Archives ofDisease in Childhood Vol 72:76-79Haas B, Crow J (1995) Towards a clinical measurement ofspasticity? Physiotherapy Vol 81(8):474-479Hesse S, Krajnik J, Luecke D, Jahnke M, Gregoric M,Mauritz K (1996) Ankle muscle activity before and afterBotulinum Toxin therapy for lower limb extensor spasticityin chronic hemiparetic patients. Stroke Vol 27(3):455-460Reiter F, Danni M, Ceravolo G, Provinciali L (1996)Disability changes after treatment of upper limb spasticitywith Botulinum Toxin. Journal of NeurologicalRehabilitation Vol 10:47-52Sampaio C, Ferreira J, Pinto A, Crespo M, Ferro J, Castro-Caldas A (1997) Botulinum Toxin Type A for the treatmentof arm and hand spasticity in stroke patients. ClinicalRehabilitation 11(1):3-7Wade D (1995) Measurement in Neurological Rehabilitation4th Edition. Oxford University PressWorld Health Organisation (1980) International classificationof impairments, disabilities and handicaps: a manualof classification relating to the consequences of disease.WHO Geneva (http://www.who.org/)Address for correspondenceBrian DurwoodHead of PhysiotherapyQueen Margaret CollegeClerwood TerraceEdinburgh EH12 8TSA simplifiedbalance measureby functionalreachDr Mathew Mackenzie University of Kent at CanterburyIntroductionStanding balance is a convenient and clinically accessiblemeasure of outcome of rehabilitation of acute conditionssuch as stroke. Methods of assessing balanceinclude the use of simple ordinal scales (Bohannon et al,1984), (Bohannon, 1989), (Berg et al, 1995),(Bohannon et al 1995) as well as more sophisticatedsystems providing ratio data (Era et al, 1985), (Berk et a],1992), (Norre et al, 1993), (Make et al, 1990). Onemuch used example is the Balance Performance Monitor(Hinman, 1997). An often cited and simpler instrumentis the Functional Reach (FR) test (Duncan et al, 1990).In this test, FR is defined as 'the difference betweenarm's length and maximal forward reach, using a fixedbase of support'. It is recorded by measuring the horizontaldistance between a subject's third metacarpal jointin upright standing and forward extended positions.Results from this test were found to be reliable, and correlatedwell with those obtained using more preciseelectronic equipment (Duncan et al, 1990).In practice, problems can arise in reproducing thestarting position for subsequent repetitions of the test.Variations may be generalised into two categories: (1)angulation of the body in the sagittal plane; and (2)rotation of the upper torso. In the first case, should thesubject be leaning forward in the start position, then theoverall reach measurement will be reduced and viceversa.Twisting the torso can have a similar effect. Forelderly subjects or those suffering from acute conditions,it is often impractical to spend a large amount of timepositioning prior to the test due to the generation offatigue. In many cases, accurate positioning is impossible.A modified balance test has been developed whicheliminates the above problems. Being simpler andquicker to perform, the test is suited to all hospital andcommunity settings, and is especially applicable to subjectswho tire easily, or those unable to maintainconsistent upright starting positions, e.g. people withstroke. The test does not require any specialist equipmentand, as nothing needs to be affixed to a wall, isideally suited to use in the home.The Modified FR TestRather than record the distance between start andextended positions, an FR assessment may be performedby measuring the distance a subject can reach in front ofthe limit of their base of support. The modified testutilises a simple measuring device consisting of a selfrecoiling tape measure connected to a handle (see Figure1). Any such device may be constructed, provided thesame device is used each time a subject is tested. Byhooking the start of the tape vertically in line with theend of the toes, the reach measurement can be readdirectly from the tape as the subject holds the handleand leans forward. Figure I illustrates the modified FRtest.Instructions for carrying out the test are as follows:■ 1. Select a vertical edge (eg a door-frame), suitablefor hooking the tape onto.■ 2.. The subject stands (without shoes), toes verticallyaligned with this edge.■ 3. The subject raises the arm that is adjacent to thevertical edge to shoulder height.■ 4. The tape is hooked onto the vertical edge atshoulder height, and extended until the subject isable to grasp the handle of the unit.■ 5. Give the following command whilst demonstratingthe movement. ‘Reach forward as far as you can then standupright again. Be careful not to lose your balance or moveyour feet. Don't look down; keep looking directly forward.’Figure 1F89

SYNAPSE ● SPRING 2000ARTICLES■ 6. As the subject leans forward, the tape will uncoil,and the maximum extension is read directly from thetape.The reach measurement (F) is the horizontal distancebetween the end of the toes, and the point atwhich the tape enters the measuring unit when thesubject is in the fully extended position. Allow threeattempts, recording the furthest reach. The followingpoints should also be taken into consideration:■ 1. Twisting the wrist may alter the recorded reachmeasurement; instruct the subject to keep the wriststraight.■ 2. The measuring device handle should be held inthe centre of the closed fist butting up to the thumb,and not extended into the fingers, which will increasethe measured distance.■ 3. There is a tendency for the subject to reach downwardsas well as forwards, which increases therecorded measurement. If necessary, keep the tapehorizontal as the subject leans forward by altering theheight at which it is hooked onto the vertical.■ 4. If the test is performed against a wall, ensure thesubject's hand is not resting against the wall toprovide additional stability. The FR measurement alsoincludes arm length, so it is inappropriate for comparingbalance between individuals. Rather, the test ismost appropriately used to detect changes in an individual'sbalance over time.Reliability and ValidityInter-rater and intra-rater reliability were investigated byperforming the test on a small sample of individualswith no disability. All individuals were trained toperform the test procedure, and acted as both subject andrater. To assess intra-rater reliability, all raters tested subjectstwice, with tests separated by 15 minute timeintervals (n=20). To assess inter-rater reliability, six subjectswere tested twice by different raters, again separatedby a 15 minute interval. Correlations were calculatedusing Pearson's product moment.From the small sample studied, coefficients ofr = 0.788 for intra-rater reliability and r = 0.991 forinter-rater reliability were obtained. Both are highly significant(p = 0.01), suggesting that the modified FR testcan provide reliable measurements. More work is neededto investigate its reliability in different settings and withdifferent subjects.The validity of the FR test as a measure of balancehas been previously demonstrated (Hinman, 1997). Themodified test also requires subjects to lean forwards asfar as they can without over-balancing, and hence fulfillsthe same purpose. The modified test is currently beingused to test the balance of acute stroke patients as part ofa larger study.REFERENCESBerg K, Wood-Dauphinee SL, Williams JI, (1995) TheBalance Scale: Reliability assessment with elderly residentsand patients with an acute stroke Scandinavian Journal ofRehabilitation Medicine 27, 27-36.Berk KO, Maki BE, Williams JL, Holliday PJ, Wood-DauphineeSL, (1992) Clinical and laboratory measures of posturalbalance in an elderly population Archives of PhysicalMedicine 73, 1073-1080.Bohannon RW, Larkin PA, Cook AC, Gear J, Singer J, (1984)Decrease in timed balance test scores with aging PhysicalTherapy 64, 7, 1067-1070.Bohannon RW, Leary KM, 1995 Standing balance and functionover the course of acute rehabilitation Archives ofPhysical Medicine 76, 994-996.Bohannon RW, (1989) Selected Determinants of AmbulatoryCapacity in Patients with hemiplegia Clinical Rehabilitation3, 47-53.Duncan PW, Weiner DK, Chandler J, Studenski S,(1990)Functional Reach: A new clinical measure of balance Journalof Gerontology 45, 6, 192-197.Era P, Heikkinen E,(1985) Postural sway during standing andunexpected disturbance of balance in random samples of menof different ages Journal of Gerontology 40, 287-295.Hinman R, (1997) Validity and reliability of measuresobtained from the balance performance monitor during quietstanding Physiotherapy 83, 11, 579-581.Make BE, Holiday PJ, Femie GR,(1990) Aging and posturalcontrol: a comparison of spontaneous and induced-swaybalance tests Journal of the American GerontologicalSociety 38, 1-9.Norre ME (1993) Sensory Interaction Testing in PlatformPosturography Journal of Laryngology and Ontology 107,496-501.Address for correspondenceDr MD MackenzieResearch CoordinatorCentre for Health Services StudiesGeorge Allen WingUniversity of Kent at CanterburyCanterburyKent CT2 7NFe-mail: M.Mackenzie@ukc.ac.ukThe future ofnational standardsfor ACPINMadeline Simpson MSc MCSPBackgroundThis project was supported financially from the ACPINmembership in an attempt to investigate the futureposition of the general standards booklet produced byACPIN. The project work formed the research elementof the Masters in Health Care programme at Exeter forthe researcher, using a qualitative approach in the formof focus groups.Aims and objectivesThe aims of this project were to explore the effects andimpact of the National Standards published by theAssociation of Chartered Physiotherapists Interested inNeurology in 1995.The objectives were to evaluate this document interms of:■ The ability to interpret the standards in relation tolocally provided services.■ The usefulness of the document in terms of uniprofessionaland multi-disciplinary clinical audit.■ The positive and negative effects of the introductionof the National standards withrecommendations for their future development.MethodThis project was carried out using focus groups withsenior physiotherapy members of ACPIN drawn fromfive of the ACPIN regions in the United Kingdom. Anattempt was made to select members for the groupswho had been ACPIN members for at least two yearsand were in a Senior post in the speciality as this wasconsidered to be the people most likely to have had theopportunity to influence the implementation of thestandards.The focus group members were asked to explorethemes related to the objectives of the project and todiscuss particular successes and problems whichparticipants had experienced in relation to the standards.Main themes for discussion included:■ Distribution and initial reaction to the standards.■ The effect on local audit.■ Which standards to choose in comparison to thoseproduced by other Clinical Interest Groups.■ Relationship to other professions where standardsmay have been used for multi-disciplinary audits.■ Any problems using the standards or in gettingaudit underway generally.■ Suggested changes for the future development ofACPIN standards.■ How should the standards be brought in to undergraduatetraining.■ Suggestions for future implementation strategies.■ Relationship to evidence based guidelines.All the focus groups were recorded and fully transcribedprior to analysis. Data was then analysed usinga modified Grounded Theory approach. The style ofthe focus groups allowed for the development of thekey themes from one group to the next giving theopportunity to test and reinforce the ideas generated.Triangulation of the results from the focus groups werediscussed in relation to:■ Information generated from a meeting to investigatethe whole area of the use of standards of physiotherapypractice by all of the clinical interest groupsof the Chartered Society of Physiotherapy and■ a discussion held with members of an additionalACPIN Regional group following a lecture givenby the researcher.ResultsA selection of key results have been chosen forreporting in this section of the article, as with all qualitativestudies a large amount of data was generated.■ Distribution and initial reaction Whilst themembership were generally enthusiastic aboutreceiving a 'free' copy of the standards, there waslittle evidence that the document had been activelyused for quality or audit projects. Commentsincluded a lack of time for such activities and thefact that the standards were too basic. Another keypoint included the fact that members had notunderstood the purpose of the document and thenhow to interpret the standards to a local level foraudit purposes.■ Content Comments included the fact that many ofthe ACPIN standards were in fact common toseveral Clinical Interest Groups, therefore standardsshould be reviewed together and in conjunctionwith the Chartered Society of Physiotherapy intheir work to produce a new set of 'core' standards.A particular emphasis was placed on the need todevelop a standard relating to manual handling ofneurologically impaired patients by physiotherapists.■ Effect on local audit Whilst there was some evidenceof physiotherapy audits across a range oftopics few had made use of the ACPIN standards.1011

SYNAPSE ● SPRING 2000ARTICLESWhere examples of good practice were discussedparticipants were keen to suggest ways of sharingthese with colleagues such as:- a list of contactnames to be included in the new edition, auditexamples to be published in Synapse. It was alsoproposed that if such a document was published inthe future then this should include a template ofhow to interpret the standards at a local level.■ Choosing ACPIN standards in comparison toother Clinical Interest Groups This had notproved to be a problem. Many of the participantswere not aware of the work from other groups,although an enthusiasm was shown for the publicationsfrom the MS Society (Freeman et al 1997),(MS Society 1997).■ Relationship with other professions Despiteearlier results about the lack of use of the ACPINstandards, where multi-disciplinary audit projectswere underway, several examples of members usingthe standards in a multi-disciplinary forum werediscussed. This often highlighted the lack of anythingsimilar in other professions and an acceptancefor some groups that these were a good startingpoint.■ Problems in using the standards Again the lackof understanding of the purpose of the documentwas brought out and also that by the time they werepublished the agenda had moved on in healthcareparticularly in relation to evidence based practiceand the need to consider outcomes rather thanstructure and processes. Several comments were alsomade about the inability of some physiotherapyteams to influence factors such as transport arrangementsfor patients which have set standards withinthe document.■ Changes for the future All the focus groupswanted to keep a publication which is unique toACPIN. However there was general recognitionthat the development of a new style document andthe follow up implementation strategies would havea significant demand on time, expertise andresources, for this to be a successful venture. It wassuggested that successful implementation could bebrought about with the use of the strength of theACPIN Regional groups which had been responsiblefor excellent educational programmes in thepast.Discussion and conclusionThe results have broadly shown that there is substantialsupport for the continuation of such a publication butwith radical changes concerning content, style andmethods of implementation. The results will be usedparticularly by ACPIN to inform the process for thedevelopment, dissemination and implementation of thenext edition of the standards document.The work has already been presented at a NationalACPIN conference and as part of the scientific programmeof World Confederation for Physical TherapyCongress 1999. An action plan was also drawn up as aresult of the work and discussed with the nationalcommittee of ACPIN to assist in the strategic visionfor the development of work on standards in thefuture.It is hoped that the methods used for this projectmay provide a framework, which other ClinicalInterest Groups could apply in the review and evaluationof their own Standards. The results may also be ofvalue to the Chartered Society of Physiotherapy insuggesting future implementation strategies and styleof delivery in the application of 'standards' documentsproduced by any of the Clinical Interest Groups.REFERENCESACPIN (1995) Standards of Physiotherapy Practice inNeurology Chartered Society of Physiotherapy, LondonFreeman J, Johnson J, Rollinson S, Thompson A, Hatch J(1997) Standards of Healthcare for People with MS TheMultiple Sclerosis Society of Great Britain andNorthern Ireland, London.Multiple Sclerosis – A Booklet for Physiotherapists, LondonThe Multiple Sclerosis Society of Great Britain andNorthern Ireland (1997)Address for CorrespondenceMadeline SimpsonHead of TherapiesWorthing and Southlands Hospitals NHS TrustLyndhurst RoadWorthingBN11 2DHe-mail: Msimpson@dial.pipex.comReflex therapyand its use inneurologyJo Smith Oliver MCSP, SRP Physiotherapist,Complementary Health Centre, Hackney, East LondonAs physiotherapists working with neurological conditions,we are dealing with aspects of co-ordination andcontrol, and teaching patients how to improve theirquality of life. Reflex Therapy is just one area of ourprofession where these issues can be easily addressedand incorporated into normal mainstream care. It is justone area of complementary medicine which encourageshomeostasis between all systems in order topromote balance. It emphasises the connectionbetween body, mind and spirit and is unique in that thefeet are seen to exist as microcosms of ourselves.Gentle pressure here can relieve pain and improvemobility in a profound and extraordinary way.HistoryReflex Therapy is old medicine. It has been practisedfor thousands of years with records found in Egyptand India as well as in the Far East. The Association ofChartered Physiotherapists in Reflex Therapy(ACPIRT) – including healthcare professionals – wasset up in 1994 after having been recognised by theCSP the previous year. There are now over 200members. It was set up by Christine Jones, a physiotherapistwho was awarded a fellowship in 1998 inrecognition of her innovative practice.ACPIRT and the Midland SchoolAt the inaugural meeting of ACPIRT it was agreedthat Reflex Therapy expressed as two words should beused as an umbrella title encompassing all differentaspects of this ancient medicine. It therefore includesreflexology, reflex zone therapy and reflextherapy astaught by the Midland School of Reflextherapy(MSR). Courses are open to physiotherapists, nursesand other healthcare professionals who have studiedanatomy and physiology to nursing level. There is astrong emphasis on the integration into mainstreamphysiotherapy. Courses are endorsed by the CSP andcredited by Coventry University.What is it?Reflexes exist in our feet that mirror us in our entirety.Our toes represent structures in and around our heads,including our thoughts. Our heels are manifestations ofour low back, hips and pelvis, the structures thatconnect us to the earth when we are relaxed. Busy,stressed people and many children with neurologicaldisorders have difficulty in letting their heels touch theground, although for different reasons! The reflexes toour vital organs are found on the soles of the feet in apattern that exactly mirrors our thorax and abdomen.The spine along the medial border of the foot. Patientswith paraplegia will present with a callus or areas ofaltered colour or sensation at the appropriate level ofthe lesion. It is often attributed to pressure from shoes.After many years in Orthopaedic Medicine, I havebeen amazed and fascinated by this system, which hasalways been present in us and so often overlooked.Immediately following a CVA, patients will presentwith a bruised area around the soft pad of the greattoe, the reflex to the brain. Only when we take thetime to look for these signs do we find them. Gentlemassage to the solar plexus reflex on the sole of thefeet, will encourage deep breathing and relaxation, afactor so important in the care of degenerative conditions,where fear is a major issue.RelaxationI have never yet met anyone who does not enjoy thistreatment. The implications of touch are profound,many papers emphasise the effects of massage on thecirculation and nervous and immune systems. With theadditional benefit of an understanding of the reflexesthis is an obvious advantage. I know children who sticktheir feet out of the duvet at bed time to help them tosleep! Willing helpers can also be taught the rudimentsof reflex therapy, enhancing connections betweenthem and their families, thus reducing strain on communityhours.MSR ApproachAs all practitioners are registered physiotherapists orhealthcare professionals, prior knowledge of underlyingpathology is always considered. The approach totreatment is always gentle and painful or hypersensitivereflexes being eased into a state of relaxation, allowinga resolution of symptoms to occur effortlessly. Theprinciples of Naturopathy and Chinese Medicine arealways considered, emphasising natural health and theconnection between mind and body.Integration into Normal PracticeReflex Therapy can be integrated into all areas ofphysiotherapy and easily included as part of a treatmentsession. It can last from anything, between two to1213

