SYNAPSE Spring 2008 - Home - ACPIN · 2019. 5. 3. · Syn’apse SPRING 2008 2 Hello and welcome to...

> Measuring movementperformance in the acutesetting: the developmentof the LEEDS MovementPerformance Index

> Improving the posturalorientation of distalreference points willimprove postural controlfor functional reach

> Outcome measurement byphysiotherapists whowork in neurology

Spring 2008

www.acpin.net

JOURNAL AND NEWSLETTER OF THE ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS INTERESTED IN NEUROLOGY

ACPIN’S AIMS1. To encourage, promote and facili-

tate the exchange of ideasbetween ACPIN members withinclinical and educational areas.

2. To promote the educational devel-opment of ACPIN members byencouraging the use of evidence-based practice and continuingprofessional development.

3. To encourage members to partici-pate in research activities and thedissemination of information.

4.To develop and maintain a recip-rocal communication process withthe Chartered Society ofPhysiotherapy on all issues relatedto neurology.

5. To promote networking withrelated organisations and profes-sional groups and improve thepublic’s perception of neurologicalphysiotherapy.

6.To encourage and participate inthe setting of guidelines withinappropriate areas of practice.

7. To be financially accountable forall ACPIN funds via the Treasurerand the ACPIN committee.

Syn’apseJOURNAL AND NEWSLETTER OF THE

ASSOCIATION OF CHARTERED

PHYSIOTHERAPISTS INTERESTED

IN NEUROLOGY

SPRING 2008

ISSN 1369-958X

CONTENTSFrom the Chair(s) 2

Article 1Measuring movement performance in the acute setting: the development of the LEEDS Movement Performance Index 3

Article 2Improving the postural orientation of distal reference points will improve postural control for functional reach 7

Article 3Outcome measurement by physiotherapists who work in neurology 14

Articles in other journals 19

Focus on…Listen to our voices – telling our stories to physiotherapistsWorld confederation for Physical Therapy International Congress 22

ACPIN news 24

General news 28

Sharing good practiceEstablishing and running an Early Supported Discharge (ESD) rehabilitation team for Stroke: four years experience 31

ACPIN national conference 2008Acquired brain injury 34

ReviewsARTICLE: Stroke patients and long term training: is it worthwhile?A randomized comparison of two different training strategies after rehabilitation 45

COURSE: 24 hour postural management of the adult neurological patient 46

Regional reports 47

Letters 50

Guidelines for authors 51

Regional representatives 52

Syn’apse ● SPRING 2008

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Hello and welcome to my finalSynapse introduction as Chair ofACPIN.

As I write, the Executive Committeeare in the final stages of organisingour residential conference and AGM,‘Acquired Brain Injury: Competencywith the Complex’ and, by the timeyou read this, we hope to have heldanother really successful event in ourresidential conference series!

On the topic of events, the ACPINcontribution to the neurology strandfor CSP Congress 2008, 17th and 18thOctober in Manchester, is lookingvery impressive, with AnneShumway Cook as keynote speakeralongside many other highlyrenowned names in the world ofneurorehabilitation – do takeadvantage of the early bird discountsand get your place booked up for therelaunch of this international event.We owe an enormous debt of grati-tude to Siobhan MacAuley who hasco-ordinated the neurology pro-gramme with such drive and profes-sionalism.

The challenge of developing ournew membership system has beenenormous – to move from the labo-rious inputting by hand of all yourmembership data to our fabulousonline database and direct debitpayment system, has been a hugecommitment, particularly for JoTuckey and Mary Cramp, who Iwould like to thank on behalf of thecommittee and membership. Weexpect some minor hiccoughs, aswith any new system, but do bearwith us as this really will be a muchmore viable system for the future.Please remind colleagues who maynot have yet re-joined that the sys-tem is now live.

This summer is very significant interms of the production of strokeguidelines – the Royal College ofPhysicians will be launching the newNational Clinical Guidelines for Strokein July, alongside NICE who will belaunching the Management of AcuteStroke Guidelines. Dr Sheila Lennon,Chris Fitzpatrick and myself continueto represent physiotherapy at the RCP

and Rhoda Allison has done somegreat work in keeping the ACPIN flagflying at NICE. It is very importantthat we continue to have a signifi-cant voice on these working partiesand we are always grateful for anycomments you can make on relevantdocuments.

In order to improve our communi-cation and utilise the tremendousknowledge base within the ACPINmembership, Louise Rogerson andSandy Chambers are heading up aproject group exploring a scopingexercise to glean information onthose therapists throughout theregions who may be happy to con-tribute to consultations and queries.More of this inside this issue.

This year sees the departure ofsome long serving members of theExecutive after considerable service tothe committee and an acknowledge-ment of their tremendous work andthanks on behalf of us all can befound in the Chair’s address to theAGM on page 25.

That just leaves me to bid you allfarewell as I depart the Chair’s seatand the Executive Committee afterten years. This has been a challeng-ing, thought-provoking and excitingtime for me. I have made manywonderful friends and the commit-ment of my colleagues in neuroreha-bilitation across the country is veryhumbling. I have been honoured tobe part of this organisation for solong, but am delighted to hand overto Jo Tuckey and Cherry Kilbride, whoI know will do an incredible job onbehalf of you all. So its goodnightfrom me, and hello from them…

Best wishes

Nicola

Hello from us!Filling the shoes of Nicola, as

Chair of National ACPIN was goingto be a gargantuan task for anyone person following on. Wetherefore decided a ‘double act’and sharing the role for a yearwas the best way serve the com-mittee and the membership as awhole!

However we know we are notalone. ACPIN is one of the biggestspecial interest groups and welook forward to harnessing the‘power of the membership’ tohelp us in our duties. For exam-ple, ACPIN as a respected voice ofneurological physiotherapists inthe UK (and increasingly beyondour shores) is frequently asked tocomment on various documentsand reports so we are very keen tomake use of the wealth ofresource throughout the member-ship. So please do participate inthe up and coming scoping exer-cise, it is crucial if we are to trulyreflect the views and opinion ofACPIN.

It goes without saying that withyour help we aim to continue thehigh standard that has been setfor our national ACPIN events. Weare already planning the 2009 oneday conference, which will focuson rehabilitation of the upperlimb and will continue to provideleadership to future neurologyprogrammes at Congress.

Finally thank you all for beingpart of ACPIN and we are bothlooking forward to working withyou in the coming year.

Jo and Cherry

FROM THE CHAIR FROM THE CHAIRS

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Within the field of neurological rehabilitation, aBobath trained physiotherapist assesses andtreats the underlying impairments that con-strain function and participation, for examplethe patient may have an inability to stabilisetheir scapula on their thorax and thereforesuffer from impaired upper limb function, andbe dependent on carer support during ADL. Theimpairment is treated specifically beforeenabling activity within the context of mean-ingful function. In other words, the ‘microdetail’ is changed during treatment to give moreefficient bio-mechanics of the movement whichalters the efficiency of the ‘macro’ detail offunction (IBITA 2006; Edwards 2002; Shumway-Cook & Woollacott 2001; Stokes 1998).

There is an abundance of validated outcomemeasures that measure movement and functioncurrently available for neurological physiothera-pists to use, for example the Berg Balance Scale(Berg et al 1992), the Ten Metre Walk (Wade 1992)the Trunk Control Test (Frangignoni et al 1997),the Postural Assessment Scale for Stroke (Benaimet al 1999), the Modified Rivermead Mobility Index(Lennon, Johnson 2000), the Motor AssessmentScale (MAS) (Carr et al 1985) and TELER (Le Roux1993; Mawson 1995, 2002). However, it is difficultto find a tool that measures change affectedduring physiotherapy intervention at componentor impairment level.

Boyce et al (1993) developed a scale that meas-ured the quality or performance of the cerebralpalsied child’s movement, which could be used inconjunction with a previously developed scale ofmotor function. In practical terms, the resultingmeasurement tool could be used to measurechange over time, compare change to intensity ofinput, and compare change to surgical interven-tion. The tool could also be used to support clinical

reasoning for physiotherapy treatment planningand the demonstration of treatment effectiveness.

