Syn’Syn’apseapseSPRING 2005 JOURNAL AND NEWSLETTER OF THE ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS INTERESTED IN NEUROLOGY

> Developing integrated stroke services – a whole system service user perspective

> Developing physiotherapy services for people with MS – lessons learned from four pilot studies

> Recovery within grasp? Investigating the short and medium term effects of the SaeboFlex (Functional Tone Management System) on chronic post stroke patients with residual upper limb deficit

> Changing self-efficacy following stroke – a single case approach www.acpin.net

Syn’apse Contents

JOURNAL AND NEWSLETTER OF THE ASSOCIATION OF CHARTERED From the Chair 2 PHYSIOTHERAPISTS INTERESTED IN NEUROLOGY Articles

SPRING 2005 • Developing integrated stroke services – a whole system ISSN 1369-958X service user perspective 3

• Developing physiotherapy services for people with MS – lessons learned from four pilot physiotherapy services 7

• Recovery within grasp? A report on a preliminary study investigating the short and medium term effects of the SaeboFlex (Functional Tone Management System) on chronic post stroke patients with residual upper limb deficit 12

• Changing self-efficacy following stroke – a single case approach 16

Articles in other journals 17

Focus on…

Sue Mawson, our new President of ACPIN who commences ACPIN’S AIMS her ‘term of office’ in March 2005 19 1. To encourage, promote and

facilitate the exchange of ideas ACPIN news 21 between ACPIN members within

clinical and educational areas. Other news 28 2. To promote the educational

development of ACPIN members Research forum 30 by encouraging the use of

evidence-based practice and ACPIN national conference March 2005 continuing professional Pain and neurodisability 34 development.

3. To encourage members to Reviews participate in research activities • Contractures in the post-stroke wrist: a pilot study of its and the dissemination of time course of development and its association with information. upper limb recovery. 41 4. To develop and maintain a reciprocal communication process • Relationship between change in balance and self-reported with the Chartered Society of handicap after vestibular rehabilitation therapy 42 Physiotherapy on all issues related • Analysis and training of walking following stroke 43

to neurology. • Assessment and treatment of patients with a 5. To promote networking with predominance of hypotonia 43 related organisations and profes-

sional groups and improve the Regional reports 44 public’s perception of neurological

physiotherapy. Guidelines for authors 47 6. To encourage and participate in

the setting of guidelines within Regional representatives 48 appropriate areas of practice. 7. To be financially accountable for all ACPIN funds via the Treasurer and the ACPIN committee. Syn’apse ● AUTUMN/WINTER 2004

a shift in existing resources and not previously Northern regional From the Chair new investment. We must continue representative. to have a voice on such matters and if I look forward to seeing as many of Nicola Hancock BSc (Hons) MCSP SRP ACPIN Chairperson any of you have any specific points to you as possible at Congress this make on the issue of funding for the Autumn and at our Silver Jubilee Welcome to the Spring 2005 edition events, we are delighted that three of implementation of NSF’s and NICE residential conference in March of Synapse. our motions for the Annual guidelines, good or bad, I would love 2006. Don’t forget that the Regional I write this Chair’s address just a Representatives Conference (ARC), to hear from you. Committees are always looking out couple of days after our 2005 AGM have been accepted and detail of This time of year always brings for new members as is ACPIN in and Conference, ‘Pain and these can be found on page 25. It is some goodbyes as Committee general, so let’s keep the interest and Neurodisability’ held once again in very important that our voice is heard members resign and move on to commitment at the incredible levels the very comfortable surroundings of annually at this event. As one of the other projects. The Executive we have seen in this and previous the Hilton Hotel, Northampton. Over largest CIG’s we potentially hold Committee wishes Alison Baily years. 120 of you joined the Committee for considerable influence at the CSP Hallam all the very best as she returns this extremely busy and challenging and ARC is a powerful way of bringing to the USA, and regional Best wishes day and a first glance at the current issues of concern for representatives Caroline Brown and evaluations reveals some very positive neurological therapists to the Sally de la Fontaine are leaving the Nicola Hancock feedback. This was a new topic to the forefront of the CSP agenda. National Committee. I thank them all ACPIN Conference agenda and The interactive CSP project is for their commitment and wish them ADDRESS FOR CORRESPONDENCE although we have, of course, touched moving towards a nationwide roll- good luck for the future. Bell House, School Road, Pockthorpe, on the issue of pain during other out, provisionally set for May. We Of course, it is also time to bid King’s Lynn, Norfolk PE31 8TE programmes, we have not before have confirmed our network farewell to Professor Ray Tallis, our email nicolahancock@btinternet. dedicated a whole day to this categories – after much deliberation President for the past three years and com important issue. Many of those who at ACPIN Executive meetings! I am a fantastic supporter of, and spoke are members of the delighted that a considerable number contributor to, ACPIN. Ray has Physiotherapy Pain Association and of our members have expressed initial proved to be the most ardent flag- we received some hugely positive interest in moderating the site. Once flyer for neurological physiotherapy, comments from them about our pro- again, I must thank those members of always flamboyant, more than active attitude to ‘cross-CIG’ working Northern region who have so occasionally controversial and and developments. I am in no doubt successfully and competently steadfastly supportive. His that further opportunities for work managed the pilot site. I have presidential addresses and openings with other CIG’s will arise to the personally found this an invaluable to Synapse have been constantly benefit of us all. Summaries of resource and urge you to log on as challenging and political, keeping at abstracts can be found from page 34 soon as possible. their heart the fundamental issues of and details of the AGM can be found The NSF – Long Term Conditions has healthcare as seen by a committed on pages 21 to 24. finally been published healthcare professional. In Synapse Momentum is gaining towards CSP (www.doh.gov.uk) as has the Autumn 2003, Ray described the Congress as ACPIN prepares to host document Working Differently which enduring values of a healthcare its two-day programme, ‘Cognition focuses on the AHP role in improving professional as, ‘compassion, and Behaviour: Complex Challenges services to people living with a long commitment and knowledge based to Rehabilitation’ on the 7th and 8th term condition. As you know, ACPIN care’ and these are certainly what he of October this year, once again at members played a key role in the represents and strives for, for all of us. the ICC in Birmingham. Early consultation process and its Whilst we will miss Professor Tallis, advertising should soon be in Frontline implementation will bring some far- I am delighted to welcome Dr Sue and our own website will be updated reaching implications to our work. Mawson to the Presidency. Sue has an when the programme, currently in the The recommendations of the incredible CV of work in the field of final stages of development, is National Service Frameworks to neurological rehabilitation and confirmed. The CSP have changed the improve care for specific patient research and we are honoured that format of Congress and there are groups and the broad multi- she will be joining us. Sue has likely to be further changes for 2006, professional consultations before expressed a wish to be actively but we have remained in constant their completion are to be applauded involved in the Committee and I liaison with them to ensure that but I continue to have concerns that know that her influence will be of ACPIN can have at least a two-day their implementation is grossly under great benefit to our organisation. slot. funded and misgivings that in many We also welcome Julia Williamson Whilst I am on the subject of cases targets are achieved due only to on to the Executive Committee,

2 ARTICLE 1

Debbie Neal, Leeds City wide Developing integrated stroke services Stroke Services coordinator & Senior Lecturer (Physiotherapy) Leeds – a whole system service user perspective Metropolitan University.

INTRODUCTION Although putting the theories into practice can present This article outlines a whole systems approach to an enormous challenge there is increasing evidence to redesigning services using the ongoing development of show the effectiveness of these methods (NHS integrated stroke services in Leeds as an example. In Modernisation Agency, 2004). 2001, the Department of Health (DoH) commissioned a pilot project as part of the implementation of the 1. Identify a need – a local or national driver for change National Service Framework (NSF) for Older People. With stroke services there have been a number of Project workers were employed to work with commis- drivers for change. In addition to the NSF for Older sioners in two pilot sites to implement a single standard People, there have also been the National Clinical of the NSF. Progress at the pilot sites was evaluated and Guidelines for stroke and the National Sentinel Audits. reports made to the DoH. In Leeds, chosen as one of National drivers to improve services are not exclusive to the pilot sites, the Older Peoples Modernisation Team stroke. Neurophysiotherapists are also affected for who part funded the post, decided to focus on instance by the recent NICE MS guidelines and the ‘Standard 5 – Stroke’. The author, a neurophysiothera- forthcoming NSF Long Term conditions. pist, was seconded to the role of Stroke Care Pathways Locally in Leeds the results of the National Sentinel Project Manager, with a remit to meet the milestones of Audit highlighted both pockets of good practice and the NSF Older People Standard 5, through the devel- deficiencies in the existing services. opment of a stroke care pathway. Leeds is a city with a population in excess of 2. Evaluate the evidence 750,000 located mostly in the city but also in some Any change in clinical service delivery should be surrounding market towns and outlying rural areas. supported by evidence of effectiveness – either from Health services are provided by the mental health trust, primary research or systematic reviews of the literature, five primary care trusts and a single large teaching trust though in areas where insufficient evidence exists, based at several sites produced from a relatively recent expert opinion contained within national clinical guide- amalgamation of two hospitals trusts. In Leeds at least lines or a local consensus, can help shape the service. 1300 people a year have their first stroke and an Either way, the opinions of those regarded by many as estimated 8000 people are living with the effects of the real experts – the patients and carers, who have stroke. A substantial proportion of health and social experienced the current services, should be actively care resources are devoted to the immediate and contin- sought. uing care of people who have had a stroke. In 2001, Before embarking on any change in service delivery although stroke specialist services were well established it is vital that data is collected about existing service within the acute trust they were not available to all ages delivery in order that any improvements can be identi- or in all locations, whereas stroke specialist services in fied (NHS Modernisation Agency, 2002). In Leeds, the community were extremely limited. there is routine data collection by the Leeds Stroke Database about lengths of stay, mortality, disability SERVICE DEVELOPMENT levels and patient satisfaction. Audits of other specific There are a number of well documented tools and tech- aspects of service were carried out prior to imple- niques to support service improvement and delivery menting any changes. (NHS Modernisation Agency, 2002) for which the following list could provide a framework. 3. Map the journeys and identify any bottlenecks or 1. Identify a need – a local or national driver for change blockages 2. Evaluate the evidence There are a number of inter-related pathways that need 3. Map the patient journey and identify any bottle- to be mapped in order to understand the totality of necks or blockages stroke services including primary prevention of stroke, 4. Redesign the service, test out and implement change services for those with TIA, services for acute stroke 5. Continue to monitor and improve services and if and secondary prevention, rehabilitation and reintegra- needed commission services to close the gaps tion services for those living with the effects of stroke.

3 Syn’apse ● SPRING 2005

Pathways need to be mapped both at high level and at amounts of detail about the service people were actually process level. High/service user level pathways should receiving as opposed to the service that people thought be a ‘bird’s eye’ view of each pathway, with a focus on they were providing. what happens to 80% of the people, 80% of the time, Although very complex, there were three key although an understanding of what happens to the findings from the mapping. Firstly, inequity in service other 20% can also be very helpful in improving provision dependent on age and location. Secondly, journeys through the system. They should enable an huge variability in pathways through the services in understanding of the major flows through the service terms of co-ordination, quality and timing leading to and the location of any bottlenecks and blockages to an some terrible and some very positive experiences. improved experience overall for those with stroke. Finally, huge amounts of health and social care For instance, as shown in the pathway below resources invested, albeit in a fragmented and disparate (Figure 1), however good the rehabilitation provided on way, into providing services for those with stroke, eg a stroke rehabilitation ward, a subsequent four month through hospital bed days, nursing home places and wait for outpatient therapy after discharge is going to primary care services. This lack of an integrated system reduce the overall effectiveness of the rehabilitation meant that there was reliance on an informal network of process. contacts and the biggest problems were during transi-

HIGH LEVEL PATHWAY PROCESS LEVEL PATHWAY

Bottleneck

Home Acute Stroke Home Life Sees GP TIA TIA stroke rehab & with Wed Clinic Home A&E MAU Tues unit ward rehab stroke 10.00am Tues 6.00am

Figure 1 9.0 0am 10.05am Appt phones dictates letter for letter sent appt out The high level pathways were mapped through infor- mation provided by the Leeds Stroke Database plus through a series of individual and group interviews with 12.30pm Thurs pm staff within the acute trust, intermediate care, receptionist Consultant community health services, social services and the types up reviews letters and referral voluntary sector. With each successive interview, infor- posts them letters mation obtained from previous interviews was checked and clarified. It became clear that although there was a Thurs am consensus that services could be improved, particularly letter through increased investment, there was a tendency to arrives at hospital blame others for the existing poor service eg clinicians blamed managers, managers blamed clinicians, community based staff blamed hospital-based staff and Figure 2 vice versa and the statutory and voluntary sectors blamed each other. Low/process level pathways provide an under- tions between different service providers. There were standing of all the individual processes that enable each some positive findings however: there were many step in the pathways to happen. It is often at process pockets of excellent practice, particularly in stroke level that cumulative small changes can make a big specialist areas, many caring, committed staff motivated difference overall. to improve services. The process level pathways were mapped partly The mapping process was completed at a stake- through the staff interviews but also through service holder day attended by service users and carers plus users and carers (Figure 2). As many service users as service providers from primary and secondary health- possible that were in the system on a single day were care, social services and the voluntary sector. identified and interviewed face to face. Some of those in Participants at the stakeholder day also agreed a vision the early stages after stroke were reinterviewed as they for stroke services, identified some of the helps and moved along the pathway. This provided enormous hindrances to an effective stroke services and used

4 ARTICLE 1

examples of patient pathways and experiences to TIA clinics, if insufficient scanning facilities are produce and prioritise a list of suggestions for change. available then appropriate management of the person with TIA cannot be instigated any sooner. Agreed vision Lack of knowledge of the whole system could lead to • An integrated stroke service for Leeds (irrespective inappropriate or ineffective investment. For instance, of age or location). knowledge that many of those with stroke go to various • Stroke prevention for those at risk of first or further medical wards due to a lack of acute stroke beds but stroke. subsequently have an increased length of stay or worse • Specialist stroke services providing acute care and outcomes, could help justify an increase in acute stroke rehabilitation. beds. Knowledge of the whole pathway might however • Long-term support for stroke survivors and their show that increased provision of community based carers. rehabilitation could have a much greater effect on overall services. Community based rehabilitation could Agreed priorities not only increase outflow from the hospital, thereby • Improved primary prevention of stroke. increasing the proportion of people able to access the • Public education that stroke is a medical emergency. acute stroke wards, but also limit the numbers of people • A protocol and structured assessment for para- admitted with complications due to lack of available medics. rehabilitation such as falls and respiratory infections. • A system that allows someone, of any age, to go PCTs may well have a preference for commissioning straight to a stroke specialist ward not via A&E. increased community rehabilitation rather than acute • Quicker access to scanning facilities. hospital beds, as it is more likely to reduce their bills for • No age barrier to stroke specialist services, care or numbers of inpatient admissions and may help with rehabilitation. their star rating targets such as total time in A&E (less • Stroke care pathway/care plan/check list to go with than four hours) and death rates from circulatory patient wherever they go – including record of diseases (ages under 75 – change in rate). previous input and advice/information. • Stroke care co-ordinator appointed on diagnosis and Managing change to follow through pathway. Although in a whole system redesign process many • Plan discharge from day of admission and involve different approaches to managing change may be family/carers and all community based services from required, the most important aspect is communication outset, including assessment of carers’ needs and to ensure all those involved are kept informed of involvement of voluntary sector. progress. This has been managed through a combina- • More community based provision of specialist and tion of newsletters, emails, intranet and internet sites long term stroke services. and staff and service user involvement in delivering • More flexible working, expanded roles/sharing of change. A key technique for change management is the skills/creative skill mix/use of assistants. use of PDSA (Plan, Do, Study, Act) which allows a • Better, more consistent and more continuing access change to be tested out in a small way before changing to sources of information provision about the stroke the whole process. The overall aim of change is to make services that exist. the pathway more efficient by reducing the number of • Better, more consistent and more sources of infor- steps in the pathway. This could be achieved by: mation provision re lifestyle changes and secondary • doing all or some tasks simultaneously where prevention following stroke. possible ie introduce parallel processes, • reducing or eliminating batching ie do today’s work 4. Redesign the service, test out and implement change today, • reducing blockages and bottlenecks by ensuring the Why a whole systems approach? right person with the right skills is delivering the The aim of a whole systems approach is to smooth out right service in the right place and the overall journey. Most of the blockages and bottle- • developing pull systems rather than push systems necks in the journey occur when crossing organisational such as developing community rehabilitation boundaries leading to a bumpy ride for service users. services. Often it is those parts of the pathway with specialist Beware some of the pitfalls with PDSA. knowledge of stroke that have driven service improve- • Not getting all stakeholders on board – everyone ments in the past, which although helpful, does nothing thinks THEY will be swamped! to improve the overall experience for the service user. • Planning stagnation – getting stuck in the planning For example, however efficient the referral processes to phase and failing to move onto action

5 Syn’apse ● SPRING 2005

• Dashing into ‘doing’ without proper planning • Develop a system that allows someone, of any age, to • Forgetting the evaluation phase and just rolling go straight to a stroke specialist ward not via A&E. something out • ‘Pilotitis’ – introducing a succession of new ideas without rolling any out Acute Home A&E MAU stroke • Changing the most effective part of the system unit • Working within existing organisations and roles rather than focusing on the impact on service users

What has changed? Acute Home A&E stroke There have been a number of changes in Leeds Stroke unit services over the last three years: • A stroke service user and carer group ‘Positive Strokes – changing outlooks’ has been established. They have produced and disseminated an informa- Acute Home stroke tion pack for those with stroke, been involved in unit stroke training sessions for healthcare staff and participated in the interview process for stroke team staff. • Develop improved access to TIA clinics and quicker • The acute trust stroke discharge summary has been access to scanning facilities. streamlined to match the GP Stroke Template. • Referral to the dysphasia support service can now be Home TIA Sees GP made by other healthcare professionals not just TIA Clinic Wed Tues Fri speech and language therapists. 10.00am 6.00am 2.00pm • The process and timing of referrals between an acute stroke ward and the community rehabilitation unit has been improved. 9.0 0am 10.05am • Nursing staff are undergoing training by speech and phones uses protocol for and books TIA language therapists in assessment of swallow. appt clinic appt by • A nutrition and dysphagia management policy has phone/ebooking been developed and implemented. • A patient held vascular risk factors booklet has been developed and is currently with acute trust and PCT SUMMARY clinical governance boards. A whole system approach to service improvement can • A five day acute integrated care pathway currently in either be achieved through a service perspective ie devel- use is under review. oping an integrated seamless stroke service that works • Outpatient therapy waiting lists are being combined. across organisational boundaries with service user and • Work is underway to simplify access to post- carer consultation or through a service user perspective discharge neurorehabilitation services, including the ie developing a stroke pathway that delivers the right development of a neuro-specialist assessment as part service at the right time in the right place for all ages of the single assessment process. with stroke survivors and carers central to the process. • A community stroke team is being piloted in one Although service improvement for those with stroke PCT. or other neurological conditions can be lengthy and • The author is piloting the role of city-wide stroke complex, keeping the service user central to the process services coordinator. has been crucial in Leeds.

5. Continue to monitor and improve services Although further work remains to be done to achieve REFERENCES the list of priorities identified at the stakeholder day, it is NHS Modernisation Agency (2002) Improvement Leaders’ Guide to important to monitor and identify any remaining gaps in Process mapping, analysis and redesign. Available at: www.modern.nhs.uk/ service. This is achieved through consultation with staff improvementguides/reading/processmapping.pdf and service users, links with the Patient Advice and NHS Modernisation Agency (2004) Ten High Impact Changes for Service Liaison Service and the use of a ‘comments, complaints Improvement and Delivery; a guide for NHS leaders. Available at and compliments’ form by the service user group. http://www.content.modern.nhs.uk/NR/rdonlyres/6E0D282A-4896- Work is underway to address the following issues: 46DF-B8C7-068AA5EA1121/654/HIC_for_web.pdf

6 ARTICLE 2

Jacqueline Stevenson Developing physiotherapy services Physiotherapy Programme Manager with the MS society for people with MS – lessons learned from four pilot physiotherapy services

BACKGROUND evaluated the effectiveness of the four services so lessons Research carried out by the Multiple Sclerosis Society learned can be shared with health and social care with regard to the services most valued by people with professionals and people affected by MS. Multiple Sclerosis (MS) has indicated that physio- The aims of the evaluation were to describe the four therapy is very highly regarded. In fact physiotherapy is pilot physiotherapy services in terms of their models of rated closely behind a ‘cure’ for MS. service delivery, intervention components and charac- With the publication of the NICE MS Guidelines in teristics of the people with MS using the service, and to 2003, we can safely say physiotherapy service delivery assess each service’s ability to: is firmly embedded as part of the multidisciplinary • deliver effective interventions for people with MS, approach to care and management of MS. However which includes offering timely and appropriate little evidence exists to date to support the specific access to services and providing acceptable informa- physiotherapy clinical interventions that people with tion, education and advice MS so value. • involve users in service development Overall, these pilot studies had two main aims. • meet the MSS Developing MS Healthcare Standards Firstly, and for the first time, to begin to unpack the and Chartered Society of Physiotherapy (CSP) ‘black box’ of physiotherapy approaches and tech- Standards of Physiotherapy Practice. niques used to treat people with MS, by describing the clinical intervention of the physiotherapist. Secondly identifying effective models of service delivery that 1. MS RELAPSE CLINIC could be replicated elsewhere in the UK. Therefore two Walton Centre for Neurology and Neurosurgery specific strands of investigation targeted clinical NHS Trust, Liverpool practice and service delivery. In 2001 the MS Society and MS Research and Relief The aim of the MS Relapse Clinic was to provide any Fund launched a programme to pilot and evaluate four patient experiencing a relapse a full multidisciplinary different models of physiotherapy services for people team assessment at one visit followed by a decision on with MS in the north of England. The four innovative optimal relapse management. Although undertaken pilots were established as part of the Developing within a multidisciplinary context, the major interven- Physiotherapy Services for People with MS Programme. tion was physiotherapy assessment and treatment. These were: The Clinic was established after research showed 1. Specialist physiotherapy as part of a multidiscipli- that patients in relapse who were treated with steroids nary approach in the MS Relapse Clinic, Walton combined with planned, comprehensive multidiscipli- Centre for Neurology & Neurosurgery NHS nary care responded better than a control group who Trust, Liverpool. received standard neurology or day-ward care for 2. The ACTIVE Programme, a 14-week education, relapse management. advice and exercise programme for people with Four appointment slots were available each week. minimal impairment, University Hospital of The multidisciplinary team – consisting of a physiother- North Tees, Stockton. apist, an occupational therapist, an MS specialist nurse, 3. A six-week fatigue management programme at the an orthoptist, a registrar and a consultant neurologist – MS Society's Woodlands Respite Care Centre, maintained close links with outside agencies in order to York. ensure appropriate monitoring and follow up of patients 4. The establishment of an MS physiotherapy post to during steroid treatment. provide care in community and hospital settings, West Cumbria Primary Care Trust. Results of evaluation The MS Relapse Clinic service was innovative, timely, EVALUATION responsive and valued highly by patients. Patients Researchers from the School of Health Community and quickly settled into the multidisciplinary assessment Education Studies at Northumbria University have though they initially felt anxious at the prospect of

7 Syn’apse ● SPRING 2005

Physiotherapy intervention: summary Physiotherapy Intervention: summary

Type of intervention ACTIVE programme protocol Strengthening (trunk most favoured) Home exercises Assessment by Consultant Advice • Diagnosis of MS; meet inclusion criteria (walk 100m without Stretching aid; score of <6.0 on EDSS; no medical conditions that Gait re-education would preclude participation) Postural re-education • Referral for ACTIVE programme

Nature/topic of advice given Discussion with MS Nurse Cardiovascular workout • Ensure patient is appropriate for programme and obtain Dizziness exercises informed consent Fatigue management Fitness/aerobic activities Functional tasks Neurological assessment by neurophysiotherapist General activity • Baseline assessment General fitness • GP informed of inclusion in programme General mobility Pacing activity Relaxation Information (from a range of speakers) and Spasticity management supervised exercise programme Work issues and fatigue • Three hour session once a week for six weeks on a Wednesday afternoon in the hospital setting facing so many professionals at once. The multidiscipli- nary approach meant patients tended not to separate out individual professionals in describing their interac- Referral to health and fitness advisor tion. However, the physiotherapy interventions have • To continue exercise programme for two months in leisure been clearly defined in the evaluation and could be centre setting replicated in other relapse management clinics. Review and assessment by neurophysiotherapist • Following two months of exercise on prescription, 2. THE ACTIVE PROGRAMME reassessment of outcome measures University Hospital of North Tees, Stockton • Placed on the Physiotherapy Register where PwMS can self refer if further advice/treatment is required The ACTIVE Programme was targeted at people with • Encouragement to continue own exercise programme MS who had minimal impairment. Its aims were to improve exercise tolerance, prevent deconditioning and secondary complications, and give access to mutual Results of evaluation support and informed advice from a range of appro- The ACTIVE Programme met a need for some people priate disciplines. with minimal impairment from MS. Participants were The underlying principle was to help people to positive about the benefits of the programme. Some understand their condition better, so they could participants felt empowered and more able to make develop effective self-management strategies. lifestyle choices. However, if it were to be rolled out The 14-week ACTIVE Programme – which stands further, tighter selection criteria would be needed. In for Advice, Coping mechanisms, Training, Information, particular consideration of the time since diagnosis for Value your health, and Exercise – combined information the individual, how they have adapted to their and exercise sessions held over a three-hour period, condition, and the expectations of the referrer. Lessons once a week for six weeks in a hospital setting. Exercise were learned about the timing for giving information: sessions included stretching, cardiovascular, core individuals need to be at the right stage of their MS stability, balance, upper-limb work and relaxation. journey, as information can have an emotional Exercise sessions continued in a leisure centre under the dimension, which may provoke stress and depression. instruction of a health and fitness adviser for a further eight weeks after the initial six-week session. Four groups of up to ten participants completed the programme over a two-year period.