SYNAPSE ● SPRING 2000ADVERTISEMENTSfifty minutes, depending on the condition of thepatient and the time available. It is a joy that this profoundand yet simple process can also stand alone in itsown right in the treatment of neurological conditions,where exercise and mobility are no longer an issue.Jo Smith is holding a one day introductory workshop inMay 2000 and can be contacted on 020 7275 8434 oremail: holistic.health@virgin.net. She also teaches oncourses for the Midland School in London and otherselected venues.ACPIN AGM and conferenceon posture and balance23-24th March 2001, Stakis Hotel, NorthamptonACPIN have decided to organise their owntwo-day residential conference for 2001.It will be held at the Stakis Hotel,Northampton, just two minutes drive off theM1 motorway at junction 15. The hotel has139 rooms all with en suite facilities. Thereis a leisure centre on site with swimmingpool, whirlpool spa, sauna, steam room,solarium and fully equipped gym.At this stage the committee are in theprocess of approaching speakers andfinalising details. The conference will includea gala dinner on the Friday night.The provisional programme, with an overall themeof posture and balance, is planned to include thefollowing topics:Friday 23rd■ The Vestibular System and its implications for Physiotherapy■ Balance and Vestibular testing■ Therapeutic Management of Vestibular Problems■ Outcome measures for Posture and Balance■ Alignment and Posture – A Normal movement ApproachSaturday 24th■ Inattention and Neglect■ Pusher Syndrome-Pathological or acquired?■ Neuromuscular Stability■ Biomechanical analysis of balance in gait■ Losing Balance-Falls in Parkinson’s diseaseMEDICO-LEGAL ASSOCIATION OFCHARTERED PHYSIOTHERAPISTSSociety of Expert Witnesses Spring ConferenceJoint meetring with the MLACPExpert witness masterclass 200012th and 13th May 20009.00am – 4.30pm (lunch and tea included)At the Swallow Hotel, BristolMultidisciplinary breakout session on Saturday 13th May‘Health Professionals – Living with Litigation’For further information please contact: Jenny Archer, Programme Organiser, Bangor PhysiotherapyPractice, 8 Ranfurly Avenue, Bangor,, Co. Down BT20 3SN Tel. 01247 270 932Exercise training following brain injurySEMINAR AND WORKSHOPS • WEDNESDAY 28TH JUNE 2000 • 10.00AM – 4.00PMREGIONAL NEUROLOGICAL REHABILITATION UNIT HOMERTON HOSPITAL HOMERTON ROW LONDON E9 6SRSeminar topics to include:Mechanisms involved in improving aerobic fitness ■Psychological aspects of exercise training ■Effects of aerobic training in early brain injured patients ■For registration forms contact the course organiser:Practical sessions will include:■ Optimising exercise training■ Monitoring the effect of training on a cycle ergometer■ Measurement of heart rate, work rate and perceivedexertionDr Andrew BatemanDepartment of Health SciencesUniversity of East LondonRomford RoadLondon E15 4LZe-mail A.Bateman@uel.ac.uktelephone 020 8223 4512Clinical seminar registration fee(including coffee, tea and lunch)£45.001415

OTHER JOURNALSARTICLES IN OTHER JOURNALSThe aim of this section is to list the titles of papers which havebeen recently published in key journals, and which may be ofinterest to ACPIN members■ ARCHIVES OF PHYSICALMEDICINE AND REHABILI-TATION• 1999 vol 80, no 6• McKinley W, Seel R,Hardmann J, Nontraumaticspinal cord injury: Incidence,epidemiology, and functionaloutcome pp619-623.• Kunkel et al, Constraintinducedmovement therapy formotor recovery in chronic strokepatients pp624-628.• Whyte J, DiPasquale M,Vaccaro M, Assessment ofcommand-following in minimallyconscious brain injuredpatients pp653-660.• Grealy M, Johnson D,Rushton S, Improving cognitivefunction after brain injury: Theuse of exercise and virtualreality pp661-667.• Urquhart D, Morris M, IansekR, Gait Consistency over a 7-dayinterval in people withparkinson's disease pp696-701.• Childers M et al, Inhibitorycasting decreases a vibratoryinhibition index of the h-reflexin the spastic upper limbpp714-716.• 1999 vol 80, no 7• Cifu D et al, A multicentreinvestigation of age-related differencesin lengths of stay,hospitalisation charges, andoutcomes for a matchedtetraplegia sample pp733-740.• Lin K et al, Abdominal weightand inspiratory resistance: theirimmediate effects on inspiratorymuscle functions duringmaximal voluntary breathing inchronic tetraplegic patientspp741-745.• Beer R, Given J, Dewald J,Task-dependent weakness at theelbow in patients with hemiparesispp766-772.• Suhr J and Grace J, Brief cognitivescreening of righthemisphere stroke: relation tofunctional outcome.pp773-777.• Kuan T, Tsou J, Su F,Hemiplegic gait of strokepatients: the effect of using acane pp777-784.• 1999 vol 80, no 8• Andresen EM, et al Performanceof health related qualityof life instruments in a spinalcord population. pp877-885.• Annaswamy T et al, RectusFemoris: Its role in normal gaitpp930-934.• Francis K, Bach J, Delisa J,Evaluation and rehabilitation ofpatients with adult motorneurone disease pp951-963.• 1999 vol 80, no 9• Paolucci S et al Post strokedepression and its role in rehabilitationof inpatientspp985-990.• Emotional and behaviouraladjustment after traumaticbrain injury pp991-997.• Gregson J et al, Reliability ofthe Tone assessment scale andthe Modified Ashworth Scale asclinical tools for assessing poststroke spasticity pp1013-1016.• Said C et al, Obstacle crossingin subjects with stroke pp1054-1059.• Tsuji T et al, Bridging activityas a mode of stress testing forpersons with hemiplegiapp1060-1065.• Kirshblum S et al, Predictorsof dysphagia after spinal cordinjury pp1101.• 1999 vol 80, no 10,• Teixeira-Salmela L et al,Muscle Strengthening and physicalconditioning to reduceimpairment and disability inchronic stroke survivorspp1211-1218.• Niam et al, Balance andPhysical impairments afterstroke pp1227-1233.• McKinley W, Huang M,Brunsvold K, Neoplastic versustraumatic spinal cord injury: anoutcome comparison after inpatientrehabilitation pp1253-1257.• Krassioukov A et al,Quantitative sensory testing inpatients with incomplete spinalcord injury pp1258-1264.• Connolly J et al, Globalaphasia: An innovative assessmentapproach pp1309-1316.■ AUSTRALIAN JOURNALOF PHYSIOTHERAPY• 1999, vol 4, No 3• Mackenzie-Knapp M, Casereport: electrical stimulation inearly stroke rehabilitation ofthe upper limb with inattentionpp223-227.■ BRITISH JOURNAL OF ■■ OCCUPATIONAL THERAPY• 1999, vol 62, No 7• Jackson T, Dyspraxia guidelinesfor interventionpp321-326.• 1999 vol 62, no 12• Stern H, Jeaco S, Millar T,Computers in neurorehabilitation:What role do they play?Part 1 pp549-553.• 1999 vol 62, no 10• Curtain M, An Analysis oftetraplegic hand grips pp444-450.■ BRITISH JOURNALOF THERAPY ANDREHABILITATION• 1999 Vol 6 No 7• Patel S, and Taylor L, Onlyhalf the world: hemianopia orneglect pp327-330.• 1999 vol 6, no 8• Morris J, The effects ofimmobilisation on the musculoskeletalsystem pp390-393.• 1999, vol 6, No 9• Horton S, Improving a servicefor dysphasia through consultationpp424-429.• Glenwright, S,Communicationand aphasia: A case studypp430-435.• Ward AB, Botulinum toxin inspasticity management pp447-452.• Watson MJ, Horn SA, BAWilson Assessing a minimallyresponsive brain injured personpp436-441• 1999 vol 6, no 11• Scullion P, ‘Equipoise’ and thenecessity of research pp528-533.■ BRITISH MEDICALJOURNAL• 1999, No 7205• Jorgnsen HS, Predictedimpact of intravenous thrombolysison prognosis of generalpopulation of stroke patients:simulation model pp288.■ CLINICAL REHABILITA-TION1999 vol 13, no 5• Pandyan AD et al, A review ofthe properties and limitationsof the Ashworth and modifiedAshworth Scales as measures ofspasticity pp373-383.• Hesse A et al, Gait pattern ofseverely disabled hemipareticsubjects on a new controlledgait trainer as compared toassisted treadmill walking withpartial body weight supportpp401-411.• Taylor P et al, Patients’ perceptionsof the Odstock DroppedFoot Stimulator (ODFS) pp439-446.• 1999 vol 13, no 6• Schonherr MC et al, Functionaloutcome of patients with spinalcord injury: rehabilitationoutcome study pp457-464.• Sanchez-Blanco et al,Predictive model of functionalindependence in stroke patientsadmitted to a rehabilitationprogramme pp464-476.• De Souza LH, The developmentof a scale of the Guttmantype for the assessment ofmobility disability in multiplesclerosis pp476-481.• Hellstrom K, Lindmark B, Fearof falling in patients withstroke: a reliability studypp509-517.■ PHYSICAL THERAPY• 1999, vol 79, No 9• Blanton S, Wolf S, An applicationof upper extremityconstraint induced movementtherapy in a patient with acutestroke pp847-853.• 1999, vol 79 No 10• Freburger J, An analysis ofthe relationship between theutilisation of physical therapyservices and outcomes forpatients with acute strokepp906-918• Brown DA, Kautz S, Speeddependent reductions of forceoutput in people with poststroke hemiparesis pp919-930• Riddle DL, Stratford PW,Interpreting validity indexes fordiagnostic tests: An illustrationusing the Berg balance testpp939-948.■ PHYSIOTHERAPY• 1999 vol 85, no 8• Barnes S et al, Developmentand inter-rater reliability of anassessment tool for measuringmuscle tone in people withhemiplegia after stroke pp405-409.• Parry R, Lincoln N, AppleyardM, Physiotherapy for the arm andhand after stroke pp417-425.• 1999 vol 85, no 9• Lettinga AT, Siemonsma PC,Veen van M, Entwinement oftheory and practice in physiotherapy:A comparative analysisof two approaches to hemiplegiain physiotherapy pp476-490.• 1999 vol 85, no 10• Richardson D, Thompson AJ,Botulinum toxin: It's use in thetreatment of acquired spasticityin adults pp541-551.• Carriere B, The 'Swiss ball': Aneffective tool in physiotherapyfor patients, families and physiotherapistspp552-561.• 1999 vol 85, no 11• Watkins C, Mechanical andneurophysiological changes inspastic muscles: Serial castingin spastic equinovarus followingtraumatic brain injury pp603-609.■ PHYSIOTHERAPYCANADA• 1999, Vol 51, No 3• Stevenson T, Using impairmentinventory scores todetermine ambulation status inindividuals with stroke pp168-174.■ PHYSIOTHERAPY THEORYAND PRACTICE.1999 vol 15, no 2• Maki B, McIlroy W, Control ofcompensatory stepping reactions:Age-related impairmentand the potential for remedialintervention pp69-90.• Vandervoort A, Ankle mobilityand postural stability pp91-104.• Skelton D, Dinan S, Exercisefor falls management: Rationalefor an exercise programmeaimed at reducing posturalinstability pp105-119.1999 vol 15, no 3• Brosseau L et al, Intra andinter-rater reliability and factorialvalidity studies of thePhysiotherapy FunctionalMobility Profile (PFMP) in acutecare patients pp147-154.• Swaine B, Sullivan SJ,Interpreting reliability of earlymotor function measurement followinghead injury pp155-164.■ SCANDINAVIANJOURNAL OF REHABILITA-TION MEDICINE• 1999 vol 31, no 4• Hummelsheim H, Eickhof C,Repetitive sensorimotor trainingfor arm and hand in a patientwith locked-in syndrome pp250-256.■ SOCIAL SCIENCE ANDMEDICINE• 1999 vol 42, no 2• Bradley E et al, Goal settingin clinical medicine pp267-278.• 1999 vol 42, No 6• Low J, The impact of strokeon informal carers: a literaturereview pp711-726.• 1999 vol 48• Albrecht G, and Devliger P,The disability paradox: Highquality of life against all oddspp977-980.• Bickenbach J, et al Models ofdisablement, universalism andthe international classificationof impairments, diseases andhandicaps pp1173-1187.• Agree E, The influence of personalcare and assistive deviceson the measurement of disabilitypp427-443.■ SOCIOLOGY OF HEALTHAND ILLNESS• 1998 vol 20, no 4• Pound P et al, Illness in thecontext of older age: The caseof stroke pp489-507.1998 vol 20, no 6• Cott C, Structure and meaningin multidisciplinary teamworkpp848-873.• 1999 vol 21, no 5Cox S, McKellin W, There’s thisthing in our family: Predictivetesting and the construction ofrisk for Huntington’s Disease.(Special issue on sociologicalperspectives on the newgenetics) pp622-646.• 1999 vol 21, no 6• Williams S, Is anybody there?Critical realism, chronic illnessand the disability debatepp797-819.1617

ACPIN NEWSACPIN NEWS■N THE WOOLF REPORT:MEDICO-LEGAL UP-DATELouise Gilbert MCSPACPIN Executive CommitteeIn July 1999 the Medico-LegalAssociation of CharteredPhysiotherapists held theirSummer Meeting. The topic ofthe evening was to give an updatefor physiotherapistsacting as expert witnesses followingthe introduction of newprocedural rules in April 1999.Mr Jeremy Hyam (LLB) wasinvited as the guest speakerand some of his main discussionpoints as to the duties ofthe physiotherapist expert andthe impact of the new civilprocedural changes areaddressed below.The two main categories inlitigation where evidence froma physiotherapist is likely to becalled are medical negligenceand personal injury. Both ofthese fields are now subject tonew procedural rules whichaffect duties of the expert tothe court and to the parties tolitigation.It is important to note thatan expert witness should neverassume the role of advocate.The duties and responsibilitiesof the expert witness are topresent expert evidence and toprovide independent assistanceto the court by way of objectiveand unbiased opinion inrelation to matters withinhis/her expertise.The New Civil ProceduralRules, the result of LordWoolf’s Access to Justice reportcame into force on 26th April1999 and apply to all civilcases. The duties of the expertwitness are given a slightly differentaspect with theintroduction of the new recommendations.Some of the mainrecommendations are summarisedbelow:■ That as a general principle asingle expert should beappointed wherever the caseconcerns a substantiallyestablished area of knowledge.■ Where opposing experts areappointed they shouldadopt a single co-operativeapproach including if possiblejoint investigation anda single report.■ Meetings between expertsadvising opposing partiesshould normally be held inprivate.■ The court should have awide power to order that anexamination or test shouldbe carried out and a reportsubmitted to the court.■ Training courses and publishedmaterials shouldprovide expert witnesseswith a basic understandingof the legal system andtheir role within it,focussing on the expert'sduty to the court.The expert must be aware ofthe relevant legal principleswhich the court applies inmedical negligence/personalinjuries cases. Firstly, the standardof proof is the balance ofprobabilities ie more likelythan not. Secondly, whereexpert evidence is involved,the 'Bolam test' is applied forjudging whether there hasbeen a breach of duty. TheBolam test applies to the standardof care expected of aprofessional in cases of allegednegligence ie that of 'the reasonableprofessional manfollowing the acceptedapproved standard of care'(Dimond 1999 p102). Thirdly,if breach of duty is proved, andthat breach has caused the relevantinjury, then the Plaintiffis entitled to compensation.The legal principle is thatdamages are awarded to putthe victim of the civil wronginto the position he wouldhave been had the wrong notbeen committed.The physiotherapist expert isusually called upon inassessing and quantifying anappropriate care regime. Alsoin giving an opinion as to thepatient's future care needswhich is usually quantified byassessing annual cost of care.The expert's report mustcomply with the requirementsset out in the practice direction.The main requirements forthe form and content of thereport are:■ Expert evidence should bean independent product ofthe expert. The report mustcontain details of theexpert's qualifications.■ The report should beaddressed to the court andnot the party from whomthe instructions arereceived.■ Opinion should be objectiveand unbiased and in relationto matters within his/herexpertise.■ It should state the facts orassumptions upon whichhis/her opinion is based.Details must be given of anyliterature or materials usedwithin making the report.■ Where there is a range ofopinion on the mattersdealt within the report therange of opinions must besummarised and reasons forthe expert's own opiniongiven.■ If the opinion is not properlyresearched becauseinsufficient data is consideredavailable, then thismust be stated with an indicationthat the opinion isno more than a provisionalone.■ A summary of conclusionsreached should be given.■ It should contain a statementthat the expertunderstands his duty to thecourt and has complied withthat duty.■ It should state the substanceof all materialinstructions (oral andwritten) on the basis ofwhich the report waswritten.■ The report must be verifiedby a Statement of Truth. TheCivil procedure Rules (CPR32.14(2). highlight that: Aperson who makes a falsestatement in a documentverified by a statement oftruth, or who causes such astatement to be made,without an honest belief inits truth, is guilty of contemptof court.The obvious change is theappointment, where possible,of a sole expert. The new rulesalso restate that the expert'soverriding duty is to the courtand not the parties. Two of themain aims of the new rules areto remove any unnecessary systematicbias and hopefully tohelp speed up the legal processand prevent long litigationdelays. An expert's evidence isbased on his/her own training(both academic and practical)and experience in a particularfield. It is the court's responsibilityto assess whether anygiven expert has the requisiteexperience and competence tobe of assistance.The physiotherapist actingas an expert witness mayincreasingly be instructed as ajoint single expert. It is importanthowever, to consider, areyou the right expert? The CSPhas laid down guidelines andcriteria for the role of expertwitness and also has a list ofexpert witnesses and areas ofspeciality. It is recommendedfor example that an expertwitness should have beenworking within the specialityconcerned for five years,should be a senior I or higher,should have credibility withpeers and some form of legaltraining. For further informationon guidelines and trainingcourses please contact PenRobinson, Director ofProfessional Affairs, at the CSP.ACPIN would be interested inyour comments and in hearingfrom any members who are currentlyinvolved in preparingreports.ReferenceDimond, B 1999 Legal Aspectsof Physiotherapy BlackwellScience UK■N CSP ANNUALREPRESENTATIVECONFERENCE 2000Eastbourne, 4-6 May 2000Nicola Hancock PROThe following motion was submittedto the ARC agendacommittee at the CSP onbehalf of ACPIN, after suitablediscussion at committee meetings:‘This conference demands thatthe CSP should impose morestringent regulations on thosemembers acting as so-called'expert witnesses' in legal cases,to ensure that only highly competentand experiencedtherapists act in this capacity.ACPIN has anecdotal evidencethat therapists withinsufficient knowledge andexperience in the field of neurologyhave submitted legalreports and provided testimony’The explanatory noterequired for the submissionprocess read as follows:‘ACPIN is extremely concernedat reports from senior membersof less than highly experiencedtherapists providing expert testimonyin legal cases. Whilst werecognise rules 1-8, scope ofprofessional practice, addresssuch issues, clearly somemembers are less than diligentin these circumstances.The Society must legislateagainst this and, as aminimum, ensure that any disciplinaryaction taken againstsuch therapists results in a'guilty' verdict. In an age ofclinical governance and withincreasing litigation, this issueof professional accountabilitymust be urgently addressed.’Unfortunately, we receivednotification that the motionwas ruled ‘inappropriate forCongress’, from PenelopeRobinson, Director ofProfessional Affairs at the CSP.I have decided to quotedirectly from her letter so thatall ACPIN members have thefullest information available onthis issue. She writes, ‘TheSociety sets standards forexpert witnesses in respect ofboth professional and legalstanding. A full CV is requestedbefore a persons’ name goes onthe list. As with all members,the Society is not a policingbody but will act on complaintsreceived. If you haveevidence of a member actingoutside their area of expertise,this information should be forwardedto the Society and aninvestigation will take place.Also, we cannot stop anymember acting as an expertand in whatever capacity, ifrequested to do so. I am awareof members with little or noexpertise agreeing to act inthis way and I have grave concernsabout this, but theSociety only has sanctions onthose on the expert witnesslist’.It is therefore clear that theCSP recognises the issue andadmits to having ‘grave concerns’but feels unable to actfurther. The ExecutiveCommittee would be delightedto hear from any members whohave thoughts on this issueand would ask that you contactNicola Hancock, PRO, as soonas possible.Please also note that anymembers who wish to havefuture involvement in ARC onbehalf of ACPIN are activelyencouraged to contact theCommittee.■N EMERGENCYRESPIRATORY CARECherry KilbrideACPIN SecretaryA meeting was called at theCSP by the respiratory specialinterest group (ACPRC) todiscuss the growing concernsaround on call/emergency respiratorywork. In addition torespiratory specialists, representativeswere also there frompaediatrics, management, communityand neurology. It waschaired by Gwyn Owen, CSPProfessional Advisor. It wasessentially a brain stormingand sharing of ideas/experiencesforum. It was clear fromall there that there was acommon concern re competencyof on-call rota staff. Thiswas especially so for thosestaff working in musculoskeletalor less acutesettings. Another area of discussionwas the managementand teaching of carers of suchtechniques as suction in thecommunity. This being obviouslypertinent to the longterm care of Multiple Sclerosisand Motor Neurone diseasepatients.The session was thought tobe successful in raising manyissues which Gwyn is to takeforward in conjunction withthe relevant parties. ACPINawaits further communicationand will keep you updated viafuture issues of Synapse.1819