Within the last thirteen years there has been asignificant amount of research within the field ofbalance and postural control in adult neurologyfocusing on the measurement of outcome atimpairment rather than at functional level.Nieuwboer et al (1995) developed a scale, basedon the visual observation of balance posture andtrunk activity in sitting, for stroke patients. Thetool was designed to be used by physiotherapistsfor the monitoring of clinical progress, treatmentoutcome, effect of intervention and to be quick,easy, reliable and valid for use. This study foundthat the items which did not measure the qualityof the movement or posture had good reliability,whereas the items which did measure the qualityof the movement (assessment of selective andsymmetrical movement) only achieved moderateor slight reliability, possible due to the variance ofclinical knowledge and experience between thetesters, resulting in measurement error.

During a more recent study by Verheyden,Nieuwboer et al (2004) the Trunk ImpairmentScale was developed by removing some items ofpoor reliability and redefining other items. Theauthors state that this scale could be used as aguide for physiotherapy treatment, but it onlylooks at trunk control in sitting. It could be thatthe measurement of the quality of trunk control insitting can be generalised and a predictor to thepatients’ overall quality of their postural control,but this isn’t claimed in the study.

Mawson (1995) developed a set of movementindicators for use by physiotherapists whentreating neurologically damaged patients. Themovement indicators were developed to fit withthe TELER technique of measurement. They weredeveloped during a two-year project, using theclinical experience of a group of senior neurolog-ical physiotherapists. The indicators were given

Measuring movement performancein the acute setting: the development of theLEEDS Movement Performance IndexDenise Ross MCSP PGDip MSc


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face validity by the British Bobath TutorsAssociation, and given concurrent validity whencompared with the MAS (Mawson 2002). On facevalue, these indicators appear to be applicable toindividual patients and sit well within the Bobathconcept, however, although clinical standards of‘normal movement’ were specifically addressed,they do not consider the quality or performance ofthe patients’ movement and postural control.

Daley et al (1999), Wang et al (2002) and Ahmedet al (2003) have demonstrated the StrokeRehabilitation Assessment of Movement Measure(STREAM) to be a psychometrically strongoutcome measure for stroke, for use in researchand clinical practice. The STREAM measures amix of selective motor activity and function thatmay be appropriate for use in clinical practice.The scoring criterion although initially appearingto be complex assesses and scores depending onwhether the movement is complete, normal ordeviated. This outcome measure therefore recog-nises the necessity of measuring the quality ofmovement in clinical practice.

It is important to measure change in thepatients’ ability and performance of movement asa result of physiotherapy intervention. The meas-ures of change that are available are, in general,function orientated and are not specificallyrelated to neurophysiotherapy clinical practice,which is:• analysis of movement and posture• problem identification• functional goal setting• treatment planning• ‘hands on’ facilitation of movement and postural

activityThere is a need to support current subjectiveobservation of our patients’ ability pre and posttreatment in order to validate physiotherapy inter-vention.

Because quality or performance of posture andmovement is important, the understanding ofwhat is meant by ‘quality’, and what componentsof this are needed in order to achieve a successfulperformance, is essential.

The purpose of this study was to establish:• what Bobath trained therapists mean by ‘quality

of movement and posture’,• the parameters of quality that are referred to in

clinical practice and• the potential to develop a measurement tool that

could quantify these qualitative observations.

METHODOLOGY The senior neuro training group within LeedsTeaching Hospitals NHS Trust PhysiotherapyDepartment worked together as a consensus

group, facilitated by one of the clinical specialists.The membership of the group is diverse in termsof specialist knowledge, representing a broad clin-ical spectrum within neurology (acuteneurosurgery, acute neurorehabilitation, strokeunit, community stroke rehabilitation, communityneurorehabilitation unit, neuro out-patients andMS specialist service). Its membership consists often experienced clinicians, with a range ofbetween four and twenty five years experience ofworking at band seven levels or above in neuro-logical rehabilitation. A series of consensus groupmeetings and Delphi type methodology was usedto develop ‘The LEEDS Movement PerformanceIndex’ (Figure 1).

RESULTSDuring their first meeting in July 2006, the con-sensus group identified and agreed two definitionsof what ‘quality of movement and posture’ meantto them. They then identified different componentsof quality of movement and agreed on five keycomponents.

A Delphi type methodology was used within thegroup, in order for individuals to anonymouslydefine and describe the five key components ofquality of movement and posture.

In November 2006, the consensus group metagain. A simple scoring system based on what thepatients ‘theoretical optimum normal’ should bewas agreed, and the resulting measure wasnamed ‘The LEEDS Movement Performance Index’(LEEDS MPI).

Each group member was randomly allocatedtwo items of the index and used it during theirroutine physiotherapy record keeping process fortwo months. There were no constraints placed onhow or when the measure should be used, onlythat it should be at the clinical judgment of eachgroup member. During this trial period, thegroups’ facilitator visited each of the group intheir clinical setting and gathered information andknowledge about how clinically useful the per-formance index was in practice.

A consensus group meeting in March 2007resulted in the decision to trial and use all fiveitems in clinical practice. This was done duringJune and July 2007.

DISCUSSIONDuring their year of research, the consensusgroup developed a measure that could supporttheir qualitative analysis of selective componentsof movement and posture during the assessmentwhich underpinned the functional goal setting andtreatment of their patients. There were no floor orceiling effects as the index could be used to

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analyse a part of, or the whole of, a pattern ofmovement. It was unanimously agreed that theindex was supportive of the clinical reasoningprocess, and was closely related to patients’ treat-ment goals and treatment plan.

During consensus group meetings it was recog-nised that the LEEDS MPI could also be developedfor use as a tool to support the development of lessexperienced physiotherapists.

The group has developed a measure of interven-tion of treatment of neurologically impairedadults, based on a sound research structure, thusachieving robust face and content validity.

The consensus group recognizes that there maybe an element of bias within this study, as all groupmembers are very specifically Bobath trained andwork at specialist level. The LEEDS MPI could beobserved to be very technical, in terms of ease ofuse and language by non-Bobath trained thera-pists. It would also be impossible to use the indexfor comparison between groups of patients due to

the variety and individualized nature of physio-therapy treatment goals and plans.

FUTURE WORK AND DISSEMINATIONIt is intended by the researcher and the consensusgroup participants, that the LEEDS MPI be furtherdeveloped, in order to:• explore reliability during use by senior Bobath

trained therapists,• explore the validity for use by senior Bobath

trained therapists, as an objective tool tomeasure intervention,

• support the more subjective descriptions currently used during the documentation of neurological therapy clinical practice and

• explore the development of use as a training aid for less experienced therapists or therapystudents.

It is intended that dissemination of the work willbe via presentation and publication, in order togain peer review and feedback.

1. Consensus groupmeetingJuly 2006

Definition of quality of movement andposture

Round 1

Anon definition ofeach parameter

Key parameters ofmovement andposture

2. Delphi typemethodologicalprocessAugust 2006

Round 2Top three favouritedefinitions foreach parameter

Round 3Top (favourite)definition for eachparameter

Agreement of scoring criteria

3. Consensusgroup meetingNovember 2006

Consensus groupmeetingMarch 2007

4. Trial of twoitemsJanuary andFebruary 2007

5. Trial of all itemsJune and July 2007

Figure 1 Research process


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ReferencesBenaim, Perennou, Villy, Pelissier(1999) Validation of a standard-ised assessment of postural controlin stroke patients: the posturalassessment scale for strokepatients (PASS) Stroke 30 (9)pp1862-8.

Berg et al (1992) MeasuringBalance in the Elderly: Validationof an instrument Can JournalPublic Health supplement 2 pp7-11.

Boyce, Gowland, Russell,Goldsmith, Rosenbaum, Plews,Lane (1993) Consensus methodol-ogy in the development of a grossmotor performance measurePhysiotherapy Canada Spring 45(2) pp94-100.

Carr, Shepherd, Nordholm, Lynne(1985) Investigation of a MotorAssessment Scale for StrokePatients Physical Therapy 65 (2)February pp175-180.

Frangignoni et al (1997) TrunkControl Test as an early predictor ofstroke rehabilitation outcomeStroke 28 pp1382-85.

IBITA (2006) Theoretical assump-tions and clinical practice 2006The Bobath Conceptwww.ibita.org

Edwards 2nd ed (2002)Neurological Physiotherapy, Aproblem solving approachChurchill Livingstone, London.