8 ARTICLE 2

3. FATIGUE MANAGEMENT PROGRAMME Fatigue management programme protocol MS Society's Woodlands Respite Care Centre, York

Screening The Fatigue Management Programme based at the MS • Diagnosis of MS; 0-6 EDSS; >4 on Fatigue Severity Scale / Society's Woodlands Respite Care Centre in York fatigue present >50% of days for >six weeks; verbal targeted those people with MS whose fatigue was permission of own PT/OT if appropriate primarily due to inactivity and deconditioning. The aim • Patients excluded: if acute onset of fatigue in prior six of the six-week exercise-based programme was to weeks; undergoing diagnosis of fatigue cause; medical reduce the impact of fatigue on everyday life, and to condition which would preclude involvement; medication challenge received wisdom that exercise can exacerbate side effects involving fatigue; significant sleep disturbance; fatigue. currently having a course of physiotherapy; or if unable to People who were interested in taking part referred give informed consent. themselves to the Centre where they were screened for suitability. If they were eligible for the programme their GP was informed and asked to notify the Centre of any Initial assessment contraindications. • Baseline assessment and consent Once accepted, the participant's baseline fitness was • GP informed of inclusion in programme assessed and a personalised exercise programme developed. People attended twice a week for six weeks, with one gym and one group exercise session each Gym induction week. During gym sessions, everyone followed their • Individual sessions to devise tailored programme own tailored proramme. Group exercise sessions were split into four parts: stretches, posture and strength- ening exercises; Pilates; a basic circuit; and relaxation. Fatigue Management Programme Participants were carefully monitored throughout the • Attendance two times weekly for six weeks for a session programme to identify any adverse reactions. At the end lasting approximately 1 hour 45 minutes, including of the programme the initial fitness assessment was refreshments/discussion; 1 x gym session / 1 x exercise class repeated and participants encouraged to continue to participate in fitness activities, for example, at local Reassessment and planning for the future leisure centres. • Assessment battery rerun • Exercise promotion using local facilities Physiotherapy Intervention: summary Physiotherapy interventions provided to all participants as part of structured group sessions Results of evaluation Participants valued the programme and felt that it Cardiovascular activities brought them identifiable physical, functional, psycho- Individualised multi-gym based programme in a group* logical and social benefits. These benefits overall Group exercise programme in exercise studio outweighed the disadvantages of the cost and effort of Strengthening (upper and lower limbs, trunk) travelling to and from the centre, fatigue and disruption Mobilising (upper and lower limbs, trunk) to their routine. The use of the gym was particularly Stretching popular and some participants felt confident to Relaxation continue exercising after completing the programme. Balance* Staffing the group sessions was problematic: reliance Postural re-education for sitting and standing on volunteers was difficult and the staff/participant ratio Pilates handouts for home exercise programme required careful consideration. Tight selection criteria Advice about exercise and fatigue limited the number of participants, but produced Gym ball* homogeneous groups that worked well together. The drawback of this physiotherapy programme was that it * Tailored to individual ability was not linked to other local MS services. This would be needed if the programme were to be replicated to ensure long-term sustainability.

9 Syn’apse ● SPRING 2005

4. MS PHYSIOTHERAPY POST Summary of advice given in the Cumbria rural service West Cumbria Primary Care Trust Specific to current physiotherapy intervention The aim of the service was to provide a dedicated MS Balance work physiotherapist for 18 hours a week to help overcome Using activities at home problems of geographical isolation and lack of transport Control of tremor that are common in predominantly rural areas. Serving Impact of physiotherapy 180 people with MS living in a 685-square-mile area of Breathing exercises west Cumbria, the service was designed to be flexible, Self stretches for neck with physiotherapy offered in a range of community and Upper limb function health service settings and also out of normal hours Standing work in kitchen where necessary. Links with the Young Disabled Unit at Whitehaven Hospital provided patients with a central Overall physical management of MS point of contact, and enabled the involvement of the Exercise multidisciplinary team. Exercise levels This service development used an action research Maintenance of lifestyle approach. During the project patients completed Posture feedback questionnaires and the results were used, Incorporating challenges into lifestyle together with insights from interviews and feedback Bilateral activities from professionals referring into the service, to identify ways of developing the service in the future. These were Management of specific MS symptoms considered by an expert panel and a decision-making Fatigue management steering group, which included people affected by MS, Effect of menopause on condition to adapt and improve the service. Energy conservation Managing sensory loss Physiotherapy Intervention: summary Visual prompting for poor memory

West Cumbria Primary Care Trust MS Physiotherapy post Disease process Disease progression Diagnosis questions Clear review Flexible working hours and Carer issues rereferral procedures Encouragement Handling techniques/advice for carers Awareness-raising of needs Central point of contact Positioning of client group through with health service MDT via Demonstrating stretching regime to carers talks/presentations Young Disabled Unit Transfers

MS PHYSIOTHERAPY POST Results of evaluation WEST CUMBRIA The service responded flexibly and creatively to the PRIMARY CARE TRUST needs of a variety of people with MS living in rural Cumbria. Before the introduction of the service, people with MS felt they were left to their own devices after Links with community Satellite clinics being diagnosed, and they had to wait a long time sports facilities and one day per month – before being referred for physiotherapy. physiotherapists running Maryport, Cockermouth, However, MS specific physiotherapy delivered by a MS Branch exercise groups Egremont, Millom knowledgeable practitioner with strong interpersonal skills was highly valued by patients. Patients liked

Out patient Community having a choice of where they had their physiotherapy. neurophysiotherapy – neurophysiotherapy – They felt the service offered was sensitive and respon- Workington, Whitehaven Workington, Whitehaven sive, and they viewed the physiotherapist as being an expert in MS management generally. Most patients waited less than two weeks for treatment after referral. The involvement of people

10 ARTICLE 2

affected by MS in service development was innovative • further research on the costs and benefits of fatigue and well developed. Patients also appreciated the conti- management nuity of service and having a single point of contact. • research on how the 'stage of adaptation' affects the A serious gap in physiotherapy provision for people dynamics of group programmes for people with MS, with MS has been left in the area since the service was and how it influences the readiness for people with withdrawn at the end of the pilot funding. MS to receive information. A further recommendation from the evaluation team RECOMMENDATIONS FROM THE EVALUATION was that, as service users, people with MS would benefit TEAM FOR FUTURE SERVICE DEVELOPMENT AND from training for their involvement in service develop- RESEARCH ment. All four physiotherapy models clearly offered benefits A copy of the full report, including an executive to patients. The multidisciplinary MS Relapse Clinic at summary, is available on the MS Society's website: the Walton Centre and the West Cumbria rural service www.mssociety.org.uk. Additionally, the website are particularly strong service models that merit being provides details of how to obtain the individual pilot sustained and replicated. The ACTIVE Programme in project site reports. . Alternatively, contact Leila Terry Stockton and the Fatigue Management Programme in (Service Development Administrator at the MS York would require further refinement and evaluation society) for further advice, telephone 0208 438 0742. before being replicated.

Developing effective physiotherapy services in the future would benefit from: • an evaluation of outcome measures used in physio- therapy practice, and the development of more appropriate MS measures

11 Syn’apse ● SPRING 2005

Sally Davenport MSc, MCSP School of Paramedic Sciences, Recovery within grasp? Physiotherapy and Radiography University of Hertfordshire A report on a preliminary study investigating the short and medium term effects of the SaeboFlex (Functional Tone Management System) on chronic post stroke patients with residual upper limb deficit

The SaeboFlex (FTM Arm Training Programme) is a environment (Carr and Shepherd 2003). This action of dynamic hand orthosis which assists subjects with prehension consists of two temporally linked movement upper limb deficit to grasp and release. Developed in components: reach and grasp (Jeannerod 1984). the United States, it has recently been introduced into Without activity in the hand, the rest of the upper limb the United Kingdom and used primarily with chronic has reduced functional use. post stroke subjects. This paper aims to present a report based on the preliminary findings from pilot The SaeboFlex research being conducted in this country. The SaeboFlex orthosis is sprung loaded on the extensor aspect, allowing subjects to use active flexion INTRODUCTION to grasp objects and, if able to release flexion, the Upper Limb Recovery springs return the hand towards a position of extension. Literature on recovery post stroke supports clinical By adjusting the springs, subjects can either be assisted experience of many patients not achieving good maximally or can be required to recruit active outcomes in upper limb function (Wade et al 1983, extension. The aim is for subjects to generate their own Nakayama et al 1994, Broeks et al 1999). What activity with less reliance on therapist facilitation, to treatment should be offered and at what intensity is still reach, grasp and release objects, with multiple repeti- not clear. Evidence suggests that more treatment may tions over a treatment period. be beneficial in the short term (Sunderland et al 1992, From anecdotal evidence and one published abstract Feys et al 1998, Kwakkel et al 1999) although this has (Farrell et al 2003), results have indicated increased not been universally found with Lincoln et al (1999) range of movement (ROM), reduced tone and increased suggesting that the type/severity of patient, the type of function from using the SaeboFlex orthosis. These treatment offered and the amount of enhanced therapy results were achieved in subjects who followed a may all potentially influence outcome. treatment paradigm similar to that used in constraint Both Feys et al (1998) and Parry et al (1999), induced movement therapy (CIMT) (described in a analysing a sub-group from the study by Lincoln et al review by Taub and Wolf 1997). In this review, (1999), commented on repetition of task as a feature of minimum motor criteria was suggested as important in their enhanced input. Outcome being influenced by determining success of CIMT with success reported in repetition of a simple functional task has been reported subjects who had a minimum of 20° wrist extension and previously (Butefisch et al 1995), although similar 10° finger extension (first quartile). The evidence for results were not found for complex tasks (Woldag et al subjects in lower quartiles benefiting from CIMT was 2003). If treatment is to include repetition it is felt to be less clear, with a case of treatment failure important to identify what activities need to be reported. Bonifer and Anderson (2003) also described a repeated. case of a subject in the third quartile (without the active Evidence suggests that the central nervous system is range above but able to pick up a rag from a table and task dependent in its organisation (Flament et al 1993, release it) who did not progress the functional use of Tinazzi et al 2003) and that movement patterns vary their upper limb following a CIMT programme. depending on the context and type of task being Increased severity of impairment resulting in poorer completed (Wu et al 2000). For upper limb rehabilita- outcome has been reported by others (Parry et al 1999, tion to be functional and task orientated it is necessary Shelton et al 2001, Hendricks et al 2002). To use the to consider what role the upper limb plays. One of the SaeboFlex to grasp and release, subjects require only main functions of the upper limb is to place the hand to small range active shoulder and elbow movement, to achieve complex movements giving interaction with the initiate a quarter range of active finger flexion and to

12 ARTICLE 3

have passive wrist extension to 15° with passive digit extension. Therefore, for patients who may benefit less from current therapies, such as those in the third/forth quartile, the Saeboflex may offer them an alternative method of treatment. Within the UK, research on the SaeboFlex has been ongoing since the end of 2003. The aim has been to investigate the short and medium term effects of the orthosis on chronic stroke subjects with severe (third/fourth quartile) upper limb deficit. Pilot data has been gathered from ten subjects pre- and post- interven- tion and at three months (full six months data is still work in progress). For this paper the results are presented from two subjects in whom six month data is complete. They are not necessarily representative of the whole.

METHOD Subjects attended a week-long clinic in response to an advertisement published in a self-help group magazine. Ethical approval was gained from the University of Hertfordshire Radiography and Physiotherapy Ethics Committee.

Intervention Treatment consisted of subjects undertaking multiple repetitions of object grasp and release using the SaeboFlex in up to six daily sessions of 45 minutes over five days. Sessions involved subjects completing task- orientated activities of picking up and placing soft balls into or on to objects. More functionally related tasks were introduced as the subjects were able to manage with the substitution of balls with real-life objects such as fruit and water bottles. Each day, spread between the ‘rest periods’, subjects had one neuromuscular elec- trical stimulation session for 20 minutes (electrodes placed to achieve wrist and finger extension, 30Hz, five seconds on/five off) and 1-2 SaeboGlideTM sessions (a gliding sleeve/pole mechanism that facilitates gleno- humeral/ proximal activity). Following completion of the weeks treatment, it was suggested to the subjects that they worked actively in the orthosis for one to two hours per day, until the three/six month follow-up.

Outcomes Prior to treatment, screening for sensory (light touch and pin prick) and perceptual (line bisection and star cancellation) deficits were conducted. Outcome measures (upper limb range of movement (ROM), hand dynamometer, upper limb section of Motor Assessment Scale (MAS), patient set goals scored on a likert and VAS scale, grasp and release of different objects, ten metre walk) were conducted at the start and end of the week and at three and six months.

13 Syn’apse ● SPRING 2005

RESULTS finger extension, if combined with wrist extension, that Mike was a 33 year old male who attended the clinic limited functional use of the hand for some activities following his stroke which had occurred twelve months and reduced glenohumeral flexion/abduction. Her earlier. He presented with residual right sided MAS score had changed from 0 to 8 with increase weakness, increased tone (primarily distally) and associ- particularly in the hand movement section. ated soft tissue changes. He was independently mobile, indoor and outdoors, with a stick and lived alone. Prior DISCUSSION to his stroke, he was right handed. His main presenting To draw definite conclusions at this stage is not problems in his right upper limb were reduced ROM possible or appropriate although several features did proximally, especially into glenohumeral flexion (active become apparent through this preliminary study that ROM 15°) and increased tone distally into flexion and will inform further work. In the group of ten subjects, pronation (hand held in fist posture). He had full active many were a year plus post stroke and all had severe flexion/extension of his elbow. His main goal was to be upper limb deficit (third/fourth quartile). They able to open his right hand sufficiently to allow him to presented with many of the secondary changes seen shake hands when greeting someone. post neurological insult, for example weakness, soft At three months, minimal change was recorded in tissue shortening and learnt non-use. Although some the objective outcome measures, however, perceived subjects changed in their ability to grasp and release change in subject set goals, as recorded on both the objects within the week-long clinic, these results were likert and VAS, had increased. In the period following maintained but generally not improved at three months. the clinic week, active use of the orthosis was limited On follow-up, it became apparent that time spent using with a focus being given to both returning to work and the orthosis was limited for most subjects. Explanation driving. of activity driven change given at this stage (now intro- Discussions with Mike relating to neuroplasticity duced from the start) may have impacted on subsequent increased his understanding of activity driven change. outcome and, at six months, for those subjects who It was stressed that active work in the orthosis, rather engaged in a programme of use of the SaeboFlex, small than the orthosis alone, may result in change in objective and perceived changes were recorded. function. At the six month follow-up use had increased The variance in intensity of use and lack of therapist to, on average, one hour per day. Although tonal guidance were two of the main differences between the changes remained into flexion, with associated soft clinic week and follow-up, and therefore may be tissue changes and altered joint alignment, without the important factors influencing outcomes seen at follow- splint on Mike was able to recruit active extension up. It is important to consider the impact of integrating through thumb and fingers to allow hand opening to an ‘exercise programme’ using the SaeboFlex into an shake hands. Subjectively Mike rated an increase in his already established daily routine. Upper limb impair- perceived ability to achieve his goals, however, there ment has been shown to be less closely related to remained minimal change on the objective outcome handicap than lower limb impairment (Desrosiers et al measures. 2003). Broeks et al (1999) showed that at four year The second subject, Susan, was a 52 year old female follow-up despite subjects reporting and demonstrating who had also had her stroke twelve months prior to the continuing upper limb dysfunction, 96% scored greater study. She presented with weakness in both the flexor than 60/100 on the Barthel Index, indicating minimal and extensor components of her right wrist/hand disability and adaptive recovery. The sensitivity of the resulting in flickers of activity in her index finger only Barthel Index in assessing upper limb disability has, (no other selective movement in other fingers or however, been questioned (Lai et al 2002). thumb). Proximally there was also weakness through Many of the findings from this subject population both her shoulder girdle and elbow with reduced ROM. were ascertained in discussion and in the subjective She was independently mobile indoor and outdoors markers rather than through the impairment/disability with no aids. Her main goal was to hold an object, for outcome measures chosen. For further research with example a saucepan, in her hand. chronic stroke subjects changes to the outcome As with Mike, at the three month follow-up, other measures used would be made. It would be of benefit to factors in Susan’s life had resulted in use of the orthosis investigate both compliance and overall quality of life. being limited. Between three and six months, however, This was highlighted by some subjects returning to she reported that she worked actively in the orthosis for work and/or driving again following the intervention 30 minutes, every other day. Objectively there was which were not officially assessed by the measures selective movement to allow finger/thumb opposition to chosen. With still relatively few subjects having used the each finger. Functionally, this allowed her to hold a pen SaeboFlex and research being so exploratory, it remains and start to write. She remained with reduced range of difficult to predict what changes may occur in the popu-

14 ARTICLE 3

lations chosen and thus what outcomes measures would REFERENCES: most accurately reflect changes made. For this reason Bonifer N, Anderson KM (2003) Application of constraint-induced the measures chosen for future research will be continu- movement therapy for an individual with severe chronic upper-extremity ally reassessed. hemiplegia Physical Therapy 83, 4 pp384-398. Future research is being planned to look at the use of Broeks JG, Lankhorst GL, Rumping K, Prevo AJH (1999) The long-term the orthosis with acute stroke patients with the aim of outcome of arm function after stroke: results of a follow-up study Disability increasing the use/repetition of early hand and upper and Rehabilitation 21, 8, pp357-364. limb movement before secondary complications become established. Butefisch C, Hummelshiem H, Denzler P, Mauritz KH (1995) Repetitive training of isolated movements improves the outcome of motor SUMMARY rehabilitation of the centrally paretic hand Journal of Neurological The SaeboFlex is a dynamic hand orthosis that assists Science 130, pp59-68. subjects with upper limb deficit to grasp and release Carr J, Shepherd R (2003) Stroke Rehabilitation Butterworth objects. Following a week of use of, on average, four 45 Heinemann, Elsevier Science Ltd. minute sessions per day it was possible for subjects with severe chronic stroke to make small gains in reaching Desrosiers J, Malouin F, Bourbonnais D, Richards CL, Rochette A, Bravo and grasping, although this was minimally reflected in G (2003) Arm and leg impairments and disabilities after stroke the outcome measures chosen. To continue to change rehabilitation: relation to handicap Clinical Rehabilitation 17, pp666-673. and overcome the secondary changes seen in the Farrell J, Hoffmann H, Snyder J, Giulian C (2003) The effects of the subjects, it appears that a level of use greater than that functional tone management system (FTM) arm training program on upper adopted by many at follow-up would be needed. extremity motor control on chronic post-stroke individuals The Journal of Subjects in this study had all adapted their lifestyles to Stroke and Cerebrovascular Diseases 12, 5, pp247. being one handed and although by attending the clinic showed intention to regain more activity, the guidance Feys HM, De Weerdt WJ, Selz BE, Cox Steck GA, Spichiger R, Vereeck at the end of the clinic of use per day was achieved by LE, Putman KD, Van Hoydonck GA (1998) Effects of a therapeutic few. Thus far, the subject who made the greatest func- intervention for the hemiplegic upper limb in the acute phase after stroke. A tional change was the one with weakness as the primary single-blind, randomized, controlled multicenter trial Stroke 29, pp785- problem. The sample, however, remains small and very 792. diverse and thus this paper is a preliminary report. Flament D, Goldsmith P, Buckley CJ, Lemon RN (1993) Task dependence of responses in first dorsal interosseous muscle to magnetic brain stimulation Journal of Physiology 464, pp361-378. Acknowledgement The author would like to thank Dr Mindy Cairns for Hendricks HT, van Limbeek J, Geurts AC, Zwarts MJ (2002) Motor her assistance with supervision and completion of this recovery after stroke: A systematic review of the literature Archives of report. Physical Medicine and Rehabilitation 83, pp1629-1637.

Jeannerod M (1984) The timing of natural prehension movements Journal of Motor Behaviour 16, pp235-254.

Kwakkel G, Wagenaar RC, Twisk JWR, Lankhorst GL, Koetsier JC (1999) Intensity of leg and arm training after primary middle cerebral artery stroke: A randomised trial Lancet 354, pp191-196.

Lai S-M, Studenski S, Duncan PW, Perera S (2002) Persisting consequences of stroke measured by the Stroke Impact Scale Stroke 33, pp1840-1844.

Lincoln NB, Parry RH, Vass CD (1999) Randomized, controlled trial to evaluate increased intensity of physiotherapy treatment of arm function after stroke Stroke 30, pp573-579.

Nakayama H, Jorgensen HS, Raaschou HO, Olsen TS (1994) Recovery of upper extremity function in stroke patients: The Copenhagen Stroke Study Archives of Physical Medicine and Rehabilitation 75, pp394-398.