SYNAPSE ● SPRING 2000ACPIN NEWS■N THE STROKEASSOCIATIONCherry KilbrideACPIN SecretaryLast year ACPIN were delightedto have been invited to beinvolved in the planning of ateaching module to be used aspart of a wider training programmefor staff who work inresidential/nursing homeslooking after clients who havehad strokes. The aim of themodule was to increase theawareness of movement problemsarising from stroke andpossible complications iepainful shoulder.Areas covered in the programmeinclude aspects ofpositioning, seating, care ofthe arm and formulation of a‘mental check list’ for potentialmovement difficultiesduring transfers or walking. Anemphasis was placed on NOTteaching any aspects of manualhandling – for obvious reasons.This programme is still in pilotform but ACPIN will keep youinformed of the eventualoutcome.■N NATIONAL CLINICALGUIDELINES FORSTROKERalph Hammond MCSPProfessional Adviser, CSPThe Royal College of Physiciansin London is soon to publishNational Clinical Guidelines forStroke. They cover the managementof patients with acutestroke from the onset, throughrehabilitation to the longerterm.This report outlines whatclinical practice guidelines are,how these particular guidelineswere developed, and aims toencourage readers to get hold ofa copy when they are published!DEVELOPMENTThese National ClinicalGuidelines have been developedby the Intercollegiate WorkingParty for Stroke, co-ordinated bythe Clinical Effectiveness andEvaluation Unit of the RoyalCollege of Physicians. TheIntercollegiate Working Party(IWP) is a multi-professionalgroup representing a wide rangeof professionals who providecare for people who have had astroke. The CSP has had a representativeon this group since itsformation, Margaret HastingsFCSP. Previous work produced bythe IWP has been OutcomeIndicators (Lennon, Hastings1996), and the NationalSentinel Audit of Stroke (Rudd1999).The guidelines have takennearly two years to develop.Work originally started in April1998. The Department of Healthprovided funding for the guidelinedevelopment, however theworking party was independentof the Department. The guidelinesare currently beingappraised for endorsement bythe National Institute forClinical Excellence (NICE).WHAT ARE CLINICALPRACTICE GUIDELINES?Clinical practice guidelines are‘systematically developed statementsto assist practitioner andpatient decisions about appropriatehealthcare for specificclinical circumstances’ (FieldMJ, Lohr KN 1992). They formpart of the evidence base fromwhich practitioners work. Theyare written on a carefullydefined topic and, after a systematicsearch, use the bestavailable evidence. They shoulddefine the search strategy, referencesused, the reasoning forhow the recommendation waswritten, and provide a gradingof the strength of the recommendationand the quality ofthe evidence.Guidelines aim to facilitateevidence-based practice, andcommissioning. They attemptto draw together all relevantresearch on the topic, considerconflicting research, and makerecommendations to help theclinician and the patient makedecisions about treatmentoptions. They are statements toinform clinicians, but not rigidrules. Clinicians still have todecide if the guideline is appropriatefor a specific patient(recognising, for example,multi-pathological states) andhow to use the guideline inindividual cases. Guidelines canalso be used to make a case forthe provision of a treatment.The process of development ofthe guideline can help to spotgaps in research literature andprovide pointers to whereresearch needs to be undertaken.PHYSIOTHERAPYREPRESENTATIONSheila Lennon MCSP and RalphHammond MCSP were the physiotherapyrepresentatives onthe working party, on behalf ofthe CSP. Margaret Hastings FCSPwas the original representative,she resigned in late 1998, nominatingRalph as her successor.The other members of theworking party (which numbered32) include representativesfrom patient and carer groups,(the College of Health, StrokeAssociation, Different Strokes),the medical, therapy, andnursing professions, (RoyalColleges), public health, andsocial services. Members wererequired to liaise with their professionalbody at all times, andwith anyone else they feltappropriate. Accordingly, aphysiotherapy working partywas set up to help with thephysiotherapy-specific element.This included: Ms AmandaArcher MCSP (on behalf of theAssociation of CharteredPhysiotherapists in theCommunity, ACPC); Dr AnnAshburn MCSP (ACPIN); MrsSuzanne Hogg MCSP (CharteredPhysiotherapists Working withOlder People, AGILE); Mrs SueIrani MCSP (ACPIN); Ms LouiseJohnson MCSP (AGILE).The guidelines were peerreviewed. The physiotherapypeer reviewers were: Mrs AntheaDendy MCSP (collating commentsfrom ACPIN members); DrAnne Forster MCSP; Dr ValPomeroy MCSP; Ms Judy MeadMCSP (Head of ClinicalEffectiveness CSP).EVIDENCE GATHERINGThe main author is ProfessorDerick Wade, who is the authorof the Epidemiologically-basedHealth Needs Assessment forAcute Cerebrovascular Disease.Evidence to underpin the guidelineswas obtained in manyways. The literature search consistedof systematic searches ofcomputerised databases(Medline, 1966, AMED, 1985,CINAHL, 1982, Embase, 1988).The Cochrane Collaborationdatabase was used, and othernational guidelines reviewed(eg Agency for Health CarePolicy and Research (ACHPR)1995, Scottish IntercollegiateGuidelines Network (SIGN)1997, 1998).Given the huge number ofjournals needing to besearched, hand searching wasnot undertaken. However theCochrane database of trials wasused. This includes informationfrom hand searched journals.Prime evidence was taken fromresearch specifically relating tostroke. In many areas thelimited research available wasless specific, but still relevant,and so some studies includepatients with other, usuallyneurological, diseases.WHY DEVELOP THESE GUIDE-LINES?The major stimulus to developthe guidelines was the burdenof stroke on the NHS. Strokeconstitutes over 4% of NHSexpenditure, is the thirdhighest cause of death in theUK, and the biggest singlecause of major disability (Wade,et al 2000). There was alsoconcern that standards ofservice vary widely around theUK, and this has been confirmedby the Clinical StandardsAdvisory Group report (CSAG,1998), and the NationalSentinel Audit of Stroke (Ruddet al 1999). This latter reportshowed that less than half ofall Trusts have stroke units, andthat patients are managedbetter within stroke units (Ruddet al, 1999).PURPOSE OF THE GUIDELINESThe aim is to provide cliniciansand managers with explicitstatements, where evidence isavailable, on the best way tomanage specific problems. Localservices will need to add detailto these statements, and adviceis given on this. They arecentred on the more commonclinical problems faced in dayto-daypractice, and areintended to be used by all professions,in all settings, and atall points in the management ofthe patient following a stroke.The underlying principles arethat they should address issuesin stroke management that areimportant, draw on publishedevidence wherever possible,indicate areas of uncertainty orcontroversy, and be useful andusable.Each recommendation is classifiedaccording to the level andgrade of evidence used. Levelsof evidence were gradedaccording to a standard classificationhierarchy: meta-analysisof randomised controlled trialsas level 1, well-designed, controlledstudies level 2,non-experimental descriptivestudies level 3, and expert committeereports etc at level 4TOPICSThe guidelines are divided intotypical patient problem areas.Within this framework the evidencepublished is oftenpertinent to several areas. Soyou have to read the wholedocument! The first chapter isfrom a report on patients’ andcarers' focus groups, conductedby the College of Health,making recommendations onareas such as service development,knowledge of staff,shared decision-making, informationonce at home.The rest is divided into 3 sections:■ 1. Service provisionTerminologyService organisationApproaches to rehabilitationCarers and Families■ 2. Clinical careAcute diagnosisAcute interventionsEarly disability assessmentand managementRehabilitation interventionsTransfer back to theCommunityLong term management■ 3. Service EvaluationTopics of more immediateinterest to clinical physiotherapistsinclude motor impairment,spasticity, sensory impairment,functional rehabilitation interventions,activities of dailyliving, equipment and adaptations,and treatment followingdischarge.CONCLUSIONThe Royal College of Physiciansis soon to publish NationalClinical Guidelines for Stroke.These have been producedunder the auspices of theIntercollegiate Working Partyfor Stroke. They make recommendationsbased on clinicalresearch to help clinicians andpatients make decisions aboutinterventions. They are not rigidand will be updated as new evidenceis published. They will bea useful source of informationfor all physiotherapists involvedin the delivery of care forpatients who have had a strokeand their carers.The National Clinical Guidelinesfor Stroke will be available fromthe Publications Department,The Royal College of Physicians,11 St Andrew's Place, LondonNW1 4LE. Price £20. Tel: 0207935 1174; Fax: 020 74873988.REFERENCESPost-stroke rehabilitation andclinical practice guidelines(1995) no16 Agency forHealth Care Policy andResearch USA1998 Clinical StandardsAdvisory Group Report on clinicaleffectiveness using strokeas an example. The StationaryOffice, London.Field MJ, Lohr KN eds (1992)Guidelines for Clinical Practice:From Development to UseWashington, DC: NationalAcademy Press.Lennon S, Hastings M (1996)Key physiotherapy indicators forquality of stroke carePhysiotherapy 82,12, 655-661Rudd AG et al (1999) Thenational sentinel audit ofstroke: a tool for raising standardsof care Journal of theRoyal College of Physicians inLondonWade DT & The IntercollegiateWorking Party for Stroke (2000)National Clinical Guidelines forStroke The Royal College ofPhysicians, LondonScottish IntercollegiateGuidelines Network (1997)Management of patients withstroke: 1: Assessment, investigation,immediate managementand secondary prevention No 13SIGN, EdinburghScottish IntercollegiateGuidelines Network (1998)Management of patients withstroke: IV: Rehabilitation, preventionand management ofcomplications, and dischargeplanning No 24 SIGN,Edinburgh2021

SYNAPSE ● SPRING 2000CONGRESS REVIEW■N UNITED KINGDOMACQUIRED BRAININJURY FORUM(UKABIF)Louise GilbertACPIN Executive CommitteeThe annual Conference andgeneral meeting was held atThe Royal Hospital for Neurodisabilityin Putney on 27thNovember 1999. This was amultidisciplinary day with awide variety of delegates.In the morning Dr. KeithAndrews gave a critique of theRoyal College of SurgeonsWorking Party Report on 'TheManagement of People withHead Injuries'. This report waspublished in June 1999. Theaims of the report were toestablish current practice,identify deficiencies in the provisionof services and makefuture recommendations tocorrect deficiencies andmonitor outcome. Some interestingpoints were madeincluding the fact that over50% of patients are managedby general surgeons, manyunits have no on-site neurosurgicalfacilities with 15% ofunits being over 50 miles away.Only 50% of surgeons havespecialist training in HeadInjury management and yettwo thirds are expected to carefor patients long term. Up to30% of orthopaedic surgeonsare caring for head injurypatients, yet again only 40%have specialist training. Only50% of neurosurgeons reviewedhad protocols for Head Injurypatients.Some of the main recommendationsare that A&Edepartments should establish aclose relationship with aNeuroscience Unit and in allbut exceptional cases patientsneeding neuroscience inputshould be referred to that unit.Each A&E department shouldhave adequately resourcedshort stay facilities for patientsfor the first 48 hours. Also,local policies consistent withnationally agreed guidelines,must be developed with thelinked neuroscience unit onappropriate management ofpatients. There are seen to beweaknesses within the reportin that there are enormousresources to be found with noattempted costing of implication.There is at present ashortage of facilities and only50% of needed consultants,with many private Brain InjuryUnits are closing due to lack offunding. The strengths of thereport however are that thereis recognition of a problemwith the need for an integratedservice noted and in theprocess of implementation.Dr Anthony Rudd from theRoyal College of Physiciansreported on the National StrokeAudit. This working Party wasset up to identify variations inthe organisation and deliveryof care and to promote consistencyof care for patients.Within the UK, 206 hospitalswere audited on 40 consecutivepatients admitted with adiagnosis of CVA (from 6894patients.). The results showedhow haphazard care is atpresent. Only 50% of patientshad access to specialist stroketeams, 64% to a specialist consultantand 29% to a clinicalpsychologist. Documentationof care was noted to be particularlypoor, for example only40% of patients were noted tohave had weight assessed, 55%had assessment of swallownoted and 23% of patients hadcognitive function noted to beassessed. There was also poordocumentation of disability,handicap and carer needs. It isof interest to note that when50% of care was provided on astroke unit that the process ofcare was significantly better invirtually all respects comparedto general wards or genericrehabilitation wards. Regionalvariances were seen in outcomes.However results areviewed with some caution asthey can be interpreted in differentways. Results of theaudit provide good evidencefor future funding andresources and development ofstandards and benchmarks ofcare. It was discussed thatIntegrated Care Pathways aremaybe not helpful in the caseof CVA due to the variability ofthe disease. The team is atpresent attempting to developrecovery curves where outcomeand recovery is predicted fromindividual input of patientvariables. This will hopefullylead to individual care pathwaysin the future.Also during the day the LordWoolf spoke about 'Access toJustice' and his recent reformsin the litigation process and DrSimon Fleminger discussed evidence-based practice inacquired brain injury.Overall the day was veryinformative and highlightedmany of the difficulties inpatient care throughout theUK. It also gave many positivevisions of, hopefully, a betterfuture.■N USEFUL WEBSITESFOR NEURO-PHYSIOTHERAPYIt has been suggested thatidentifying websites appropriateto neurophysiotherapywould be helpful. If you haveany addresses that you finduseful, please let us know.1. OUTCOME MEASURESRELATED TO SPASTICITYhttp://wemove.org/spa_pal.html#a_cgs2. CSP OUTCOME MEASUREDATABASEhttp://www.nice.org.uk• click on 'databases' (top,centre icon)• click 'search online'• Search for: put in key worde.g stroke or to see the wholedatabase key in 'csp'• Search categories: tick –'Title', 'Abstract', 'Keywords'• Database: tick –'Bibliography'• Date: 'until' '1999'• Results: tick – 'simple'When you see the wholemeasure you are interested in,double click on the 'title' andthe whole record will beexpanded.3. TRAUMATIC BRAIN INJURYMODEL SYSTEMS NATIONALDATABASEhttp://www.tbims.org/to/database.htmlThis site contains extensiveinformation on 1051 cases, andannual follow up informationextending to ten years postinjury.■C A NEW BEGINNINGCSP ANNUAL CONGRESS ANDTRADE EXHIBITIONNeurophysiology and ClinicalPracticeRos WadeACPIN Events GroupThe new format of theChartered Society ofPhysiotherapy (CSP) annualcongress, A New Beginning,took place at the InternationalConvention Centre inBirmingham in October 1999.The CSP joined together withseven special interest groupsand keynote speakers to run aconference with concurrentlecture programmes, discussionsand supported by thelargest trade exhibition for aphysiotherapy function.The keynote speakers wereMr Simon Eisberger, ManagingDirector of Cellnet, who spokeon 'Promoting a Global Brand'and Mr Chris Moon MBE whospoke on ‘Motivation’.ACPIN’s programme, bringingtogether a clinical and academicfocus to our speciality,was supported by highlyacclaimed speakers. I wouldlike to take this opportunityagain to thank each one fortheir presentations and theirsupport for ACPIN. It was anexciting programme and promotedmuch discussion.ACPIN was allocated alecture hall for 300 delegates.From our previous conferenceit had been requested not toallow delegates late entry intolectures. Inevitably this didcause some difficulties and Ican only apologise to thosepeople who missed a lecturedue to this. Next year all lectureswill be open. There werealso some problems with AVAwhich again hopefully will beaddressed for next time.However, overall the programmeworked well and thefeedback on the content of thetalks was positive. All ACPIN’stalks were well supported, sothank you too for your support.And then there was theCongress dinner. I won’t sayanymore, except that next yearACPIN and other SIGs will beholding their own meetings onthe Saturday night!Putting together the programme,planning andco-ordinating the conference,even down to chairing the sessionsin front of 300 people (!)has been a major learningexperience for the Executivecommittee. It has required agreat deal of time andinevitably we made mistakes.However, I think overall, mostpeople who attended the newformat Congress would agreethat it was a highly professionalevent and this certainlyis the way forwards for promotingphysiotherapy into thenext century.And so to next year. The CSPAnnual Congress and Tradeexhibition will be held again atthe International ConventionCentre, Birmingham fromOctober 20th-22nd. The title is‘Expanding Horizons’; and withthis in mind ACPIN have againhad a programme acceptedentitled ‘Neurophysiotherapy:The CNS and Beyond’. Again,we are extremely grateful tothe speakers who have agreedto support the programme. Fulldetails are on page 25 and abooking form appears on pages45 and 46. Again there will beconcurrent lecture programmesfrom SIGs, and the support of alarge trade exhibition.Sir Ranulph Fiennes will bethe only keynote speaker, andwill present the Founderslecture on the Saturdaymorning.Socially, the welcome receptionon the Friday is to beextended, and then the SIGsand Congress dinner will beheld on the Saturday. ACPINhave organised a buffet at theNovotel hotel, so you can comealong, eat, drink and relaxwhilst discussing the majorpoints of the day!It is important to note thatthe Motor Show will be on inBirmingham the same weekendand therefore accommodationwill be limited; so book early.Note the early booking fee of£135.00 before 31 May 2000.We look forward to seeingyou there!■C CONGRESS REPORTLouise RogersonSenior 1 physiotherapistBurton House RehabilitationCentre, Manchester.On entering the impressiveInternational ConventionCentre building in Birminghamyou were greeted by promotionalinformation for thegeneral public and a large spaciousarea for registration. Thewhole system was very wellorganised and you were givenan extensive welcome packincluding business cards, a freebag and a pen! The lectureroom for ACPIN was veryimpressive although a littlesmall on occasions with thelarge numbers attending.The opening lecture by professorRaymond Tallis wasentertaining, informative, andchallenging which seemed toset the tone for the weekend,with excellent presentationtools and informative content.The set lectures over the wholeweekend were highly informativeand quite inspirational,reminding us all that researchis going on, and that our practiceis continually beingappraised and developed, basedon the evidence.The free paper sessions wereboth cerebrally and cardiovascularlychallenging – firstlydeciding which lecture toattend, and secondly could yourun fast enough to get to thetheatre in time for it to start!Once again the presentationformats were excellent andcould be clearly seen by all.Overall, the weekend was runin a very professional manner,the lectures were well introducedand sessions ran to timeas planned. The content wasvaried and interesting, andmost importantly seemed to2223