Lennon, Johnson (2000) TheModified Rivermead MobilityIndex: validity and reliabilityDisability and Rehabilitation 22(18)pp833-39.

Le Roux (1993) TELER the conceptPhysiotherapy 79 (11) pp755-65.

Mawson (1995) TELER NormalMovement Indicators TheCromwell Press, Wiltshire.

Mawson (2002) TELER versus MAS;Validating TELER indicator defini-tions for use in the measurementof physiotherapy outcomes inacute stroke rehabilitationPhysiotherapy 88 (2) pp67-76.

Nieuwboer et al (1995) Developinga clinical tool to measure sittingbalance after stroke: a reliabilitystudy Physiotherapy 81 (8) pp439-45.

Shumway-Cook, Woollacott (2001)Motor Control Theory and PracticalApplications (2nd Ed) LippincottWilliams and Wilkins. MarylandUSA.

Stokes (1998) NeurologicalPhysiotherapy Mosby, London.

Verheyden, Nieuwboer, Mertin,Kiekens, De Weerdt (2004) Thetrunk impairment scale: a newtool to measure motor impairmentof the trunk after stroke ClinicalRehabilitation 18 pp326-34.

Wade (1992) Measurement inNeurological RehabilitationOxford University Press. Oxford.

AcknowledgementsDr Sue Mawson, Professor BipinBhakta, Alan Bass, Cat Williams,Alison Gullvag, Liz Walker.

Names of consensus group membersAlan Bass, Sally Bowes, Jill Hall,Maddie Kenny, Gill Lether, DeniseRoss, Liz Walker, Kate Warner, Cat Williams, Karen Wood.

CorrespondencePhysiotherapy DepartmentLincoln WingSt James University HospitalBeckett StreetLEEDSLS7 [email protected]

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This study aims to investigate whetherimproving the postural orientation of distalreference points, that is, the hands and feet,influences postural control in a patient fol-lowing an acute stroke. Postural control willbe explored, with particular attention beingpaid to postural orientation, body schema andsomatosensory information from hands andfeet. A case study design will be used to inves-tigate this topic in relation to the functionaltask of reaching and the Bobath concept.

LITERATURE REVIEW OF EVIDENCE BASEPostural controlPostural control (PC) is defined by Shumway-Cookand Woollacott (2007) as the ability to controlbody position in space for the dual purpose of ‘sta-bility’ and ‘orientation’. ‘Postural orientation’maintains alignment between body and segments,between body and environment and involvesestablishing a vertical orientation. PosturalControl (PC) requires information and integrationbetween the systems responsible for visual,vestibular and somatosensory input and motoroutput (Lackner and DiZio 2005).

Hands and feet: postural orientationThe hands and feet have a vast number of recep-tors and have the largest representation in thesensory cortex, (Hsiao et al 2002). Their role inpostural orientation seems to be of particularimportance and will be the focus of this study.Several studies reviewed: Maravita et al (2003);Jeka (1997); Kavounoudias et al (2002; 2001;1998) and Lackner and DiZio (2005) were inagreement that touch and pressure information,particularly from hand and foot in contact with astable surface, will influence apparent body orien-tation and therefore postural control.

Neuroplasticity and therapy aimsThe current theoretical assumptions underpinningthe Bobath concept state ‘the therapist is aiming tore-educate the patient’s own internal referencingsystem, to provide accurate afferent input to givethe patient the best opportunity to be efficient, spe-cific and have movement choices’ (Raine 2007).Cortical representation areas (maps) can be modi-fied by sensory input, experience and learning, aswell as in response to injury (IBITA 2007).

Movement analysis: functional reachReaching involves transportation of the hand andarm in space. The ability to organise the body withrespect to gravity and alignment of body segmentsaround midline is important. A key aspect is cre-ating an efficient and effective background of PCto free an upper limb for functional reach. Thevestibulospinal tract and reticulospinal tracts areimportant in PC and antigravity muscle activation(IBITA 2007).

To accurately locate the target, co-ordination ofeye and head movements and processing of visualand proprioceptive information is involved(Castiello 2005). Afferent input travels to the CNSvia the ascending systems: the information isselectively received and incorporated into usefulfunctional behaviour, ie selective movement of thearm for reach.

The descending system particularly linked to thespatial orientation of the upper limb and hand isthe corticospinal tract and is responsible for singledigit movement of the fingers (Lemon andGriffiths, 2005). The rubrospinal tract, thought tobe less important in humans, is believed to have arole in opening and re-shaping of the hand forreach and grasp (Canedo 1997).

HypothesisFrom the literature there appears to be evidenceto support that PC is influenced by postural orien-

Improving the postural orientationof distal reference points will improve posturalcontrol for functional reachEmma Bretherton BSc (Hons) Physiotherapy Senior Physiotherapist, University Hospitals Leicester


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tation of hands or feet (Maravita et al 2003; Jeka1997; Kavounoudias et al (2002; 2001; 1998);Lackner and DiZio 2005). Fewer studies wereavailable on people with lesions of the CNS orwhere randomised control groups were used.Despite the links between the distal referencepoints, no study was found where both hands andfeet were investigated together. I therefore feelthis warrants further investigation and the fol-lowing hypothesis was generated for this study‘improving the postural orientation of distalreference points will improve postural controlfor functional reach’.

CLINICAL CASE ANALYSIS AND REASONINGPatient A is an 86 year-old male, admitted to hos-pital, with sudden onset right (R) sided weaknessand severe dysphasia. A CT head scan diagnosed alarge left (L) MCA infarct.

Initial physiotherapy assessment was completedon his second day post stroke, where he presentedwith reduced activity in (R) upper limb (UL) andlower limb (LL), but was able to actively movelimbs against gravity. UL was more affected thanLL. He displayed poor postural orientation aroundmidline, which became increasingly apparentwhen the task became more challenging, such asstanding, where he showed signs of over-activitythrough the (L) side. Initial assessment findingsguided development of the problem list (Table 1)and negotiation of patient centred short-termgoals (Table 2).

TREATMENT HYPOTHESESThree treatment hypotheses were generated spe-cific to the individual. The clinical reasoningprocess, interventions and how treatment evolvedis described and related to the main hypothesis forthis project.

1. By creating acceptance of BOS and orientationaround midline in sitting PC will increase.

In sitting on plinth, worked on realignment andpostural orientation around midline. Hands wereplaced into a more functional and symmetrical posi-tion. Orientation to feet, their alignment andinteraction with floor, was increased. An improvedsupply of afferent information was therefore pro-vided, to develop a more accurate internalreferencing system, for greater postural orientation.A folded towel was placed under (R) buttock, whichcan be termed ‘packing’, to maintain better align-ment, more equal weight distribution, increasesensory input and improve acceptance of BOS.

Treatment progressed to develop inter-seg-mental trunk control through facilitation fromthorax and pelvis, working on control of ante-rior/posterior and lateral pelvic tilt. Improving

position, mobility and stability of pelvis developedthe ability to ‘weight transfer’ and greater inter-play between (R) and (L). Creating alignment ofthorax on pelvis improved inter-segmental trunkcontrol promoting selective extension/symmetrical

Impairment

1 Reduced activation and selective movement throughout (R) UL,particularly at hand (able to move against gravity proximally,flickers in fingers and thumb).

2 Reduced activation and selective movement throughout (R) LL(able to move against gravity throughout).

3 Inattention to (R) side, decreased orientation to (R) side.

4 Poor interaction of (R) and (L) foot with supporting surface.

5 Reduced segmental trunk control, reduced activation of core sta-bility muscles, particularly abdominals and poor eccentriclengthening of trunk extensors.

6 Reduced head righting and balance reactions.

7 Poor alignment and interaction of thorax and pelvis, difficultytranslating COM anteriorly over BOS.

8 Increased weight bearing with decreased control through (R)buttock.

9 Lateral weight ‘shift’, poor weight ‘transfer’ to (R) or (L).

10 Severe expressive dysphasia, no verbal communication, demon-strates appropriate use of head gestures. Communication barrierlimits ability to perform certain detailed assessments, such as,sensation.