Parry RH, Lincoln NB, Vass CD (1999) Effect of severity of arm impairment on response to additional physiotherapy early after stroke Clinical Rehabilitation 13, pp187-198.

15 Syn’apse ● SPRING 2005

Fiona Jones Senior Lecturer Changing self-efficacy following stroke St George’s Hospital Medical School London – a single case approach. Summary of a study completed in August 2004 which was part funded by an ACPIN research bursary

The aims of the study were to test the effects of a self- addition the effect of the intervention was further management intervention on self-efficacy following evaluated with a randomisation test (Todman and stroke. Dugard 2001), and stroke self-efficacy scores demon- A series of ten single case studies using a Multiple strated a significant change (p=<0.01). AB Basic Design were carried out over a four month Self-management interventions which are based on data collection period. Subjects were seven male and self-efficacy theory have been used extensively in other three female who were an average of 24.2 weeks (sd chronic disease but not with stroke survivors (Barlow, 18.29) post stroke, with a mean age of 61.5 years (sd Wright et al. 2002). Changes in self-efficacy may also 8.15) years. All subjects were living in their own home, have a beneficial effect on other variables such as mood three lived alone, the remainder lived with partners. and self-esteem. Given the high incidence of mood The intervention used to increase self-efficacy was a disorders following stroke, it may be valuable to learn self-management workbook designed for stroke more about these methods. Further analysis of other survivors based on sources of self-efficacy described by variables used in this study also seem to support the Bandura (1997). The workbook provided ten vignettes relationship between self-efficacy, mood and activity. A derived from stroke survivors with examples of strong fuller write up of these results is in preparation. levels of self-efficacy, also practical solutions to common problems and a diary section for a record of personal targets and mastery experiences. Further REFERENCES details about the development of the workbook can be Barlow J, Wright C et al (2002) Self-management approaches for people found in Spring Synapse 2004. with chronic conditions: a review Patient Education and Counselling 48 Each of the ten subjects were assessed every five to pp177-187. seven days over a total of 14 weeks. After three training Jones F, Partridge C et al (2004) Towards a new measurement of self- sessions, the workbook was randomly introduced at efficacy following stroke British Geriatric Society Conference, different times for each subject. This method allowed Harrowgate. for statistical analysis of group effects and meant that some subjects started the workbook as early as week Schwartzer R and Jerusalem M (1995) Causal and control beliefs: the five, and some as late as week nine. The workbook was generalised self-efficacy scale. Measures in health psychology: A user’s used for a total of four weeks by each subject. Self- portfolio Weinman J, Wright S and Johnston M, Windsor, NFER- efficacy was measured by the Stroke Self-efficacy Nelson pp35-37. Questionnaire (Jones, Partridge et al. 2004), and the Todman J and Dugard P (2001) Single-case and small-n experimental General Self-efficacy Scale (Schwartzer and Jerusalem designs: a pratical guide to randomisation tests New Jersey, Lawrence 1995). Erlbaum Associates. Visual inspection of stroke self-efficacy scores showed an upward trend in data for all ten subjects. In

16 ARTICLES IN OTHER JOURNALS

Task-Related Training Versus Progressive stroke: A randomised controlled trial Articles in other journals Resistive Exercise pp1613-1618. pp219-226.

• Wong et al Foot Contact Pattern ■ THE BRITISH JOURNAL OF Analysis in Hemiplegic Stroke Patients: OCCUPATIONAL THERAPY ■ ADVANCES IN CLINICAL maintenance of balance, gait and An Implication for Neurologic Status Vol 67: No 11 NEUROSCIENCE AND posture in Parkinson’s disease: A pilot Determination pp1625-1630. • Bell A et al Improvement in upper REHABILITATION study pp898-908. Vol 85, No 11Special Edition limb motor performance following stroke: Vol 4, No 3 • Williams G et al Measuring high-level Spinal Injury the use of mental practice pp501-507. •Perry H The impact of systemic mobility after traumatic brain injury • Marino R, Graves D Etric Properties of inflammation on brain inflammation pp910-920. the ASIA Motor Score: Subscales Improve ■ CLINICAL pp8-10. Correlation With functional Activities REHABILITATION ■ Vol 4, No 4 ARCHIVES OF PHYSICAL pp1804-1810. Vol 18, No 5 • O’Connor R Musculoskeletal MEDICINE AND • Burke JH et al The effect of an ankle- • McKinley W et al Outcomes of Early complications of neurological conditions REHABILITATION foot orthosis on walking ability in chronic Surgical Management Versus Late or No pp32-35. Vol 85, No 9 stroke patients: a randomized controlled Surgical Intervention After Acute Spinal • Citterio A et al Nontraumatic Spinal trial pp550-557. Cord Injury pp1818-1825. • Parton A et al Spatial neglect pp17-20. Cord Injury: An Italian Survey pp1483- • Dijkerman HC et al Does motor 1487. • Whiteneck G et al Environmental ■ AGE AND AGEING imagery training improve hand function Factors and Their Role in Participation Vol 33, No 5 • Hart T et al Awareness of Behavioural, in chronic stroke patients? A pilot study and Life Satisfaction After Spinal Cord • Anderson S, Marlett N Cognitive, and Physical Deficits in Acute pp538-549. Injury pp1793-1803. Communication in stroke: the overlooked Traumatic Brain Injury pp1450-1456. • Fjaertoft, H et al Acute stroke unit rehabilitation tool pp440-443. Vol 85, No 12 • LiuK et al Mental Imagery for care combined with early supported • Bode R et al Patterns of Therapy Promoting Relearning for People After discharge. Long-term effects on quality of ■ AMERICAN JOURNAL OF Activities Across Length of Stay and Stroke: A Randomized Controlled Trial life. A randomized controlled trial PHYSICAL MEDICINE AND Impairment Levels: Peering Inside the pp1403-1409. pp580-586. REHABILITATION ‘Black Box’ of Inpatient Stroke Vol 83, No 8 • Ploughman M, Corbett D Can Rehabilitation pp1901-1908. • Gage H , Storey L Rehabilitation for • De Kroon J et al Electrical stimulation Forced-Use Therapy Be Clinically Applied Parkinson's disease: a systematic review • Coster W et al Development of an of the upper limb in stroke: stimulation of After Stroke? An Exploratory Randomized of available evidence pp463-482. Applied Cognition Scale to Measure the extensors of the hand vs alternate Controlled Trial pp1417-1423. Rehabilitation Outcomes pp2030-2035. • The Glasgow Augmented stimulation of the flexors and extensors. Vol 85, No 10 Physiotherapy Study Group Can pp592-600. • Huitema R et al Functional recovery • Chung S et al Biomechanic Changes augmented physiotherapy input enhance Of Gait and Joint Kinematics After Right Vol 83, No 9 in Passive Properties of Hemiplegic recovery of mobility after stroke? A Hemispheric Stroke pp1982-1988. • Dalyan Aras M et al Shoulder pain in Ankles With Spastic Hypertonia pp1638- randomized controlled trial pp529-537. hemiplagia: results from a national 1646. • Newsam C, Baker L Effect of an • Salbach NM et al A task-orientated rehabilitation hospital in Turkey pp713- Electric Stimulation Facilitation Program • Mackay-Lyons M, Makrides L intervention enhances walking distance 719. on Quadriceps Motor Unit Recruitment Longitudinal Changes in Exercise and speed in the first year post stroke: a After Stroke pp. 2040-2045. • Fujiwara T et al Development of a new Capacity After Stroke pp1608-1612. randomized controlled trial pp509-519. measure to assess trunk impairment after • Rochester L et al Attending to the ■ AUSTRALIAN JOURNAL Vol 18, No 6 stroke (trunk impairment scale): its task: Interference Effects of Functional OF PHYSIOTHERAPY • Eich H-J et al Aerobic treadmill plus psychometric properties pp681-688. Tasks on Walking in Parkinson’s Disease Vol 50, No 3 Bobath walking training improves • Stein J et al Comparison of two and the Roles of Cognition, Depression, • McClellan R, Ada L A six-week, walking in subacute stroke: a randomised techniques of robot aided upper limb Fatigue, and Balance pp1578-1585. resource-efficent mobility program after controlled trial pp640-652. exercise training after stroke pp720-728. discharge from rehabilitation improves • Taly A et al Efficacy of • Rome K, Brown CL Randomised standing in people affected by stroke: Vol 83, No 10 supplement Multiwavelength Light Therapy in the clinical trial into the impact of rigid foot Placebo-controlled, randomised trial • Page S Spasticity management: Treatment of Pressure Ulcers in Subjects orthosis on balance parameters in pp163-168. concepts, applications and prospects With Disorders of the Spinal Cord: A excessively pronated feet pp624-631. ppS1-S59. Randomized Double-Blind Controlled Vol 50, No 4 • Parry RH Communication during goal Trial pp1657-1661. • Blennerhassett J, Dite W Additional Vol 83, No 12 setting in physiotherapy treatment task-related practice improves mobility • Nallegowda M et al Role of sensory • Thielman G, Dean C, Gentile A sessions pp668-683. and upper limb function early after input and muscle strength in Rehabilitation of Reaching After Stroke:

17 Syn’apse ● AUTUMN/WINTER 2004

• Surakka J et al Assessment of muscle Vol 19, No 1 Vol 84, No 12 Vol 76, No 1 strength and motor fatigue with a knee • Filiz M, Cakmak A, Ozcan E The • Dickstein R et al Motor imagery for • Burne J, Carleton VL, 0’Dwyer N The dynamometer in subjects with multiple effectiveness of exercise programmes gait rehabilitation in post-stroke spasticity paradox: movement disorder or sclerosis: a new fatigue index pp52-660. after lumbar disc surgery: a randomized hemiparesis pp1167-1177. disorder of resting limbs? pp47-54. controlled study pp4-11. Vol 18, No 7 • Makuuchi M, Kaminaga T, Sugishita ■ PHYSICAL THERAPY • Cheng P et al Effects of visual • Howe TE et al Lateral weight M Brain activation during ideomotor REVIEWS feedback rhythmic weight-shift training transference exercises following acute praxias:imitation and movements No 9 on hemiplegic stroke patients pp747-753. stroke: a preliminary study of clinical executed by verbal command pp25-33. • Nightingale P The Effect of Positioning effectiveness pp45-53. • Low JTS, Roderick P, Payne S An on the Severity of Sleep Apnea Syndrome Vol 76, No 2 exploration looking at the impact of • Mehrholz J et al The influence of and its Relevance in the Avoidance of • Rambold H, Helmchen C domiciliary and day hospital delivery of contractures and variation in Hypoxia in Acute Stroke pp161-172. Spontaneous nystagmus in dorsolateral stroke rehabilitation on informal carers measurement stretching velocity on the medullary infarction indicates vestibular pp776-784. reliability of the Modified Ashworth ■ JOURNAL OF semicircular canal imbalance pp88-94. Scale in patients with severe brain injury. NEUROLOGY • McGrath J Beyond restoration to pp63-72. NEUROSURGERY AND ■ MULTIPLE SCLEROSIS: transformation: positive outcomes in the PSYCHIATRY CLINICAL AND rehabilitation of acquired brain injury • Wade D Investigating the effectiveness Vol 75: No 9 LABORATORY RESEARCH pp767-775. of rehabilitation professions – a • Carpenter MG et al Postural misguided enterprise? pp1-3. Vol 10, No 5 • Smith S, Hembree J, Thompson M abnormalities to multidirectional stance • Hoogervorst ELJ et al Multiple Berg Balance Scale and Functional • Wang R et al Effects of an ankle-foot perturbations in Parkinson’s disease Sclerosis Impact Scale (MSIS-29): Reach: determining the best clinical tool orthosis on balance performance in pp1245-1254. relation to established measures of for individuals post acute stroke pp811- patients with hemiparesis of different Vol 75, No 10 impairment and disability pp569-574. 818. durations pp37-44. • Farne A et al Patterns of spontaneous • Rizzo MA et al Prevalence and • Surakka J et al Effects of aerobic and recovery of neglect and associated ■ INTERNATIONAL treatment of spasticity reported by strength exercise on motor fatigue in men disorders in acute right brain-damaged JOURNAL OF THERAPY AND multiple sclerosis patients pp589-595. and women with multiple sclerosis: a patients pp1401-1410. REHABILITATION randomized controlled trial pp737-746. Vol 10, No 6 • Masson C et al Spinal cord infarction: Vol 11, No 7 • White LJ et al Resistance training • Turton A, Butler S A multiple case clinical and magnetic resonance imaging • Hoffmann T et al Evaluating current improves strength and functional design experiment to investigate the findings and short term outcome practice in the provision of written capacity in persons with multiple performance and neural effects of a pp1431-1435. information to stroke patients and their sclerosis pp668-675. programme for training hand function carers pp303-310. • Pambakian ALM et al Saccadic visual after stroke pp754-763. search training: a treatment for patients ■ STROKE Vol 11, No 8 • Tyson S, DeSouza L Development of with homonymous hemianopia pp1443. • Clark J, Michael S, Morrow M Vol 35, No 11 the Brunel Balance Assessment: a new Wheelchair postural support for young Vol 75, No 11 • Bode et al Relative Importance of measure of balance disability post stroke people with progressive neuromuscular • Bakheit AMO et al The beneficial Rehabilitation Therapy Characteristics pp801-810. disorders pp365-373. antispasticity effect of botulinum toxin on Functional Outcomes for Persons Vol 18, No 8 type A is maintained after repeated With Stroke pp2537-2542. • Luke C, Dodd K, Brock K Outcomes ■ PHYSICAL THERAPY treatment cycles pp1558-1561. Vol 35, No 11 (supplement 1) of the Bobath concept on upper limb Vol 84, No 10 • Francis et al Does reducing spasticity • Grotta J et al Constraint-Induced recovery following stroke pp888-898. • Gallichio J Pharmocologic translate into functional benefit? An Movement Therapy pp2699-2701. • Tyson S, DeSouza L Reliability and management of spasticity following exploratory meta-analysis pp1547-1552. Vol 35, No 12 validity of functional balance tests post stroke pp973-982. Vol 75: No 12 •Boter H Multicenter Randomized stroke pp916-923. Vol 84, No 11 • Jobges M et al Repetitive training of Controlled Trial of an Outreach Nursing • Tyson SF, Nightingale P The effects of • Sullivan J et al A Home program of compensatory steps: a therapeutic Support Program for Recently position on oxygen saturation in acute sensory and neuromuscular electrical approach for postural instability in Discharged Stroke patients pp2867- stroke: a systematic review pp863-871. stimulation with upper limb task practice Pasrkinson’s disease pp1682-1687. 2872. in a patient 5 years after a stroke • Van Peppen RPS et al The impact of • Wolfe C et al Variations in care and • Danells C et al Poststroke ‘Pushing’ pp1045–1055. physical therapy on functional outcomes outcome in the first year after stroke: a Natural History and Relationships to after stroke: what’s the evidence? Western and Central European Motor and Functional Recovery pp2873- pp833-862. perspective pp1702-1707. 2878.

18 FOCUS ON

FOCUS ON Sue Mawson our new President of ACPIN commences her ‘term of office’ in March 2005

Sue, could you tell us a little about your career background? Can you summarise some of the achievements you are Yes this is difficult without giving my age away! Having known almost proudest of? from day one that physiotherapy was the right choice for me it is Top of the list must be my two children who are now at university perhaps interesting to identify the people who have had the most doing medicine and architecture. They are both accomplished at significant influences on my professional life and in a way resulted in sports, have good careers and are great company and good friends. me being where I am today. I qualified as a physiotherapist in the Becoming a Reader at Sheffield Hallam University has probably been 1970s working initially in adult neurology and was lucky enough to get my greatest academic achievement. My main role here is to develop the opportunity to work under Mrs Bobath for a week at the Bobath research capacity and capability in others, staff and students. This I Centre in London. This as you can imagine was inspirational and began find exciting and fulfilling. Finally the Msc in Neurological my long passion for neurorehabilitation. She instilled in me, from this Rehabilitation which we validated eight years ago. This has given me a early stage in my career, the importance of the trunk and selective great sense of achievement as I have seen senior clinical specialists activity as a foundation for normal movement. come onto the modules lacking confidence in their own academic During the 1980s I worked both in the UK and South Africa again ability and graduating in the autumn of each year with proud faces having the good fortune to undertake the eight week basic and the and happy families. two week advanced paediatric Bobath courses taught by Joan Mohr NDT (USA) and Sheena Urwin-Caruthers (IBTA) SA. During this time I What projects are you involved in currently? again began to understand how selective trunk activity develops and I’m currently working in a number of areas all in neurorehabilitation. the relationship between core activity and limb control. (We neuro We are currently doing a RCT of Botox A as an adjunct to physiotherapists were using concepts of core stability long before the physiotherapy for the management of upper limb spasticity. I’m also a musculoskeletal and pilates crew hit the press!). partner on a project developing an exoskeleton for remote In the late 80s I began my research training having decided rehabilitation of spinal injury patients (don't ask, engineers are a without a doubt that I didn't want to go down the management mystery to behold!) I’m also partner on a large stroke study looking at route. At this point I met Bunny Le Roux, mathematician and health technology developments as an adjunct to rehabilitation. Again I care statistician, who has become my academic mentor and from think my role here is keeping the engineers in the real world of stroke whom I have learnt so much about the theory of measurement and patients and their needs. As ever I’m continuing my work with TELER the importance of quantifying the individual’s response to treatment. developing with colleagues a library of stroke indicators validating Like many physiotherapists in the early 1990s I had observed changes them locally and hopefully nationally. Finally I’m working in the area in patients during physiotherapy but could not explain why the of falls analysing the characteristics of balance on a large population change was occurring until, in 1991, I went to my first Nigel Lawes of over 60 females. As you can imagine there are more projects on the lecture on neuroplasticity. I new I had to know more and approached boil however finding time is ever a problem. Nigel asking him to became one of my PhD supervisors. In this role he helped me to identify potential mechanisms to explain how neuro- What do you see your role as ACPIN president involving? physiotherapists effect change within the Central Nervous System. Ever This is a very difficult question to answer as I follow such distinguished the questioning mind Nigel once said that he hated seeing me in the predecessors who have given so much as presidents of ACPIN. I audience, as I was the one who always asked the difficult questions! suppose I see my role as providing academic leadership for the group During the early part of my doctoral studies I was introduced to at a national level. As I am currently working two days a week as Mary Lynch-Ellerington without whom my work on trunk activity research lead for allied health professions within the NHS I feel I am would not have progressed. Mary had the vision to see the uniqueness quite politically aware, this should enable me to help drive ACPINs of the TELER method, giving my PhD her full support (with BBTA) as I agenda forwards within the current NHS environment. I hope that sought to develop a measuring tool (the TELER Normal Movement through this leadership I can empower others within ACPIN to seize Indicators) that would enable me to investigate the characteristics of the opportunities that foundation status offers us putting trunk recovery following a stroke. Like all good researchers I found neurological rehabilitation at the forefront of many NHS that gaining my PhD simply showed me how little I really knew and I organisations. have continued in the quest for knowledge trying to provide evidence to underpin neurological rehabilitation. >>

19 Syn’apse ● SPRING 2005

What are your aspirations and hopes for the future? ‘Evidence’ is going to be the theme for my Presidency. I hope to enable and encourage colleagues to be able to use the evidence that’s out in the clinical and public domain, look at existing scientific research and extrapolate the findings to neurorehabilitation and provide new evidence of efficient and effective neurological intervention. My hopes are for more clinical specialists to undertake professional doctorates and to see the development of more consultant posts in neurological rehabilitation.

ADDRESS FOR CORRESPONDENCE

Sue Mawson MCSP BSc.(Hon) PhD Reader in Health and Social Care Research Sheffield Hallum University

Clinical Research Lead Professional Services Directorate Sheffield Teaching Hospital Foundation Trust

e-mail [email protected]

20 ACPIN NEWS

Many of you will of course know future of the healthcare professions – ACPIN news Sue as one of the leading figures in physiotherapy, medicine and so on. I neurophysiotherapy in the United must say, I still feel nervous about Kingdom at the present time. For what the politicians have in store for those few of you who do not know us. Though I am less worried than I ACPIN AGM 2005 •Jo Kileff Committee member her, here are some facts which hardly was. Politicians are starting to realise majority vote begin to do justice to her that it is no use throwing managers 5th March 2005. • Mary Cramp Honorary Research achievements. She has made an and documents at medical problems: Hilton Hotel Officer majority vote enormous contribution to placing in the end, the quality of care for the Northampton. • Cherry Kilbride Honorary Secretary research into neurological patients depends on the people, such majority vote rehabilitation on a sound basis as yourselves, who are actually giving MINUTES • Jackie Sharp Honorary Treasurer through her work in developing the it. Opened at 12.25pm majority vote TELER system. This system addresses I am very privileged at present to • Jo Tuckey Honorary Membership one of the toughest challenges in be a member of a Working Group of 1. Present Secretary majority vote neurorehabilitation research: that of the Royal College of Physicians - Mary Cramp • Anne Rodger Diversity Officer determining the impact of headed up by Baroness Cumberlege – Louise Dunthorne majority vote treatments by measuring things looking at Defining and Maintaining Emma Forbes which are not only objective, valid Professional Values in Medicine. Being Nicola Hancock 9. Election of new executive and repeatable but also, at the same involved in this group has been very Cherry Kilbride committee member time, relevant to patients’ goals. In stimulating. It is multi-professional Jo Kileff Julia Williamson was voted in by addition, she is engaged in cutting and includes experts outside of the Sue Mawson unanimous decision. edge research looking at the use of healthcare professions. We have had Louise Rogerson innovative technology in patients the opportunity to quiz some key Jackie Sharp 10. AOB with a variety of conditions, including players – Dame Janet Smith of the Ray Tallis none stroke. She is currently supervising Shipman report, Sir Liam Donaldson Jo Tuckey four PhD students and has (the Chief Medical Officer) and Sir Meeting closed at 12.50pm. innumerable publications under her Nigel Crisp to name just a few – and 2. Apologies belt. In short, ladies and gentlemen, there are more to come. I feel very Ros Cox your new President is a hopeful that this report really will Louise Gilbert PRESIDENTIAL physiotherapist and clinical scientist make clear what it is about Sesa Isheya VALEDICTORY of the greatest distinction. professionals that is valuable, how we

Anne Rodger Ray Tallis FRCP, DLitt, F Med Sci It will be obvious from this that the should define our relationship to the good ship HMS ACPIN has an public, and how (very importantly) 3. Minutes of AGM 2004 I can’t believe it. My term of office is excellent Commodore. And, of we may assert our leadership in Accepted as accurate record of now completed and I shall walk out course, a wonderful crew headed up advancing the science-base of our events. Proposed Cherry Kilbride, into the sunset at the end of today as by Captain N Hancock and her merry profession, in developing new seconded Linzie Bassett. an ex-President of ACPIN. It hardly band of officers – another group of treatments, and in improving the seems a day (as they say) since Sue seemingly effortless multi-taskers in ways in which we deliver care. The 4. Retiring President’s address Edwards handed over the baton to the heroic mould of Linzie Basset. All report will be out at the end of the Ray Tallis me and here I am handing over the of this makes being President, Sue, year and we shall be spending the baton to another Sue: a Ray between absolutely wonderful. If you model early part of 2006 publicising it. I am 5. New President’s address two Sues; a thorn between two roses; yourself on me, it consists of just looking forward – (hint, hint!) – to Sue Mawson a wannabe physio between two swaggering around, pontificating at talking to you about the report, instances of the real thing. intervals, and accepting the which, although it is mainly about the 6. Chair’s address I have felt very proud to have been occasional bottle of wine and kisses medical profession, has messages for Nicola Hancock an ectopic medic in your domain and on the cheek. As a lifestyle, I strongly all professions. We have more in I feel even prouder when I think of recommend it, although, given that common than whatever it is that 7. Treasurer’s report the eminence of both my predecessor you are the real thing rather than a separates us, as my experience of Jackie Sharp. Accountants voted in by and my successor. When I assumed wannabe, I imagine you will be much being President of ACPIN has made a majority vote. my present office, it was an more hands on in the true even plainer to me than it was before. opportunity to say some nice (and physiotherapist mould than myself. Being free to be professionals - 8. Election of re-standing true) things about Sue Edwards. My Anyway, it’s time to say goodbye. accountable to the public but not executive committee members: demitting from office is an The usual thing is to to look back. subject to endless external •Ros Cox Committee member opportunity to say some nice (and When I do so, it strikes me how many interference – is particularly majority vote true) things about Sue Mawson. glum things I have said about the important at the present. For we have