SYNAPSE ● SPRING 2000ADVERTISEMENTdeliver what the title promised.I am sure that all the delegateswould join me in a bigthank you to all the committeemembers of ACPIN for all theirhard work and planning – itcertainly paid off! Of course,the standard is set now –you’ve got a lot to live up toACPIN!ABSTRACTS &LECTURE NOTES■C PLASTICITY OF THENERVOUS SYSTEM ANDTHE FUTURE OF NEURO-PHYSIOTHERAPYProfessor Raymond TallisThere is increasing evidencethat rehabilitation is effectivefollowing stroke. Manypatients, however, still remainsignificantly disabled. The artof stroke rehabilitation is,therefore, relatively undevelopedas a science. We have noclear idea of the elements ofthe rehabilitation package thatbring about the benefits thatare seen and even less evidenceabout the respectivemerits of the particular techniquesof remedial therapy.Many of these have anywaygrown up as a result of customand practice rather than beingfully grounded in what isknown about the damagedbrain and ways in whichrecovery might be promoted.The talk will focus on waysin which stroke rehabilitationin future may be made moreeffective. Several strategieswill be considered but the mainemphasis will be on reversingimpairments, either by buildingon elements of current techniquesidentified by rigorousstudies as effective or, andmore importantly, by developingnew techniques designedto drive neuroplasticity.Current understanding aboutthe ability of the brain to reorganisein response to damageand, more widely, the ability ofexcitable tissue (brain, nerve,muscle) to respond to externalstimuli in ways that may beuseful for neurological rehabilitationwill be discussed. Thecentral role of appropriateafferent information inenhancing desirable plasticchanges and inhibiting maladaptiveones will be discussedand their application illustratedwith examples. Thevalue of using simpler modelssuch as the reversal of musclewasting will be emphasisedand examples will also be givenof the process of driving plasticityin the cerebral cortex.The huge effort that will berequired to bring neurotherapyclose to neuroscience hasimplications for the organisationof research. These, too,will be discussed. As stroketherapy becomes more scientific,other elements of humanecare will not become lessimportant. Just as an appeal to‘holism’ should not be used tojustify an unscientific,approach to therapy, theadvent of scientific treatmentsshould not excuse forgettingholistic care.Professor Tallis is Professor ofGeriatric Medicine at theUniversity of Manchester andan Honorary ConsultantPhysician in Geriatric Medicinewith Salford Royal HospitalsNHS Trust. He is the author ofover 150 medical publications,but has also published andbroadcast extensively on nonmedicaltopics. He wasawarded an Honorary Doctorateof Letters for his contributionsto literature and philosophy in1997.■C THE ROLE OFCENTRAL PATTERNGENERATORS INWALKINGDr Pam Evans BA, MCSP, Dip TPThe presence of spinal centrescapable of independently generatinglocomotion was firstdemonstrated in cats in 1947.Much of the early work whichfollowed was concerned withexamining the autonomy andthe flexibility of these ‘centralpattern generators’ (CPGs) indifferent species.With the growth in understandingof the cellularmechanisms underlying biologicalfunction came furtheropportunities to investigatehow the generators mightwork. It became possible tostudy the circuitry of CPGs ofsimple animals and to identifythe behaviour of individualcells within them. Currentlyevidence indicates that thecyclical patterns of locomotionare usually produced byintrinsic characteristics ofpacemaker cells, but that thispattern is reinforced by the circuitryof the network. Suchlayers of reinforcement ensurethe remarkable functional reliabilityof CPGs.Efforts to understand thecomplex networks which makeup mammalian CPGs have concentratedupon theinteractions between the generatornetworks and signalsboth from sensory receptorsand from the locomotor centresin the brain. In recent yearssuch studies have revealed thatCPGs have close, two-way relationshipswith the braincentres and also with thespinal pathways which mediatesensory input and motoractivity. The first reports ofisolated CPG activity in humansfollowing the success of our programme at the 1999 Congress,ACPIN have put together another exciting programme to expandour knowledge both of the CNS and treatment concepts inneurophysiotherapy. We are delighted to have the support of such awide variety of speakers, covering such a range of topics.The conference will again combine concurrent SIG programmes,discussion times and social events. Sir Ranulph Fiennes is the keynotespeaker for the congress and there will again be a large tradeexhibition.ACPIN have organised a buffet supper at the Novotel Hotel, and atonly £10 per head (including a glass of wine) come along, relax anddiscuss the major points of the day!Friday 20th October14.00WelcomeLinzie BassettChair of ACPIN14.05Adaptation of nerve, muscleand soft tissue toImmobilisationProfessor Goldspink15.00Tea15.30The Application of FunctionalElectrical Stimulation (FES)Dr Jane Burridge MCSP16.15-17.00 Neurodynamics-Effect in the NeurologicallyImpaired PatientAnita Wade MCSPSaturday 21st October10.30Coffee11.00The Holistic Approach toAlignmentPatty Shelley MCSPSenior Bobath Tutor11.45-12.30Mulligan Concept: Stability orMobilityAnnette Bishop MCSP16.15-17.30Acupuncture in NeurologicalConditionsVal Hopwood MSc, MCSPThis lecture is jointly supportedby AACP & ACPIN19.30ACPIN Buffet Supper at theNovotel HotelSunday 22nd October9.30Muscle Imbalance in Relationto the Neurologically ImpairedPatient.Dave Fitzgerald Dip Eng,MISCP, MCSP, Grad Dip ManipTher.10.15The Forgotten AutonomicNervous SystemPatty Shelley MCSPSenior Bobath Tutor11.00Coffee11.30The Bobath Concept TodayDr Margaret Mayston, PhD,MCSPDirector of the Bobath Centre12.30CloseLinzie BassettChair ACPIN24

SYNAPSE ● SPRING 2000CONGRESS REVIEWShave also appeared.These experimental observationscould have importantimplications for therapists concernedwith the re-educationof walking. In the short termthey may pose more questionsthan they answer, but somequestions could form the basisof future clinical studies.Pam Evans has wide experienceboth as a clinician and as alecturer. She gained her MSc inphysiology in 1992 and hascontinued to research on apart-time basis in neurophysiologyin the field of motorcontrol. She is also a SeniorLecturer at the Faculty ofHealthcare Sciences, StGeorges Medical School andKingston University.■C THE USE OF THETREADMILL WITHNEUROLOGICALLYIMPAIRED ADULTSCatherine Ann Kendrick GradDip Phys SRP, MCSP.The use of the motorised treadmillwith neurological patientsis a developing field in neurologicalrehabilitation. Itfollows the task orientedapproach to skill acquisitionand can be used either on itsown as an exercise tool or withbody weight support (BWS) tore-educate gait.Many stroke patients arephysically deconditioned andfatigue easily. This furtherlimits functional mobility.Recent studies suggest thataerobic exercise will not onlyimprove cardiovascular functionbut may also improvemotor recovery. (Potempa1995, Macko 1997).The treadmill may thereforebe an appropriate tool toenable patients to exercise aerobicallyand additionallyprovide a task-orientedtraining for gait.Early treadmill studies werecarried out on cats followingspinal cord transection. Theanimals were trained on atreadmill with some of theirbody weight supported in orderto restore gait. (Barbeau1987). Later treadmill trainingwith BWS was shown to beeffective in re-educating gaitafter incomplete spinal cordinjuries (Barbeau 1992). Theanimal and spinal cord studiesboth support the existence ofthe interneuronal circuitsresponsible for locomotion.More recent studies haveinvestigated the use of BWSand the treadmill with earlystroke patients in optimisinggait recovery (Visintin 1998).The research I am currentlyinvolved with is investigatingboth the effects of exercise onfunctional mobility and the useof BWS and the treadmill withchronic stroke patients.The use of the treadmill withneurological patients has manypotential benefits for a varietyof patients but requires furtherinvestigation to clarify its rolein physiotherapy practice.Catherine Ann Kendrick hasin the last year taken on apart-time research post fundedfor two years by the StrokeAssociation to investigate theuse of treadmill training inchronic stroke patients. This iscomplimented by a part-timeclinical position in theRegional Rehabilitation Unit,Addenbrookes Hospital.■C PHYSIOTHERAPY FORPEOPLE WITHPARKINSON’S DISEASE– DESCRIBING UKPRACTICEDr Ann Ashburn, BrendaLovgreen, Diana JonesAn investigation of best practicephysiotherapy inParkinson's disease in the UKhas been undertaken by a teamof clinical and academic physiotherapists.The project aimswere to develop a consensuson service delivery and treatmentframeworks, and providea baseline model of practice toguide future research. Stage Iwas a Delphi survey of specialistphysiotherapists (SeniorI or above and at least 2 yearsexperience working with theclient group, a current caseload).Statements relating tocontext, reasons, actions, andeffects of physiotherapy wererated on a scale of 1-9 byn=49. Specialists (> 20 yearspost qualification; with 1Oyears treating the client group,with 11 patients a month)worked mostly in Care of theElderly (60%). Marked variationwas evident in actual practicecontexts, and early referral wasrare. However there was strongconsensus on the elements ofan optimal context whichincluded early referral, and thereason for physiotherapy – tomaximise functional ability andminimise secondary complicationsthrough movementrehabilitation within a contextof education and support forthe whole person. In theactions domain an eclecticapproach to treatment, withtechniques drawn from a rangeof approaches, was consideredto have the best outcomes.Effects should be measured ata functional level and relate tospecified aims of treatment.Stage 2 involved case studiesof nine best practice sites.Direct case study of three sitesinvolved site visits and face toface interviews with clinicians,managers, multidisciplinaryteam members, patients andcarers. Indirect case study ofsix sites involved telephoneinterviews with clinicians andmanagers. The foci of Stage 2were clinical activity, servicestructure and patient views.Final results in all three areaswill be discussed. The projecthas been sponsored by GlaxoWellcome under the auspices ofthe Parkinson’s DiseaseSociety. Plans to extend theproject into Europe will be presented.Dr Ann Ashburn is a SeniorLecturer in Rehabilitation atthe University of Southampton.She is one of a team of physiotherapistsinvestigating bestpractice for people withParkinson’s disease in the UK.Brenda Lovgreen is a SeniorLecturer at the ManchesterSchool of Physiotherapy. She isa founder member of thePhysiotherapy ResearchSociety.Diana Jones is a ResearchPhysiotherapist at theInstitute of Rehabilitation,University of Northumbria atNewcastle. She will be thephysiotherapist on TheCochrane CollaborationMovement Disorders Groupteam undertaking a review ofthe paramedical professionsand Parkinson’s disease.■C IS SPASTICITY JUSTHYPERREFLEXIA?Dr John Rothwell BA, PhDSpasticity is both the name ofa syndrome (increased tone,increased flexor reflexes andreduced motor performance)and a description of a particulartype of muscle tone. Ishall consider only the latter,and describe to what extentstretch reflexes, increasedbackground muscle contractionand changes in mechanicalproperties of muscle all contributeto the clinicalimpression of increased resistanceto movement.The sensitivity of the stretchreflex is controlled by activityin descending systems from thebrainstem reticular formation.When these are deprived ofinput from the cerebral motorareas, stretch reflexes areenhanced. Classically,enhanced stretch reflexes arethought to interfere with voluntarymovement by, forexample, producing inappropriateactivity in antagonistmuscles during contraction ofthe agonist. However, this maynot be the whole story.Sometimes stretch reflexes areonly enhanced when examinedat rest. Stretch reflexes elicitedduring voluntary movementmay be relatively normal. Theoutcome is that there is littlereflex interference withongoing movement. The mostlikely cause of disordered voluntarymovement is notenhanced tone, but inappropriatelyfocused commands fromthe central nervous system.Finally it is worth consideringthe possible benefits ofincreased muscle tone. It canstiffen the legs to bear weight.In addition, increased reflexfeedback may even be useful tosupplement voluntary contractionsthrough spinal reflexloops.Dr John Rothwell is Head ofMovement Disorders, MRCHuman Movement and BalanceUnit, Institute of Neurology,Queen Square, London. He hastwo areas of special interest;transcranial magnetic stimulationand the pathophysiologyof movement control inpatients with diseases of thebasal ganglia. He is deputyeditor of Brain, NeurophysiologyEditor for ExperimentalBrain Research and Editor forthe Journal of Physiology.■C PHYSIOTHERAPYMANAGEMENT OFESTABLISHEDSPASTICITYSue Edwards FCSPAbstract with additional lecturenotes.Increased tone is a commonmanifestation of neurologicalpathology and is often a keydeterminant of the severity ofdisability. The physiologicaldefinition of spasticity, that of‘a motor disorder characterisedby a velocity dependentincrease in tonic stretchreflexes with exaggeratedtendon jerks’ (Lance 1980) hassurvived for nearly twentyyears and yet has little relevancein clinical practice ormore importantly to thepatient.So what are we treating?Hypertonia is a combination ofboth neural and non-neuralcomponents. The centralnervous system (CNS) knowshow to organise and controlmovements, and so changedmotor patterns should be consideredadaptive rather thanpathological (Latash and Anson1996). Neural aspects of toneare described as positiverelease phenomenon or anacquired response to CNSdamage. The presentation ofhypertonia is different betweengross cerebral pathology suchas in head injury and morelocalised lesions as occurs withcerebrovascular accident. Thereis also a difference betweencerebral and spinal hypertonus.Non-neural aspects of toneinclude the intrinsic stiffness ofthe muscle structure whichoccurs, described asthixotrophy, and stiffness andcontracture in external structuressuch as connective tissue.2627

SYNAPSE ● SPRING 2000CONGRESS REVIEWSTherapeutic approachesdiffer significantly in theanalysis and interpretation ofthe term spasticity. Some viewthe abnormal, neural aspects oftone as being the main causeof the posture and movementdisorder and others, thechanges in muscle and softtissue, that is the non-neuralaspects of tone, as being thekey disabling factor.Increased muscle tone isoften apparent followingcentral nervous system damageand the stereotyped patternswhich invariably result fromthe increased tone contributeto the development ofabnormal movements and postures.What are the general principlesof treatment? Shouldtreatment be aimed at normalisingtone? Positioning andmovement form the basis fortherapeutic intervention.Positioning in bed, in sittingand in standing are essential inmaintaining range of movementand in stimulatingappropriate activity. Equally,passive and active movementsto maintain range, enable thiseffective positioning.Splinting has been shown tobe effective in the maintenanceof muscle and jointrange and yet there is still controversybetween therapists asto the value of splinting forpatients with increased tone.It has been shown that 87% ofpatients with severe or evenmoderate head injury developcontractures.Splinting, therefore, may beused to maintain or regainrange of movement, and can beprophylactic or corrective. Itmay be useful as a means ofassessment for a more permanentdevice. Splinting shouldalways be seen as an adjunctto treatment and the purposeof the splint considered. Forexample, it could be that theuse of a splint distally has apositive effect on proximalcontrol, but in other casts thespasticity is shunted to themore proximal muscles. Somepatients are able to accommodateto the splint, but inothers it just serves as a resistanceagainst which thepatients’ tone is exacerbated.It has also been clearly shownthat muscles which are immobilisedwill atrophy. Theadvantage of splinting is thatit maintains optimal joint position,and removable castsenables treatment of muscleand soft tissues during physiotherapysessions. In additionto the purpose of splintingthere are also implicationsaround whether splinting isconstant or intermittent, whensplinting should take place andfor how long, as well as whatmaterials to use and for whichtype of patient.The use of botulinum toxinas an adjunct to therapeuticintervention has shown positiveresults. It has the abilityto cause prolonged focalmuscle weakness without systemictoxicity, but is noteffective for more widespreadhypertonus. It works byblocking the release of acetylcholineat the neuromuscularjunction (Anderson et al1992), but then recoveryoccurs over weeks and monthsby terminal sprouting whichrestores end-plate neurotransmission(Marsden and Quinn1990).Stereotyped patterns whichresult from increased tone contributeto the development ofabnormal movements and postures.While quality ofmovement is imperative foroptimal function, the restorationof normal movement isoften an unattainable goal inthe presence of CNS damage. Itis important to determine afunctional goal. There must bea balance between re-educationof more normal movementpatterns and acceptance ofnecessary and desirable compensation.The therapeutic skilllies in determining that compensationwhich is necessaryand even essential for functionand that which is unnecessaryand potentially detrimental tothe patient. There is a paucityof clinically based researchstudies and what evidencethere is from studies is notrobust and is often conflicting.Sue Edwards trained at theRobert Jones and Agnes HuntOrthopaedic Hospital,Oswestry, Shropshire, qualifyingin 1971. Throughout hercareer she has specialised inthe management and treatmentof patients with neurologicaldisability. She has lecturedboth nationally and internationallyon many aspects ofneurological physiotherapy,and more recently this hasbeen primarily on the use ofsplinting for patients with neurologicaldysfunction. She wasawarded a Fellowship of theChartered Society ofPhysiotherapy in 1995 and waselected President of ACPIN inMarch 1998. She is the editorand main contributor ofNeurological physiotherapy: aproblem-solving approach whichwas published in June 1996.■C WHAT AREASSOCIATEDREACTIONS?Mary Lynch-Ellerington MCSP,SRPThere follows a transcript fromthe lecture notes.Twitchell (1951), Walshe(1923) and others havedescribed ‘associated reactions’as a phenomena seen aftercerebrovascular accident (CVA)only in the hemiplegic side andalways demonstrating physiologicalsigns associated withpotential hypertonia and henceeventually seen as a pattern ofstereotypical behaviour iehypertonia. Of course, it is alsoknown that associated reactionscan be seen intetraplegia and spinal cordinjured patients. This wasrecognised by Brunstromm(1956), Lazarus (1992),Bobath et al.On investigation of the historicalperspective of the studyof associated reactions it isseen that the history began in1921 and continues to thepresent day. Indeed last yearthe phenomena and discussionregarding its neurophysiologicalbasis between Stephensonet al, Roberta Shepherd andmyself (Physiotherapy ResearchInternational 1998) may welllead to some conclusiveresearch in the near future.Riddoch and Buzzard (1921)appear to be the first authorsto adopt the term 'associatedreactions' using it to describethe uncontrolled motor activityseen in the limbs of hemiplegicand quadriplegic subjects inassociation with voluntarymovements.However, in conjunctionwith making valid observations,the authors alsocontributed to some confusionswhich remain today,despite more recent publishedwork by Dr M Mayston. That isthe authors did not considerassociated reactions to be aphenomenon linked to theaffected limbs of subjects butnoted merely that reactionswere stronger in the hemiplegiclimbs. Many researchersconfuse associated reactionsand associated movements andswitch the terminology.Further definitions havesought to be more precise butagain often leading to confusion.Mulley's definition in1982 has not been accepted byother authors and/or cliniciansas both his own work and thatof others has shown that associatedreactions and voluntarymovement could co-exist in ahemiplegic limb albeit underdifferent environmental controls.Again, although someauthors have utilised Dewald’s1987 definition for theirstudies, notably Dvir et al in1993 and 1996, the referenceto associated reactions beinginvoluntary movements is contentiousand potentiatesfurther confusion between theterms associated reactions andassociated movements.Secondly, no evidence has, asyet, been provided to supportany link between associatedreactions and spasticity andtherefore Dewald’s use of theterm in definition is misleading.Associated reactions,hypertonia and biomechanicalchanges in muscle can all occurin parallel and in somepatients the link betweenthese differing positive aspectsof an Upper Motor Neurone(UMN) syndrome may bestronger than in others.So which definition is themost correct or the most relevantto the present day clinicalpresentation? The Walshe definitioncontinues to be themost frequently quoted. It wasadopted by the Bobath conceptbecause it reflected the clinicalpicture they were studying. TheBobath concept and its currentpractitioners refute any suggestionthat associatedreactions are reflex responsesand therefore predictable andstereotypical. The Walshe definitionwas qualified by thefollowing statement he madeas a result of his study, ‘it isessential in studying associatedreactions that theconditions of examination beconstant. If the conditions arechanged then the resultantassociated reactions mayundergo even more strikingvariations’.Secondly, Dr and Mrs Bobathobserved that voluntary effortwas a key feature of the potentiationof associated reactionsand also that the stronger theeffort, the greater the excursionof the hemiplegic limband/or the stronger the afterdischargecontraction pattern.Walshe’s study supportedtheir observations in that heconcluded that from a range ofstimuli, strong tonic voluntarymuscular contraction of thenormal limbs was the type ofstimulus most effective in elicitingan associated reactionbut he noted that the force ofan associated reaction cannotalways be measured by theactual excursion of a limb.RELEVANT RESEARCHIt is probably because of thenature of considerable variancewithin the manifestation ofassociated reactions that relevantresearch is sparse. Theindividualistic nature of thephenomena prevents studies ofa homogenous group. With twonotable exceptions, theresearch has, therefore, concentratedon studies such as byCornall, Dvir and Panturin thatuse associated reactions as anoutcome measure to evaluateintervention. Using electromyographicstudies (EMG),Dickstein in 1996 concludedthat associated reactions areindeed ‘postural reactions’ thatare triggered by a destabilisingtask eg walking, and generallyinvolve the activation ofmuscles remote from the areaof displacement.Furthermore, Dr Mayston1996 and 1998, in her study onthe neurophysiology of associatedmovements in man,revealed different mechanismsof neural connectivity with significantclinical relevance formanagement.CLINICAL IMPLICATIONSFirstly, associated reactions areseen as a positive response ofan UMN lesion. The delayedand slow emergence of associatedreactions is taken asevidence that they, like otherpositive features of an UMNlesion, are not the simpleunbalancing of excitation andinhibition but involve somefunctional or structuralrearrangement of the centralnervous system ie centralnervous system plasticity,involving collateral sproutingand changes in receptor sensitivity.Secondly, all authors agreethat a contraction of the relevantmuscles is necessary toproduce an excursion of thelimb or body. Some authorssuch as Dvir and Panturin andDickstein refer to associatedreactions as phasic contractionslacking a background ofpostural control ie contractionswithout the necessary stabilisingcomponents (the slowoxidative components). However,repeated contractions caneventually potentiateincreasing changes in musclefibre type from fast glycolitic(fg) to slow oxidative (so).Presumably, though yet to beinvestigated, a posture of thelimb may be held when biomechanicalchanges in muscle andsoft tissue have been potentiated.During twenty five years ofclinical experience the controlrather than the inhibition ofassociated reactions has beena major focus in my interactionswith patients. Associatedreactions are there for areason. They represent, in oneaspect, an element of therecovery of motor function iethey are seen as a positiveaspect of an UMN lesion bymany authors. However,although positive in one sense,they are always accompaniedby areas of low tone or weaknessas the neurologist sees it,or selective hypotonia as theclinician sees it. For example,patients who repetitivelydemonstrate an inadequatepostural tone particularlyagainst gravity on, say, sit tostand task produce flexor associatedreactions during thetask that more than often initiallydisappear when anupright alignment has beenachieved. It is an effort forthem to stand. When thepatient then starts to walk,they have difficulty in reactingappropriately to the constantdisplacement and associatedreactions are manifestedincreasingly as the task continues.Although associated reactionsand associatedmovements occur under similarcircumstances, associated reactionsare always associatedwith hypertonia. Associated2829