Compensations/ over activity

1 Over activity of trunk extensors, fixating with whole trunk.

2 Over activity and fixing with bilateral hip adductors and hip flex-ors. Reduced dissociation between (R) and (L) LL.

3 Over activity with (L) side towards (R) side, decreased acceptanceof BOS (L) side.

4 Use of (L) hip flexor strategy.

Activities

1 Dependent on 2 to move in bed and get in/out of bed.

2 Dependent on 2 to crouch transfer to (L) side.

3 Dependent on 2 to stand.

4 Unable to mobilise.

5 Unable to use (R) UL for function.

6 Dependent on 1-2 for all PADL’s and ADL’s.

Participation

1 Unable to return home at present to previous role living inde-pendently with wife.

2 Unable to return to hobby as a jazz singer.

Table 1 Problem listTable 1 Problem list

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activity. The patient responded well to incorpo-rating functional reaching tasks during facilitationof lateral tilt. Figures 1 to 4 show progression oftreatment.

2. By providing somatosensory input through (R)hand & foot, will increase orientation to (R) sideand develop internal representation/body schemaand influence PC.

Specific sensory stimulation, with focus on areaswith highest density of receptors, thenar andhyperthenar eminence and fingertips, was pro-vided to (R) hand, and facilitation of single digitand thumb active movement, promoting activationof the corticospinal tract. In order for theascending systems to provide accurate informa-tion relating to the patients body schema,alignment of soft tissues and joints was required(Raine 2007). Handling, touch, joint compression,alignment, movement, vision and attention to (R)hand and foot provided afferent information toCNS about body position in space to improve pos-tural orientation and activate the descendingtracts for PC (IBITA 2007).

The underpinning knowledge was applied whenusing various different facilitation techniquesfrom the distal reference points. Two of the tech-niques used are described in Figures 5 and 6overleaf.

Throughout the ten treatment sessions partic-ular attention was paid to the distal referencepoints. Improvements were demonstratedthrough clinical observation and use of outcomemeasures. Pre and post treatment photos of staticsitting alignment were also used but are notincluded for the purpose of this report.

3. By creating efficient and effective PC through(R) will free (L) UL for functional reach.

Treatment evolved up into standing. Standingincreases somatosensory input (foot to floorcontact) providing information regarding posturalorientation, influencing PC (Kavounoudias et al2001). Vestibulospinal system and reticulospinalsystem are stimulated by activities against gravity,increasing PC and developing anti-gravity muscleactivation/ strengthening of (R) LL (IBITA 2007).Careful observation skills were used to guidetreatment progression. Signs of over activitythrough (L) indicated when the task was overchallenging for the patient. Figures 8 and 9 over-leaf demonstrate the improvements made overtwo weeks.

Table 2 Short term goals and achievements

Figure 1

Weight ‘shift’/ fall to (R).Increased weight bearingthrough (R) pelvis. Reduced PCthrough (R) side. Poor headrighting and visual orientation.

Figure 2

Resistance of weight transfer(L). Reduced acceptance of BOSthrough (L) pelvis. Over-activethrough (L) side.

Short-term (two weeks)functional goals

1 To improve postural orientation and control in sitting to be able to free upper limbs for reachingactivities.

2 To be able to transfer, i.e.move to and from lying to sitting, get to and from bed to chair, independently.

3 To be able to maintain postural control in standingand perform reaching tasks.

Achievements following twoweeks therapy intervention

1 Able to sit unsupported andperform reaching tasks moving within and out of BOS (compare Figures 1 to 4).

2 Able to move to and from lying to sitting independently.Able to perform a low levelcrouch transfer towards (R) or (L) with assistance of 1.

3 Able to stand independentlyand reach for an object fromhigh table in front (compareFigures 8 and 9).

Physiotherapy session – day 2

Figure 3

Improved weight transfer (R).Better visual and head orientation, & attention ontask, improving PC. Placementof (R) UL on table for referencepoint of stability and orientation.

Figure 4

Sensory input to (R) handimproves contralateral stability,improving ability to weighttransfer (L) during reach.

Physiotherapy session – beginning of week 2


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Considerations made regarding ‘task’ ofreaching included:• Adapting the ‘environment’ for each task/inter-

vention to; decrease fear, increase safety, givereference point for stability and influence pos-tural orientation.

• Linking tasks to patient’s interests, eg cup of tea(patient’s favourite drink) to increase motivation,attention and arousal, stimulating limbic system(Holubar & Rice 2006; Lackner & Hummelsheim2003).

• Opportunities for active learning of new skills,stimulating inferior olive (IBITA 2007).

• Providing variation and feedback, to promote‘generalization’ of learning (Carey & Matyas2005).

• 24 hour management of the patient was funda-mental to reinforce the improved change in thebody schema (IBITA 2007).

RESULTSTo improve reliability of this study, variables werestandardised where possible, that is, plinth andtable height, distance of object on table, sameobject used.

Following a review of the literature the outcomemeasures below were selected as seemed mostsuitable for the patient and their reliability/validity is supported by evidence.

Outcome measures used

Photographs Pre and post treatment photographsillustrated changes in postural orientation andalignment statically (sitting) and dynamically

Figure 5 Creating an active hand for reaching, facilitation of pronation/ supination

Ulna border of hand is impor-tant for stability. Therefore con-tact with supporting surfacewas maintained. Therapists (L)hand provided stability downthrough olecranon and forwardinto wrist. Therapists (R) handmaintained wrist alignmentand provided distraction athand to lengthen flexor reti-naculam. The patient wasencouraged to actively partici-pate during the movements.Timing of handling within andbetween therapists hands wasimportant to facilitate muscleactivation.

Figure 6 Facilitation of ‘weight over foot’ in standing to gain betterpostural orientation

(R) hand shown over talus,maintained alignment,increased sensory awarenessand provided compressionthrough the joint, stimulatingthe vestibulospinal tract andactivating anti-gravity musclesparticularly soleus, which isimportant for PC (IBITA 2007). (L)hand stabilised around lateralgastrocnemius and head offibula with thumb to facilitateforward translation of kneeover foot/big toe. Towel wasused under heel to maintainalignment at pelvis and helpactivate lateral pelvic tilt. UL’swere actively placed on a hightable in front to improve postural orientation.

Figure 7 Pre-treatment footalignment in sitting.

Figure 8 Functional reach instanding week 1

Under-active (R) trunk,increased side flexion (R),increased skin creases (R) trunk.Reduced proximal stability at(R) shoulder and pelvis. Over-activity through (L) UL.Dependence on (L) UL andunable to free UL for functionalreach, loss of contra-lateralstability through (R).

Figure 9 Functional reach instanding end of week 2

Improved PC throughout trunk.Placement of (R) handimproved postural orientationand provided a reference pointof stability. Improved trunkalignment and selective extension. More equal skincreases bilaterally. Improvedpelvic alignment and control.Able to reach independentlyand maintain contra-lateralstability through (R).

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(standing and reaching). Improvements can beseen in previous section and Appendix A.

Postural Assessment Scale for Stroke (PASS)(Benaim et al, 1999). PASS was selected to measurethe ability to maintain a given posture and ability toensure equilibrium in changing position. Researchsuggests it is one of the most valid, reliable andresponsive measures of postural control in stroke(Benaim et al 1999; Mao et al 2002).

Goal Attainment Scale (GAS) GAS provided anindividualised measurement approach whereby arange of criterion referenced goals using a five-point ordinal scale (see Table 3) were specified forthe patient (Hill & Denisenko, 2005). A goal thatwas both realistic and meaningful for the patientwas identified and represents the target goal, point(0) on the GAS. The patient’s level prior to interven-tion is rated (-2). A score (-1) representsimprovement that is less than the expected level ofattainment. (+1) and (+2) represent goals thatexceed target goal expectations, often representinga long-term goal for the patient. See Table 4 forGAS devised for patient A in sitting and standing.