21 Syn’apse ● AUTUMN/WINTER 2004

grounds for being cheerful about the intellectually and gratifying because survive,’ by 1997 only eight years after Committees for their tremendous future of the basic science and the of what we can do for our patients. I read Ray’s words I was writing in my support in this first phase of my clinical science underpinning the Achieving Mission Possible will, of doctoral thesis ‘without Chairmanship and to those of you activity that is our central course, be a huge challenge: the measurement the physiotherapy who sent me personal messages last preoccupation – the rehabilitation of desired outcome will not happen of profession won’t survive’. I had Spring. I trust I can rely on your people with neurological disability. its own accord. All the more reason, learned how significant his words had ongoing support as the next year The day of science-based and then, to resist any attempts by been. progresses. evidence-based – as well as wisdom- government, managers and others to Professor Tallis had galvanised me As usual, it has been a busy year for based and humanity-based – practice deprofessionalise us, to dumb down into action and contributed to my us all. One major project has been the is coming closer and ACPIN, of our approaches to care, to force us to future direction and quest to provide development of the Neurology course, is in the forefront of this. And take short cuts to meet targets, and the evidence of effective Network for Interactive CSP, which will this is part of a more cheerful picture to short–change our patients. rehabilitation. How strange, but apt, be launched nationwide in May which I want to share with you. It seems to me that the role of that I should succeed the man who following a successful pilot in Everyone knows that people are ACPIN, in defining, maintaining and ignited my passion for both Northern region. My thanks to all living longer. The facts are staggering. further improving standards of care measurement and evidence and who those in this region involved in In the UK, life expectancy at birth cannot be over-stated. So all power in an indirect way resulted in me developing and moderating the pilot increased by 30 years over last to your elbow. being where I am today! As President site, you have represented ACPIN century. In the last 20 years alone – Finally, this is my chance to say my theme will be evidence – what most positively. I would encourage since I became a consultant – life ‘thank you’ for a most interesting, evidence actually is in a health care you all to log on to this excellent tool expectancy for men has increased by fun-packed, gratifying and inspiring environment, what evidence as soon as possible. Northern region five years. Some people have tried to three years working with you all and currently exists in the field of really have excelled themselves as turn this wonderful trend into for the great honour you conferred on neuroscience, cognitive behavioural they were also closely involved in the grounds for being gloomy by worrying me by making me your President. You science as biomechanics and finally development and publication of the that, since people are living longer, deserve the gratitude of your patients how do we provide new evidence physiotherapy booklet following the they are going to suffer more chronic and your colleagues. You certainly from a measurement and research NICE Guidelines for MS, a very useful illness. This is not turning out to be have mine. design perspective. working document. the case. There are data from both In a conversation earlier today, Ray As you know, many ACPIN the UK and USA to show that the age- suggested that I would be a better members consulted on the NSF adjusted incidence of chronic illness NEW PRESIDENT’S ADDRESS President than he because I was a ‘Long-Term Conditions’ and we finally

and disability is declining. Many Sue Mawson MCSP BSc.(Hon) PhD physiotherapist. This is in fact is far have a publication date of 10th factors have fed into this but the role from the truth. As a professional body March. On the 14th March, the of good preventative care and of first- In 1989 an article was published in we have frequently been described as document Working Differently will be rate rehabilitation for those who fall Geriatric Medicine entitled: charlatans because of our lack of a launched at the AHP Federation victim to chronic disease has been Measurement and the future of research base. With his huge annual conference, which focuses on central. There is an excellent prospect rehabilitation. In the article the author reputation as a neuroscientist Ray has the AHP role in improving services to that, if present trends continue, we Professor Raymond Tallis quoting provided us with much needed people living with a long term shall find that, increasingly, people evidence published by the King’s credibility in the scientific world. condition. I have had feedback from are living to a ripe old age with Fund Consensus Forum on stroke To ACPIN members I would like to the CSP this week that the support relatively little chronic disability in management stated, ‘Rehabilitation say how lucky we have been for Ray’s from physiotherapists and ACPIN in their final years. In short, the mission varies widely, mainly reflecting leadership, support and vision and to particular has been instrumental in its of medicine in the wider sense – of differences in resources but also Professor Tallis I would like say that I development. helping people to have a long life widely reflecting different beliefs. promise to continue on the path that The review of the Splinting ending in an independent old age – is There is no absolute proof that he inadvertently but without doubt Guidelines has unfortunately fallen a looking less and less like Mission individuals or collective services placed me on sixteen years ago. little to the back burner, but I can Impossible. benefit patients.’ Porfessor Tallis assure you that this is a priority for The role of the rehabilitative posed the question, ‘Should the coming months. professions in helping to achieve this rehabilitation be abandoned?’ As CHAIRPERSON’S ADDRESS Our Autumn Conference ‘Hands

utterly worthwhile (and achievable) novice researcher and neuro-clinician Nicola Hancock BSc (Hons) MCSP SRP On Neurophysiology’ was well goal – by the prevention, limitation it was this statement that stunned me attended and received, held in the and reversal of disability – is, and will I was incensed by the arrogance of As I stand here in front of you today, I very appropriate surroundings of the remain, absolutely central. And, given the man a medic to boot, little find it hard to believe that another National Hospital for Neurology and that neurodisability is the most realising that his words were so true. year on the ACPIN calendar, and my Neurosurgery, London serious challenge for the future, In 1986 Richard Schmitt the doyen first as Chair, has passed by. I would We took a break from CSP neurophysiotherapists will be pivotal. of motor learning wrote, ‘Without like to begin by offering my sincere Congress this year but will be back in The future will be both exciting movement the human race would not thanks to the Executive and National style on the 7th/8th October 2005,

22 ACPIN NEWS

with our programme ‘Cognition and There were, quite understandably, TREASURER’S REPORT INCOME Behaviour: Complex Challenges to some definite rumblings in the Jackie Sharp 2004 2003 Rehabilitation’ Congress format has masses when Ray first took up his ££ changed significantly but we have post; ‘A medic! President of ACPIN! I will now present a summary of the Courses 24,392 40,921 fought hard to maintain the right to a What were we thinking of!?’ financial accounts for National Membership 31,621 31,439 two day programme for our Fortunately, it transpired that we ACPIN for the year end 31st Capitation 5,358 2,740 membership and we now have CSP were thinking extremely clearly, one December 2004. Manual Handling 207 269 approval. I wonder following all the might even say we were enlightened Over the past two years it has been Database 205 358 negotiations if our programme should in our choice. Ray has proved to be the Executive committee’s intention Sundries 671 285 be subtitled ‘Complex challenges to the most ardent flag flyer for to enhance national ACPIN’s reserves. Total 62,454 76,012 Organisation!’ but Jo Tuckey is doing neurological physiotherapy, always This was on the advice of our a great job. flamboyant, more than occasionally accountants and I am pleased to Figure 1 Departures from the committee controversial and steadfastly report that for the year end 31st include both Sally de la Fontaine and supportive. His work for the Royal December 2004 we had a net surplus

Caroline Brown, regional reps from College of Physicians and the of £18,616. EXPENDITURE Surrey and Borders and Yorkshire Department of Health have proved The accounts show a reduction in 2004 2003 respectively and I thank them for invaluable to our organisation and I the total income and expenditure for ££ their commitment and wish them truly believe there are a far higher 2004 compared with the previous Courses 16,819 39,946 well in future ventures. Membership number of physicians and year. Synapse 8,587 7,518 of the regional committees is very government ministers who know The total income (Figure 1) was Travel 3,765 6,903 variable, some are more buoyant than more of this job that we all love than reduced by £13,500.00 and this was Administration 5,973 5,983 others, and I would urge you all to get there were three years ago. primarily because we did not hold a Capitation 5,144 5,048 involved at this level, however small a On a personal note, Ray and I residential course in 2004. In 2003 Website 1,398 1,951 contribution you think you can make. share two other passions, those of our March residential course Research bursary 734 784 From the Executive Committee, good red wine and our families, and generated over £34K but last year the Accountants, we have had the resignation of Alison we have spent a few lovely evenings single day March conference bank charges, Bailey Hallam who has moved back to sinking one whilst discussing the generated only half of that. and sundries 1,418 1,751 the US with her family. other. Membership income was only Total 43,838 69,884 Membership for the year in general We will miss you Ray, and thank slightly up on the previous year is progressing well, over 850 already you for everything. despite the increase in membership Figure 2 and still rising towards last year’s total Fortunately, we have the great fees by £2.50 but capitation income of 1250. honour of welcoming Dr Sue Mawson from the CSP had doubled. This was Physiotherapy Services which was sent Synapse continues to develop and as our new President and I know that due to the CSP catching up with a out to all the membership. This has progress and I feel particularly proud Sue is extremely keen to play an payment owed to ACPIN from 2002. been included under expenditure for biannually as it drops on the mat. It is active role in the committee, on We have continued to make a Synapse which accounts for the incredible that Louise Dunthorne co- which she has previously served as an small income from charging for copies increase in costs here. ordinates and completes this journal Executive member. I thoroughly of the manual handling guidelines Figure 3 (overleaf) divides the entirely voluntarily and on top of her welcome you, Sue and look forward and our database. course income and expenditure up work and family commitments. to working with you. Expenditure (Figure 2) for 2004 was between the two conferences held Indeed this applies to all the I hope that this has given you considerably down on 2003, again as last year. In 2003 we were able to Executive committee posts. Thanks some idea of our work in 2004/5 and a result of less course expenditure. bring both conferences in on budget also to our graphic designer Kevin plans for the coming year. But overheads were also less and this after a number of years of losses, but Wade. I hope to see you all at Congress was mainly due to travelling in 2004 we made a profit on both I am also pleased to inform you and of course back here for our Silver expenses. These are expenses courses. This was achieved by tighter that we have had three motions Jubilee Residential Conference in incurred by members of the control of organisational overheads, accepted for ARC and are now 2006, when we will be revisiting and committee travelling to and from in particular for the November actively seeking ACPIN members to exploring Stroke. Look out for the national and executive committee conference, where they were kept present and support these. adverts… meetings. The reduction was deliberately low by hosting the event Before I cease my ramblings, I do unexpected but there was a 20% at a hospital venue rather than in a of course have one further goodbye drop in the number of expense claims hotel. High conference attendance and indeed a hello to make. The time I received from committee members rates and lower than usual speaker has come for us to part company with last year, possibly reflecting less and committee travelling expense Professor Ray Tallis, our President now attendance at meetings. claims for the November conference for three years. An additional expense for 2004 also added to the profit made. What does one say about Ray? was the ACPIN survey of Neurological The balance sheet (Figure 4) on the

23 Syn’apse ● AUTUMN/WINTER 2004

into producing an integrated care is looking at whether the type of COURSE INCOME AND EXPENDITURE pathway for hemiplegic shoulder stroke according to Bamford’s Income Expenditure Surplus/(Deficit) pain. She discussed how the develop - classification (TACI/PACI/LACI/ £££ ment of this tool improved POCI/bleed) correlates with the level March 2004 documentation surrounding patients’ of thermal sensory perception and Exploring gait 16,052 13,818 2,234 pain and how it led to the setting up how these compare to healthy November 2004 of a shoulder clinic to ensure that the normal subjects. It will be interesting Hands on neurophysiology 8,190 2,891 5,299 MDT kept the issue at the front of to see what results this study finds. Figure 3 their minds. The day was certainly very Diana Jackson, a senior clinical successful and I am sure that research fellow discussed the use of a everyone present will have taken BALANCE SHEET AT 31 DECEMBER 2004 tool to assess shoulder pain in home useful information to help Capital and reserves patients with cognitive and or understand the pain that so many of £ communication deficits. She our patients are suffering and Reserves brought forward at 1 January 2004 16,444 highlighted that when a patient’s pain challenge our ideas on how to best Surplus/(deficit) for the year 18,616 is estimated by someone else there is measure and treat them. Reserves carried forward at 31 December 2004 35,060 very poor reliability and it is much more accurate to assess self reported Figure 4 pain. She discussed the pros and cons of visual analogue scales, numerical 31st December 2004 showed a profit exchange of ideas and catching up rating scales and diagrams of faces of £18,616, and we were able to carry with old acquaintances. when assessing stroke patients and forward reserves of £35,060 into The day was opened by Mick Thacker introduced her concept of SPIN – a 2005. Whilst these reserves may seem who gave an excellent lecture to set pictorial scale of pain intensity. This high, they are essential as both our the scene for the other speakers of uses pictures of people doing programme at the CSP congress later the day. He took us back to the different activities or in different this year and the next residential neurophysiology of pain that we’d all postures and circles with increasing conference early in 2006 will both forgotten. His enthusiasm ensured percentages shaded red to indicate require a significant financial that we were all awake and attentive an increase in pain for patients to commitment now. and that we remembered his take point to. home message that pain is in the Dr Chris McCarthy shared the Copies of Accounts 2004 brain not the tissues. background and work to date on his Full copies of the ACPIN accounts are Heather Cameron followed with study looking at classifying low back available on request an interesting talk on the pain to help in the management of measurement and treatment of this complex area. His very Vote for Accountants neuropathic pain. We had a whistle- entertaining talk discussed which Vote to retain the current stop tour of pharmacology for pain common factors should go into a accountants for 2004: Langers, 8-10 and touched on eletrical stimulation non-specific low back pain Gatley Road, Cheadle, Cheshire, SK8 as a cost effective treatment. assessment which included a 1PY. Lester Jones gave us an insight psychosocial assessment, functional into the cognitive side of pain, demonstration of movements critiquing the currrent evidence bringing on the pain as well as the DELEGATE REPORT surrounding patients attending to more traditional elements such as Kirsten Cheadle South West Regional and catastrophising their pain. He body charts, red flags and palpation. Representative highlighted the importance of: past His study aims to look for clusters of experience, the meaning of pain, patients reporting similar findings on As always, ACPIN put together a associated fear and the rehabilitation assessment and to then look at varied and interesting programme for process in the patients perception of strategies for treating these clusters. the conference this year. The speakers their pain. See www.backclass for more were experts in their field and many The afternoon session started with information. are members of the Physiotherapy In two talks by physios from the The final lecture of the day was Pain Association (PPA) special Regional Rehabilitation Unit at presented by Mark Smith who interest group. There were 120 Northwick Park Hospital. Lisa Knight discussed his research into the delegates from all over the UK which showed the hard work and commit- measurement of thermal sensory meant that it was a good forum for ment by the whole team that went perception after stroke. His research

24 ACPIN NEWS

EVENTS SUBGROUP from physiotherapy-relevant research COMMUNICATION government to secure funding for the REPORT to explain their benefits and SUBGROUP NHS to provide equal access to limitations. neurological rehabilitation following Anne Rodger Dr Martine Nadler discussed Emma Forbes discharge from acute services to end transcranial magnetic stimulation regional discrepancies and indeed The Autumn one day course on (TMS) tracing changes during and The Communication subgroup have variations in the provision of patient ‘Hands On Neurophysiology’ at the after constraint-induced therapy, been working towards updating the care. National Hospital for Neurology and giving a motor cortical map of Regional Representative Pack. It should Neurosurgery in November 2004 activity. CMR has been used to show be available on electronic format and Explanatory notes proved very popular. The day went changes to certain responses of on new headed paper very soon. It is becoming increasingly evident very well, and the ‘open forum voluntary EMGs during the We have also been busy writing that some geographical areas have question’ session promoted lots of acquisition of a novel motor skill and, the motions (see below) for the outpatient and/or community discussion. subsequently to recovery of hand Annual Representatives Conference neurological rehabilitation services The Spring Conference and AGM function post-stroke. in Cardiff. insitu while in other areas there is in Northampton on ‘Pain and Allie Turton highlighted the We submitted four motions and minimal neurological physiotherapy Neurodisability’, 5th March 2005 also usefulness of TMS as a non-invasive have had three of these accepted. At provision following acute services. attracted good support (see previous and painless technique to explore the this moment we are unaware whether With research evidence and RCP and item). corticospinal pathway activity. The these will feature on the first or BSRM guidelines both stating The CSP Congress in October pros and cons of TMS were brought to secondary agenda. These deal with adequate outpatient and community 2005, will be following a slightly life with a memorable cardboard issues of extended scope services are required to achieve different format, and will be held over model, photographs and a few more practitioners, rehab services and successful outcomes with neurological two days on Friday 7th to Saturday ‘wiggly lines’. TMS has been used to guidelines. patients the CSP should lobby the 8th October. ACPIN will be scrutinise hand function and We actively participate in ARC and government to raise the profile of organising two full days of lectures on swallowing post-stroke, and there is a are keen to campaign for real issues follow up neurological rehabilitation the topic of ‘Cognition, Perception potential for rapid rate TMS as a that matter to our membership. Any services and secure funding promptly. and Behaviour’. rehabilitation tool. ideas for next years ARC should be 2006 will be our Silver Jubilee A discussion forum then helped us forwarded to myself. Wheelchairs Year. ACPIN is organising a two day to link what we’d just heard to our We also need four delegates to This conference demands the CSP residential course at the own clinical perspectives. attend ARC for this year and anybody immediately provide standards for Northampton Hilton with a Caroline Alexander gave a keen should again contact myself. wheelchair provision which ensure celebratory dinner on the Friday thought-provoking and highly equal consideration is given to night. The provisional topic is relevant presentation on reflex ARC MOTIONS lifestyle and physical needs. neuromuscular disorders. control of the shoulder girdle Extended Scope Practitioner Details of all ACPIN courses are on muscles. EMG studies explored the This conference demands the CSP Explanatory notes the website and are advertised in relationship between the upper and urgently provide a framework of core There is evidence to suggest the basic Frontline. Feedback on course lower fibres of trapezius; taping along competencies to facilitate the principles of seating are to programmes are always valued. or across the lower fibres of trapezius development of extended scope understand the different needs of Thank you for your continuing and whether general or task-specific practitioner posts in neurology. each user group including physical, support. concentration will facilitate shoulder psychological and social. The CSP girdle musculature. Explanatory notes should develop guidelines to Dr Marko Bogdanovic presented There is a requirement for extended highlight the aspect of social needs HANDS ON work on partial body-weight support scope practitioner posts across the and lifestyle so patients’ seating has a NEUROPHYSIOLOGY treadmill ambulatory training using country to insure neurological positive impact on quality of life and Delegate report functional magnetic resonance physiotherapy experience is does not compromise patients ability ACPIN Day Conference, Saturday 13th imaging. MRI picks up an increased recognised and indeed utilised. The to participate in life. November 2004, National Hospital for flow of oxy-haemaglobin which CSP should develop a framework to Neurology and Neurosurgery London. John Hall occurs when areas of the brain have ensure the development of these Guidelines been activated. In the group studied, posts are facilitated and standardised This conference demands that the CSP Dr Mayston started the day by reorganisation of dorsal pre-motor across the country. This would ensure immediately lobby government to addressing the various techniques to and motor areas of the cortex were high standards are maintained and clearly identify the funding required measure CNS activity, to test the CNS demonstrated. posts can be created without delay. and the source from which such by stimulation and to picture the In summary, the conference was funding should come to allow the CNS. Electromyography, cutaneo- very well organised, lived up to my Rehabilitation Services implementation of national guidelines muscular reflex (CMR), PET and expectations and has given me plenty This conference demands the CSP including RCP, NICE and NSF. SPECT were explored, using examples of ideas to take up for CPD. should immediately lobby the

25 ACPIN programme for CSP Congress 2005 Birmingham Friday 7th & Saturday 8th October

Cognitionand behaviiur complex challenges to rehabilitation

Friday 7th October The conference aims to explore • An introduction to cognition and implications for physiotherapists various aspects of cognition and Anne Brannagan, Clinical Specialist Occupational Therapist and behaviour and some of the problems Kit Malia, Cognitive Rehabilitation Therapist encountered following brain injury. Both are from Headley Court, Epsom, Surrey. Most importantly it aims to highlight • “No good telling me I’ve got to do it myself”: enabling personal why an understanding of this area is confidence in progress following stroke Fiona Jones, School of Physiotherapy, St George’s Hospital beneficial to physiotherapists working Medical School, London in neurology as well as provide some • Memory impairment following brain injury – rehabilitation of memory useful advice on the treatment and Donna Malley, Clinical Specialist OT, Oliver Zangwill Centre, management of patients with Cambridgeshire. cognitive or behavioural issues. Saturday 8th October • Conversion disorder Physiotherapy team, National Hospital for Neurology and Neurosurgery, London

• Managing patients with challenging behaviour Katrina Moles, Physiotherapist, Royal Hospital for Neuro Disability, Putney

• Understanding and treating dyspraxia Therese Jackson, Head Occupational Therapist, Aberdeen Royal Infirmary ACPIN NEWS

Explanatory notes help compile it into a feature article. All members agree that production of This idea is in its ‘early stages’ so guidelines is a positive move to watch this space! If anyone would like ensure the standardised use of to share their good practice, please clinically effective practice. However, contact Louise Dunthorne, the this is only possible is appropriate Synapse co-ordinator. funding is identified otherwise guidelines remain a paper exercise and not put into practice. We believe RESEARCH SUBGROUP the CSP should campaign on behalf of all members to insure the The Research subgroup would like to government provide the funding to thank members for their involvement fulfil the purpose of the guidelines. in the Research Questionnaire and the Survey of Neurological Service in 2004. Reports of these activities were CLINICAL PRACTICE AND included in Synapse Autumn/Winter AUDIT GROUP 2004 issue and there is still some further work to do with this As explained in the groups report for information. However, this type of the Autumn edition of Synapse, activity is time-demanding for ACPIN following a regional review of the Core members, the research subgroup and Standards of Physiotherapy Practice by the national committee. In line with ACPIN members it was generally felt our initial plan, we are not repeating that there was no need for additional the Research Questionnaire in 2005 neurology specific standards. In and we will review this decision in addition the CSP made it clear, 2006. As a result, the research following our review, that special subgroup is taking the opportunity to interest groups should not publish consider its future plans. We plan to additional standards of practice. continue the ACPIN research bursary. Unfortunately the revised CSP core The value of the bursary has been standards are still awaited and it is as increased to £800 and the next yet unknown whether the revised deadline is 1st June 2005. Details can standards will address the areas of be obtained from Mary Cramp concern raised by members in some of (Honorary Research Officer). We also the regions. The main areas of concern plan to continue with Research Forum, were that the current core standards the section in Synapse that focuses on lack recognition covering issues research-related issues. We are always surrounding patients with cognitive, happy to receive suggestions about communicative or behavioural impair - the issues you would like to see ments, as well as a lack of reference to addressed in Research Forum. In a National Service Frameworks or broader context, we also welcome guidelines. Once the new standards suggestions about how you would like are published, the group will reassess the research subgroup to support you. them in light of the comments made. Our aims for 2005 are as follows: The other projects this group is • To provide support for ACPIN working on include revamping the national committee & liaise with ACPIN welcome letter that is sent to the CSP and external agencies on all members at the beginning of the research-related issues year, plus compiling a new feature for • To promote and support research Synapse which aims to promote and activity within the membership share good practice. The intention is • To advance understanding of that members can write in and tell us aspects of research among the about innovative practice, membership programmes or projects that they are • To continue with research focused involved in, and the sub-group will section in Synapse