SYNAPSE ● SPRING 2000CONGRESS REVIEWSreactions do not mirror theintended movement or activitythe person potentiates. Theycan be seen as an exaggerationof the pattern of hypertoniaalready.In summary, associated reactionsappear to be manifestedfrom a number of causal factorsrelated to the impairment, themanagement of the disabilityand the demands of the environmentie the rehabilitationsetting.The impairment alwaysbrings with it a loss of antigravityactivity particularlyrelated to locomotion low tonearound the ipsilateral pelvisand therefore eventual weaknessof muscle activation is acommon problem. Due to thepossible effect on the ipsilateralpathways there may bealso low tone in the truncalcomponents of the non hemiplegicside. This may be alsocomplicated by the use of medication,in particular baclofen.Effort, as Walshe et al so eloquentlydescribed, producessummation and irradiation.Effort however in a repetitivetask such as self-propellingwheelchair activities also producesstereotypical patterningand loss of joint range.Hypersensitivity is seen inpatients who have a dysfunctionof the cortico-spinal tractand/or system. Documented byPaten and Lemon, hypersensitivityis often seen moreprevalently distally, eg positivesupporting reaction. Hypersensitivitycan be treated andcertainly should not beignored.Clearly emotion and fear alsoplay a part in increasing tonenaturally and in an exaggeratedresponse in patients withlesions of the central nervoussystem.Perturbation, which is unexpectedor sudden displacementas Dickstein et al found, producesstrong associatedreactions. For an effectiveresponse to displacementselective movement isrequired.Habituation where patientseventually learn to functionand many use the associatedreactions as an alternative,albeit pathological, form ofpostural fixation when stabilityhas been lost or is unable to beaccessed.Finally the Bobath conceptstill believes that in manyinstances associated reactionsprevent the recovery of selectivemovement and thereforefunction. In today’s world ofhealth care which revolvesaround budgets not peoplethere is a very strong and disturbingtrend to ‘manage thedisability’, rather than treat oralter the impairment.Associated reactions createnoise and therefore bringingthis noise into order can allowthe therapist to more specificallychange the causal factors.That is to:■ Isolate the inefficient component■ Reduce the effort bychanging the environmenteg power chair.■ Cost effective by changingthe task.■ Employ plasticity to changeresponse to hypersensitivity.■ Use manual means to alterbiomechanical changes.■ A full text of Mary Lynch-Ellerington’s second lecture atCongress, ‘Why do movementsinvolving rotatory componentsalter tone in muscle’, willappear in the Autumn issue ofSynapse.■C THE ROLE OF THERETICULAR SYSTEM;ITS IMPORTANCE FORPHYSIOTHERAPISTSDr Nigel Lawes MB, BSSummary of slide presentation.WHERE IS IT?■ The reticular formation is inthe brain stem (excludesother ‘reticular’ nuclei)■ It is arranged in four groups■ The neurones extend wellbeyond the limits of a‘nucleus’WHAT ARE ITS CONNECTIONS?■ With most of the centralnervous system (CNS)■ General and special sensorypathways■ Somatic motor pathways■ Visceral and endocrinesystems■ Emotional, attentional andmotivational systems■ Not with frontal and temporalpolesWHAT DOES IT DO?■ Most somatic and visceralfunctions■ Somatic efferents to the dorsolateralsystem ( discretedistal flexion of the upperlimbs), and ventromedialsystem (synergistic extensionof upper limbs, lowerlimbs and trunk)■ Initiates locomotion andmediates cortical effects■ Co-operative asymmetries ofantigravity muscles■ Injury to the dorsolateralsystem results in loss of discreteflexion of the fingersand elbow, but axial postureand locomotion are normal■ Injury to ventromedialsystem results in fingers andelbow normal, but unable toreach out; axial postureslumped and immobile, andlocomotion and rightingreactions impairedHOW DOES IT WORK?■ It excites or inhibitsinterneurons that:• control the level ofextensor tone• regulate the balance ofstiffness and compliance• select temporal andspatial windows for input• prepare the cord for voluntarymovement• regulate reciprocitybetween antagonists• regulate tension(increaseson movement, decreasesin static postures)SUMMARY■ Where is it? In the brainstem■ What are its connections?With most of the CNS■ What does it do? Mostsomatic and visceral functions■ How does it work?Modulates inhibition andexcitation■ What is its relation tophysiotherapy? Restores itsmodulation of surviving patternsDr Nigel Lawes read medicineat St Thomas’ Hospital Medicalschool. In 1973 he worked aspart of the clinical scientificstaff in the MRC Hearing andBalance Unit and then as lecturerin the Depart-ment ofBiomedical Science, Universityof Sheffield. He is currentlysenior lecturer in Neuro-sciencein the Department of HealthSciences, University of EastLondon.A full list of references for thislecture can be sent via e-mail.Please contact Ros Wade,Synapse administrator.■C AN OVERVIEW OF THECEREBELLUMJon F Marsden MSc, MCSP, SRPThe treatment and managementof Cerebellar ataxiacontinues to be a challenge forphysiotherapists. This paperseeks to explore present viewson Cerebellar function in orderto provide a basis for furtherunderstanding of the efficacyof physiotherapy intervention.Throughout its’ extent theCerebellar cortex has a remarkablyuniform cytoarchitecturewith different (micro)zones inthe cerebellum receiving differentinputs and in turnprojecting to different outputs(Voogd et al 1998). In view ofthis uniform cytoarchitecture itis proposed that the Cerebellumperforms one commoncomputational function onthese separate input-outputchannels (Wolpert et al 1998).Proposed theories ofCerebellar function include its’role in co-ordination (Thach etal 1992), timing (Llinas 1991),motor learning and adaptation(Bell et al 1996) and morerecently cognition(Schmahmann 1997). Theanatomical and physiologicalbases of each of these theorieswill be reviewed in turn. Howthe theories help to explainthe signs and symptoms ofsubjects with Cerebellar lesionswill be discussed and possibleimplications for therapy will bespeculated upon.REFERENCESBell C, Cordo P, Harnad S,(1996) Controversies inNeuroscience IV :Motor learningand synaptic plasticity in theCerebellum Behavioural andBrain Sciences vol 19 no3.Llinas R. (1991) The noncontinuousnature of movement executionIn: Humphrey DR et al,eds. Motor control: Conceptsand issues John Wiley andsons Ltd pp223-242.Schmahmann JD, The cerebellumand cognition Orlando:Academic Press, 1997:Thach WT, Goodkin HP, KeatingJG. (1992) The cerebellum andthe adaptive co-ordination ofmovement Annual review ofNeuroscience 15, pp403-442.Voogd J, Glickstein M,(1998)The anatomy of the cerebellumTrends in cognitive sciences2, pp307-313.Wolpert DM, Miall RC, KawatoM. (1998) Internal models inthe cerebellum Trends in cognitivesciences 2, pp338-347.Jon Marsden qualified as aphysiotherapist in 1991 andgained experience first at theUnited Bristol Healthcare Trustand later at the NationalHospital for Neurology andNeurosurgery. He is currentlyundertaking a PhD attached tothe MRC Human Movement andBalance Unit, Queen Square,entitled Oscillations andSynchronisation in the MotorSystem in Health and Disease.■C MANAGEMENT OFATAXIALynne Fletcher MCSPAn understanding of the problemsataxia presents to thepatient is essential for aneffective treatment and management.The individual symptoms arevariable depending on the siteof lesion but also considerablyin the compensatory activitythe patient adopts.Facilitating the patient toexperience movement in asvaried a way as possible maintainingtheir ability to errorcorrect and improve the qualityof their movement performanceis an essential part of therapy.Many patients limit theirpotential by fixation due tofear of falling and the subsequentlimited movementexperience leaves no possibilityto improve co-ordinationskills.Goals of physiotherapy mustmanage the problems of thepatient in terms of function,safety and the need to challengethe system to updateskills rather than shut downthe system through compensatoryactivity.Lynne Fletcher qualified in1976 and worked in the NHSfor 17 years almost exclusivelywith neurological patients. Shequalified as a Bobath tutor in1986 and as an advanced tutorin 1994. She now works inprivate practice and teachesBobath related courses bothnationally and internationally.A full text of this presentationwill appear in the Autumnissue of Synapse.3URIHVVLRQDO'LSORPDFRXUVHIRUWKRVHFDULQJIRUSHRSOHZKRKDYH6WURNH♦ GHVLJQHGIRUWKHµKDQGVRQSURIHVVLRQDO♦ VWXG\E\VHOIFRQWDLQHG'LVWDQFH/HDUQLQJ♦ HQURODQ\WLPHZRUNDW\RXURZQSDFH♦ VXFFHVVFRQWULEXWHVWR&RQWLQXLQJ3URIHVVLRQDO'HYHORSPHQW♦ 8QLYHUVLW\DFFUHGLWDWLRQGHJUHHOHYHOFUHGLWSRLQWV♦ IHHVFRYHUFRXUVHUHDGHUWH[WERRNVWDSHUHFRUGHGPDWHULDODQGVXSSRUWZRUNVKRSVRUJDQLVHGORFDOO\WRJURXSVRIVWXGHQWV7KHFRXUVHLVRIIHUHGLQDVVRFLDWLRQZLWK1HXUR(GXFDWLRQE\WKH&HQWUHIRU&RPPXQLW\1HXURORJLFDO6WXGLHV/HHGV0HWURSROLWDQ8QLYHUVLW\'&DOYHUOH\6WUHHW/HHGV/6+(IRUIXOOGHWDLOVFRQWDFWWKH&HQWUH0DQDJHU'U6WHYH0HUDE\HPDLOVPHUD#OPXDFXNRUWKH&HQWUH$GPLQLVWUDWRU-DQHW%XFNLQJKDPE\HPDLOMEXFNLQJKDP#OPXDFXNRUE\SKRQHRQ3031

REVIEWSREVIEWSThe purpose of this section is to enable therapists to submitreviews on articles that they have read and discussed or coursesthey have recently attended and are of interest and relevance tocurrent clinical practice and academic teaching. The viewsexpressed in these pages are not necessarily those of theSynapse committee, and in the case of articles we recommendthat you should read each article in full.COURSES■C MANAGINGDISABILITIES INNEUROLOGICALDISORDERS10 June 1999 MurrayfieldStadium Conference Centre.This free seminar, sponsored byAthena Neurosciences, wasattended by a large number ofphysiotherapists and otherhealth professionals includingnurses, occupational therapistsspeech therapists and doctors.The program was predominantlymedically oriented, withpresentations on managementstrategies in Parkinson’sDisease (PD) and MultipleSclerosis (MS). These includeddiscussion of recent studies onsome of the newer drug therapies,and the management ofspasticity, in MS with mostdetail given on medical strategies,although the importanceof the whole multidisciplinaryteam was frequently acknowledged.Multiple Sclerosis is an autoimmunedisease resulting inrecurrent areas of inflammationwithin the optic nerves, brainand spinal cord. It has a prevalenceof 100 / 100 000 of thepopulation and is the commonestcause of neurologicaldisability in young adults. Thepeak age of onset is 33 yearswith a ratio of female to maleof 3:2.Dr Crawley from AberdeenRoyal Infirmary, presented anexcellent lecture entitled‘Disease modification: Therapyin Multiple Sclerosis’ (MS), butspoke on one aspect only, thevery topical issue of the use ofBeta Interferon in MS.He emphasised that theburden of MS is disability, notreduced lifespan, and describedsome of the outcome measuresused in research on disabilityin MS, notably the NeurologicalAssessment Kurtzke ExpandedDisability Status Scale (EDSS).Details of this assessment weregiven, and can be found inMultiple Sclerosis (1997),edited by Jurg Kesselring,Cambridge University Press,Cambridge, and other sources.In studies of Beta interferon,the key units for thisscale were between six (able towalk with assistance – cane,crutch or brace) to seven(essentially restricted towheelchair).KURTZKE SCALE■ 1 No disability, minimalsigns (eg extensor plantar)■ 2 Minimal disability egslight weakness■ 3 Moderate disability,although able to walk■ 4 Able to walk and self sufficientdespite relativelysevere disability■ 5 Walking for 1/4 mileunaided.■ 6 Assistance(crutches/sticks) for walking■ 7 Wheelchair use■ 8 Restricted to bed witheffective use of arms■ 9 Totally helpless andbedridden■ 10 Death due to MSIts limitations, identified byKurtzke himself, who neveradvocated its use as a definitivemeasure in MS, are that itis not linear, there can be largeand small differences betweenunits, and that it only measuresmobility, which is onlypart of the disability of MS.The progression of MS fromthe early demyelination, shownby MRI scans, which isrepairable, to the more frequentlesions of the relapsingprogressive type, in whichaxonal loss occurs and disabilityis present, was shown ina very clear diagram. There aretwo forms of the disease, withthe majority of MS (85% ofcases) are described as‘relapsing – remitting’ with50% of these showing progressivesymptoms in ten years,and wheelchair bound withinfifteen years. This is thendefined as ‘secondary progressive’.The second, and lesscommon presentation, isdescribed as ‘primary – progressive’.This tends to have anolder age of onset, 40-60 yearsand with less marked changeson MRI and little inflammatorychange in the cerebrospinalfluid.Dr Crawley also addressedthe question what does BetaInterferon do in MS patients?Short trials show a 30% reductionin relapse rate, and a50-75% reduction in activelesions seen in MRI scans. Theimmunology suggests that itreduces T-cell modulation,blocking T-cell activity, andthus reducing inflammationand the resultant nervedamage. Questions still need tobe answered about the methodof administration and doseeffect. In the PRIMS study, it isgiven subcutaneously, andthere is doubt that intramuscularinterferon is effective inthe dose given in otherstudies.A recent trial between 1995-1998 (published in the Lancet)was described from theEuropean Study Group onInterferon beta (1b).Details also appear in areview by Hall GL, Compston A,Scolding NJ, (1997) Beta interferonand multiple sclerosis.Trends in neurosciences 20, 2pp63-7.The trial group were 18-55,with secondary progressivedisease, defined as sustaineddisability for six months. TheEDSS scores ranged from 3.0-6.5, and the trial was placebocontrolled. Apologies for nothaving the number of patientsinvolved.Outcome measures were theprimary end point – the timetaken to confirmed progressionby one step on the EDSS scale;and the secondary end point –the time to becoming wheelchairdependant ie 7.0 on theEDSS scale.There was a 25% drop out inboth placebo and treatedgroups. There were four deathswhich occurred during thestudy; two were suicides, andtwo were cardiovascularrelated.The results showed thatpatients on Beta Interferoncontinued to deteriorate, butat a slower rate, and thatpatients gained a year between6.5 and 7.0 on the EDSS scale,effectively a year out of thewheelchair.Dr Crawley then consideredsome of the problems, such as‘Does the improvement continueor can neutralisingantibodies develop?’The side effects are minimal,but frequent, such as mild flulikesymptoms (occurring in upto 60% of cases) and injectionsite problems, which con-tributed to a 10% drop outrate.The cost – currently is£10,000 per patient per year.For example, if Highland regionwished to use interferon on100 patients, it would cost£1,000,000 per year and atpresent, post code prescribingexists, as it is available insome regions and not others egGrampian – yes but Strathclyde– no.The current guidelines onthe prescription of Interferonfor consultant neurologistsonly,(not GPs), as of June1999, have only two criteria.■ 1. The patient must be diagnosedas the relapsing/remitting type of MS withtwo defined relapses in twoyears.■ 2. The patient must still beambulant ie below 7 on theEDSS.A new study, which iseagerly awaited, is bySPECTRIMS – SecondaryProgressive Interferon beta(Seroma) in MS, and Dr Crawleyhad some preliminary releasesfrom June 1999, whichappeared to be very similar tothe previous study. More concretedata showing moreimprovement is required beforethe drug becomes available forall postcodes. (The generalfeeling of the meeting was thata year out of a wheelchair issurely worth paying for! Also,any improvements in functionapart from mobility are surelysignificant, and should be considered).As well as Beta Interferon,other therapy was describedbriefly. Copaxone-Glatirame –has similar efficacy to betainterferon, at a similar cost.There are a large number ofdrugs which are classified asimmune modulators, and whichmay assist in remyelination byoligodendrite genesis. Thiswould delay or prevent axonalloss in the early stages, andmay reduce disability.Following this lecture MsRhona Currie, a MS specialistnurse gave a presentation on ‘apatient’s perspective on Betainterferon therapy, or thenurses interpretation of it.’She is the nursing team leaderfor the Beta interferon programat the Southern GeneralHospital in Glasgow. The clinicshares the home monitoringwith a private nursing firm.Each patient and familymembers are trained in givinginjections and educated aboutthe program, side effects andother aspects of the treatment.Contraindications to the treatmentinclude pregnancy, andfemale patients of childbearingage must be on contraceptiveprotection.Side effects were noted in96% of patients again predominantlyassociated with flu typesymptoms and problems withthe injections site. These graduallyeased over three monthswith 96% of patientsexpressing the symptoms wereat a bearable level by then.Patients found that takingparacetamol at the same time,and injecting before going tosleep at night eased this sideeffect. Local skin reactionswere settled by using an autoinjection device. Heavierperiods occurred with femalepatients.Ms Currie reported that at anine month review, manypatients were depressed, for avariety of reasons. Many dislikedgiving themselves regularinjections, and many found theside effects wearing. Thesuicide rate in the studydescribed by Dr Crawley bearsevidence to this as well.Ongoing support for patientson the program was given inthe form of regular meetings,ostensibly to give information,and there was a good rate ofattendance, with 50% of thepatients involved .She stated that whenpatients said they were unsureabout the programme, it meantthey needed more information,and possibly counselling.Some patients were payingfor the treatment, and theyhad their own problems andagenda.The issue of postcode prescribingis very real, andcauses much distress topatients, carers and the managementteam.In conclusion, she emphasisedthat education andinformation – not misinformation– about Beta interferontherapy is essential forpatients, carers and the entiremanagement team, so that thisvaluable treatment option canbe delivered most effectively.These lectures gave anoverview of a controversialtopic, and many insights intothis therapy.The speakers all gave polishedpresentations andinsights into new and recentdevelopments, which areimportant for therapists tounderstand, when dealing withpatients, support groups andrelatives. One criticism wasthat the lecturers’ notes werenot available, and would havesaved frantic scribbling of references.Otherwise, the venue,food and weather were the bestthat could have been provided,with Edinburgh basking in sunshinefor the whole evening.■C MANUAL HANDLINGFEEDBACKSiobhan GallowayMerseyside ACPINThis is a report back on a workshopwhich was held in August1999 at Clatterbridge Hospitalentitled, ‘Guidelines forMoving and Handling Practicewithin NeurologicalPhysiotherapy: Discussionand Questioning’.A physiotherapist who has apost-graduate qualification inErgonomics, Philip Morrow,started the day with an introductorylecture, which includedlooking at present regulationsand moved onto challengingour practice by analysing sometechniques from a purelyergonomic stance. Audienceresponse to this was mixed, butperhaps we should be moreopen to closer scrutiny of ourseemingly widespread methods.An hour of general discussionwas then held with areasof interest noted. Six discussionsubgroups were formed,and feedback then collated.The six areas were:■ 1. General considerations forsetting guidelines.■ 2. More prescriptive writingof guidelines.■ 3. Equipment.■ 4. Evidence Base/Research.■ 5. How do we judge skill?■ 6. Risk assessments.Prior to the discussion therewas a break and three companyrepresentatives were present todemonstrate relevant equipment.1. CONSIDERATIONS FORSETTING GUIDELINESThe discussion group wasassigned the task of examiningwhat should be key considerationswhen assessing movingand handling situations. The3233