Patient A, seemed to have reduced neural driveaffecting more the vestibulospinal tract, with diffi-culty orientating his body in space, and medialreticulospinal tract, with reduced control moreproximally and around trunk. The loss of activityin (R) hand also suggests reduced drive in corti-cospinal tract. Directing facilitation through thedistal reference points and applying the Bobathconcept, proved particularly effective for thispatients recovery. He showed significant develop-ment in ability to reach in sitting over the twoweeks, which carried over to improvements inability to stand and reach independently, demonstrated visually in photographs, andimprovements in PASS & GAS scores. The patientprogressed to standing with support from onehand but could not progress further in this timeperiod, illustrated in the PASS score, and insupport with previous studies that placement ofone hand influences postural orientation andimproves PC (Lackner and DiZio, 2005; Jeka,1997).

Large improvements in PASS scores were foundin just two weeks, which could indicate the ceilingis reached too quickly for this outcome measure.The GAS does not appear to be widely used butseemed to be very easy, clear and patient specific.Its use therefore warrants further research.

This study supports the application of theBobath concept and the current evidence avail-able, particularly the studies described earlier byKavoundias et al (2002; 2001; 1998) with regardsto the ‘foot’ and the work reviewed by Maravita etal (2003) and Jeka (1997) regarding the ‘hand’.The experimental design studies by Kavounoudiaset al (2002; 2001; 1998), suggesting that cuta-neous afferents from human plantar sole andankle proprioceptive information, contribute tothe coding and the spatial representation of bodyposture, can be further supported by this casestudy. Whilst acknowledging that it is an isolatedcase study, it could have implications to clinicalpractice to support that somatosensory inputsfrom the foot and hand can be influenced duringtherapy to improve postural orientation andcontrol.

CONCLUSIONOn completion of this study and learning moreabout the Bobath concept my personal physio-therapy practice has changed. Particularly in thatI have a greater awareness of the importance ofcareful preparation work, and how through han-dling or environmental factors I can influencesomatosensory information the patient receives,important for postural orientation and control.

A limitation of this study is that it is not possible

GAS: Sitting

-2 Able to reach a cup from a central position on table, 10” fromedge with less-affected UL and maintain PC with assistance of 1 person.

-1 As above but independently.

0 As above but reach a cup from a central position on table, greaterthan 10” away from edge.

+1 As above but reach a cup from lateral position to (L) side.

+2 As above but reach a cup from lateral position to (R) side.

Table 3 The scale was repeated in standing with the same range of criterion referenced goals.

Table 4 PASS and GAS scores pre, during and post intervention

Timescale

Beginning of week 1

End of week 1

End of week 2

PASSscore

10

16

23

GAS scoresitting

-2

+1

+2

GAS scorestanding

-2

-1

0

DISCUSSIONThis study suggests that through improving thepostural orientation of hands and feet duringintervention, postural orientation may also beimproved. This may create a better internal refer-encing system for more efficient PC, an essentialrequirement for the functional task of reaching.


12

to attribute improvements found in the patient tofacilitation through distal reference points,because treatment sessions evolved incorporatingmultiple influencing factors, including, differentpostural sets, techniques, environmental factorsand tasks.

Greenhalgh (1997) reported that case studiesare useful in research as a great deal of detailedinformation can be conveyed that would be lost ina clinical trial or survey. However, more random-ized control trials on larger groups are needed todevelop stronger evidence based practice. To con-clude therefore the hypothesis could neither beproved nor disproved. Recommendations forfurther investigation are indicated with greatercontrols to help, if possible, to attribute improve-ment more to a particular variable, ie the specificinfluence of distal reference points.

ReferencesBenaim C, Perennou A, Villy J,Rousseaux M, Pelissier Y (1999)Validation of a StandardizedAssessment of Postural Control inStroke Patients. The PosturalAssessment Scale for StrokePatients (PASS) Stroke 30 pp1862-1868.

Canedo A (1997) Primary motorcortex influences on the descend-ing and ascending systems Prog inNeurobiology 51 pp287-335.

Carey LM, Matyas TA (2005)Training of SomatosensoryDiscrimination After Stroke:Facilitation of StimulationGeneralization Am J Phys MedRehabilitation 84 pp428-442.

Castiello U (2005) The Neuroscienceof Grasping Nature Reviews/Neuroscience 6 pp726-736.

Greenhalgh T (1997) How to read apaper: getting your bearings(deciding what the paper isabout). The science of ‘trashing’papers BMJ 315 pp243-246, 305-308.

Holubar MN, Rice MS (2006) Theeffects of contextual relevance andownership on a reaching andplacing task AustralianOccupational Therapy Journal 53pp35-42.

Hill K, Denisenko S (2005) ClinicalOutcome Measurement in AdultNeurological Physiotherapy 3rdedition National Neurology GroupAustralian PhysiotherapyAssociation.

Hsiao S, Lane J, Fitzgerald P (2002)Representation of orientation inthe somatosensory systemBehavioral brain research 135pp93-103.

Jeka JJ (1997) Light Touch Contactas a Balance Aid Physical Therapy,77 (5) pp476-487.

Kavounoudias A, Roll R, Roll JP(1998) The plantar sole is a‘dynamometric map’ for humanbalance control Neuro Report 9pp3247-3252.

Kavounoudias A, Roll R, Roll JP(2001) Foot sole and ankle muscleinputs contribute jointly to human

erect posture regulation Journal ofPhysiology pp532: 869-878.

Kavounoudias A, Roll R, Roll JP(2002) Cutaneous afferents fromhuman plantar sole contribute tobody posture awareness NeuroReport 13 (15) pp1957-1961.

Lackner E, Hummelsheim H (2003)Motor-evoked potentials are facil-itated during perceptual identifi-cation of hand position in healthysubjects and stroke patientsClinical Rehabilitation 17 pp648-655.

Lackner JR, DiZio P (2005)Vestibular, proprioceptive, andhaptic contributions to spatial ori-entation Annual Review ofPsychology 56 pp115- 147.

Lemon RN, Griffiths J (2005)Comparing the function of thecorticospinal system in differentspecies: organizational differencesfor motor specialization? Muscle &Nerve 32 pp261-279.

Mao HF, Hsueh IP, Tang PF, Sheu CF,Hsieh CL (2002) Analysis andComparison of the PsychometricProperties of Three BalanceMeasures for Stroke Patients Stroke33 pp1022-1027.

Maravita A, Spence C, Driver J(2003) Multisensory Integrationand the Body Schema: Close toHand and Within Reach CurrentBiology 13 pp531-539.

Raine S (2007) The current theoret-ical assumptions of the Bobathconcept as determined by themembers of BBTA Physiotherapytheory and Practice 23 (3) pp137 –152.

Shumway-Cook A, Woollacott MH(2007) Motor control: theory andpractical applications 3rd editionBaltimore, Lippincott Williams andWilkins.

www.ibita.org

www.bbtauk.org

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Anterior view pre treatment

(R) hip laterally rotated, poorinteraction with (R) foot andfloor. Poor organisation within(R) LL and decreased connec-tion of LL to trunk. (L) LL more posterior and over active. Nointeraction of hands with supporting surface. Reducedproximal stability around (R)shoulder girdle (more anterior,slightly depressed and mediallyrotated).

Anterior view post treatment

Greater acceptance with sup-porting surfaces of buttocks,feet and hands. (R) LL displaysgreater organisation and inter-action with trunk. Feet alignedand interacting with floor.Placement of hands improvedpostural orientation aroundmidline. Over activity damp-ened down in (L). Proximalstability around (R) shouldergirdle remains reduced.

Anterior view pre treatment

Body weight posterior, pooralignment of thorax more posterior on pelvis. Poor segmental trunk control, ‘flatback’ loss of anterior pelvic tilt.Head forward protracted.

Anterior view post treatment

Improved translation of bodyweight anterior over pelvis(COM over BOS).

Appendix A Sitting patient A pre and post treatment


14

Measuring the outcome of intervention is acore standard of physiotherapy practice (CSP2005) and there are many outcome measure-ment scales and tools available for use byphysiotherapists. This study is a preliminarypart of a PhD and was initially planned toexplore what outcome measures are beingused for walking, gait and balance by physio-therapists who work with patients withneurological problems. The results of this havebeen reported elsewhere (Yoward et al 2007).

The importance placed on outcome measurementby physiotherapists is unclear and it is unknown ifthere are specific factors that influence a physio-therapist in outcome measurement use or if theyare used simply to fulfil guidelines and standards.Some studies have attempted to discover some ofthese issues in rehabilitation and/or therapy(Chesson et al 1996; Turner-Stokes and Turner-Stokes 1997; Maher and Williams 2005; Abrams etal 2006) but, to the authors’ knowledge, there hasbeen no literature on the influences and factors forphysiotherapists specifically working in neurology.