27 Syn’apse ● AUTUMN/WINTER 2004

about techniques you have tried, KEY CHARACTERISTICS Other news share ideas, and provide clinical tips. OF ICSP ACPIN will be responsible for the • Easy to use network, and will shortly be asking for • Built around specific interests, volunteers to help them to run or such as acupuncture, diversity, DEVELOP YOUR WHAT IS IT? moderate it. This essentially means respiratory, research PROFESSIONAL SKILLS • interactiveCSP is an easy to use overseeing content added by users • It’s personal and flexible AND KEEP UP TO DATE web site and contributing items based on your • Access is for CSP members only • Designed for physiotherapists knowledge and experience to ensure Ralph Hammond • Users can add content , Training and Promotions and assistants that the network builds into a Manager, iCSP, The Chartered Society of • It’s fully searchable valuable library of relevant Physiotherapy, London, UK. • Signposts to knowledge on specific clinical and knowledge and an active exchange of Clinicians frequently report they have professional interests information and experience between Once you start to participate you no easy way of discussing clinical • Email facility to contact users. The role can be shared among could use this as an example of your problems with colleagues, that they everyone on the network several people, does not require development and how your have no time to access up to date • The address is advanced computer skills, and can be professional profile is evolving as you research, and are inundated with new www.interactivecsp.org.uk adapted to suit the time that you learn more about the profession and policies – now there’s a new way to have available – taking perhaps a few wider health policy. overcome these challenges. hours a month. All moderators will interactiveCSP is an easy to use web The system was then piloted in the What do your colleagues think site, designed to enable physio- Northern and Yorkshire regions and of it? therapists and assistants to gain comprehensively evaluated. I have managed to be more The pilot website was run in Spring There are 60 networks; many aware of what is going on than ever 2003 in the Northern and Yorkshire moderated by physiotherapists. There “before. regions of England. It was evaluated The system is very user are over 7,000 items of content, and Chartered Physiotherapist, during Summer 2003 with extremely N&Y Pilot evaluation response, 2003 friendly and has become my point this will rise and rise. To help iCSP is positive findings: “of reference on a wide variety of fully searchable and includes an email • 93% of users (all members of the issues from managerial to clinical. bulletin that sends out regular also receive initial and follow-up CSP) thought iCSP either ‘good’ or updates to each network user training on both the system and the ‘excellent’ Chartered Physiotherapist, N&Y Pilot evaluation response, 2003 summarising any new content. role, and ongoing support. • Over 90% rated the services either useful or very useful. How is ACPIN involved? Developing your professional skills • More than two thirds indicated iCSP access and share knowledge on ACPIN plans to establish a Being a moderator will put you at the had added significant value to their specific clinical and professional ‘neurology’ network on the system centre of clinical and professional CSP membership. interests. It has an email facility to when it rolls out across the UK in knowledge-sharing regarding • One member said, ‘a wonderful enable you to tap into the ‘know 2005. This will provide you with physiotherapy practice in neurology– resource for keeping up to date with how’ of the profession. It was access to a range of content related to irrespective of where you live or work. national developments and peers.’ purpose-built to meet the needs of You will be able to both learn from Register to interactiveCSP – if you are physiotherapists and assistants. Don’t and participate in valuable not yet registered the best way to get believe how easy it is to use? Check it I consider myself really discussions with your peers and it will a proper feel for the system is to out: www.interactivecsp.org.uk fortunate to have been in the greatly improve your IT skills and register and use it. To register, go to “northern region during its pilot confidence. www.interactivecsp.org.uk, click on Why and how it was developed and value the impact it’s had on ‘register’, and fill in the on-line interactiveCSP was developed to the information I can easily access. Is it doable? registration form. You need to know strengthen the communications and Chartered Physiotherapist, Currently over half of the moderators your membership number and your networking capacity of physiothera- N&Y Pilot evaluation response, 2003 on the pilot system are physiother- email address to complete the pists to meet the current needs and pists, covering all ages, grades and IT registration process. changing requirements emerging the aims of the specialty. The network skill levels. So, yes, it is doable! from the health modernisation will contain services including: news, interactiveCSP will help improve Interested in finding out more reforms of recent years. events, documents, discussions, links your professional skills. You can use it about becoming a moderator? The system was designed and built to useful websites, and projects, all to keep up to date with research, A letter was sent out over the new in response to a range of demands providing content related to learn about local and regional year to all members of ACPIN telling identified through extensive neurology. You can post clinical initiatives as well as government you more about moderating. Contact consultation with physiotherapists in questions to other physiotherapists policy, and get to know more about Ralph at: [email protected] the Northern and Yorkshire regions. who share your interests, tell them what is going on in the profession.

28 COGNITIVE REHABILITATION

Brain Tree & Training PHYSIOTHERAPY rd COURSE LOCATION: Gatwick Hilton, Gatwick Airport, Sussex, UK Dec 3 2005

COURSE CONTENT: INSTRUCTORS: Kit Malia & Anne Brannagan

'Neuro-physiotherapists need to be not only skilled in INTRODUCTION: Why run this course? Defining cognition. The 5 the physical management of neurological deficits, but cognitive modules – attention, visual processing, information processing, also experienced in recognition and handling of memory & executive functions. Metacognition. Identifying the impact of cognitive problems on physical rehabilitation. The 4 approaches to associated cognitive and behavioural deficits which may treating cognitive problems. impact on the patient's ability to engage and cooperate in therapy sessions and to carry over physical gains into ATTENTION & INFORMATION PROCESSING SKILLS: Defining daily activities' attention. The 5 levels of attention. The importance of attention. Understanding what it is like to have attention problems. Defining Section 7.2 (p.39) of Rehabilitation following acquired information processing. The relationship to memory and organisation brain injury: National Clinical Guidelines (2003) (Turner- skills. Capacity, speed and control. Recognising information processing Stokes L, Ed). Royal College of Physicians and British problems. Society of Rehabilitation Medicine. London: RCP, ATTENTION/INFORMATION PROCESSING AND THE BSRM PHYSIOTHERAPIST: Ordering motor tasks according to cognitive demands. Evidence from published articles. Concept of resource COURSE DESCRIPTION: competition and overload. Conscious versus automatic skills. What this means for the day to day practice of physiotherapy. Practical organisation This one day interactive workshop is suitable for and treatment strategies to incorporate rehabilitation of attention and physiotherapists working with adults who have information processing deficits into the physiotherapy department. cognitive problems following brain injury. VISUAL PROCESSING/MEMORY AND THE PHYSIOTHERAPIST: Defining visual processing. Hierarchical visual processing model. Understanding what it is like to have a visual The course presents a practical model within processing problem. Visual processing and the PT. Defining memory. The which to understand cognitive problems in the 5 processes involved in memory. Memory and the PT – practical suggestions. physiotherapy environment. The workshop format encourages the development of practical EXECUTIVE FUNCTIONS AND THE PHYSIOTHERAPIST: Defining executive functions. Suggestions for the PT to use in helping activities that can be put into practice within the develop executive functions. department. REVIEW OF OWN PRACTICE: In small groups time is spent reviewing practice. How will you alter practice to take account of AIMS: cognitive problems? How could you structure physiotherapy sessions to improve cognitive deficits? Practical demonstration of how physical skills • To define cognition can be used to treat cognitive deficits. • To provide a practical cognitive framework • To increase therapists’ understanding of cognitive problems and how these impact on physical function • To provide practical ideas that physical therapists can implement • To demonstrate how physical therapy sessions can be used to treat cognitive problems £66 Brain Tree Training

www.braintreetraining.co.uk TO BOOK A PLACE: If you would like to attend, please pay online or send your name, address, phone number and email address to Sally Dawson at the address below.

Brain Tree Training 01276 472 369 PO Box 79, Leatherhead [email protected] Surrey, KT23 4YT, UK Syn’apse ● AUTUMN/WINTER 2004

an abstract of their work for consider- The possible answers to the above Research forum ation. For all ACPIN conferences, questions were: details will be published with the •A lot conference details in Synapse, in • Somewhat Frontline, on our website and • A little In the last issue of Synapse, we national conferences per year and hopefully on iCSP, which is due to • Not at all reported about the survey of these conferences are great occasions come online to all the membership in • Not applicable. neurological physiotherapy services, to engage in interesting and May. If you have any further queries 197 of the 277 members who sent out with the 2004 Spring issue of stimulating discussion with fellow about presenting your research to returned the survey indicated that Synapse. We are following up on one physiotherapists working in ACPIN members, you can contact they treated stroke patients. With interesting aspect of the survey that neurological services throughout the Mary Cramp, Honorary Research non-responders and those who stimulated discussion within the country. They are also an ideal forum Officer (address: School of Health & answered not applicable excluded, research subgroups, that is, the to gain experience of presenting Bioscience, University of East London, 188 responses were analysed and are response to questions about clinical research and exposure for an area of Romford Road, Stratford, London, E15 described below. Figure 1 shows the guidelines. Clinical guidelines utilise research of interest to you. ACPIN 4LZ; email: [email protected]). percentage response rates in each research evidence and it therefore national committee would like to category to the questions above. seemed appropriate to consider provide support for members (and Indications are that, although there some issues relating to them in other interested parties) to present CLINICAL GUIDELINES: ARE was good awareness of the RCP Stroke Research Forum. and discuss their research work with THEY RELEVANT? guidelines, the guidelines have had Another important matter to bring ACPIN members. However, we feel The survey of neurological services in limited impact on clinical practice. to your attention is one of the stated that many people are unaware of the 2004 asked two questions of The results interested the Research aims of ACPIN which is ‘to encourage opportunities available to present members in relation to Royal College Subgroup of the ACPIN national members to participate in research their work at national conferences of Physicians (RCP) Stroke Guidelines: committee. Given that clinical activities and the dissemination of and response to calls for recent guidelines draw on available research information’. We hope that you are conferences have been poor. 1. Have you or do you refer to the evidence, it seems pertinent to aware of the ACPIN research bursary ACPIN conferences are generally RCP Stroke Guidelines? discuss in this forum some of the – but in case you missed it last time, one or two day affairs held in March 2. Have the RCP Stroke Guidelines issues related to clinical guidelines we are including the terms and and October/November (with improved your clinical practice? and draw attention to key sources conditions for the bursary again. If exception of recent ACPIN you are interested, the date for you to programmes at CSP Congress). PERCENTAGE RESPONSES note is 1st June – the next deadline Forthcoming ACPIN conferences will 6% for submission of an application. offer opportunity for presentation of Firstly though, we want to inform research relevant to neurological 23% A lot 23% members how ACPIN would like to physiotherapy. Poster presentations Somewhat 46% support researchers and clinicians will be held at one day conferences 25%

who would like to present and discuss and both poster and oral presentation A little 25% their research with other ACPIN sessions will be held at two day Not at all 6% members. conferences. This applies to ACPIN 46% conferences only – ACPIN PRESENT YOUR RESEARCH programmes at CSP Congress will not TO ACPIN MEMBERS! operate in this way but follow Question 1 – Refer to RCP Stroke Guidelines standard procedures for CSP Congress. • Do you think your research (large or ACPIN will be running a small scale) is interesting and programme at CSP Congress, October 11 % relevant to neurological 2005 and the next ACPIN conference 17% A lot 11 % physiotherapy? where you can present your work will Somewhat 40% • Do you want to gain experience of be in March 2006. So there is plenty

presenting your research, either by of time to plan ahead! This will be a A little 32% 40% poster or oral presentation to a special occasion, as it will mark the 32% friendly and supportive group? 25th anniversary of ACPIN. The Not at all 17% • Would you like to discuss you work process for applying to present your with professional colleagues with work is simple. When conference interest and experience of details are published, a call will be Question 2 – Improve clinical practice neurological physiotherapy? made for poster/oral presentations ACPIN normally organises two and interested parties should submit Figure 1

30 RESEARCH FORUM

about clinical guidelines. needs to be considered. GUIDELINE STRENGTH: LEVEL OF EVIDENCE AND GRADE OF Clinical guidelines are defined as Clinical guidelines do provide an RECOMMENDATION ‘systematically developed statements opportunity to promote the value of Level of Type of Evidence Grade of to assist patient and practitioner physiotherapy and to argue for Evidence recommendation decisions about appropriate health resources to improve services. We Ia Meta-analysis of randomised controlled care for specific clinical have to be careful here though. For trials (RCTs) A circumstances’ (Field & Lohr, 1992). example, many departments Ib At least one RCT A While clinical guidelines may be purchased treadmills on the strength IIa At least one well designed controlled study derived from consensus or expert of the recommendations made in the but without randomisation B opinion, an evidence-based approach first edition of the National Clinical IIb At least one well designed, to the development of clinical Guidelines for Stroke in 2001. Later quasi-experimental study B guidelines is increasingly utilised. review of the literature suggested that III At least one well designed, Therefore, a key aspect of any clinical lack of research into conventional non-experimental descriptive study guidelines is consideration of the therapy interventions, poor quality of (eg comparative studies, correlation nature of evidence used to formulate and difficulty comparing primary students, case studies) B the guidelines. studies plus the use of a variety of IV Expert committee reports, opinions outcome measures meant there is and/or experience of respected authorities. What is the nature of evidence? little hard evidence as yet to justify This grading indicates that directly applicable Literature search strategies and changing clinical practice in favour of clinical studies of good quality are absent. C evaluation of the evidence are key treadmill training of gait after stroke Consensus Recommended good practice based processes in the development of (Manning & Pomeroy, 2003). To of working on clinical experience of the Guideline clinical guidelines. Published clinical advance this situation, it is important party Development Group D guidelines provide information about that department and clinicians share the assessment of evidence. For Table 1 protocols/parameters of training and example, the National Clinical the clinical outcomes of the training. Intercollegiate Stroke Working Party (2004) National Clinical Guidelines for Stroke: Guidelines for Stroke: Second Edition Second Edition. p6 As outlined above, ‘clinical evidence’ includes a table (Table 1) as guidance is also a valuable resource to inform to the import given to the evidence. practice. It is therefore essential to consider deemed to be the gold standard. position in the healthcare system There is a lack of evidence into the nature of evidence included in It has been recently documented (Hendriks et al, 2000). Guidelines can conventional therapy interventions the guidelines and grading applied to that many therapists find guidelines be used to ‘guide’ professionals in and indeed which components are different types of evidence when too broad and not easy to implement; their daily practice and make it most effective. Do we disregard reading clinical guidelines. disappointment was also voiced that explicit what we do and why we do it. clinical interventions just because of Evidence based practice is shaped the current system fails to They are a frame of reference and can lack of evidence or current quality by what forms of knowledge are acknowledge the value of practice- help us in our decision making research? Do guidelines lead to counted as evidence (Gibson & generated knowledge (Ilott et al, process, decrease variability in ‘recipe’ treatment based on RCTs of Martin, 2003 p351). Questions are 2004). Therefore, it is perhaps timely practice and can initiate changes in selected ‘uniform’ patient groups? being raised about the nature of to remember that other forms of our established patterns of practice Most evidence is from experimental evidence in clinical practice and the evidence can be utilised in the (Hendriks et al, 2000; Woolf et al, studies of groups of patients but apparent over-reliance on the delivery of evidence-based 1999). patients are individuals and may randomised controlled trial (RCT). healthcare. These include gleaning Clinically, a survey of physiothera- respond differently and application Hierarchies of evidence, which place knowledge from clinical experience, pists’ attitudes towards evidence of ‘recipes’ may compromise quality RCT’s at the pinnacle of the triangle patients, clients and carers, the local based practice and personal of care. It has been argued that a (and so imply superiority), can be context and environment as well as experiences in the Wessex area starting point for the application of commonly found in prominent more formal research (Rycroft – (Barnard & Wiles, 2001) demon- any evidence to an individual patient publications used by physiotherapists Malone et al, 2004). strated that some therapists, should be in determining how the such as the National Clinical Guidelines particularly those working in the patient is similar to the patients in for Stroke (Intercollegiate Stroke What is the clinical relevance of community setting, felt a lack of the study group and not how they are Working Party, 2004) and National guidelines? engagement with the development of different (Scalzitti, 2001) and that we Service Frameworks eg the NSF for Older The development of practice clinical guidelines. This was due to should use the results of research People (Department of Health, 2001). guidelines aims to improve the poor access to library facilities and trials as part of our decision making However, the use of research design quality and efficiency of care. They difficulties meeting peers. The CSP for an estimate of treatment effect should therefore be driven by the can be seen as a logical step in the has worked hard to advertise and for the individual patient (Herbert et nature of the question being asked process of professionalisation of promote new guidelines on their al, 2001). and not by the method that is physiotherapy and a way to justify our release but access to information Do we provide management of our

31 Syn’apse ● AUTUMN/WINTER 2004

as an information source for References 1010101010101010101010 STATS NOTE 1010101010101010101010 continuing professional education Barnard S, Wiles R (2001) Evidence and as instruments for self assessment –based physiotherapy: physiotherapists’ THE MEDIAN – PIGGY IN THE MIDDLE /peer review to learn about potential attitudes and experiences in the Wessex Our STATS NOTE series on the measures of central tendency used in gaps in performance (Feder et al, area Physiotherapy, Vol 87 pp115-124. 1999). However, studies have shown descriptive statistics would not be complete without examining the MEDIAN Davis DA, Taylor-Vaisey A (1997) that medical clinicians might be in a little more detail. Translating guidelines into practice. A concerned about the impact of The median is literally the mid-point in a set of results, such that if you systematic review of theoretic concepts, clinical guidelines on their clinical arrange your data in increasing order, there are as many values above the practical experience and research autonomy and satisfaction with median as below it. If you have an odd number of results then the median is evidence in the adopting of clinical, practice (Davis & Taylor-Vaisey, 1997). the actual value of the middle score itself. If however if you have an even practice guidelines Canadian Medical Reading the clinical guidelines are number of results then the median is the average of the two middle scores. Association Journal, Vol 157 pp408- an opportunity to reflect upon our As with the mode and the mean, the median can be easily calculated by hand 416. or using a computer spreadsheet programme. current service provision and The median is most useful when used with skewed values or data with organisation, to see how we can Department of Health, (2001) outliers. In the following illustrations the median remains stable, whilst the improve the quality service for our National Service Framework for Older mean is radically affected by large changes to the scores in the two different patients eg the need for increasing People London: Stationery Office. information for patients and flexible situations. Say, for example you wanted to investigate the current practice in Feder G, Eccles M, Grol R, Griffiths C, referral systems. This may lead to your area for the number of days between botulinum toxin injection to the Grimshaw J (1999) Using clinical further research or innovative upper limb and subsequent splinting, you might be presented with the guidelines BMJ, Vol 318 pp728-730. following set of results changes to services for patients. Field MJ, Lohr KN (1992) Guidelines for 1127772128354256 Sourcing clinical guidelines Clinical Practice: from development to where the median length of time would be calculated as 7 days, the mode 7 There are now a number of web- use Institute of Medicine, National days and the mean 18.8 days. If however your data did not have such based resources to provide up-to- Academy Press, Washington DC. date information and access to extremes of scores, for example Gibson BE, & Martin DK (2003) clinical guidelines. Qualitative Research and Evidence 123457778910 • http://libraries.nelh.nhs.uk/ based Physiotherapy Practice guidelinesFinder/ then although the median and the mode would still be 7 days, the mean Physiotherapy, Vol 89 pp350-358. would be considerably reduced to just 5.7 days. A database of UK approved evidence- Other points to consider: based clinical guidelines available on Hendriks HJM, Bekkering GE, van- • On its own the median give us insufficient information about our data - if the internet in full-text and associated Ettekoven H, Brandsma JW, van-der- our research is to be accurately interpreted then we need to know more information (maintained by the Wees PJ, de-Bie RA (2000) about the nature of our results such as the range of scores Sheffield Evidence for Effectiveness Development and implementation of • The median is mainly used with numerical values but it can also be used and Knowledge service) national practice guidelines: a prospect with ordinal and some nominal data. • www.csp.org.uk/effectivepractice/ for continuous quality improvement in As with the mode the general rule of thumb should be that it is usually guidelines.cfm physiotherapy Physiotherapy, Vol 86 advisable to calculate the mean if your data allows, however: Web pages maintained by the pp535. Chartered Society of Physiotherapy to • If you have calculated the mean but would like to know more information Herbert R, Sherrington C, Maher C, inform members about current about your results Moseley A (2001) Evidence-based guidelines relevant to physiotherapy • Or if you have skewed values where the mean would be adversely affected practice- imperfect but necessary. and ongoing developments. by outliers Physiotherapy Theory and Practice, • www.nice.org.uk then THE MEDIAN is a useful measure to use. Vol 17 pp201-211. National Institute of Clinical Effectiveness Ilott I, Mead J, Roberts J, Hammond R • www.sign.ac.uk (2004) Enhancing Stakeholder patients in accordance with current guidelines (Strand, 2005) but it also Scottish Intercollegiate Guidelines Involvement in Nice Guideline clinical guidelines? As yet a literature highlighted areas of deficit which in Network (SIGN) Developments: Learning lessons from the search by the authors showed no itself is a useful tool to further The last two are key agencies for the experience of the allied health current published articles relating to improve quality of care. Clinical audit development and publication of professions, health visiting, midwifery clinical guidelines for neurological is a useful way of evaluating our clinical guidelines within the UK. and nursing Clinical Effectiveness rehabilitation. A recent survey of practice alongside guidelines. Again, Forum for Allied Health Professionals, manual therapists showed that to results need to be disseminated to available from www.csp.org.uk/ some extent they were acting in the profession as a whole. Clinical effectivepractice/guidelines.cfm accordance to the main areas of the guidelines have been recommended