SYNAPSE ● SPRING 2000REVIEWSgroup identified 6 specific areasthat would require analysis:■ Objective/Ultimate goal■ Facilitators ability/availability■ Patient ability■ Equipmentrequirements/availability■ Environment■ Legislation/ResponsibilitiesThe general conclusion ofthe group was that many of theareas covered led along a routetowards standardising RiskAssessments already in use bymany Trusts and encouraginghandlers to take individualresponsibility for assessingspecific situations. Severalareas of confusion were alsohighlighted which will requireclarification for future developments.These included:■ Understanding of the term‘transfer’.■ How do manual handlingissues fit in with the rehabilitationphilosophy.■ How do we improve methodsof disseminating informationon any new legislation?■ Concerns around expectationsof the physiotherapyprofession, irrespective ofgrade/skill level.Within all of the discussiondescribed the importance ofgaining a solid evidence basewas consistent and thereforeshould underpin all guidelinesdeveloped.2. MORE PRESCRIPTIVEWRITING OF GUIDELINESThis group started by consideringsystems that have beenused before or that they hadexperience of. This includedRed/Amber/Green levels of riskand possible coding or scoringsystems. The pros and cons ofthese were considered and theidea of a flow chart whichcould be used to choose atechnique depending on what apatient was capable of was alsomuted. It was thought importantthat a positive approachbe taken highlighting capabilitiesrather than inabilities, andalso empowering nursing staffto be leaders in this area.Another factor to be consideredwas to assess cognition, perceptionand receptive languageability prior to physical assessmentso that adjustments couldbe made if necessary.The group found it difficultwithin the time constraints toagree a specific way toapproach breaking down techniquesor ability basedsystems.3. EQUIPMENTInitially the group formulated alist of the different pieces ofequipment available to us toassist in moving and handling,including transfer boards, slingand standing hoists, slidingsheets, standing frames,transfer belts, and turn tables.Two pieces of equipmentwere then chosen and the prosand cons of using them werediscussed.Sling Hoists■ Advantages – suitable forunpredictable patients,heavy patients, patients withmany compensations,patients who fatigue easily,patients who need more thantwo people to transfer manuallyand for handlers lackingin specific handling skills.■ Disadvantages – use of hoistmay be unsafe if staff areuntrained in its use, itresults in reduced opportunityfor weight bearing, ifthe patient feels unsafe itmay result in increased toneincreased compensations anda lack of confidence in thetherapist.Transfer boards■ Advantages – portable,cheap, may encourage someweight bearing through thelower limbs, may assist toreduce compensations intoextension, may promoteindependent transfers, canassist to break down a ‘pivot’transfer into stages.■ Disadvantages – reducedfacilitation of extension,some types of seating areunsuitable to use with atransfer board, the patient isrequired to have sittingbalance, they can be difficultto use towards a hemiplegicside due to reduced ability toweight bear through theupper limb.Other considerations thatwere made:■ We should increase ourawareness of equipmentavailable.■ We should took at equipmentpositively and use it as anadjunct to rehabilitation.■ It is important to be trainedin the use of equipment. Thiswas considered to be the roleof the company representativeinitially. It was thenthought that the therapistshould then make a clinicaljudgment as to the appropriatenessof the piece ofequipment for a certain task.No decision was made as towho should be responsiblefor ongoing training.4. EVIDENCE BASE/RESEARCHThe group started with a ‘brainstorm’ on ‘What research do weneed as evidence?’The field is so diverse thatwe could not draw any definiteconclusions as to the correctresearch to suggest but ideasincluded:■ What transfer should we lookat?■ Should we research NormalMovement first as a baseline?■ Should we research skill levelof therapists, including whattraining and supervision isavailable?■ What makes us decide it isnecessary or appropriate totransfer and not use equipment?■ What objective measurescould be used eg EMG, Gaitlabs, Pressure pads etc?■ Is it only the low back regionwe should address or shouldwe look at other regions egpelvis and shoulder girdle?We then discussed that wehad very little knowledgebetween us of what evidencethere is already available andwhat the implications of thiscurrent evidence are. We feltthe first area of study in thisfield should be to look at theavailable evidence and alsoinvestigate what evidence theRCN document, which dictatesso much of our practice, isactually based on.The next step would be to tryto describe the normal movementconcept and use this to‘define the problem’.It was difficult using thisdiscussion to ascertain whichtype of research should beimplemented. It was suggesteda quantitative survey might beuseful to find out what therapists’currently base theirpractice on and current techniquesin use. This would theninform a further qualitativestudy. There would be a lot ofplanning and preparationrequired for this to obtain thebest study proposal, design andmethodology.It was also felt importantthat ACPIN should set up linkswith research units and othertherapy groups e.g. NANOT tocombine forces in thismammoth project.In conclusion from thisgroup, we were unable toclearly define a specificproblem and study design butwe felt that with the appropriate,skilled people inResearch and in Clinical practiceinvolved, ACPIN couldstrive towards gaining someevidence for our daily clinicalpractice in this field.5. HOW DO WE JUDGE SKILL?The group thought that weneed to set a minimum criteriaskill level required for a safetransfer of a neurologicallyimpaired patient. This seemedmore applicable than namingcertain professions/gradeswithin a profession asskilled/unskilled etc as thisdoes not guarantee a level.There was much discussionbefore the group finally agreedthe following set of criteria:■ Understanding of ‘technique’including patient ability,cognition and physicalability, patients condition,tone, shoulder etc, environment,principals of normalmovement■ Awareness of own physicallimitations■ Communication, with patientand colleagues and planningand risk assessment■ Manual handling education■ Knowledge of availableequipment and correct/safeuse of.The group also felt thatpeople are trained by namedcompetent professionals andnot just physiotherapists as weare unable to be responsible fortraining everybody.6. RISK ASSESSMENTSTo derive therapeutic benefitthe group felt that it was necessaryto accept an element ofrisk.Risk assessments are currentlybeing carried out, butnot always formally documented,partly because there issome confusion as to what islegally acceptable.An individuals’ experienceproduces variances in riskassessments, so a baseline inknowledge through recognisedtraining would help to minimizethis.CONCLUSIONThis topic of moving and handlingis obviously one of greatinterest at the moment.Participation was limited toseventy people although moreshowed interest. It had beendecided to include all disciplinesand most wererepresented, even though wehad decided to limit this largetopic to neurophysiotherapyguidelines so that it was moremanageable. We also haddecided that we should look atourselves first and the issuesrelating to us before looking atother areas. Not surprisinglymore questions were askedthan there were answers. It hasbeen suggested that a nationalday may be needed. Themomentum now needs to becontinued, the question ishow? Merseyside ACPIN committeehave nominated aliaison person for further ideasto be relayed to a nationallevel but we do feel it is alsoup to the members to carry thisforward in their own areas.Writing guidelines for movingand handling within neurophysiotherapyis a big task andone which obviously needsfurther consideration.For any further information,suggestions please contactSiobhan Galloway on 0151 4284078■C RESPONSE TOMERSEYSIDE ACPINWORKSHOPAnthea DendyACPIN Executive CommitteeThe National ACPIN committeeare very grateful to MerseysideACPIN for reporting back onthe workshop they held inAugust last year. This reportwas sent to myself and providedthe basis for some of thepreliminary discussion of theworking party. The openingcomment that some of theaudience were not comfortablewith the challenge thrown upto our current practice was aninteresting and very valid one.Those of us with a particularinterest in this field have nowbeen left in no doubt that wemust look at the way we dosome things within therapysessions and ask ourselves howappropriate these are, if we aredoing them in the most appropriateway and if not is thereanother way of achieving thesame or similar therapeuticeffect. Asking colleaguesworking outside our area ofclinical practice to stand in thecorner of the room and watchwhat we get up to is a veryuseful and enlightening exercise,as I found myself when Iasked a colleague from musculoskeletalout patients towatch us in the gym at StGeorge's one morning! Thisexercise highlighted to us theneed to look at some of thehigh risk handling techniqueswe carry out, and to carry outrisk assessments and writeaccompanying protocols forthem.The subgroup that looked atguidelines writing came upwith some interesting pointsand the idea of a flow chart isone that is being utilised bythe working party. Similarly wehave discussed formulating anequipment list with pros andcons. When visiting departmentsit is noticeable thatmany already have chosen toinvest in electric standingframes and walking hoists. Atpresent ACPIN would like toencourage members to sharetheir experiences with piecesof equipment with each other.Synapse would seem to be avery appropriate way toachieve this and we can onlyencourage you all again towrite a short summary forSynapse so that departmentsdo not purchase inappropriateequipment, and that we do buythe piece of equipment thatmost suits our needs.Personally I think we shouldremember that no piece ofequipment, it seems to me, willfulfill our therapeutic ‘ideal’but we must look at ways ofusing equipment to help usachieve our aims whilstreducing risks to ourselves, ourcolleagues, our clients andtheir carers.Research in this field isanother huge area and againnot something ACPIN is in aposition to directly undertake.However we may feel we couldusefully draw up a list of possiblepriority areas to assist indirecting appropriate research.In addition to those ideas suggestedwe must also considerthe evidence for the use of thetechniques and interventionswe advocate. For example whenwe are training carers to assistclients into standing frameshow much scientific evidencehave we got to support thevalue of regular standing tojustify any associated risk incarrying out the procedure?The same could be said formuch of what we do and advocate,unfortunately, and we3435

SYNAPSE ● SPRING 2000REVIEWSmust continue to utilise ourclinical experience in thesedecision making processes. Weshould not however be carryingout a pivot transfer rather thanhoisting just because its in thegym so therefore its therapy!Documentation of riskassessment is a key requirementin our clinical practiceand an area we would urge allmembers to place particularemphasis on. It is particularlyimportant to document theclinical reasoning for carryingout a particular procedure,especially if within therapythis is different to the manualhandling being used by otherdisciplines.In conclusion the workshopwas obviously a very usefulday. I am sure everyone wouldbe interested in the next stageand how Merseyside ACPINmembers have moved on fromthe conclusions drawn. If otherareas of the country decide toor have nominated liaisonpeople in the same wayperhaps we could use theworking party to facilitate aNational network to assist insharing all of the good workthat is going on throughoutthe country and save some ofthe reinventing of the wheelthat notoriously happens inthese situations.■C ACPIN MANUALHANDLING WORKINGPARTYAnthea DendyACPIN Executive CommitteeThis group was formed in theautumn last year as members’concerns regarding manualhandling issues continued, andas the CSP working partywithin which we had representationhad not reformed.To date the group has mettwice. The members of thegroup are:■ Anthea Dendy, ClinicalSpecialist, St GeorgesHospital, London■ Vicky Sparkes, Lecturer,University of Hertfordshire■ Monica Busse,Physiotherapist, PrivateRehabilitation Centre■ Rosie Hitchcock, Lecturer,University of SouthamptonFollowing correspondencewith the Superintendents inSpinal Cord Injury we have alsobeen pleased to welcome theirrepresentative, Dot Tussler(Superintendent Physiotherapist,Stoke Mandeville) to thegroup.At our first meeting webrainstormed all the issuesaround manual handling and,as always, seemed to end upwith more questions thananswers! We agreed that wewould limit our current work tolooking at Manual Handling inTherapy, and associated topics.From this we drew up a list ofseveral sub sections such asrisk assessment, equipment,research etc. and agreed todecide on which aspect to considertackling first. We were allin agreement that attemptingto write National guidelines formanual handling in therapywas a huge task which wecould not feasibly take on andfelt that by the time we hadachieved our objective most ofour members would have localguidelines in place and wouldtherefore gain little benefit.As all areas will have to lookat this issue locally consideringthe environment, staff andcarers, client group, etc we feltit would be more useful to tryand provide some frameworkswith which people could workto assist them in the riskassessment process.The group is therefore currentlytrying to develop a flowchart demonstrating the riskassessment process for handlingin neurophysiotherapy,indicating where risk assessmentsmay be required andwhere a protocol format maybe able to be utilised for this.Headings to consider for theseprotocols with one or twoexamples may also be developed.The group will continue tomeet every two months anddisseminate its work throughSynapse and the regionalnetwork as appropriate.Examples of local work whichwe have received have beeninvaluable in assisting with ourdiscussions so please continueto send these to the addressbelow so that we can shareyour work with ACPIN membersnationally.Anthea DendyPhysiotherapy DepartmentSt George’s HospitalBlackshaw RoadTootingLondon SW17ARTICLES■A SHARED RESPONSI-BILITY FOR ONGOINGREHABILITATION: ANEW APPROACH TOHOME-BASED THERAPYAFTER STROKEJonathan J Basket, Joanna BBroad, Gabrielle Reekie, ClareHocking and Geoff Green.Clinical Rehabilitation 1999,13: 23-33Anne Murray, Linzie Bassett,Lucy Johnson, Annette PriceThis article describes a comparisonbetween a hospitalbased outpatient therapy programmeand a community styleapproach for two groups ofstroke patients.The paper itself is clear toread and divided well into sectionsaiding its review. It wasfelt that the title does not adequatelyreflect the article, butthe abstract is well written andlogically presented. Althoughan address for correspondenceis included there is no backgroundinformation about theauthors.OVERVIEWA randomised control designwas used to ‘assess the efficacyof a programme of continuingself directed exercises forpeople discharged home afterstroke, supervised once a weekby therapists’. A total of 100stroke patients were assessedon the week of discharge, atsix weeks and at three monthspost discharge. A range ofoutcome measures were usedto evaluate gait speed, limbfunction and activities of dailyliving. Therapist contact time,the mood of the patients andcarers together with theiranticipated and perceived outcomeswere assessed. Theresults demonstrated no statisticaldifferences between thecontrol and experimentalgroups, except relating to thecontact times (p=0.003). Theauthors concluded that thesupervised home based programmeis as effective asoutpatient or day hospitaltherapy.CRITICAL REVIEWIntroductionThe aims of the study areclearly stated but the backgroundto the development ofthe design refers mainly to theauthors’ past experience ratherthan the literature.MethodThe method described appearsto be comprehensive. Inclusioncriteria are stated; the exclusioncriteria appear later in theresults. Ethics approval andinformed consent wereobtained. The method of randomisationis clearly described.Baseline data were collectedfor all subjects to evaluate ifthe two groups of strokepatients were comparable.The patients in the controlgroup were treated either in aDay Hospital setting or the relevantoutpatient department,when only physiotherapy oroccupational therapy wasrequired. Thus, there may havebeen a difference in inputgiven within this group. Dayhospital patients were assessedby the multidisciplinary teamand treatment goals agreed.Patients attended two or threetimes a week, with progressmonitored at weekly reviewsbut the duration of outpatienttherapy input is not clarified.Information is provided on thetreatment approaches, butthere is none on the skill mixof the therapy teams.The patients in the experimentalgroup were assessed athome by a research physiotherapistand occupationaltherapist and goals set. Noinformation is provided of thelevel of expertise in neurologicalrehabilitation of eithertherapist. The subjects followeda self-directed therapyprogramme, receiving weeklyvisits from the therapist for amaximum of 13 weeks or ‘aslong as judged necessary’. It iscommented that if the therapistdecided that some ‘handson’ therapy was essential, itwas provided and the time documented.It is noted that transfer tothe control group could bemade, when patients requiredmedical input or support,which could not be provided onthe home-based programme.Outcome was assessed bytwo independent ‘research officers’,who were blind to thenature of the two interventionprogrammes. A series of referencedmeasures were used toassess both the experimentaland control groups over time.The authors comment thatevery ‘effort was made to standardiseassessments’. Anun-referenced scale is used tomeasure and record thepatients and ‘caregivers’ expectationsand perceivedimprovements from thetherapy.Statistical informationregarding the size of groupsthat are required to determinesignificant changes in the testsis given, stating that a samplesize of 45 subjects in eachgroup is necessary to detectclinical significance withvarious measures.Acknowledgement of thelimitation of the ModifiedBarthel Score to detectimprovement when the entryscore is high is included.ResultsA clear diagrammatic representationof the patient progressthrough the study is provided.Out of the 50 patients ineach group at the start, 46 ofthe control and 44 from theexperimental group were finallyassessed at three months.However, one subject who wasinitially allocated to the hometherapy group crossed into thecontrol group, as the caregivercould not be provided withenough support; this subjectremained in the experimentalgroup for data analysis ratherthan being excluded from thestudy.It is stated that there wereno significant differencesbetween the two groups, inage, sex, side or severity ofstroke or associated diseases orconditions at the beginning ofthe study.The results state that therewere no significant differencesbetween the groups for neurological,physical and activitiesof daily living function as measuredby the assessments atbaseline, six weeks and threemonths. The data is included ina table, showing the mean andstandard deviation for eachmeasure. A statistical significantbias towards the controlgroup was obtained for theBarthel score (p=0.048). Theauthors comment that this wasnot apparent when very lowscores (