METHODA survey of members of a randomly selectedsample of ACPIN branches took place during 2005using a questionnaire. The procedure for devel-oping the questionnaire has been explainedelsewhere (Yoward et al 2007) but, in brief, thequestionnaire comprised three parts wherebyrespondents completed sections according to pre-vious responses for using outcome measures withpatients. This report is based on the final sectionof the questionnaire where participants wereasked to respond to the statement: ‘I am influ-enced in my choice of measure by…’. A list wasprovided of possible influences including equip-ment and time available; the environment; using

the same measure as colleagues; patient diag-nosis, compliance, cognitive state and goals;reliability, validity and sensitivity of the test; whowill see the data; and training/confidence in usingthe measure. A space was available for respon-dents to insert their own suggestions and thepossible options for level of influence were ‘very’,‘partly’ or ‘not at all’

Participants were also asked to rate a range ofstatements with options presented in five pointLikert-style (strongly agree, agree, neither agreenor disagree, disagree and strongly disagree). Thestatements are shown below in the results section.

347 questionnaires were sent to the sample withfollow up reminder letters and repeat question-naires sent to those who had not responded by theallotted time. The results were analysed usingSPSS version 14.

Ethical approval was granted by York St JohnCollege (now York St John University) and consentwas assumed from return of completed question-naires. All questionnaires were anonymous.

RESULTS269 questionnaires were returned completed, aresponse rate of 78%. The results reported hereare from section three of the questionnaire. Not allrespondents were expected to complete thesequestions depending on answers supplied fromparts 1 and 2. Therefore, results presented arefrom those who answered the relevant questionsrather than from the whole sample.

InfluencesFigure 1 shows the level of influence in choice ofmeasure.

Rating statementsTable 1 below shows the rating of statements,related to outcome measurement, by percentageof respondents who answered the question.

Outcome measurement by physiotherapists who work in neurologyLS Yoward*, P Doherty, C Boyes

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DISCUSSIONThe results overall suggest that the vast majorityof respondents are committed to outcome meas-urement. Most consider that measurementsshould be routinely taken during assessment(81.4% who agreed or strongly agreed) and that itis the duty of the physiotherapist to measureoutcome of intervention (93.2%). Only a small per-

centage of respondents (less than 10%) weremeasuring outcome solely for the purposes of ful-filling guidelines and policies. This is reassuring asit is a core standard (CSP 2005) that all physio-therapists should measure outcome and thissample of physiotherapists are reporting adher-ence to the standard. This is perhaps a differentpicture to that of a decade ago when the results of

The reliability of a test is important to me 36.6 (87) 60.5 (144) 2.9 (7) 0 0

The validity of a test is important to me 37.8 (90) 58.4 (139) 3.8 (9) 0 0

Consistency in using a measure is important 46.6 (111) 51.3 (122) 1.7 (4) 0.4 (1) 0

Measurement should be routinely carried out during assessment 33.9 (80) 47.5 (112) 11.4 (27) 7.2 (17) 0

It is a physiotherapist’s duty to measure outcome of intervention 43.2 (102) 50.0 (118) 4.7 (11) 2.1 (5) 0

I show the results of measurement to the patient concerned 23.2 (55) 51.9 (123) 23.2 (55) 1.7 (4) 0

I use the results of measurement to evaluate my own performance 9.2 (22) 47.1 (112) 25.6 (61) 18.1 (43) 0

My manager/team leader asks for the results of measure(s)* 3.0 (7) 10.4 (24) 26.5 (61) 44.3 (102) 15.7 (36)

I always analyse the data collected* 5.5 (13) 40.8 (97) 28.2 (67) 23.1 (55) 2.5 (6)

I feel confident in using the measure(s) I use 14.3 (34) 77.3 (184) 6.7 (16) 1.7 (4) 0

I only use outcome measurement to fulfil the requirements of guidelines and policy 1.7 (4) 7.6 (18) 17.6 (42) 55.0 (131) 18.1 (43)

I would prefer to use a different measure(s) to the one(s) I do use 2.6 (6) 15.1 (35) 51.3 (119) 30.6 (71) 0.4 (1)

Equipmentavailable

Timeavailable

Theenvironment

Usingthe same

measure mycolleagues

use

Patientdiagnosis

Patientcompliance

Patient’scognitive

state

Patient’sgoals

Thereliabilty of

a test

Thevalidity of

a test

Thesensitivityof a test

Who willsee the

data

Training/confidencein using the

measure

70

60

50

40

30

20

10

0

% o

f tho

se th

at a

nsw

ered

the

ques

tion

Very Partly Not at allFigure 1 Influences in choice of measure

Table 1

Statement Stronglyagree

Agree Neitheragree ordisagree

Disagree Stronglydisagree

Figures in parentheses indicate actual numberTotal percentages differ from 100% due to rounding


16

an outcome measures project for ACPIN memberssuggested that few therapists were routinely usingstandardised scales (Hitchcock 1997). The rele-vant core standard is explicit in that the measureused should be valid and reliable (CSP 2005). Themajority of respondents rate these aspects of themeasures used as important considerations sug-gesting an understanding of the psychometricrequirements of tests and scales used.

Although the majority of respondents felt confi-dent with the measures that they were using,there was a mixed response to whether an alter-native measure would be preferred. Results alsosuggested that approximately three quarters ofrespondents were very or partly influenced intheir choice of measure by the one/s that their col-leagues use. It may be that departments have abattery of tests/scales that are used with patientsand that all physiotherapists working in thedepartment adhere to using the same tests.Standardisation of outcome measure use can bebeneficial in that the health status of patients fol-lowing intervention can be more easily compared(Hammond 2000). However, there may need to bescope for alternative measures to be used if a cli-nician becomes aware of a more appropriatemeasure or assistance given to a clinician if theylack training or confidence in the measure beingused by the team. These results show that a highpercentage of respondents were influenced intheir choice of measure by the training/confidencein using the measure.

A high percentage of respondents were veryinfluenced by aspects of the patient in the choiceof measure for example, the patient’s cognition,goals and compliance. This is to be expected inclient centred care. Approximately three quartersof the respondents show the results to the patientconcerned. This again supports client centred careand inclusivity. Presumably the figure is nothigher still as showing the results to the patientwill depend on their ability, emotional and cogni-tive state and consciousness, all of which could bevariable for patients with neurological problems.

Surprisingly, less than half were very influencedin their choice of measure by the time availablealthough a significant majority (87.6%) were influ-enced to some extent (very or partly) by the timeavailable. This corresponds closely with resultsfrom a survey of physiotherapists working withpatients who have had a lung transplant where83% stated that their outcome measurement usewas limited by the lack of time (Maher andWilliams 2005). Clinicians may be selective abouthow often the measure is used if it is lengthy butsuitable for purpose; this aspect would benefitfrom further investigation.

The environment also influenced choice ofmeasure for many of the respondents. This may bebecause of environmental constraints. Forexample, when working in a patient’s home, spacemay limit the type of test that can be administered(21% of all respondents worked in a communitysetting with neurological patients and 12%worked in a general community setting; these arenot necessarily a different group of people assome listed more than one place of work). Theoutcome measure used by most respondents tothe questionnaire was the ten metre walk testwhich clearly demands a significant amount ofspace. The environment would have an impact onbeing able to use this test particularly in apatient’s home. However, it has been shown to beacceptable if performed as a five metre walk witha turn and five metre return (van Herk et al 1998).Equipment may be a factor in choice of measure,with most respondents being very or partly influ-enced. This could be linked to the environment inthat some means of measuring require specificequipment. It would be impractical for thoseworking in some environments to be able to usecertain measures, for example if working in apatient’s home, the use of force plate data wouldbe impossible. Financial considerations may alsoinfluence the equipment that is available irrespec-tive of the environment and lack of confidence ortraining in the equipment that is available couldlimit its use.