32 RESEARCH FORUM

Intercollegiate Stroke Working Party Eligibility involved institutions. Evidence of Other news (2004) National Clinical Guidelines for • Applicants will be full members of ethical approval and insurance Stroke:Second Edition Royal College of ACPIN of at least two years standing. arrangements may be requested. extra Physicians, London. • Applicants will be resident in the UK. 2.Bursaries must be used solely for • Applicants will be planning to or the purposes set out in the Rycroft- Malone J, Seers K, Titchen A, ASSOCIATION OF currently involved in research. application procedure. Any changes Harvey G, Kitson A, McCormack B CHARTERED • Research must be related to in proposed expenditure must be (2004) What counts as evidence in PHYSIOTHERAPISTS physiotherapy for neurological agreed to by ACPIN. At the end of evidence-based practice? Journal of INTERESTED IN conditions. the research project, any remaining Advanced Nursing, Vol 47 pp81-90. VESTIBULAR • Members conducting research as balance should be returned to REHABILITATION (ACPIVR) Scalzitti DA (2001) Evidence-based part of an educational course are ACPIN. guidelines:application to clinical practice eligible to apply for support. 3.A summary of expenditure A small but committed group of Physical Therapy, Vol 81 pp1622-1628. • Applicants are expected to be the accompanied by receipts (where physiotherapists interested in active participant in the proposed appropriate) will be required. vestibular rehabilitation have been Strand LI, Kvale A, Raheim M, project. 4.ACPIN must be notified of any meeting regularly in the last few Ljunggren AE (2005) Do Norwegian • Applicants cannot apply for more further changes in the proposed years, with an aim of promoting manual therapists provide management than one bursary. project eg timescale etc. vestibular rehabilitation. for patients with acute low back pain in 5.Recipients of a research bursary will We have collected a database of accordance with clinical guidelines? Application procedure be required to produce a report for about 200 physiotherapists who have Manual Therapy, Vol 10 pp38-43. • Applications for the award must be Synapse on completion of the expressed an interest in vestibular Woolf S, Grol R, Hutchinson A, Eccles submitted on the standard research project. The report will be rehabilitation. The group is now ready M, Grimshaw J (1999) Potential application form (available expected within six months of to formalise its agenda and we are benefits, limitations, and harms of published in Synapse or can be completion of the project. looking at moving towards becoming clinical guidelines BMJ, Vol 318 pp527- obtained from Mary Cramp (Hon. a recognised Clinical Interest Group 530. Research Officer). within the CSP. We anticipate that • Applications will be considered membership to ACPIVR will be £10 twice annually. Completed per annum. The group’s initial ACPIN RESEARCH BURSARY application forms should be priorities will be: organising relevant 2004/2005 received by 1st December or by 1st courses, looking at competencies and We thought it would be timely to June for consideration at the improving recognition of vestibular remind members about the ACPIN National Committee meetings in disorders within physiotherapy Research Bursaries. The purpose of the January and July respectively. If you would like to find out more award is to encourage research activity • An application once submitted may about the group, or if you are among the membership and to assist only be re-submitted upon interested in joining the committee, members undertaking research as part invitation. please contact: Anne Rodger, Clinical of their current workload or Applications will be considered in Specialist in Physiotherapy, Therapy undertaking research as part of an competition bi-annually. Completed Services, National Hospital for educational course. There are some applications will be considered and Neurology and Neurosurgery, amendments to the application graded independently by members London. WC1N 3BG. (0207 837 3611 procedure and the value of the award. of the Research Subgroup, ACPIN x3438). [email protected] Bursaries of up to £800 are available National Committee. Recommenda- If you were previously on the to cover research-related costs. tions for awards will be reviewed by database, please also contact Anne so an independent expert referee. that it can be updated. Awards Awards will not given automatically • The maximum award allowable is for each competitive round. £800. Applicants will be informed of the • Awards will be made to cover decision of the committee within two research-related costs in relation to months of the application deadline. a specific project, eg Equipment; The decision of the Committee is final. Materials/Consumables; Specialist software; Travel expenses. Terms and conditions • Awards will not be granted to cover 1.Awards are made on the the following: course fees; understanding that the computers, staff time (secretarial investigations comply with ethical support of data entry; blinded Rx) and safety requirements of the

33 Syn’apse ● AUTUMN/WINTER 2004

LECTURE 1

Mick Thacker MSc Grad Dip Phys MCSP MMACP International Lecturer, PhD student, King’s College, London Brain pain: an overview of pain and the central nervous system

This talk will focus on the recent advances in the neurophysi- ology of neuropathic pain. It will take a broad based approach to the molecular aspects of pain and will include a discussion of the role of neuropeptides, neurotrophins and cytokines/chemokines in the production and maintenance of neuropathic pain following nerve injury. Both alterations in the peripheral and central nervous systems will be outlined and correlates between pain production and neuro-de/regeneration identified. The effects of this pathobiology on higher level processing will be described and the implications of this science for the clinician will also be included. The talk will also include a brief discussion on the Pain modern concepts in the management of neuropathic pain. Biography Brunel University and then St &neurodisability Mick qualified in 1987 and went to George’s Medical School before work at St Stephen's Hospital. He moving to King’s College London. He pursued his interests in neuromuscu- is in the last stages of his PhD ACPIN loskeletal physiotherapy undertaking (supervisors Prof Pat Wall, Prof Steve the MACP modular course, which he McMahon and Dr Steve Thompson) national passed with distinction in 1991. He which focuses on the role of the continued to work in out-patients immune system in the production of conference and formed a strong professional neuropathic pain. Mick lectures both relationship with David Butler and nationally and internation-ally on & AGM Louis Gifford. He obtained his MSc in pain neuroscience and treatment. He 1995 from University College London, is co-author of the several articles and where he was able to foster his book chapters including most notably interest in pain neurophysiology. Mick the chapter on physiotherapy in the Abstracts, began his lecturing career in 1994 at new edition of The Textbook of Pain. references LECTURE 2

and Heather Cameron MCSP, MSc biographies Research Fellow, Pain Research Institute, University of Liverpool Mechanisms and management of neuropathic pain

Saturday 5th March 2005 Pain is a multidimensional phenomenon that can vary in intensity, location, time pattern and quality. Neuropathic pain Hilton Hotel (NP) has been defined by the International Association for the Collingtree Study of Pain as ‘pain initiated or caused by a primary lesion or dysfunction in the nervous system’. Northampton Unlike acute nociceptive pain, neuropathic pain does not

34 PAIN & NEURODISABILITY CONFERENCE

signal noxious tissue stimulation and therefore to the sufferer • Casey KL, J Lorenz et al (2003) • Woolf CJ, Salter MW (2000). often feels abnormal. It may have a burning or electrical quality Insights into the pathophysiology of Neuronal Plasticity: Increasing the Gain and is often associated with allodynia (a painful response to a neuropathic pain through functional in Pain Science 288(5472) pp1765- non-noxious stimulus) and/or hyperalgesia (a heightened brain imaging Exp Neurol 184 Suppl 1 1768. response to a noxious stimulus). These not only cause distress S80-88. and discomfort to the sufferer but can be a barrier to rehabilita- • Chen AC (2001) New perspectives in tion. The presence of allodynia can make the lightest of touches Biography EEG/MEG brain mapping and PET/fMRI painful and therefore hinder therapy of which skin contact is Heather Cameron qualified in 1990 neuroimaging of human pain Int J frequently an integral component. In addition to the pain, and since then has worked in various Psychophysiol 42(2) pp147-159. symptoms may include numbness, lack of sensation, weakness, hospitals on Merseyside. reduced function, loss of balance and co-ordination, abnormal • Dworkin RH, M Backonja et al (2003) She has specialised in pain reflexes, discolouration of the affected skin and trophic changes Advances in Neuropathic Pain: medicine and neuro-modulation for in the affected area. Diagnosis, Mechanisms, and Treatment about eight years; her most recent Traditionally NP has been classified as ‘peripheral’ or ‘central’ Recommendations Arch Neurol 60(11) clinical post was in the pain clinic at according to where the site of the lesion occurs. Whilst these pp1524-1534. The Walton Centre for Neurology and terms are still generally utilised, research has demonstrated that Neurosurgery, Liverpool. During this • Lorenz J, Cross DJ et al (2002) A central changes occur in response to peripheral injury and vice time she developed an interest in Unique Representation of Heat versa. A number of researchers are now calling for a more mecha- both neuropathic pain and the Allodynia in the Human Brain Neuron nistic classification whereby NP is classified according to central mechanisms of pain and 35(2) pp383-393. underlying mechanisms producing symptoms rather than site of undertook an MSc in Pain trauma or disease process. This may allow treatment strategies to • Maihofner C, Handwerker HO et al Management in 2003. be better targeted, however in reality we are some way from this (2004) Cortical reorganization during She is currently a full time in the clinical situation. Modern imaging technologies in the form recovery from complex regional pain Research Fellow in the Pain Research of functional magnetic resonance imaging (fMRI), Positron syndrome Neurology 63(4) pp693-701. Institute, University of Liverpool and Emission Tomography (PET) and magnetoencephalography is undertaking a PhD, having received • Moseley GL (2004) Graded motor (MEG) have also allowed us to further understand the functional a researcher development award from imagery is effective for long-standing aspects of NP. the Department of Health in 2004. complex regional pain syndrome: a NP is often associated with a disease process e.g. diabetes Her current research is randomised controlled trial Pain 108(1- mellitus, herpes zoster, multiple sclerosis or may be secondary to investigating the psychophysical 2) pp192-198. trauma eg peripheral nerve/spinal cord injury, CVA or head properties and neural correlates of trauma. As neurological deficit is often apparent it is upon this • Peyron R, B Laurent et al (2000) experimental and clinical pain that medical attention frequently focuses. However the NP may Functional imaging of brain responses to utilising functional magnetic contribute as much or even more to a patient’s actual distress or pain. A review and meta-analysis resonance imaging (fMRI) of the disability. Neurophysiol Clin 30(5) pp263-288. brain. Despite extensive research, particularly in the past two • Pleger B, Janssen F et al (2004) decades, chronic NP remains an unmet therapeutic challenge. Repetitive transcranial magnetic Management typically relies on pharmacological agents however stimulation of the motor cortex NP does not respond to traditional analgesics such as Non- attenuates pain perception in complex Steroidal Anti Inflammatory Drugs. Anticonvulsants and regional pain syndrome type I Neurosci antidepressants therefore remain the mainstay and have shown Lett 356(2) pp87-90. some efficacy. Novel agents however are emerging although efficacy has yet to be demonstrated. • Swanson LW (1995) Mapping the In some instances neuromodulation therapies (TENS, spinal human brain: past, present, and future cord stimulation, Deep Brain or Motor Cortex stimulation) or Trends Neurosciences 18(11) pp471- Neuroablative procedures (eg Drez, Thalamotomy) may be 474. appropriate and effective for specific NP. • Soros P, Knecht S et al (2001) Current theories on mechanisms of and the clinical manage- Functional reorganization of the human ment of neuropathic pain will be discussed. primary somatosensory cortex after acute pain demonstrated by References • Bingel U, J Lorenz et al (2004) magnetoencephalography Neurosci • Almeida TF, S Roizenblatt et al Somatotopic organization of human Lett 298(3) pp195-198. (2004) Afferent pain pathways: a neuro- somatosensory cortices for pain: a single anatomical review Brain Research trial fMRI study NeuroImage 23(1) • Treede RD, Kenshalo DR et al (1999) 1000 (1-2) pp40-56. pp224-232. The cortical representation of pain Pain 79(2-3) pp105-111.

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LECTURE 3 of Physiotherapy), and in November Management’, run by the University 2004 was appointed as honorary of Sydney. His interests include the Lester Jones MSc Med Senior Lecturer, in the Faculty of study of pain and management of Senior Lecturer Kingston University and St George’s Hospital Medical School Medicine at the University of Sydney. pain, application of cognitive- He is also involved as an online tutor behavioural principles, the bio- The cognitive component for the certificate and diploma psycho-social model and education. distance-learning courses in ‘Pain of pain LECTURE 4

Pain is defined as ‘an unpleasant sensory and emotional experi- Lisa Knight Grad Dip Phys ence associated with actual or potential tissue damage, or Private Practitioner and Educator, MSc Student described in terms of such damage’ (IASP). And, as has been presented at a previous ACPIN conference, pain is always ‘located’ in the brain! It is a perception based on the evaluation of Developing a tool for the inputs, outputs and previous experiences of the brain, and the attached nervous system. team management of shoulder Cognition can be defined as mental activity that encompasses perceiving, remembering, learning, thinking, interpreting, pain in hemiplegia believing, and problem solving. These cognitive processes all have the potential to influence the pain experience and also to individualise that experience. Hemiplegic shoulder pain is a common and distressing sequel to Focus of attention is considered an important aspect of neurological damage. It is currently believed to affect 40% of perception of pain. This session will explore how past experi- stroke patients with residual impairments, at some point during ences, the meaning of the pain, associated fears and the the year post onset (Gamble et al, 2002; Ratnasbapathy et al, rehabilitation process might enhance or inhibit the attentional 2003). The significance of pain to the rehabilitation team is that it focus, and therefore the perception of pain. interferes with many aspects of therapy, limits functional use of A final point will be made about pain measurement and how the arm and may increase the period of hospitalization (Roy, the use of simple scales may not be enough. 1995). The government has encouraged development of evidence References changes in chronic low back pain and based clinical guidelines and the introduction of defined • Melzack R (1999) From the gate to the disability European Journal of Pain 8 protocols as a means of improving care (DOH, 1996). There is neuromatrix Pain S6 S121-S126. pp201-210. some evidence to suggest that management in the acute phase • Roelofs J, Madelon LP, Patijn J, benefits from this structured approach (Sulch and Kalra, 2000). Schouten EGW, Vlaeyen JWS (2004) Biography In neurological rehabilitation, where care is often individualised Electronic diary assessment of pain- Prior to arriving in the UK in 2000, in complex cases, it may be more practical to look at specific related fear, attention to pain, and pain Lester Jones worked at the University aspects of management. intensity in chronic low back pain of Sydney, Pain Management and Since 1997 the team at the Regional Rehabilitation Unit, patients Pain 112 pp335-342. Research Centre in a clinical role. This Northwick Park Hospital, have been using and developing an involved the management of patients integrated care pathway for the manage-ment of hemiplegic • Viane I, Crombez G, Eccleston C, suffering complex pain conditions in shoulder pain. This stemmed from an initial retrospective notes Devulder J, De Corte W (2004) a programme modelled on the INPUT audit, that revealed inadequate documentation of the problem Acceptance of the unpleasant reality of programme at St. Thomas’. As well as and no system for management (Jackson et al, 2002). The inte- chronic pain: effects upon attention to his physiotherapy training (La Trobe grated care pathway was informed by a systematic literature pain and engagement with daily University, Australia), he has a review (Turner-Stokes and Jackson, 2002) and clinical activities Pain 112(3) pp282-288. psychology degree, a post-graduate consensus. It prioritized pain management, support and posi- • Williams AC de C, Oakley Davies HT, psychology qualification, and a tioning, but was not prescriptive in terms of treatment. There was Chadury Y (2000) Simple pain rating Masters Degree in ‘Pain Management’ emphasis on the recording of variance to inform further develop- scales hide complex idiosyncratic from the Faculty of Medicine, ment of the tool. meanings Pain 85(3) pp457-463. University of Sydney. He is currently The second round audit showed an increased awareness of employed in the Faculty of Health shoulder pain as a documented problem (Jackson et al, 2002). • Woby SR, Watson PJ, Roach NK, Care and Social Sciences, Kingston However, the ongoing documentation and monitoring were Urmston M (2004) Are changes in fear- University & St George's Hospital inconsistent. A fortnightly multidisciplinary review allowed for avoidance beliefs, catastrophising, and Medical School (University of better consideration of treatment strategies for persistent or appraisals of control, predictive of London), as a Senior Lecturer (School resistant symptoms. Centralisation of the documentation and

36 PAIN & NEURODISABILITY CONFERENCE

categorisation of outcome were also introduced. Differences in LECTURE 5 results between the second and third round audits demonstrated Diana Jackson Msc MCSP several important factors when developing multidisciplinary Senior Clinical Research Fellow, Academic Department of Rehabilitation, King’s College Hospital and management tools. These include the need for regular review of RRU, Northwick Park Hospital, London both patients and notes, user-friendly documentation, ongoing education of staff and strong leadership and commitment (Jackson et al, 2003). Assessing shoulder pain in References • Sulch D, Kalra L (2000) Integrated patients with cognitive/ • Gamble GE, Barberan E, Laasch H-U, care pathways in stroke management Bowsher D, Tyrrell PJ, Jones AKP Age and Ageing 29 pp349-352. communication deficits (2002) Post-stroke shoulder pain: a • Turner-Stokes L, Jackson D (2002) prospective study of the association and Shoulder pain after stroke: a review of National clinical guidelines for stroke stress the importance of risk factors in 152 patients from a the evidence base to inform the regular pain assessment to aid diagnosis and management of consecutive cohort of 205 patients development of an integrated care conditions such as shoulder pain and to enable patients to partici- presenting with stroke European 1 pathway Clinical Rehabilitation, 16 pate in decisions about their care . Valid and reliable pain Journal of Pain 6 pp467-74. pp276-298. assessment is also essential for research into the efficacy of inter- • Jackson D, Turner-Stokes L, Khatoon ventions to alleviate pain. However, there is no consensus as to A, Stern H, Knight L, O'Connell A Biography how pain should be assessed in stroke patients. The systematic (2002) Development of an integrated Lisa Knight qualified in1989 from St communication, assessment and documenting of pain symptoms 2 care pathway for the management of Thomas’s Hospital, London and, since in health care settings generally has been shown to be poor and hemiplegic shoulder pain Disability and 1991, has been working within this is especially so for patients with aphasia, perceptual deficits Rehabilitation 24 (7) pp390-398. neurosciences. She has experience of and cognitive problems. They may have difficulty alerting clini- acute, post-acute and community cians to the presence of pain, be unable to use pain scales • Jackson D, Turner-Stokes L, Williams settings. Her most recent post was as designed for the general population3, and may not receive the H, Das-Gupta R (2003) Use of an clinical specialist at the Regional treatment they need4,5. integrated care pathway: a third round Rehabilitation Unit, Northwick Park Shoulder pain assessment in patients with such difficulties will audit of the management of shoulder Hospital. be considered here in the context of theoretical models of pain pain in neurological conditions Journal In 2002 Lisa started to work communication6,7. These explain assessment as a sequence of of Rehabilitation Medicine 35 pp1-7. towards an MSc in events during which the inner experience of pain is transmitted to • Mann T (1996) Clinical guidelines: neurorehabilitation and is hoping to the outside world through verbal report and/or behaviours using clinical guidelines to improve complete this in the near future. She suggestive of pain. A number of intrinsic and extrinsic variables patient care within the NHS DOH is now working in private practice, affect all stages of this process. document. combining clinical work with Transmission of information through self-report is arguably education. the best reflection of someone’s pain. Alongside our care pathway • Ratnasabapathy Y, Broad J, Baskett J, Her areas of interest are the for hemiplegic shoulder pain (also presented in this programme), Pledger M, Marshall J, Bonita R (2003) management of severe complex we have therefore been investigating more accessible ways of Shoulder pain in people with a stroke: a disability, specifically head injury, helping patients with communication deficits to describe their population-based study Clinical ataxia, and treatment of the pain using tools that exploit their particular strengths. For Rehabilitation 17 pp304-311. hemiplegic shoulder. She is example, presenting simple questions in either verbal, numeric or • Roy CW, Sands MR, Hill LD, Harrison committed to the development of pictorial form and taking time to create a ‘communication ramp’ 8,9 A, Marshall S (1995) The effect of clinical guidelines in by staged teaching in their use . shoulder pain on outcome of acute neurophysiotherapy. Where patients are unable to self-report reliably, proxy judge- hemiplegia Clinical Rehabilitation 9 ments of shoulder pain made by clinicians offer the only pp21-27. alternative, but should be regarded with caution. As well as rating a different dimension of pain, they are subject to additional measurement error, that of the proxy rater10. Furthermore, these two dimensions of pain correlate poorly in patients with chronic pain11. This problem could be improved by the development of a specific scale of shoulder pain behaviour using previously applied methods12,13,14. The first phase of a study to design such a tool will be described and ways of taking this work forward will be proposed.

37 Syn’apse ● AUTUMN/WINTER 2004

References Congress of the International Society Southampton University. Using mixed Care and Policy at Kings College 1 The Intercollegiate Stroke Working of Physical and Rehabilitation methods, contributory studies London, Diana is currently Party (2004) National Clinical Medicine – ISPRM Prague. examined shoulder pain assessment researching the experiences of carers Guidelines for Stroke 2nd edition from the perspectives of stroke of adults with acquired brain injury. 10 Pomeroy VM, Frames C, Faragher London: Royal College of Physicians patients and health professionals. She is also preparing to build on her EB, Hesketh A, Hill E, Watson P et al of London. Now a Senior Clinical Research earlier work, with the objective of (2000) Reliability of a measure of post- Fellow in Academic Rehabilitation developing guidelines for shoulder 2 de Rond MEJ, de Wit R, van Dam stroke shoulder pain in patients with and within the Department of Palliative pain assessment in stroke. FSAM, Muller MJ (2000) A pain without aphasia and/or unilateral monitoring program for nurses: effects on spatial neglect Clinical Rehabilitation communication, assessment and 14 pp584-591. LECTURE 6 documentation of patients’ pain Journal 11 Labus JS, Keefe FJ, Jensen MP Dr Chris McCarthy PhD MCSP MMACP of Pain and Symptom Management (2003) Self-reports of pain intensity and Research Physiotherapist (Chair of MACP) The Centre for Rehabilitation Science, 20 (6) pp424-439. direct observations of pain behavior: University of Manchester 3 Price CIM, Curless RH, Rodgers H when are they correlated? Pain 102 (1999) Can stroke patients use visual pp109-124. analogue scales? Stroke 30 pp1357- The diagnosis and 12 Vlaeyen JWS, van Eek H, 1361. Groenman NH, Schuerman JA (1985) classification of low back pain 4 Kehayia E, Korner-Bitensky N, Construction of an observation scale for Singer F, Becker R, Lamarche M, the behaviour of pain patients in neurology Georges P et al (1997) Differences in International Journal of Rehabilitation pain medication use in stroke patients Research 10 (4 Suppl. 5) pp263-266. We work in a culture that encourages evidence based practice with aphasia and without aphasia 13 Parke B (1998) Gerontological and the critical analysis of the evidence we use to make clinical Stroke 28 (10) pp1867-1870. nurses' ways of knowing: realizing the decisions. In the neuro-musculoskeletal fields an evidence base to 5 Blomqvist K, Hallberg IR (1999) Pain presence of pain in cognitively impaired support some of our treatment approaches is slowly developing. in older adults living in sheltered older adults Journal of Gerontological A major problem in our evidence base is the size of the treatment accommodation – agreement between Nursing 24 (6) pp21-28. effects that are often demonstrated in clinical trials of rehabilita- assessments by older adults and staff tion approaches. Is it possible that our best efforts to identify 14 Zwakhalen SMG, van Dongen KAJ, Journal of Clinical Nursing 8 pp159- effective treatments for patients are being thwarted by the lack of Hamers JPH, Huijer Abu-Saad H 169. consideration of heterogeneity in our trial designs? Low back (2004) Pain assessment in intellectually pain is a classic example of a ‘catch all’ diagnosis that results in 6 Prkachin KM, Craig KD (1995) disabled people: non-verbal indicators diverse, heterogeneous clinical presentations. Consequently, Expressing pain: the communication and Journal of Advanced Nursing 45 (3) trials of interventions in ‘Low Back Pain’ suffer from considerable interpretation of facial pain signals pp236-245. washout effects, where the benefits for some are offset by the lack Journal of Nonverbal Behaviour 19 (4) of benefit for others. There is recognition that this lack of diag- pp191-205. Biography nostic specificity may be reducing the effect sizes of intervention 7 Hadjistavropoulos T, Craig KD Diana Jackson trained as a physio- in clinical trials and thus reducing the confidence we have in our (2002) A theoretical framework for therapist at Kings College Hospital treatments. understanding self-report and and worked in various settings before Clinical trial designs need to reflect the fact that in clinical observational measures of pain: a specialising in neurological practice treatments are ‘matched’ to clinical presentations and communications model Behaviour rehabilitation. Following an MSc in that menu treatment is not applied to every one who presents Research and Therapy 40 pp551-570. Rehabilitation Studies at with a broad diagnosis of ‘pain’, for example. The author is Southampton University, she joined currently conducting a study that aims to produce a system to 8 Turner-Stokes L, Rusconi S (2003) the Regional Rehabilitation Unit at sub-classify non-specific low back pain and enable subgroups of Screening for ability to complete a Northwick Park Hospital in 1996 as a patients to be identified who may be more suited to particular, questionnaire: a preliminary evaluation Research Associate working on a trial specific interventions. It is hoped that this process will strike a of the AbilityQ and ShoulderQ for of aerobic exercise training for chord with colleagues working in the neuro-rehabilitation field assessing shoulder pain in stroke patients patients with acquired brain injury. and that similar processes may be initiated or encouraged. Clinical Rehabilitation 17 pp150-157. A subsequent project to develop 9 Jackson D, Hasson A, Turner-Stokes an ICP for managing hemiplegic References review Physical Therapy Reviews 9 L, Horn S, Kersten P (2003) shoulder pain rekindled a long-term • McCarthy CJ, Arnall FA, Strimpakos pp17-30. Development of a pictorial scale of pain interest in this problem; specifically N, Freemont A, Oldham JA (2004) The intensity (SPIN) for dysphasic stroke the difficulty of assessing pain. This • McCarthy CJ There is no panacea for bio-psycho-social classification of non- patients with shoulder pain 2nd World led to a PhD in the subject from Low Back Pain Physiotherapy 91 pp1, 2-3. specific low back pain: A systematic