SYNAPSE ● SPRING 2000REGIONAL REPORTSanother, should have beenundertaken.Although significance wasnot reached, it is observed that53% of the caregivers in thehome group compared to 36%in the control group appearedto judge the outcomefavourably. The authorssuggest that the home groupcaregivers felt more supportedand may have benefited fromdiscussion with the therapist,opportunities which the caregiversin the hospital groupmay not have been able toaccess.There are no summarisingconclusions, but acknowledgementsare included to thoseinvolved in the study and forproject funding.ReferencesThe comprehensive referencelist includes up to date and relevantliterature.Summary of reviewOn the whole, the paper waseasy to read and relativelyclear, only on more detailedreview did questions withregard to the protocol andmethod arise. Although discussionof the results appearedthorough, issues with regard tothe increasing variance inwalking speed in the hometherapy group were not introduceduntil the discussion.Thus, it was felt that an importantpoint had been omitted,which could have contradictedthe conclusions made.The numbers for this studywere relatively small for significance.Prior to a change inworking practice, questionswith regard to subgroups thatmay respond differently to thehome therapy approach wouldneed to be answered. Largergroup numbers and clearmethodology would be required.■A A NEW APPROACH TORETRAIN GAIT INSTROKE PATIENTSTHROUGH BODYWEIGHT SUPPORT ANDTREADMILLSTIMULATIONVisintin Et Al Stroke (1998)29 pp1122-1128Jo Kipling and Anne MarshSenior PhysiotherapistsSt Lukes Hospital, BradfordThe title briefly outlines thearticle, however, it does notmention the comparisons thatwill be made between trainingwith full body weight and bodyweight support.The abstract however, summarisesthe article well, butthe key words are somewhatbrief and perhaps could include‘treadmill’ and ‘gait’. Some ofthe authors are from schools ofPhysiotherapy andOccupational Therapy, it is notclear regarding the backgroundof others, but all have studiedat either PhD or MSc levels.The introduction shows evidenceof a literature searchwith adequate backgroundinformation and clear aims,(although more than 10 referenceswere their own).The methodology is that of arandomised control trialinvolving 100 patients whofitted the criteria for studyover the period October 1992to January 1995. They weresplit into two groups by blockrandomisation. Both groupsreceived gait training by theirown physiotherapists for sixweeks, four times a week.The experimental groupreceived training on a treadmillwith a percentage of their bodyweight supported on an overheadharness, while the controlgroup received their trainingon a treadmill with a harnessbut while supporting their fullbody weight themselves. Theapparatus was well describedwith an accompanying photograph.All subjects receivedregular weekday physiotherapyin addition to the above,aimed at maximising function.Measurements were made byan evaluator blind to themethod, before commencementof training, at completion ofthe six week period and at athree month follow up. Theoutcome measures used werethe balance scale, an earlyversion of the lower extremityportion of the stroke rehabilitationassessment ofmovement (STREAM), walkingspeed and endurance. Thewalking speed and endurancewere fully explained in the textand would be easy to reproduce.Despite the balance scalebeing referenced it remainsunclear as to its reliability forstroke, as only 46% of subjectsin the study had sufferedstroke. It is also not explainedwhy an early version of theSTREAM was used as opposedto the refined version.However, this may be becausethe STREAM was still underresearch at the time.The article did go to somelengths to explain the reasonswhy some subjects failed tocomplete the study and thegeneral characteristics of thesesubjects.Results of the study were ineasily understandable tablesand clear graphs. The ANOVAstatistical test was used.The results indicate thatwhilst both groups showedimprovement at completion oftraining and at three monthfollow up in all four outcomemeasures used, the group withbody weight support showed asignificant improvement in theSTREAM scale and for walkingspeed. No significant resultswere found in balance orwalking endurance.The article suggests thatfurther research is desirable inorder to identify the optimalperiod in which to use thismethod of training, althoughthis could be limited by thespecialist equipment needed.The authors do not discuss anyweakness in their research ormethod, but in general itseems to be a well designedstudy, which should provokediscussions regarding thetreadmill as a future treatmentmodality.■ EAST ANGLIALouise DunthorneRegional RepresentativeTel: 01473 712587East Anglia ACPIN suffered apoor year last year with notimetabled events and a subsequentdrop in interest ormotivation amongst members.However, Millennium fever hasspread and we are now rejuvenated!The committee hasbeen re-appointed, and haveheld a couple of meetings toorganise events for the comingyear. The Chairman is SharonGriffin.We have also had a re-surgeof interest and our Regionalmembership total has risen to41. We are hoping to increasethis further with activerecruiting by the committee.Because of the huge geographicalarea covered by ourRegion, evening lectures havetraditionally been poorlyattended. We have decided tofocus on a number of studydays/half days instead.Topics planned are:■ June Management ofSpasticity for theCommunity MS Patient. Tobe held at the University ofEast Anglia, and being sponsoredby AthenaNeurosciences. It willinclude relevant neurophysiology,neurophysiotherapyand case studies.■ September Manual Handlingin a Clinical SettingRunning on a workshopbasis, this day will enabletherapists working in neurorehabilitationto share ideasand problem solve aboutmanual handling issues.■ November RespiratoryProblems with theNeurological Patient Thevenue will be Addenbrook'sHospital, and the day willcover both acute andchronic conditions that canbe encountered.We do hope the future looksbrighter for the East AnglianACPIN branch, and lookforward to active participationof our members to this end!■ KENTJanice ChampionRegional RepresentativeTel: 01634 270198The Kent region held three successfulevening meetingsduring the year which were allwell attended. We also heldtwo Friday/Saturday coursestitled ‘A practical approach toMusculo-Skeletal techniquesfor Physiotherapists inNeurology’ in January andFebruary 2000, tutored byHeather McKibben.We held our AGM in March atMedway Maritime Hospitalwhen Janice Champion demonstrateda patient treatment.Our June meeting, held at theWilliam Harvey Hospital inAshford, was a symposiumlooking at assessment andevaluation titled ‘Is your treatmenteffective?’ This meetingwas chaired by Dr. CecilyPartridge and several ACPINmembers presented their ideas.Our November meeting was alecture ‘Do we need to talk toour patients?’ based on theBio-psycho-social model givenby Lis Willmet who is theSenior physiotherapist with thepain management team basedat Medway Maritime Hospital.This was followed by a discussionfacilitated by mulled wineand mince pies!This March, Gill Williams,who has been our chairpersonfor several years will beresigning. Gill has worked veryhard promoting ACPIN in Kentand keeping our group motivatedand alive. We would liketo thank Gill very much for herdedication and enthusiasm.This means we need a newchairperson – any volunteers?Our aims for the forthcomingyear are to improve the networkingof the "neuro-physios"in the region and to supportthe professional developmentof our members by providinginformative and thought provokingmeetings and studydays.Next years programme is stillin the planning stage but theAGM is confirmed as an‘Introduction to Pilates’ bySusan Rhodes who is the specialistclinician inmusculo-skeletal physiotherapyat Medway Maritime hospital.This will be held in thePhysiotherapy department atMedway on 15th March 2000.■ LONDONAnne McDonnellRegional RepresentativeTel: 020 7830 24381999 has been another successfulyear for the Londonregion. The programme hasremained varied with eveninglectures, and half or fullweekend days. Attendance wasgood for the majority of lectureswhich included:‘Neuropathology/Myopathy’(Jane Nicklin); ‘Cognition andPerception’ (Theresa Jackson);and ‘Bobath into the year 2000– a Personal Perspective’ (AnnaHamer).2000 began well with theMillennium Extravaganza whichwas well supported. Lecturesthis year include:■ Surgery for Parkinson'sDisease Dr Gary Hotten■ FES The latest developmentsJane Burridge■ PVS/Locked in SyndromeAmanda Wright■ Management of AcuteSpinal Injury Sue Rowley■ Management of DystoniaSophie Mullen/AnitaGregson■ Spasticity/hypertonia: TheClinical Implications SueEdwards■ Joint ACPIN and NANOTStudy Day on CurrentResearch in Stroke■ MANCHESTERLouise RogersonRegional Representative(from March 2000)Manchester’s 1999 programmecontinued in the same formatas previous years with tenevening lectures/workshops,with a break in August andDecember. We had a disappointingresponse to fliers sentout asking, for ideas for the2000 programme, with only ahandful returned from approximatelysixty sent out. Thecommittee has decided alongwith the response we receivedto continue with the format ofevening lectures. Any memberswho would like to see changesmade to this format in thefuture please contact the secretary;Gill Dean Lofthouse on01204 360010. The eveningprogramme last year covered avariety of topics including,‘Seating’, ‘Update on CT/MRIscans’, ‘Research on Parkinson’sdisease’, feedback from AlisonBatchelor on ‘Stroke rehabilitationin the USA’, muscleimbalance workshops andpatient demonstrations.Attendance varied with thepatient treatment/workshopsalways bringing in the largernumbers.Our committee is just abouthanging as several members3839

SYNAPSE ● SPRING 2000REGIONAL REPORTShave teaching and researchcommitments as well as a babyboom in the last couple ofyears.Our current ‘official’ membershipis 30, well below our usual60-70 members.A new initiative has beenset up in the region by PaulaKershaw, senior I physiotherapistat Hope hospital inSalford, to encourage regionalin service training for senior 1physiotherapists working inneurology. These take placeevery three months half a dayand have so far includedpatient treatment and problemsolving and a workshop onoutcome measures. Paula canbe contacted on 0161 7875328 for further information.Manchester’s 2000 programmeincludes:■ Research in Neurology,Hilary Chatterton■ Current trends in the managementof MS■ Management of neurogenicshoulder pain in patients■ Patient workshop on UpperLimb Pam Mullholland■ Update on the use of Botoxin patients with spasticity■ Update on Physiotherapyfor Parkinsons Disease■ ANT in the treatment ofneurological patients■ MERSEYSIDEJenny CraigRegional Representative(Resigned March 2000)On behalf of the MerseyCommittee, I would like tothank all our members andspeakers during 1999 for theirsupport and also to extend ourthanks once more to SharonWilliams, who continues withher invaluable support both asour President and with her biannualworkshops, which arealways a great success. Ourmembership reached 58 thisyear despite all the Nationalmembership difficulties, so wehope to continue to grow in2000! The Committee remainsdedicated to providing a comprehensivelecture programmefor next year and also supportfor members. Some changes inCommittee positions will occurduring next year but memberswill be informed of theselocally.Our current bank balance ishealthy, following the implementationof charges forlectures and we still have thecomputer, which is accessiblefor committee members, andare compiling databases etc onthis.The highlight for the lectureprogramme for us in 1999 hasto be the Moving and HandlingWorkshop. I would like tothank all the Committee fortheir extremely hard work inpreparing this.Other events in the yearincluded a successful MuscleImbalance two weekend courseby Nick Hodie and two veryinteresting lectures on thehistory and development ofNeurosurgery andNeuroradiology. Other successfullectures were MedicalManagement of PVS,Dystrophy’s and CJD.This year’s programmeincludes: two follow up courseson Trigger points; a workshopwith Sharon Williams; and lectureson acupuncture, orthoticsand spinal cord injury.■ NORTHERNLesley YuleRegional RepresentativeTel: 0191 200 7086/7214Thank you to ACPIN membersfor your continued supportthroughout 1999 and into2000. Northern ACPIN has hadan eventful programme ofevening lectures and weekendcourses throughout 1999. Wewould like to thank all thosewho have educated andinspired us in the last year. Wehope there is something tooffer everyone in the comingyear.Events last year included: aweekend course on neurophysiology;the upper limb andpainful shoulder; and a Bobathworkshop.Current membership stands at70-80 members. The programmefor 2000 is takingshape and will include furtherweekend courses on: movementscience; pain; pilates, muscleimbalance; communication inCVA as well as Bobath workshops.■ NORTHERN IRELANDMargaret LewisRegional RepresentativeTel: 01232 240503 ext 2238Northern Ireland has had a busyand successful 1999 with continuedsupport from ourmembership and a full andactive committee.We have had a varied programme,which has provided abroad range of evening lectures,practical workshops, patientdemonstrations and weekendcourses. These included anintroductory normal movementcourse, weekend workshops onthe upper and lower limbs andmuscle imbalance for the lowerquadrant with David Fitzgeraldof the Dublin PhysiotherapyClinic. In addition, for the firsttime in Northern Ireland weheld courses on the Assessmentand treatment of the adult withhigh and low tone.Unfortunately we wereunable to run a planned 3-daysplinting course, but hope torun this in the coming year.We have enjoyed input fromboth physiotherapists and fromother disciplines through ourevening lectures and patientdemonstrations which havesparked discussion and interestamongst the membership.Our programme has beenfinalised for the 2000 andpromises to challenge usfurther in our clinical practiceand research. We hope to continueto increase ourmembership and draw fromthroughout Northern Ireland.Many thanks to our existingmembership for their continuingsupport.■ NORTH TRENTSteve CheslettRegional RepresentativeTel: 01709 5613991999 was generally a successfulyear for ACPIN in North Trentwith an increase in membershipto 38 and generally wellattended events, which tookplace approximately every othermonth.Events included the AGMwhich was combined with alecture on Neuroplasticity andChronic Pain. This drew a goodaudience of both members andnon members. Meetings alsoincluded a lecture by Paulinevan Vliet on ‘The Carr andShepherd Approach’ and a oneday course on ‘Lower limb functionalanatomy and strapping’by Karen Rowlands and SteveHodgson.Following a summer break theautumn brought an evening presentationby local clinicians on‘Recent developments in themanagement and treatment ofParkinsons Disease’ ,includingConductive Education.The Committee has seenseveral changes during the yearbut have been very busy planningand organising acomprehensive programme forthe new Millennium, with agood mix of evening and fullday courses.Many thanks to all themembers who have contributedduring the last year and to theguest speakers and clinicianswho have made the events possible!Our programme for 2000includes a lecture on Dyspraxiaand day courses on the upperlimb, including strapping, posturalcontrol with Nigel Lawes;and ataxia and the cerebellumwith Jon Marsden.■ OXFORDNicky SharmanRegional RepresentativeTel: 01296 315000 ext 59191999 provided us with a busyand varied programme forOxford. We have had eveninglectures every four to six weeksand an excellent splintingcourse which was held inOctober. This course has providedfresh ideas both fortreatment and further lectures.Our recent lectures have rangedfrom ‘MS’, ‘CT Scans made easy’,‘Neurosurgery’, ‘Perception andcognition within normal movement‘and a critical appraisal ofan article.The Oxford committee hasundergone a major reshuffle inthe recent months. I would liketo express our thanks to thosemembers stepping down and towelcome all those who aretaking up the challenges oftheir new posts! LouiseGatehouse, the previousregional representative, hasmoved on to the ExecutiveCommittee, although she stillremains an active member atregional level ( especially as Isettle into her old post!)I wish to express our thanksto everyone who has supportedthe region over the last year.Our numbers have increased tonearly fifty members and theevening lectures are wellattended. However, we arealways keen to involve newmembers and are enthusiasticabout fresh ideas for the yearahead.The provisional Programmefor 2000 includes: a half daycourse on Gait Analysis; the useof the treadmill in Strokepatients; and ATTP overlap.■ SCOTLANDEmma ForbesRegional RepresentativeTel: 01786 473 499The AGM was held in StirlingRoyal Infirmary in May andincorporated a problem solvingworkshop and networking sessionson CVA, MS and HeadInjury. This was attended by 20people and two new memberswere recruited to the committee.The study evening in Junetitled from ‘Russia with Love’was to give us an insight tophysiotherapy in Russia. Thisunfortunately had to be canceleddue to a lack of responsefrom our members.In November we ran a studyday on Parkinson’s Disease andSeating issues in conjunctionwith the Neuroscience NursesGroup. This was a great successand we hope to run furtherjoint study days in the future.At our committee meeting inDecember we had a volunteerto join our committee so wenow have eight members.The programme for 2000includes a meeting in May onmuscle imbalance with variousspeakers and the AGM, and inNovember a meeting on measurementin neurology.■ SOUTH TRENTLinda CargillRegional RepresentativeTel: 01332 340131 ext 56321999 has been a busy and successfulyear for the region, withmembership at 61.We offered eight events overthe year in either eveninglecture or day course format.Particular interest was gainedfor the ‘Movement ScienceApproach’ led by Paulette vanVliet, ‘Normal Movement of theUpper Limb’ with Erica Malcolmand ‘Gait Analysis’ which washeld in a gait laboratory withFran Polak.There have been a number ofchanges on the committee overthe year. We welcome JoannaRobertson as the new Chair, andwe do thank everyone for theirhard work. We are always keento attract new members to thecommittee, and would particularlywelcome anyone from theLeicester and Derby regions.As always we welcome feedbackon the programme, andhow South Trent ACPIN is run.The programme for 2000includes evening meetings onthe ‘Role of the assistant inneurological practice’;‘Communication with StrokePatients’ and day courses onsensory aspects of balance.■ SOUTH WEST(FORMERLY BRISTOL)Liz BrittonRegional RepresentativeTel: 0117 918 6565The first big change for this yearwas the re-naming of ourregional group from BristolACPIN to South West ACPIN. Itwas felt by members at the AGMthat this title more accuratelyreflected the catchment that wecover.Our ACPIN year started verysuccessfully with our AGM entitled‘Hands off – adjuncts toneurophysiotherapy’.We had a mixed programmebut found it difficult at times toarrange speakers. We promise totry harder in 2000! The highlightsof the programmeincluded ‘Hydrotherapy in neurology’,‘Biomechanics of thefoot’, and a motor-sciencefollow up day. Evening lectures,which are usually less wellattended, included a talk on‘Dysphasia’ by a speech therapistand a lecture on ‘MultipleSclerosis’.The committee are keen topursue the idea of trying morehalf day workshops rather thanevening lectures and wouldwelcome your response to thisidea.Other items on our agendainclude the setting up of ourown web-page as a method ofimproving communication.Bristol has also been pickedas a venue for a course entitled‘Spasticity in the community’.This is a venture run nationallyby National ACPIN and sponsoredby Athena Neuroscience.Further details will be publishedin Frontline.My annual report would notbe complete without the pleafor more committee membersand for those of you who feelthey are not receiving our4041