The majority of respondents were not influencedat all by who would see the data. No attempt wasmade to clarify in the questionnaire if differentindividuals seeing the data collected may cause adifference in the level of influence, for example ifthe respondent would feel differently were apatient, colleague or manager seeing the results.The results from the rating scales suggest that it isgenerally not managers who ask to see the resultsso presumably the response is mostly directedtowards not being influenced by colleagues orpatients seeing the results of measurement.Although it seems that managers do not routinelyask to see the data collected, suggesting that theresults do not form part of appraisal, the majorityof respondents use the data to evaluate their ownperformance. It is unclear how the data is used toevaluate own performance as 56% agreed orstrongly agreed with this statement yet only 46%agreed or strongly agreed that they alwaysanalysed the data collected. Without analysis ofthe data, the use of it for evaluation purposes maynot be objective. The results for analysing the datais a little lower than that found amongst a sampleof professionals (the majority of respondents weredoctors) who work in rehabilitation centres where

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57% reported collating and analysing the data col-lected (Turner-Stokes and Turner-Stokes 1997).The use of data, once collected, warrants furtherinvestigation.

The respondents are those who are members ofa special interest group and in being so are pre-sumably interested in their work and specialty. Inaddition, those that were contacted for the surveyare only those who have given their permission toACPIN to be contacted for the purposes ofresearch and are therefore willing to share theirpractice. This may have positively influenced theresults achieved if compared to a general sampleof physiotherapists. In addition, questionnaireslend themselves to data of reported rather thanactual behaviour (Abrams et al 2006) potentiallyleading to overly positive results.

CONCLUSIONACPIN members surveyed by questionnairebelieve that it is their duty to measure theoutcome of intervention and they are influenced intheir choice of measure by many factors includingpatient issues, time available and psychometricproperties of the measures. It would be useful toinvestigate further the destiny of the data that iscollected and the means by which outcome meas-urement could be used for evaluation ofperformance.

ReferencesAbrams D, Davidson M, Harrick J,Harcourt P, Zylinski M, Clancy J(2006) Monitoring the change:Current trends in outcome meas-ure usage in physiotherapyManual Therapy 11 pp46-53.

Chartered Society of Physiotherapy(2005) Core standards of physio-therapy practice London:Chartered Society ofPhysiotherapy.

Chesson R, Macleod M, Massie S(1996) Outcome measures used intherapy departments in ScotlandPhysiotherapy 82 (12) pp673-679.

Hammond R (2000) Evaluation ofphysiotherapy by measuring theoutcome Physiotherapy 86 (4)pp170-172.

Hitchcock R (1997) Outcome meas-ures project 1996 Synapse Autumnpp44-45.

Maher C, Williams M (2005) Factorsinfluencing the use of outcomemeasures in physiotherapy man-agement of lung transplantpatients in Australia and NewZealand Physiotherapy Theory andPractice 21 (4) pp201-217.

Turner-Stokes L, Turner-Stokes T(1997) The use of standardisedoutcome measures in rehabilita-tion centres in the UK ClinicalRehabilitation 11 pp306-313.

Van Herk IEH, Arendzen JH,Rispens P (1998) Ten metre walk,with or without a turn? ClinicalRehabilitation 12 pp30-35.

Yoward LS, Doherty P, Boyes C(2007) A survey of outcome meas-urement of balance, walking andgait amongst physiotherapistsworking in neurology in the UK Inpress.

AcknowledgementsMany thanks to ACPIN memberswho completed and returnedtheir questionnaires. Thanks alsoto physiotherapy staff at BarnsleyPrimary Care NHS Trust and lectur-ers at York St John University forassistance with devising andpiloting the questionnaire, and toEd Kirby for administration of thesurvey.

Funding for the project, as part ofa doctoral study, was provided bythe Faculty of Health and LifeSciences at York St John University

* Corresponding author. Authorsall from Faculty of Health and LifeSciences, York St John University,Lord Mayor’s Walk, York, YO31 7EX.


18

heads up! is a specialist out-patient neurological physiotherapy

practice with clinics at South Holmwood (near Dorking), New Victoria

Hospital (Kingston), Roehampton and Sevenoaks. We are committed

to developing one of the best neurological physiotherapy practices in

the country.

We currently have no vacancies but please feel free to email your CV at any time if youwould like to be considered for a future position. Further details can be found atwww.headsup.co.uk/recruitment.htm

heads up!

For more information, please call Sally Watt,

the Practice Manager, on 01306 888171

Please send your cv to [email protected]

We offer:• the opportunity to treat patients with a

wide range of neurological conditions atdifferent levels of rehabilitation andmaintenance

• the chance to focus fully on treatment

• the opportunity to provide patients withregular quality treatment based on clinicalneed over extended periods

• the chance to work (and learn) with othersenior neuro-physiotherapists

• the opportunity to work with a group ofdedicated and enthusiastic patients

• weekly in-house CPD

• funding for relevant courses (including theAdvanced Bobath course and the MSc inthe Bobath Concept)

• the opportunity to treat some patients intheir own homes

• contribution towards relocation expenses

We require:• you to be five years qualified

• at least three years’ neurological clinicalexperience

• completion of the three week basic Bobathcourse on Adult Hemiplegia

• enthusiasm

• flexibility

• ability to work well within a team

• professional commitment

• motivation and organisational abilities

• willingness to work in different locations/within the community

• use of own car

heads up! 9 Warwick Road, South Holmwood, Dorking, Surrey RH5 4NP

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ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATIONVolume 88:9

• Adams M M et al The Spinal CordInjury Spasticity Evaluation Tool:Development and Evaluationpp1185-1192.

• De Niet M et al The Stroke Upper-Limb Activity Monitor: ItsSensitivity to Measure HemiplegicUpper-Limb Activity During DailyLife pp1121-1126.

• Desrosiers J et al Effect of a HomeLeisure Education Program AfterStroke: A Randomized ControlledTrial pp1095-1100.

• Herman T et al Six Weeks ofIntensive Treadmill TrainingImproves Gait and Quality of Lifein Patients With Parkinson’sDisease: A Pilot Study pp1154-1158.

• Koenig K L et al Stroke-RelatedKnowledge and Health BehaviorsAmong Poststroke Patients inInpatient Rehabilitation pp1214-1216.

• Lewis J E et al The RelationshipBetween Perceived Exertion andPhysiologic Indicators of StressDuring Graded Arm Exercise inPersons With Spinal Cord Injuriespp1205-1211.

• Lynch E A et al Sensory Retrainingof the Lower Limb After AcuteStroke: A Randomized ControlledPilot Trial pp1101-1107.

• Turns L J et al RelationshipsBetween Muscle Activity andAnteroposterior Ground ReactionForces in Hemiparetic Walkingpp1127-1135.

• White J H et al Community-Dwelling Stroke Survivors:Function Is Not the Whole StoryWith Quality of Life pp1140-1146.

Volume 88:10

• Chang J J et al Effects of Robot-Aided Bilateral Force-InducedIsokinetic Arm Training CombinedWith Conventional Rehabilitation

on Arm Motor Function in PatientsWith Chronic Stroke pp1332-1338.

• Danielsson A et al Measurement ofEnergy Cost by the PhysiologicalCost Index in Walking After Strokepp1298-1303.

• Dyson-Hudson T A et alAcupuncture for Chronic ShoulderPain in Persons With Spinal CordInjury: A Small-Scale Clinical Trialpp1276-1283.

• Jutai J et al Mobility AssistiveDevice Utilization in a ProspectiveStudy of Patients With First-EverStroke pp1268-1275.

• Lechner H E et al The Effect ofHippotherapy on Spasticity andon Mental Well-Being of PersonsWith Spinal Cord Injury pp1241-1248.

• Mehrholz J et al Predictive Validityand Responsiveness of theFunctional Ambulation Categoryin Hemiparetic Patients AfterStroke pp1314-1319.

• Van Vliet P M and Sheridan M RCoordination Between Reachingand Grasping in Patients WithHemiparesis and Healthy Subjectspp1325-1331.

• Verheyden G et al Validity of theTrunk Impairment Scale as aMeasure of Trunk Performance inPeople With Parkinson’s Diseasepp1304-1308.

• Wilde M C et al CognitiveImpairment in Patients WithTraumatic Brain Injury andObstructive Sleep Apnea pp1284-1288.