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Biography evaluation of how we as After qualifying from Coventry physiotherapists sub-classify a pain thermal sensory stimuli and the recording of various parameters School of Physiotherapy in 1989, Chris syndrome we will have all either of the subjects’ responses. The Thermal Sensory Analyser (TSA- McCarthy worked clinically in the experienced ourselves or seen in our 2001, Medoc) is a system that provides a means of testing North West for ten years before patients – non-specific low back pain. patients’ responses to such stimuli. undertaking a PhD at the University He will argue that we are not helping The overall aim of this research is to compare the thermal of Manchester. His thesis investigated our cause in the endless search for a perception ability of stroke patients of differing types with a the relative effectiveness of home panacea for ‘low back pain’ and that healthy sample of people. Hot and cold sensation thresholds are and class-based exercise for patients in common with a great many clinical established using method of limits. Random sequences of pairs of with osteoarthritis of the knee, syndromes we need to be more temperatures (2AFC) in warm and cool ranges (eg 36-38°C and (Findings: classes reduce pain and are specific in our diagnoses. We need to 18-20°C) are used in a forced-choice paradigm to establish cost effective – three years be evaluating specific treatments for sensory discrimination. Non-parametric Signal Detection Theory summarised in seven words!). His specific neuromusculoskeletal (SDT) techniques are then used to determine P(A) for sensitivity Post-doctoral fellowship work is an presentations. and B Criterion for selection bias measures, to determine the extent of variation between stroke and healthy populations. It is proposed to measure the differences between and within the LECTURE 7 various groups using Student’s T-test and ANOVA, assuming

Mark Smith Grad Dip Phys, BSc (Hons) Health Studies normal distribution, and non-parametric testing such as the Clinical Specialist Physiotherapist-Stroke Services/ Chief Scientist Office Research Training Fellow, Wilcoxon Matched Pairs Signed-Ranks Test should the distribu- Royal Victoria Hospital, Edinburgh. tion be abnormal. A p-value of <0.05 will be set as the level of statistical significance in the interpretation of the results. Pilot data suggest that statistically significant differences do Measuring thermal sensory exist between the thermal sensory perceptual abilities of certain stroke subgroups in comparison with healthy individuals – these perception as an adjunct to will be described. Variations include relative paraesthesia in affected limbs and hypersensitivity in non-affected limbs and the understanding abnormal pain perception of cold as heat. Estimates from the effect sizes within the pilot sample suggested that around 30 individuals will be perception after stroke required within each sub-group for subsequent study. This will total 150 stroke patients and 30 healthy controls. Stroke patients suffer from various pain-related syndromes. This work is still in progress and we do not yet have a full set Alterations in sensation, causing hyperaesthesia or relative anaes- of results to discuss. However this technique may provide a thesia, may affect pain perception. This factor has been valuable tool in the clinical management of patients with stroke. associated with the development of Central Post-Stroke Pain. Pain causes untold distress, may delay discharge from hospital References • Boivie J, Leijon G, Johannson I, and is not well understood in stroke. It is challenging to research • Adams RW, Burke D (1989) Deficits (1989) Central Post Stroke Pain – and difficult to assess using common clinical methods within this Of Thermal Sensation In Patients With Neurological Symptoms And Pain patient group and so may hinder effective treatment. A system for Unilateral Cerebral Lesions Electro- Characteristics Pain 36 (1): pp13-25. the clinical classification of differing subgroups of stroke has been encephalogr Clin Neurophysiol 73(5) • Bowsher D, (1995) The Management shown by cerebral imaging to have validity and reliability through pp443-452. Of Central Post Stroke Pain Postgrad consistent agreement with the site and size of the cerebrovascular • Andersen G, Vestergaard K, Med J 71 (840) pp598-604. lesion. Thermally generated sensory stimuli travel within the Ingeman-Nielsen M, Jensen TS (1995) nervous system in established pathways common to the transmis- • Chen JI, Ha B, Bushnell MC (2002) Incidence Of Central Post Stroke Pain sion of nocioceptive signals (somatosensory cortex, ventral Differentiating Noxious- And Pain 61 (2) pp187-193. posterior thalamus, anterior and lateral spinothalamic tracts and Innocuous-Related Activation Of A /C fibres). Studying the ability of different types of stroke • Bamford J, Sandercock P, Dennis M, Human Somatosensory Cortices Using patient to perceive changes in temperature via the skin may illu- Burn J, Warlow C (1991) Classification Temporal Analysis Of fMRI Journal minate theoretical issues related to the neurophysiology of And Natural History Of Clinically Neurophysiol 88(1) pp464-474. nocioceptive transmission. This could subsequently inform the Identifiable Subtypes Of Cerebral • Chong PS, Cros DP (2004) Technology quantification and execution of pain management and soft tissue Infarction Lancet 337 pp1521-1526. Literature Review: Quantitative Sensory protection strategies. • Boivie J, Leijon G, Johannson I, Testing Muscle Nerve 29(5) pp734-747. The measurement technique employs Quantitative Sensory (1989) Central Post Stroke Pain – A Testing (QST), a technique for the objective assessment of • Defrin R, Ohry A, Blumen N (2002) Study Of The Mechanisms Through sensory perception that has not been widely used in the stroke Sensory Determinants Of Thermal Pain Analyses Of The Sensory Abnormalities population. This involves the delivery of accurately measured Brain 125(Pt) 3 pp501-510. Pain 37 (2) pp173-185.

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• Evans ER, Rendell MS, Bartek JP • Melzack R (1999) From The Gate To • Woolf CJ, Decosterd I (1999) measurement of various outcomes of (1992) Current Perception Thresholds In The Neuromatrix Pain Supplement 6 Implications Of Recent Advances In The different types of stroke patient. His Ageing Age Ageing 21(4) pp273-279. S121-S126. Understanding Of Pain Pathophysiology publications relate to mobility For The Assessment Of Pain In Patients outcomes of stroke – ‘mobility • Greenspan JD, Joy Se, McGillis Sl • Price CIM, Curless RH, Rodgers H Pain Supplement 6 S141-S147. milestones’, developing outcome (1997) A Longitudinal Study Of (1999) Can Stroke Patients Use Visual prediction models and the study of Somesthetic Perceptual Disorders In An Analogue Scales? Stroke 30 (7) pp1357- • Yarnitsky D, Sprecher E (1994) pain perception in patients with brain Individual With A Unilateral Thalamic 1361. Thermal Testing: Normative Data And damage following stroke, particularly Lesion Pain 72(1-2) pp13-25. Repeatability For Various Test Algorithms • Reulen JP, Lansbergen MD, hemiplegic shoulder pain. Jour Neurol Sci 125(1) pp39-45. • Greenspan JD, Ohara S, Sarlani E Verstraete E (2003) Comparison Of He currently holds a three-year (2004) Allodynia In Patients With Post- Thermal Threshold Tests To Assess Small • Yarnitsky D, Fowler CJ (1995) research fellowship from the Scottish Stroke Central Pain (CPSP) Studied By Nerve Fibre Function: Limits v Levels Quantitative Sensory Testing Clinical Executive, Chief Scientist’s Office Statistical Quantitative Sensory Testing Clinical Neurophysiology 114(3) Neurophysiology pp253-270. (government funding) for 0.5 WTE of Within Individuals Pain 109(3) pp357- pp556-563. clinical time, and an HSA Scholarship, 366. Biography through the CSP, for academic pursuit • Rutledge D, Donaldson NE (1998) Mark Smith graduated in Physio- of a PhD degree at Queen Margaret • Harris AJ (1999) Cortical Origin Of Pain Assessment And Documentation: therapy, Edinburgh 1985. He University College, Edinburgh. Pathological Pain Lancet 354 pp1464- Part II. Special Population Of Adults on- completed a BSc Hons degree in His committee work has included 1466. line Journal Of Clinical Innovations at: Health Studies 1991. He then worked the National Advisory Committee for www.Cinhal.Com 15; 1(6) pp1-29. • Jamal GA, Hansen S, Weir AI, in Dunfermline hospitals for almost Stroke (Scotland), the British Stroke Ballantyne JP (1985) An Improved • Samuelsson M, Samuelsson L, two years, then at Western General Research Group and SIGN 64 Automated Method For The Lindell D (1994) Sensory Symptoms And Hospital, Edinburgh for twelve years Management of Stroke Guideline Measurement Of Thermal Thresholds 1. Signs And Results Of Quantitative from 1986 until 1998. Since 1998 has Group. Normal Subjects Journal Of Neurology Sensory Thermal Testing In Patients With been clinically based at the Royal His international experiences have Neurosurgery And Psychiatry 48 Lacunar Infarct Syndromes Stroke Victoria hospital, Edinburgh. He there included working in St Petersburg, pp354-360. 25(11) pp2165-2170. developed an interest in neurological Russia and Blantyre, Malawi, East rehabilitation, initially in the Africa developing stroke services. • Lindley RI, Warlow CP, Wardlaw JM, • Segatore M (1996) Understanding Department of Clinical Neuro- Dennis MS, Slattery J, Sandercock DM Central Post-Stroke Pain Journal of sciences and then was a founder (1993) Interobserver Reliability Of A Neuroscience Nursing 28(1) pp28-35. member of the Stroke Team at the Clinical Classification Of Acute Cerebral • Siao P, Cros DP (2003) Quantitative WGH in 1992. Infarction Stroke 24 (12) pp1801-1804. Sensory Testing Phys Med Rehabil Clin He has pursued an interest in the N Am 14(2) pp261-286.

40 REVIEWS

detail. Resting posture, passive wrist functional group, but not in the non- Reviews range of motion and resistance to functional group. passive wrist extension were used to articles, books, courses quantify contracture; these were all Discussion The groups profile did not measured on a piece of equipment alter significantly over the study Reviews of research articles, books and courses in Synapse are offered by Regional ACPIN groups or designed for a previous study. The period, suggesting that contractures individuals in response to requests from the ACPIN committee. In the spirit of an extension of the authors do not provide the reader were worsening in the whole group, ERA (Evaluating research articles) project they are offered as information for members and as an opportunity for some members to hone their reviewing skills. Editing is kept to a minimum and the with a clear understanding of the in spite of improvement in function. reviews reflect the opinions of the authors only. We give the authors of the original book or paper measuring system, but refer to their The authors consider that this the opportunity to respond. We hope these reviews will encourage members to read the original previous study. ambiguity may be due to the article and not simply take the views of the reviewers at face value. influence of the NF group and they Data analysis Mean and standard then further discuss the subgroup ■A CONTRACTURES IN THE recovery would lead to the error were used to summarize the analysis rather than the whole group. POST-STROKE WRIST: A development of contractures. results and the Friedman’s test to Would a matched sample design have PILOT STUDY OF ITS TIME determine if changes had occurred. been better? COURSE OF DEVELOPMENT Method This is a longitudinal study, The Mann-Whitney U-test was used Authors’ comment: Heterogeneity in AND ITS ASSOCIATION where the subjects had been selected to determine if differences existed any convenience sample is a problem WITH UPPER LIMB from a control group of a previous between the groups at the start of and I am not convinced that a RECOVERY randomised control trial carried out the study. No power analysis and matched pair design is viable when Pandyan, AD, Cameron M, Powell J, by the researchers. minimal descriptive statistics are only one centre is involved.) Stott DJ and Granat M.H in Clinical included. Given the restricted sample In the NF group, changes Rehabilitation (2003) 17, pp88-95 size, it is difficult to comment on the consistent with developing wrist 22 patients recruited usefulness of the quantitative flexion contractures were seen and Articled reviewed by Surrey & Borders ACPIN from another study and statistics performed. appeared in the first six to eight assigned to groups Authors’ comment: In the absence of weeks. The authors speculate that the based on UL functional Aims To identify the time course of any baseline data a power analysis is most likely cause is immobilization. movement contracture formation at the wrist in redundant, ie it cannot be done. The Given that the choice of outcome an acute stroke population. To study standard error (SE) was specifically measures measured a combination of its relationship to physical impair - Functional Non provided to enable other researchers neural and non-neural factors, this ments and functional recovery. (F) recovery functional to conduct appropriate power seems a plausible inference. group (NF) group calculations. (Given the small sample Clinically, this work heightens our Abstract Good overview of the n=8 n=14 the tests used were the best available) awareness of at risk patients. Patients objectives of the study and their who may be more at risk are those method. Reading this, makes you Results The researchers provide with less motor and functional want to read the rest of the study. results for the sample as a whole and recovery. They are also more likely to for the two assigned groups. The demonstrate changes in passive Introduction The researchers report Measurements taken at analysis from the subgroup highlights movement and resistance. the fact that contractures in upper 0, 4, 8, 20 and 32 weeks from the fact that, what was quantified as limbs in stroke are common, but that day of recruitment of: ‘contracture’ showed little change in General comments there is little information available in • wrist resting posture range and the functional group, but significant STRENGTHS the literature on the time course of then total passive range change in the non-functioning group; • Despite arbitrary nature of dividing contractures. It mentions the fact • resistance to passive the resting postures were more the sample into two groups, it was a that immobility and spasticity, as well movement flexed, resistance had increased and useful way of investigating the as other factors such as neglect and • visual analogue rating of pain passive range of movement different qualities (more so if the pain are thought to contribute to the • neglect using star cancellation decreased. subjects had been matched). development of contractures, but test Whereas the modified Ashworth Authors comment: Limitations are that the evidence to support this • active wrist extension range scale and neglect changed little in the identified and possible alternatives claim is tenuous. Although significant and isometric strength functional group, the Ashworth scale are highlighted. to the nature of this study, they do • grip strength increased significantly and neglect not however define what is meant by • ARAT decreased in the non-functional LIMITATIONS contracture. (ADP: Note the word • nine hole peg test group. Pain did not change • Assumed a common understanding spasticity is also not defined) significantly in either group. of contracture. The introduction clearly states the As might be expected active range Authors comment: Contracture (and aim of the study and ends with the Baseline measurements and most of movement, strength and the spasticity) are two commonly used hypothesis that poor functional outcome measures are described in functional tests all improved in the words which have far too many

41 Syn’apse ● AUTUMN/WINTER 2004

definitions. Given the restriction on programme used and the need for analysis was carried out and a the number of words and the fact ■A RELATIONSHIP BETWEEN psychological input were each backed negative correlation between the that such a paper is written for a CHANGE IN BALANCE AND up by only one referenced article SBM and the DHI was shown. professional audience such a SELF-REPORTED HANDICAP even though the text stated ‘various However, on presentation of the definition is redundant. One would AFTER VESTIBULAR studies and authors’. There was also statistics inconsistency between expect the readers to pick up the REHABILITATION THERAPY no reference made to the widely used graphs were noted. In Figure 2 the citations and check for the K Murray, S Carroll, K Hill (2001) Cawthorne-Cooksey Exercies or the mean average was used, but in Figure appropriate definition. in Physiotherapy Research International Brandt Daroff Regime. 3 it was the median score which may • Validity of outcome measures, 6(4) pp251-263 have resulted in a skewing of the especially as some specifically Methods 16 subjects with vestibular figures towards a more positive developed for their study. Articled reviewed by Gillian Park, disease identifed by a neurologist, treatment effect. Figure 4 was also physiotherapist, Area Rehabilitation Team, Authors comment: Validity is implicit and a history of dizziness and impaired not clearly labelled and therefore Stirling Royal Infirmary and in the absence of an accepted balance were used in the study. difficult to analyse. definition of contracture one has to The Smart Balance Master System On first reading it was interesting go back to measure from first Overview This trial aimed to (SBM) and the Dizziness Handicap that the authors analysed the principles. investigate the relationship between Inventory (DHI) were the outcome changes in the functional, physical • Readers not informed of the change in balance performance and measures used prior to and on and emotional subscales of the DHI. A physiotherapy input (splinting, change in self-related handicap after completion of the four-week exercise positive change was noted on the positioning etc) the subjects were a home exercise programme in programme. physical subscale. However, as they receiving during the study. patients with chronic vestibular The exercise programme included had excluded any individuals with ‘a Authors comment: Agree a serious dysfunction. It was reviewed as part habituation training, gaze stability, primary psychological disorder’ it limitation, we attempted to of a journal club because the title balance and mobility training and seems unreasonable to show any quantify physiotherapy but failed. appeared relevant to us as we are fitness activities for ten minutes, change in the emotional subscale. Maybe this is the challenge to the currently looking into the evidence three times a day. The programmes Therefore the comparisons with other physiotherapist, documentation of available on Vestibular Rehabilitation were reviewed weekly and updated studies looking at psychological your treatments in a transparent by the physiotherapist. A diary was problems appear inappropriate due way. Abstract The abstract clearly also completed by each patient to to the exclusion of this client group. • Matched sample design may have outlined the aims of the study to show completion of the exercises. been better. investigate the relationship between Some limitations in the In summary With the absence of a Authors comment: This is a moot two outcome measures. It indicated methodology were noted. It was a control group we feel that an point. that the home-based exercise small sample size, fourteen of which opportunity has been missed to • Small sample size. programme used significantly were female, and there was no develop a recommended regime of • Authors’ conclusion is strong, based improved balance abilities in people control. The length of time since exercises for the treatment of this on the small sample size and the with chronic vestibular dysfunction. onset of symptoms ranged from three client group. We did feel that the use fact they were looking at both However, this positive outcome months to 78 months and there was of the patient diary was advantageous neural/non-neural aspects. would be later questioned following no analysis made to acute or chronic to patient compliance throughout Authors comment: I see statistics as a further reading of the article. patients The site of lesion of each the four-week programme. This is an tool to prove the obvious. Given patient was classified as either central aspect of this study that we feel we the nature of relationship Introduction The background to the or peripheral, however, there was no can go on to implement in our own demonstrated and the theoretical authors is unknown from the title explanation as to how this clinical practice. understanding of the phenomenon page or anywhere in the article. classification was made especially of contractures the conclusion is However, later in the study we when some of the diagnoses were reasonable. questioned whether the unknown. Authors comment: We should have physiotherapist involved in the data The home exercise programme was used simultaneous EMG collection was in fact one of the not clearly explained so therefore measurements to further authors. This was never confirmed could not be replicated in future investigate neural factors. however, if this was indeed the case studies. With four variables in the could have lead to great bias in the treatment programme it was also results due to a lack of objectivity. impossible to identify which of these resulted in the changes identified. Literature review The literature We question whether comparisons review had various limitations with can be made between subjects due regards to the literature supporting it. the wide variety of treatments used. The concept of vestibular rehabilitation, the specific exercise Results Appropriate statistical

42 REVIEWS

Theory sessions were interspersed ■C ANALYSIS AND TRAINING ■C ASSESSMENT AND with practical sessions and patient OF WALKING FOLLOWING TREATMENT OF PATIENTS demonstrations. a high percentage of STROKE WITH A PREDOMINANCE the time was spent in practical Tutors: Paulette van Vliet and OF HYPOTONIA sessions. As we had two instructors on Andrew Foxhall Tutor: Debbie Strang, Bobath tutor the course we all received good 28th/29th November 2004 27th, 28th August 2004 individual feedback regarding our Lightburn Hospital, Glasgow. Drumchapel Hospital, Glasgow handling and the opportunity to discuss issues in smaller groups. Review by Lynn Speirs, Senior Physiotherapist, Review by Alison Murray MCSP, SRP Feedback was very positive, there St John’s Hospital, West Lothian. was a lot of information to take in but This course was the second of three good reading material, course notes This two-day course was a mixture of study weekends offered by the tutor. and references were provided. We all informal lectures with discussion and The first course was an ‘Introduction left invigorated to try out new clinical sessions with patients. to Normal Movement’ and the third techniques in our own clinical areas Time was spent using the was ‘The Assessment and Treatment and look forward to the complemen- philosophy of movement science in of Patients with a predominance of tary course in assessment and the analysis of gait (biomechanical hypertonia’. treatment of patients with model) to look at the kinematics of The course consisted of theory hypertonia. walking (and therefore the missing sessions, practical sessions and aspects) and then to link them to the patient presentations. An initial compensations. The advice after this theory session looked into the was to initially choose the greatest pathology of hypotonia. Participants problem to concentrate on in learnt that the initial ‘flaccid’ state treatment. Analysis then became seen in some patients immediately more specific, for example decreased post stroke is not actually hip control became decreased hip representative of the damage extension mid to late stance. incurred by the stroke. Rather it is a After using the kinetic model of response of the CNS to shock and it is gait and the correct terms to assess a brief, transitory phase. True the deviation and compensations, hypotonia is a loss of influence from possible causes were then assessed ie higher centres of control onto the muscle shortening and/or muscle spinal cord. This occurs in two major weakness. Research has shown any systems, the reticular system and the muscular changes in the plantar- corticospinal system. The ‘apparent’ flexors have a profound effect on gait weakness seen in hypotonia is as soleus is responsible for knee produced through a deviation of flexion in swing rather than the reciprocal innervation, which in turn hamstrings. Increasing the speed of affects tone and normal movement. walking with improved hip extension The decreased stability seen in elicits more hip flexion activity, which hypotonia can lead to muscles that in turn allows more knee flexion. are normally global mobilisers Training strategies concentrated on becoming stabilisers to maintain maintaining muscle length through a posture and balance with an ultimate variety of methods and strength reduction in the ability to move training, eccentrically and selectively. concentrically, using body weight Principles of treatment were where appropriate. Importance was explored emphasising the care placed on choosing the appropriate required when handling positions for effective strengthening. compensations. It is however The main messages of this course important not to discourage active were therefore to use an evidence- movement as we need it to activate based approach, systematically the CNS through movement and analyse, use task specific exercise and reciprocal innervation develops with anticipate and aim to avoid experience of movement.