SYNAPSE ● SPRING 2000LETTERSposters to contact me as I try tokeep updating our mailing list.We look forward to seeing youat one of our courses this year.This year’s programme includestalks by Paulette van Vliet on‘Motor Science Gait’; ‘LifeBeyond Normal Movement’ (SueEdwards); and a day course onsplinting with Sue Edwards; alsoa half day workshop on‘Parkinson's Disease’ with GayMoore.■ SUSSEXHelen FosterRegional RepresentativeTel: 01703 777222 bleep 2547Sussex ACPIN has had anothersuccessful year. Membership hasbeen stable despite difficultiescaused by the CSP membershipdepartment. Financially theregion is in good health and hasused its funds to organisetraining and education for itsmembers. Attendance at courseshas as always been variable.The programme for 2000 isprovisional (members are askedto contact the secretary or theChair for details) and includes:a splinting course; a lecture on‘Acupuncture in Neurology’; theGuillain Barre Support Group;‘Nags & Snags in Neurology’;and Pilates.■ WESSEXRos CoxRegional RepresentativeTel: 01703 777222 ext 45621999 has again been a year ofchanges for Wessex ACPIN. TheChairperson Clare Blaxill hasgone back to Perth with herfamily. We thank her for herhard work and wish her all thebest in Australia. Helen Fosterhas taken over as Chairperson,and now has to juggle a babyinto her busy life. Ros Coxbecame Regional Representativefrom previously beingsecretary, so let’s hope shedoesn’t become pregnant aswell! Jo Nisbett has stepped inas Secretary. Carol continues tohold the purse strings.Despite having some verygood speakers the lectures havenot been well attended thisyear. Unfortunately theSplinting Course organised inSalisbury had to be cancelled.We have therefore sent out aquestionnaire to the HospitalRepresentatives and members toascertain why. This has highlightedsome problems that thecommittee is currently dealingwith. So we are hoping forimproved attendance in year2000. We are now keeping aregister of people attending, sothose members who haveattended most regularly, canhave priority for the morepopular courses.The October Strapping StudyDay was very popular and hadgood feedback and the Movingand Handling Study Day run inconjunction with SouthamptonUniversity Hospital was veryinformative. It has highlightedthe need for risk assessmentand has motivated therapists toreview their Moving andHandling Policy.Wessex ACPIN Membershipnumbers have increased thisyear to 62, and we would like toopenly invite all members toattend the committee meetings,which are held an hour beforethe evening lectures.The programme for 2000includes: a ‘Forum on differentapproaches to StrokeTreatment’; a Strapping StudyDay; a workshop on the‘Assessment and treatment ofindividuals with balance impairments’;a study day on the‘Management of Spasticity’; andlectures on Perceptual Testingand Sensory Inattention.■ WEST MIDLANDSKatie MarslandRegional RepresentativeTel: 0121 766 6611 ext 79101999 has been a much betteryear for our region. The movefrom evening lectures to studydays has proved successful andappears to cater better formembers. The timetable for theyear included study days onAtaxia, Older CP, Neglect andNeuroplasticity. The feedbackfrom these courses was generallygood, although numbers ofparticipants was not always ashigh as we would have liked. Wealso organised a junior introductoryday, but this had to becancelled due to lack ofinterest.Plans for next year include afollow up (more practical) dayon Ataxia and an advancedworkshop with Lynne Fletcher.The aim is to continue with thestudy days every two to threemonths.The committee has beenrather thin on the ground dueto maternity leaves, so ifanyone is interested in joiningplease contact Katie Marslandon 0121 624 1584. This is yourregion, and we would love tohave a committee representingthe region, including hospitalsin the more outlying areas.■ YORKSHIRESally BowesRegional Representative(from March 2000)Yorkshire ACPIN has hadanother successful year withmembership growing to 97 andeven some new volunteers forthe hard working committee!Lectures have taken place inthe evenings, at weekends andduring the working week. Thisformat seems to suit themajority of members and so willcontinue into 2000.Events that were particularlywell attended included thestudy day on muscle imbalancewhen our speaker Liz McKayblended theory and practice toproduce an inspiring and enjoyableday. Equally popular wasan evening lecture by Alan Basson the management of acutehead injury. The evening providedmuch food for thought bychallenging the traditionalnursing and physiotherapymanagement of these patients.The committee would like tothank all who have contributedto a successful 1999 lectureprogramme, particularly somelocal speakers who regularlygive up their time to supportYorkshire ACPIN.Looking forward to thecoming months a variety ofspeakers have been approachedto cater for a broad range ofinterests. The programme is notyet fully confirmed but includesexperts in their field such asPaulette van Vliet (Movementscience) and Janice Champion(gymball).Also planned is a lecture onParkinson’s Disease and Multi-System Atrophy, and a weekendcourse on Neurodynamics.The committee is, as ever, onthe lookout for new ideas andmembers. Please feel free toapproach any of the committeewith your ideas and opinions.BENCHMARKING FORSTROKEDear Colleagues,We are currently in the processof setting up an Acute StrokeUnit at Southampton GeneralHospital. The 22 patients staywith us an average of 10 days(range 6 - 36). The patientsare aged 18 upwards.We would be very grateful tohear of any similar StrokeAssessment Units who couldhelp us with a benchmarkingproject.Yours sincerelyHelen Foster MCSPTel:01703 777222 Bleep 2547email: ion.foster@gbr.xerox.comSouthampton UniversityHospitals TrustSTROKE CONFERENCEREPORTDear Colleagues,The Stroke Conference thattook place in April 1999 hasnow had the summaries compiled.It has taken a while forthe speakers to agree whatshould go in to the summaries,but this is now complete. Ifthere are any ACPIN memberswho would like a copy, pleasecontact me or Lina McDonnellat: CHSS, George Allen Wing,The University, Canterbury,Kent CT2 7NF. Please enclose acheque for £3.00 payable toUNIKENT.Best wishes,Dr Cecily PartridgeAPOLOGYNEUROLOGICALPHYSIOTHERAPY –EDITOR: MARIA STOKESA review of the above book waspublished in the Autumn 1999issue of Synapse. The openingparagraph of the review statedthat ‘The author of this bookclaims it to be “A new, dynamictextbook that every studentshould own…”‘, and goes onto comment that this is an‘extravagant claim’. Synapsewould like to point out thatthe author DID NOT make thisclaim. This was in fact thestatement made by the publishersin their sales pitch onthe back cover, and the authorhad no control over what waswritten, and was unaware ofthis statement prior to publication.Neurological Physiotherapy iscertainly a book that hasreceived a number of very positivereviews, and we wish toapologise to Professor Stokesfor any embarrassment causedby this error.Ros Wadeon behalf of the SynapsecommitteeACPIN are saddened toannounce the recentdeath of Moira Banks. Shewas a committed ACPINmember and formerRegional Representativefor Scotland. Our sympathygoesto her family.ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST& UNIVERSITY COLLEGE LONDONPUTTING THESCIENCE INTOREHABILITATIONA MAJOR INTERNATIONAL CONFERENCE ON ADVANCES INSPINAL INJURY • JUNE 2-3 2000 • QUEEN ELIZABETH II CONFERENCECENTRE WESTMINSTER LONDON UK• Nerve regeneration and prospects for ‘the cure’• Functional neuro-muscular stimulation• Advances in rehabilitation• Neuro-plasticity• Implications for health policy, resources and future planningKEYNOTE PRESENTERSWise Young • Kristjan RagnarssonPeter Mansell • Emmanuel RabischongHunter Peckham • Geoffrey RaisemanAn important conference for all involved in research,clinical management and policy relating to spinal cord injury.For further information please contact:THE EVENT ORGANISATION COMPANY+44(0)20 7228 8034 or email:eventorg@event.org.comor www.ucl.ac.uk/spinal-injury-conference/4243

SYNAPSE ● SPRING 2000UNIVERSITY COLLEGE LONDONMaster of Science &Graduate Diploma inNeurophysiotherapyONE YEAR FULL TIME OR UP TO THREEYEARS PART TIME MODULAR COURSECourse tutor: Margaret Mayston PhD MCSPPhysiology Department,University College London &the Bobath Centre, LondonThe course will provide physiotherapists working withneurological movement disorders (adult and paediatric)with a theoretical basis for clinical practice. The coursewill also include a major skills component to enabletherapists to gain greater expertise in the managementof clients with neurological disorder. It will enhance thephysiotherapists’ awareness of other aspects of clientmanagement and will provide them with a framework todevelop evidence-based practice. The full MSc optionprovides the opportunity to carry out an in depth investigationof a particular area of interest. The course isbeing presented in association with The Bobath Centre,London, giving participants the opportunityto gain a basic Bobath qualification inaddition to the MSc.For further details and anapplication form please contact:Mrs Fiona CookMSc AdministratorInstitute of Human PerformanceRNOHTBrockley HillStanmoreMiddlesexHA7 4LPThe Managementof Spasticity inthe CommunityMAY AND JUNE 2000REGIONAL STUDY DAYSLast September, ACPIN was approached by Ian EllisDirector of Athena Neurosciences Business Unit, to cohosta series of regional study days on the theme of‘The management of spasticity in the community’ withthe emphasis on neurophysiotherapy and MultipleSclerosis. Following much debate ACPIN decided thatthis was an excellent chance to promote neurophysiotherapy.Six regions volunteered to host the days, and the datesare as follows:■ Liverpool 26th April■ Stirling 22 May■ Poole 5th June■ Bristol early June■ Norwich 30 June■ Kent date to be confirmedLater in the year the course will also be available inLondon and Northern Ireland.All of the regions have been actively involved in planningthe programme in conjunction with AthenaNeurosciences. A stimulating day has been organisedincorporating a Medical Update as introduction, andtopics such as neurophysiology, seating and posture,and neurophysiotherapy with a case study example.The aim of each day being to provide the opportunityfor acute and community based physiotherapists to joinforces to expand their knowledge of spasticity management,highlighting problems experienced in primarycare.The study days will include refreshments and lunch. AllACPIN members will be able to attend free of charge,but places will be limited. The whole venture has beensponsored by Athena, to whom we are extremelygrateful for such an invitation.For further information please contact: Lucie Flint atAthena Neurosciences, Letchworth SG6 2HU or by fax on01462 707273.E X P A N D I N G H O R I Z O N S20–22 October 20002000 Congress and Exhibition of the Chartered Society of PhysiotherapyInternational Convention Centre, BirminghamREGISTRATION FORMPLEASE USE BLOCK CAPITALSTitle Mr/Ms/Mrs/Miss/Dr/Prof (DELETE AS APPROPRIATE)First name....................................................................... Surname .............................................................................................................Job Title (eg Senior 1P.T, senior lecturer or private practitioner).........................................................................................................................Address.........................................................................................................................................................................................................Town/Country .................................................................................... Post code........................................................................................Telephone number................................................ Fax ................................................................................................................................THE ABOVE INFORMATION WILL APPEAR ON THE DELEGATE LIST AND YOUR NAME BADGE.Do you have any dietary/special requirements? ■Would you like details about creche facilities? ■If YES, please detail ......................................................................................................................................................................................IF YOU REGISTER BEFORE 15 SEPTEMBER, YOU WILL RECEIVE A COMPLIMENTARY SET OF BUSINESS CARDSFirst name....................................................................... Surname .............................................................................................................Job Title .................................................... Town/city(eg London or Glasgow)...............................................................................................THE ABOVE INFORMATION WILL APPEAR ON YOUR BUSINESS CARD.A · REGISTRATION DETAILSB · SPECIFIC INTEREST GROUP PROGRAMMESAre you a:If you are registering for the conference sessions pleasestate which programme you will be mainly attendingPLEASE TICK ONE BOX ONLY(for room allocation).■ CSP memberPLEASE TICK ONE BOX ONLY. You can swop between sessions.■ non CSP member■ acupuncture■ neurology■ Physiotherapy student■ learning disabilities ■ pain■ Retired/unwaged CSP member■ occupational health ■ reflextherapy■ orthopaedics ■ sports medicine■ Free-paper speaker■ older people■ therapeutic riding■ SIG speaker■ mental healthcare ■ undecided■ Exhibitor............................................................................Are you a member of a SIG■ Exhibition visitor only (NO FEE)YES ■ NO ■exhibition will be open on Friday and Saturday onlyif YES which one? .................................44

GUIDELINESC · REGISTRATION FEESPLEASE SEE NOTES ABOUT BOOKINGFull registration to include all daytime catering as specified on the programme, entry to all conference sessions andtrade exhibition (open Friday and Saturday only) and VAT at the current rate. Please note the delegate rates are NOTinterchangeable. All fees are strictly as stated below.PLEASE TICK BOXCSP MEMBERS Full registration BEFORE 31 MAY 2000* £135.00 ■1 JULY - 31 AUGUST 2000* £165.00 ■AFTER 1 SEPTEMBER 2000* £190.00 ■Day delegate rate (half day rates are not available) £90.00 ■ state which day ..............NON CSP MEMBERS Full registration UNTIL 1 OCTOBER 2000* £165.00 ■Full registration AFTER 1 OCTOBER 2000* £200.00 ■Day delegate rate *DATE AS POSTMARKED £99.00 ■ state which day ...............DISCOUNTED RATESPHYSIOTHERAPY STUDENTS(please attach a letter from your physiotherapy school)Full registration £65.00 ■Day delegate rates £30.00 ■ state which day ...............RETIRED CSP MEMBERS/UNWAGED Full registration £70.00 ■Day delegate rates £50.00 ■ state which day ...............D · SOCIAL EVENTS AND OVERNIGHT ACCOMMODATIONSIG SUPPERSWould you like to receive details on any of the suppers being organised by the groups in section B.YES ■ NO ■if YES which ? .........................................................E · PAYMENT DETAILSRegistration fee £ ......................... all cheques to be made payable to theChartered Society of PhysiotherapyTotal £ ......................... payable in pounds sterling onlyInclusive of VAT (reg. VAT No. 232323800)CREDIT CARD PAYMENTS VISA/MASTERCARD/ACCESS are acceptedCard number ........................................................................................................Expiry date ...................................................................Card holders signature ........................................................................................Amount to debited ......................................................ACCOMMODATION INFORMATIONA list of hotels will be sent to you. Please make reservations via the Birmingham Convention and visitor Bureau. All theinformation will be on the booking form.BOOKING CONDITIONSPLEASE NOTE· Please enclose full payment to secure your booking - Invoices possible for group bookings only (3 or more)· All fees quoted are inclusive of VAT at the current rate of 17.5%· Please note that delegate fees do not include travel or accommodation or social events· Please use one registration form per person - please photocopy this form if necessary. Delegates are advised to take a copyof their registration form for their own records.· All cancellations will be refunded in full or part up until the closing date but are all subject to a £15.00 fee, howeversubstitute delegates are welcomed at no additional charge· A receipt will be sent to acknowledge payment- Invoices are not available after the closing dateGuidelines■ FOR AUTHORS INSYNAPSESynapse is the officialnewsletter of ACPIN. It aims toprovide a channel of communicationbetween ACPINmembers, to provide a forum toinform, instruct and debateregarding all aspects of neurologicalphysiotherapy. Anumber of types of articleshave been identified whichfulfil these aims. The types ofarticle are:RESEARCH REPORTA report which permits examinationof the method,argument and analysis ofresearch using any method ordesign (quantitative, qualitative,single case study or singlecase design etc).AUDIT REPORTA report which contains examinationof the method, results,analysis, conclusions andservice developments of auditrelating to neurology and physiotherapy,using any method ordesign.REVIEW PAPERA critical appraisal of primarysource material on a specifictopic related to neurology.TREATMENT REPORT/CASESTUDIESA report of the treatment of apatient or series of patientswhich provides a base linedescription of establishedtreatments, or a new insightinto the techniques or treatmentof people with a specificproblem.SERVICE DEVELOPMENTQUALITY ASSURANCE REPORTA report of changes in servicedelivery aimed at improvingquality.ABSTRACTSAbstracts from research projects,including those fromundergraduate or higherdegrees, audits or presentations.They should be up to300 words and where possiblethe conventional format: introduction,purpose, method,results, discussion, conclusion.TECHNICAL EVALUATIONA description of a mechanicalor technical device used inassessment, treatment, managementor education toinclude specifications andsummary evaluation.PRODUCT NEWSA short appraisal of up to 500words, used to bring new orredesigned equipment to thenotice of the readers. ACPINand Synapse take no responsibilityfor these assessments, itis not an endorsement of theequipment. If an official trialhas been carried out thisshould be presented as a technicalevaluation.POINTS OF VIEWArticles discussing issues ofcontemporary interest and anyother matters relating to neurologicalphysiotherapy.LETTERS TO SYNAPSEThese can be about any issuepertinent to neurological physiotherapyor ACPIN. They mayrelate to material published inthe previous issue(s) of Synapse.COPY SHOULD BE:• typed or printed• double spaced• on one-sided A4 paper withat least a 1” margin allround• consecutively numbered• include the name, qualifications,current position, andcontact address of theauthor(s).• Ideally, a disk copy of thematerial should also beincluded. Documents preferredin Microsoft Word forMacintosh or Windows.References should use theHarvard system. In the textquote the author(s) surnameand date (Bloggs 1994). Atthe end of the article givethe full references with thefirst author/editors name inalphabetical order, eg BloggsA (1994). ‘The use of bandagesin the treatment ofpeople with head injuries’.Physiotherapy 67, 3, pp56-58.Tables and figures should begiven appropriate titles andnumbered consecutively asthey appear in the text. Eachshould be presented on separatesheets of paper afterthe text.Any photographs and linedrawings should be in blackand white, in sharp focuswith good contrast and atleast 5” x 7”.Two copies of each articleshould be sent to:Ros WadeSynapse Administrator30 Heyworth RoadStratfordLondon E15 1STThe Editorial Board reservesthe right to edit all materialsubmitted. Likewise, theviews expressed in thisjournal are not necessarilythose of the EditorialBoard, nor of ACPIN.Inclusion of any advertisingmatter in this journaldoes not necessarilyimply endorsement of theadvertised product byACPIN.Whilst every care is takento ensure that the datapublished herein is accurate,neither ACPIN nor thepublisher can acceptresponsibility for any omissionsor inaccuraciesappearing or for any consequencesarising therefrom.ACPIN and the publisherdo not sponsor nor otherwisesupport any substance,commodity, process, equipment,organisation orservice in this publication.Note: all material submitted tothe administrator is normallyacknowledged within twoweeks of receipt.CLOSING DATE FOR APPLICATIONS IS 2 OCTOBER 2000 · BUT PLEASE REGISTER AS SOON AS POSSIBLEAny queries regarding your booking, please contact: The Events Unit · CSP14 Bedford Row, London WC1R 4ED · Tel: 020 7306 6621/2 · Fax: 020 7306 6623 · E-Mail durhams@csphysio.org.uk■ Please tick this box if you do not wish to receive separate mailings of commercial nature eg. from CSP exhibitors/sponsors47