43 Syn’apse ● AUTUMN/WINTER 2004

planning a half day Normal Please keep an eye out in Frontline for Regional reports Movement course this year. specific details of those courses not yet finalised. Programme for 2005 At the time of writing, our current • May Trauma and shock. membership stands at 23, since it was ■ KENT Region. In 2003 and 2004 the • June Negotiating treatment. 55 at the end of 2004 I sense that Lisa White attendance at the evening lectures • July Pilates, gym ball and core more than a few members (and dare I Regional Representative steadily dwindled. We have asked for stability. say, even some committee!) have Throughout 2004 the Kent feedback and we have decided to try • September and October ‘filed’ their 2005 application forms in committee of four members was very scheduling fewer sessions but to Biomechanics of gait and treadmill the pre – Xmas furure! So please, dig active, albeit behind the scenes. We include more half-day programmes. walking: lecture and research them out, fill them in and send them ran a shoulder study day in November Additionally we are increasing our presentation. off asap! Jo Howarth’s departure from 2004 which was well attended. It was advertising to remind people that, as • November Biomechanics of gait and the committee is imminent and will a locally hosted event with speakers ACPIN members, they have a no-cost treadmill walking: patient leave us with 9 (10 little Indians from the surrounding areas. Lectures opportunity to hear interesting and demonstration. comes to mind!) and whilst this is still ranged from basic anatomy of the relevant topics – as well as to meet- Flyers with more details about a relatively healthy number new shoulder complex to the use of up with old (and new!) friends. forthcoming events are sent to each ‘blood’ is always welcome. Our thanks acupuncture in pain relief in member and appear in Frontline. to Jo for all her hard work on the hemiplegic shoulders. The day was Programme for 2005 Poster displays at each evening committee in various guises over the generally well received, although the • 18th June (morning half-day) meeting will continue, these can be years, and we wish her every success difficulty of aiming lectures to an Topics in evidence-based practice Prof about a research project, practice and with her studies. audience of varying levels of Val Pomeroy, Cathy Donaldson, and service development or an area team And finally … at the risk of experience was acknowledged. Emma Cook (St George’s Hospital). – anything that helps information repeating myself yet again, feedback Professor John Rothwell will be • 10th September (study day) sharing in the region. and new ideas are always very returning to Kent following his highly Orthotic management of gait and the If you are interested in becoming a welcome and very useful! successful study day two years ago. lower limbs in the neurologically committee member, or have any On July 2nd he will be taking a study impaired adult – theory, evidence and suggestions for topics or speakers for day at the Chatham Dockyard Venue clinical reasoning Paul Charlton, future lectures please let any of the ■ NORTHERN REGION entitled ‘The cerebellum, the basal Richard Sealy, and Gita Ramdharry committee members know. Julia Williamson Regional Representative ganglia and movement disorders with (NHNN Queen Square). a bias to therapy’. Fliers and Please watch for further details in Although it was some time ago now, I application forms will be sent out to Frontline. ACPIN members will be ■ MERSEYSIDE wish you all a Happy New Year. Here’s Kent members shortly. posted a flyer soon. As ever, we Jo Jones the latest update of events in the Regional Representative We had a successful and well welcome new Committee members North of England. attended AGM in March when Janice who want to represent ACPIN, help 2004 ended with a very successful In October 2004, we held a Champion guided us through the use organise events, or to be more rerun of our Vestibular Rehabilitation successful MS study afternoon. It was of the gym ball in neurological involved with their neurology- Study Day with Pam Mulholland, and well attended and participants were therapy. We would like to thank colleagues – doing a little or a lot – we 2005 has started with an equally able to find out about local projects Janice for her continued support of can always find a place. Please contact popular and successful ‘Acupuncture funded and supported by the MS the Kent Region. us if you have ideas or questions. in Neurology’ course facilitated by Society. This was followed in Following the AGM we have had an Val Hopwood. Keeping the November by an afternoon of increase in both ACPIN and momentum going, the remainder of lectures based around the use of committee members and we now ■ MANCHESTER our 2005 schedule is as follows: Botulinum toxin in Stroke, and a look forward to a highly active and Nina Smith • May 21st Advanced Splinting – a one randomised controlled trial, which Regional Representative productive 2005. day programme to include lecture, will look into this area. Again, this was Thank you to all speakers for their patient demo, practical, discussion well-attended and offered contribution in 2004, and those who and problem-solving Sue Edwards. participants insight into the demands ■ LONDON will be involved in the 2005 • June Evening lecture Current MS of conducting such research. We Sandy Chambers programme. Projects and Service Development in took December and January off, I Region Representative Evening lectures are generally well the region Jenny Thain. hope no-body minded, but it just From the London Region Committee, attended and membership continues • September 23rd/24th Basic Splinting seemed such a busy time of year! may we wish all of you a belated to be steady. Manchester ACPIN Sue Edwards. So, refreshed, a busy year is ahead. Happy 2005! As some of you know, Committee meets every month for • November Two day course FES By the time you read this, the we have been busy re-organising the programme planning, evaluation, and Christine Singleton and Jenny Regional AGM will have happened (I coming year’s CPD format for London information exchange. We are Thain. hope I saw you there). Whatever time

44 REGIONAL REPORTS

of year, we are always on the look out time confirmed dates and venues. It Programme for 2005 for more committee members, the would be wonderful if attendance • May 11th Practical workshop Spinal ■ SOUTH WEST workload is not heavy and we tend to remained as high as it was for injuries (National Spinal Injuries Kirsten Cheadle Regional representative hold meetings during the day January’s lecture – thank you Centre, Stoke Mandeville). (including free coffee and biscuits!) If everyone for your support. • June Pilates evening (Oxford Centre South West ACPIN have had a you cannot commit to a committee We are also hoping to put on a for Enablement) (details to be number of evening and weekend post, we are keen for people based in couple of courses but these are still in confirmed). courses which have been successful, if the middle of the region (Hexham the planning stage. If you have any • July 20th Summer social evening – not fully subscribed. Sue Edwards’ direction) to possibly host a course or ideas for courses or lectures they will Punting (Meet Cherwell Boathouse, Complex Disability course was both two, which would be more accessible be very gratefully received, as would Oxford – time to be announced) enjoyable and informative. The gym for those travelling from the west of any offers to join the committee- • September Orthotics evening (High ball evening and Huntington’s Disease the region. Wherever you are based, contact myself (emma.procter@ Wycombe) (details to be presentation were also well received. we are always very keen to hear your sth.nhs.uk) or any of its members if confirmed). ideas for courses and events; you are interested. • O c to b e r 12 t h 7. 30 p m Managing the Programme for 2005/6 everything we organise has been painful shoulder; A Musculoskeletal • June Posture management course suggested by members. perspective Jane Moser (Oxford Wendy Murphy and Pauline Pope, ■ OXFORD Centre for Enablement) (Cardiff). Programme for 2005 Fiona Cuthbertson • November 3rd/4th Hydrotherapy in • September Interpreting scans Regional Representative • May 7th Neuroplasticity John Neurology Alison Skinner (Oxford). • November Practice and Feedback for Rothwell (Education Centre, I would like to extend a big thank you We will send out fliers with further Stroke Patients Paulette van Vliet Sunderland). on behalf of the Oxford ACPIN details of individual lectures and • February Spinal Cord Injury • October Case report writing (exact committee to everybody who courses. Please also refer to the branch Rehabilitation date and place tba). contributed to our excellent 2004 news noticeboard section of Frontline We also hope to offer a free place at • November FES (exact date and programme and to all of our members where up to date lecture and course Congress to one of our members, place tba). who continue to support events both details can always be found. more details to follow. Any ideas/suggestions for courses, regionally and nationally with great Please see our website please send to Julia.williamson@ enthusiasm. www.southwestacpin.net for further nuth.northy.nhs.uk Oxford’s 2004 programme came to ■ SCOTLAND details. All courses will also be a close with an extremely well Paula Cowan advertised in the branch news notice - Regional Representative received course led by Bobath Tutor board section of Frontline as ususal. ■ NORTH TRENT Pam Mulholland entitled Postural The Scottish committee is flourishing We ended 2004 with almost 120 Emma Procter Control and the Upper Limb – indeed at the moment. We would like to members and encourage everyone to Regional Representative the course was such a success that we welcome six new members: Cassie subscribe again this year. With thanks The last year has seen many changes have already booked Pam to come Gibson, Julie Hooper, Julie to our contacts in South Wales we are on the committee, which was back in 2006. McDonald, Wendy Juner, Lynn able to run a course in Cardiff and are partially due to a baby boom Our 2005 programme kicked off to Donnelly and Lindsay Masterton. We building links in Plymouth so hope to (Congratulations Alex and Sharon) an impressive start with a very look forward to a productive year. hold some lectures there. If anyone and I would like to take this successful evening in Reading led by else is interested in being part of the opportunity to thank all those Helen Talaga on the practical Programme for 2005 committee – even via the internet/ departing for their hard work over the management of patients with ataxia. • September Orthotics (Glasgow). telephone, or has suggestions for years. As this was the last evening lecture to • November Vestibular Rehab courses or speakers, please give one The membership is thriving and be held at Battle Hospital before its (Stirling). of the committee a ring to discuss this the committee is endeavouring to closure, I would like to take this further (all details on our website). put together a varied lecture program opportunity to thank all of those who Feedback: We have had several Thank you to all members for their for 2005. have been involved in their successful courses last year namely a support and we look forward to organisation over the past few years, gait course, dyspraxia and spasticity. If seeing many of you throughout 2005. Programme for 2005 especially Liz and George. you would like further info then • May Pusher Syndrome L McKay (TBC) Finally we would love to hear from please contact the committee. • July 13th Neurophysiology of Learning you if you are interested in becoming A wee reminder to renew your ■ SURREY & BORDERS N Snowdon a committee member or if you have membership because with such a Brigitt Bailey Regional Representative • September 6th Guidelines for Long any ideas for our 2006 programme. healthy committee this will be a good term Conditions – Discussion on Please feel free to let any of the year to be a Scottish member! We have a membership of nearly 60 Implications for practice J Petty committee know or contact Claire and attendance at our evening • November 17th Botox Trial A Clarke Guy on 01865 737372/5. lectures has been generally very good We will let members know nearer the whilst our courses have also been

45 Syn’apse ● AUTUMN/WINTER 2004

successful, which is all positive news! both of which had very good Helen Lindfield and Laura Finucane lines and an evening on Brain Gym. Our first lecture from an feedback. We began 2005 with an ran the Outpatient Techniques in Programme for 2005 Occupational Therapist, Sarah Porter, excellent evening lecture on Neurology weekend, which was once • May 14th AGM and study day on ‘How much effort do you put into ‘Orthotic management of Spasticity’. again over subscribed and very well Neural control of gait and CPGs getting up in the morning?’ – an Thank you to speakers for their received. On November 6th we Dr Lyn Rochester and FES Christine activity analysis focused on cognition support and time. welcomed Kate Fernyhough back to Singleton. and perception, was very practical The committee is very Birmingham to run the popular • June 14th Outpatient techniques and well received, so hopefully conscientious but quite small. Naomi Pilates day. Phil Commons NANOT will be able to suggest Wells has just joined us as treasurer • September 24th Posture another topic in the future. after the birth of baby Jack but we Programme for 2005 Management study day Pauline Pope In November Diane Jackson gave a are really keen for some exciting ideas • Saturday September 3rd Study day I will sadly be standing down at our lecture on the Northwick Park ICP for and new blood. Anyone interested in Practice and feedback for stroke AGM as Yorkshire Regional painful hemiplegic shoulders which joining the committee is very patients Paulette van Vliet (Venue is Representative, and would like to created lots of discussion and welcome. We meet 30 minutes prior to be confirmed). take this opportunity to say how interest. to evening lectures or contact any We do have some other study days much I have enjoyed being involved We have put together the member of the committee for further and evening lectures in the pipeline with ACPIN at both a Regional and following programme for 2005 and information. Thank you to the but at present have not been National level. I really recommend it will advertise in Frontline, as a current committee for all their hard confirmed. For example a possible for helping to push practice forward reminder, as well as sending out flyers. work. splinting course in May. and also for all the excellent Thank you for your continued networking opportunities. I will, of Programme for 2005 Programme for 2005 support. We always value your course, still be attending lots of • June 15th, 7.00pm Case studies • Pilates for People with Neurological opinions and ideas for future events. ACPIN events. It is anticipated that looking at the Management of Posture Problems Lucia White and Moira Any queries about the courses Jill Fisher will take my place and I’m Pauline Pope (Woking Community Rees advertised, suggestions or interest in sure she will also value the Hospital). • Early Management of Spinal Cord joining the committee please contact experience. • September Core stability (date, Injuries Salisbury Spinal Injury Unit Liz Cohen. As a committee we are always speaker and venue to be • Taping Techniques Melissa Benyon looking for new ideas for future confirmed). MCSP lectures/ courses, so please either • November 10th, 7.30pm • Facial Palsy Management Lorraine ■ YORKSHIRE contact one of us with your Communication Rosemary Townsend Clapham MCSP Regional Representative – post currently suggestions ( my email is vacant – Speech and Language Therapist • Research Emma Stack Ph.D [email protected]) or why (St Peter’s Hospital, Chertsey). Yorkshire ACPIN continues with a mix not join the committee yourself? We The sad news is that we will be losing of evening lectures and study days. look forward to hearing from you. some of the committee this year but ■ WEST MIDLANDS Over the last few months this has have had only one member Liz Cohen included Paulette van Vliet leading a Regional Representative expressing an interest in joining. day workshop on practice and Hopefully, at our AGM in February we The West Midlands branch feedback with stroke patients, and will be able to recruit some new membership has remained strong in Jacki Stephenson giving an update on blood to provide fresh ideas and 2004 with over 90 members. The the MS society funded projects. Our enthusiasm to keep this branch committee continues to be active most recent evening was a Botulinum running successfully. with about ten regular attendees. Toxin interactive session, where I was In the meantime, a BIG thank you Study days and courses remained persuaded to practice my to all the committee for all their hard well subscribed throughout the end presentation skills! work since the formation of the of 2004. On Tuesday September 21st We continue to advertise our branch in February 2002. we held a successful evening lecture lectures in Frontline, but recently at The Priory Hospital in Birmingham advertised on the CSP interactive site welcoming Carron Sintler who shared which, amazingly, generated interest ■ WESSEX the findings from her MSc from a physiotherapist in Australia, Helen Foster dissertation entitled ‘The Patient and who requested copies of the Regional Representative Carers perspective after Stroke’. We Botulinum presentation as he was Since the autumn report Wessex originally planned two lectures, but unable to attend! Region have run a couple of due to unforeseen circumstances Jill For the future we are currently successful courses. This included an Ramsay who was going to talk about planning several meetings including a ‘Early Stroke Treatment Study Day’ ‘upper limb proprioception’ had to stroke update, following the and a ‘Posture Management’ course, cancel. On September 25th and 26th publication of the latest RCP guide-

46 GUIDELINES SECTIONFOR AUTHORS TITLE

■ REVIEW OF BOOKS, SOFTWARE measurements in parentheses. If the article Guidelines AND VIDEOS mentions an outcome measure, Short reviews of up to 500 words to appropriate information about it should be include details of availability, price and included, describing measurement for authors source for purchasing. properties and where it may be obtained.

Synapse is the official newsletter of Implications for practice ■ LETTERS TO SYNAPSE Permissions and ethical certification ACPIN. It aims to provide a channel of Discuss the knowledge gained, with These can be about any issue pertinent to Protection of subjects: Either provide communication between ACPIN reference to published research findings neurological physiotherapy or ACPIN. They written permission from patients, parents members, to provide a forum to inform, and/or evidence about clinical may relate to material published in the or guardians to publish photographs of instruct and debate regarding all effectiveness. For example: previous issue(s) of Synapse. recognisable individuals, or obscure facial aspects of neurological physiotherapy. • Outcome for the patient. features. For reports of research involving A number of types of articles have been • Drawbacks. PREPARATION OF EDITORIAL people, written confirmation of informed identified which fulfil these aims. The • Insights for treatment of similar patients. MATERIAL consent is required. The use of names for types of article are: • Potential for application to other Copy should be produced in Microsoft patients is encouraged in case studies for conditions. Word. Wherever possible diagrams and clarity and humanity, but they should not ■ CASE REPORTS tables should be produced in electronic be their real names. Synapse is pleased to accept case reports Summary form, eg Excel, and the software used from practitioners, that provide List the main lessons to be drawn from this clearly identified. Submission of articles information which will encourage other example. The disk and two hard copies of each practitioners to improve or make changes Hard copies should be as close to journal article, should be sent with a covering in their own practice or clinical reasoning References style as possible, on one side of A4 paper letter from the principal author stating the of how to influence a change or plan a These should be in the Harvard style (see with at least a 25mm margin all around, type of article being submitted, releasing treatment for that condition. The section on ‘Measurements’ below). consecutively numbered. copyright, confirming that appropriate maximum length is 2000 words including permissions have been obtained, or stating references. An outline is given as follows: Further guidelines for writing case reports The first page should give: what reprinting permissions are needed. were published in the Spring 2001 issue of • The title of the article Introduction Synapse, page 19. • The names of the author(s) State the purpose of the report and why • A complete name and address for For further information, please contact the the case is worth reading about to include ■ ABSTRACTS OF THESIS correspondence Synapse co-ordinator: in short sentences: AND DISSERTATIONS • Professional and academic qualifications Louise Dunthorne • The patient and the condition. Abstracts from research projects, including for all authors, and their current 24 Warren Heath Avenue • How the case came to your attention. those from undergraduate or postgraduate positions Ipswich • What is new or different about it. degrees, audits or presentations. They • For research papers, a brief note about Suffolk • The main features worth reporting. should be up to 500 words and where each author which indicates their 01473 704150 possible the conventional format: contribution and a summary of any The patient introduction, purpose, method, results, funds supporting the work Note: all material submitted to the Give a concise description of the patient discussion, conclusion. administrator is normally acknowledged and condition that shows the key All articles within two weeks of receipt. physiotherapeutic, biomedical and ■ AUDIT REPORT • The text should be well organised and psychosocial features. The patient’s A report which contains examination of written in simple, clear correct English. perspective on the problem and priorities the method, results, analysis, conclusions The positions of tables, charts or The Editorial Board reserves the right to for treatment are important. Give the and service developments of audit relating photographs should be appropriately edit all material submitted. Likewise, patient a name in the interests of to neurology and physiotherapy, using any titled and numbered consecutively in the views expressed in this journal are humanity, but not the real name. Do not method or design. This could also include a the text. not necessarily those of the Editorial include any other identifying details or Service Development Quality Assurance • All abbreviations must be explained. Board, nor of ACPIN. Inclusion of any photographs without the patient's Report of changes in service delivery aimed • Any photographs or line drawings should advertising matter in this journal does permission. at improving quality. These should be up to be in sharp focus with good contrast for not necessarily imply endorsement of 2000 words including references. best reproduction. the advertised product by ACPIN. Intervention • All charts should be in black and white Whilst every care is taken to ensure Describe what you did, how the patient ■ REVIEW OF ARTICLES only and captions should reflect this. that the data published herein is progressed, and the outcome. This section A critical appraisal of primary source • References should be listed accurate, neither ACPIN nor the should cover: material on a specific topic related to alphabetically, in the Harvard style with publisher can accept responsibility for • Aims of physiotherapy. neurology. Download the ACPIN punctuation as follows: Bloggs A, Collins any omissions or inaccuracies appearing • Treatment, problems and progress. information sheet Reviewing research B (1998) The use of bandages in treating or for any consequences arising • Outcomes, including any changes in articles for further guidance from the head injuries Physiotherapy 67,3 pp12-13. therefrom. impairment and disability. ACPIN website. • In the text, the reference should be ACPIN and the publisher do not • Justification of your choice of treatment; quoted as the author(s) names followed sponsor nor otherwise support any clinical reasoning ■ PRODUCT NEWS by the date: Bloggs A (1994) substance, commodity, process, • The patient’s level of satisfaction and the A short appraisal of up to 500 words, used • Acknowledgements are listed at the end. equipment, organisation or service in outcome and the impact on quality of to bring new or redesigned equipment to this publication. life. the notice of the readers. ACPIN and Measurements Synapse take no responsibility for these As the International System of Units (SI) is Method assessments, it is not an endorsement of not yet universal, both metric and imperial This should clarify what intervention took the equipment. If an official trial has been units are used in the United Kingdom in place and what measurements were taken. carried out this should be presented as a different circumstances. Depending on It should include: technical evaluation. This may include a which units were used for the original • Description(s) of outcome measures description of a mechanical or technical calculations, data may be reported in used and reference device used in assessment, treatment, imperial units followed by the SI • Interventions carried out (where, when, management or education to include equivalent in parentheses, or SI by whom if relevant) specifications and summary evaluation. measurements followed by imperial

47 Syn’apse ● AUTUMN/WINTER 2004

Regional representatives ■ SOUTH TRENT ■ WEST MIDLANDS Currently vacant Liz Cohen e: [email protected] School of Health Sciences University of Birmingham ■ SOUTH WEST Edgbaston B15 2TT ■ EAST ANGLIA ■ NORTHERN Kirsten Cheadle t: 0121 414 8379 Sesa Ishaya Julia Williamson Physiotherapy Department e: [email protected] t: 01473 702072 t: 0191 233 6161 blp 1913 The Royal United Hospital e: [email protected] e: [email protected] Coombe Park ■ YORKSHIRE ■ KENT ■ NORTHERN IRELAND Bath BA1 3NG Currently vacant t: 01225 821957 Lisa White Siobhan MacAuley e: neuro.therapists@ t: 01634 810998 Physiotherapy Department ruh-bath.swest.nhs.uk e: [email protected] Belfast City Hospital Lisburn Road ■ SURREY & BORDERS ■ LONDON Belfast Brigitt Bailey Sandy Chambers t: 0289 90263851 ext 2545 e: [email protected] Physiotherapy Department e: [email protected] St Thomas’ Hospital ■ SUSSEX Lambeth Palace Road ■ NORTH TRENT Clare Hall London SE1 7EH Emma Procter Physiotherapy Department t: 020 7188 5088 Brearly Physiotherapy Department Conquest Hospital e: sandra.chambers@ Northern General Hospital The Ridge gstt.nhs.uk Sheffield S5 7AU St Leonards-on-Sea t: 0114 271 5088 East Sussex TN37 7RD ■ MANCHESTER e: [email protected] t: 01424 755255 ext 6435 Nina Smith e: [email protected] e: [email protected] ■ OXFORD Fiona Cuthbertson ■ WESSEX ■ MERSEYSIDE t: 01865 224196 Helen Foster Jo Jones e: [email protected] Physiotherapy Department t: 0151 282 6000 ext 6098 Royal Hampshire County Hospital e: [email protected] ■ SCOTLAND Romsey Road Paula Cowan Winchester ■ NORTHAMPTON Physiotherapy Department Hants Sarah Littlewood Department of Clinical t: 01962 824917 Royal Leamington Spa Neurosciences e: [email protected] Rehabilitation Hospital Western General Hospital Heathcote Lane Crewe Road South Warwick Scotland EH4 2XU t: 01926 317712 t: 0131 537 2120 e: [email protected] e: [email protected]

Syn’apse Administrator Design Address for correspondence Louise Dunthorne kwgraphicdesign Louise Dunthorne t & f: 44 (0) 1395 263677 Synapse Administrator Editorial Advisory Committee e: [email protected] 24 Warren Heath Avenue Members of ACPIN executive and Ipswich national committees as required. Printers Suffolk MF Barnwell & Sons, Norwich e: [email protected] t: 44 (0)1473 712587

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JOURNAL AND NEWSLETTER OF THE ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS INTERESTED IN NEUROLOGY www.acpin.net

SPRING 2005

ISSN 1369-958X