• Yang Y et al Dual-Task ExerciseImproves Walking Ability inChronic Stroke: A RandomizedControlled Trial pp1236-1240.

Volume 88:11

• Celnik P et al SomatosensoryStimulation Enhances the Effectsof Training Functional Hand Tasksin Patients With Chronic Strokepp1369-1376.

• Cup E H et al Exercise Therapy andOther Types of Physical Therapy forPatients With NeuromuscularDiseases: A Systematic Reviewpp1452-1464.

• Jonsdottir J and Cattaneo DReliability and Validity of theDynamic Gait Index in PersonsWith Chronic Stroke pp1410-1415.

Volume 88:12

• Baker K et al The Immediate Effectof Attentional, Auditory, and aCombined Cue Strategy on GaitDuring Single and Dual Tasks inParkinson’s Disease pp1593-1600.

• Haisam J A et al Prognostic Modelsfor Physical Capacity at Dischargeand 1 Year Postdischarge FromRehabilitation in Persons WithSpinal Cord Injury pp1694-1703.

• Mudge S et al Criterion Validity ofthe StepWatch Activity Monitor asa Measure of Walking Activity inPatients After Stroke pp1710-1715.

• Paltamaa J et al Measures ofPhysical Functioning Predict Self-Reported Performance in Self-Care, Mobility, and Domestic Lifein Ambulatory Persons WithMultiple Sclerosis pp1649-1657.

• Wada N et al Clinical Analysis ofRisk Factors for Falls in Home-Living Stroke Patients UsingFunctional Evaluation Toolspp1601-1605.

Volume 89:1

• Chestnut C and Haaland K YFunctional Significance ofIpsilesional Motor Deficits AfterUnilateral Stroke pp62-68.

• Sherer M et al Effect of Severity ofPost-Traumatic Confusion and ItsConstituent Symptoms on OutcomeAfter Traumatic Brain Injury pp42-47.

• Stoquart G G et al Effect ofBotulinum Toxin Injection in theRectus Femoris on Stiff-Knee Gaitin People With Stroke:

A Prospective Observational Studypp56-61.

• Vickery C D et al RelationshipsAmong Premorbid Alcohol Use,Acute Intoxication, and EarlyFunctional Status After TraumaticBrain Injury pp48-55.

Volume 89:2

• Caty G D et al ABILOCO: A Rasch-Built 13-Item Questionnaire toAssess Locomotion Ability in StrokePatients pp284-290.

• Cowan R E et al PreliminaryOutcomes of the SmartWheelUsers’ Group Database: AProposed Framework forClinicians to Objectively EvaluateManual Wheelchair Propulsionpp260-268.

• Jensen M P et al Chronic Pain inPersons With Myotonic Dystrophyand FacioscapulohumeralDystrophy pp320-328.

• Malmouin F et al Reliability ofMental Chronometry for AssessingMotor Imagery Ability After Strokepp311-319.

• Niessen M H et al Proprioceptionof the Shoulder After Stroke pp333-338.

• Patterson K K et al Gait Asymmetryin Community-Ambulating StrokeSurvivors pp304-310.

CLINICAL REHABILITATIONVolume 21:9

• Cakit B D et al The effects of incre-mental speed-dependent tread-mill training on posturalinstability and fear of falling inParkinson's disease pp698-705.

• Cattaneo D et al Effects of balanceexercises on people with multiplesclerosis: a pilot study pp771-781.

• Chang Y et al Decrease of hyperto-nia after continuous passivemotion treatment in individualswith spinal cord injury pp712-718.

ARTICLES IN OTHER JOURNALS


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• Fong K et al The effect of volun-tary trunk rotation and half-fieldeye-patching for patients withunilateral neglect in stroke: arandomized controlled trialpp729-741.

• Knottnerus A M et al Diagnosisand treatment of depression fol-lowing acquired brain injury: acomparison of practice in the UKand the Netherlands pp805-811.

• Tihanyi T K et al One session ofwhole body vibration increasesvoluntary muscle strength tran-siently in patients with strokepp782-793.

Volume 21:10

• Bereton L et al Interventions foradult family carers of people whohave had a stroke: a systematicreview pp867-884.

• Burns A et al Does the use of aconstraint mitten to encourageuse of the hemiplegic upper limbimprove arm function in adultswith subacute stroke? pp895-904.

• Haisam J A et al Physical fitness inpeople with a spinal cord injury:the association with complica-tions and duration of rehabilita-tion pp932-940.

• Kaplon R T et al Six hours in thelaboratory: a quantification ofpractice time during constraint-induced therapy (CIT) pp950-958.

Volume 21:11

• Lannin N A et al A systematicreview of upper extremity castingfor children and adults with cen-tral nervous system motor disor-ders pp963-976.

• Willemse-van Son A H P et alPrognostic factors of long-termfunctioning and productivity aftertraumatic brain injury: a system-atic review of prospective cohortstudies pp1024-1038.

Volume 21:12

• Lin K C et al Effects of modifiedconstraint-induced movementtherapy on reach-to-grasp move-ments and functional perform-

ance after chronic stroke: a ran-domized controlled study pp1075-1087.

• Michael S M et al Tilted seat posi-tion for non-ambulant individu-als with eurological andneuromuscular impairment: asystematic review pp1063-1074.

Volume 22:1

• Hart S and Morris R Screening fordepression after stroke: an explo-ration of professionals' compli-ance with guidelines pp60-71.

• Sveen U et al Self-rated compe-tency in activities predicts func-tioning and participation oneyear after traumatic brain injurypp38-45.

Volume 22:2

• Dalton et al A novel cause ofintrathecal baclofen overdosage:lessons to be learnt pp188-190.

• Myint J et al A study of constraint-induced movement therapy insubacute stroke patients in HongKong pp112-124.

• Vickery C D et al Self-esteem in anacute stroke rehabilitation sam-ple: a control group comparisonpp179-187.

DISABILITY AND REHABILITATIONVolume 29:17

• Whole volume dedicated to issuesaround return to work, includesstroke, SCI and TBI.

Volume 29:18

• De Jong L et al The hemiplegicarm: Interrater reliability andconcurrent validity of passiverange of motion measurementspp1442-1448.

Volume 29:19

• Teixeira-Salmela L et al Validationof the human activity profile instroke: A comparison of observed,proxy and self-reported scorespp1518-1524.

Volume 29:20/21

• Cott C et al Continuity, transitionand participation: Preparingclients for life in the communitypost-stroke pp1566-1574.

Volume 29:23

• Gracies J et al The role of botu-linum toxin injections in themanagement of muscle overac-tivity of the lower limb pp1789-1805.

• Scott A Development of botu-linum toxin pp 1757-1758

• Singer K and Singer B The role ofbotulinum toxin injection inachieving balanced muscle func-tion pp1759-1760.

• Turner-Stokes L and Ashford SSerial injection of botulinum toxinfor muscle imbalance due toregional spasticity in the upperlimb pp1806-1812.

Volume 29:24

• Alaszewski A et al Working after astroke: Survivors' experiences andperceptions of barriers to andfacilitators of the return to paidemployment pp1858-1869.

• Cattaneo D et al Reliability of fourscales on balance disorders inpersons with multiple sclerosispp1920 -1925.

• Van de Port I et al Identification ofrisk factors related to perceivedunmet demands in patients withchronic stroke pp1841-1846.

• Voerman G et al Clinometric prop-erties of a clinical spasticitymeasurement tool pp1870-1880.

Volume 30:2

• Yorkston K et al Measuring partic-ipation in people living with mul-tiple sclerosis: A comparison ofself-reported frequency, impor-tance and self-efficacy pp88-97.

• Tyson S et al Development of aframework for the evidence-based choice of outcome meas-ures in neurologicalphysiotherapy pp142-149.

Volume 30:4

• Klaske W et al The MultipleSclerosis Impact Profile (MSIP).Development and testing psycho-metric properties of an ICF-basedhealth measure pp261-274.

• Pryor J A nursing perspective onthe relationship between nursingand allied health in inpatientrehabilitation pp314.

• Yukihiro H et al A home-basedrehabilitation program for thehemiplegic upper extremity bypower-assisted functional electri-cal stimulation pp296-304

PHYSICAL THERAPYVolume 87:9

• Chien-Ho L et al Effect of TaskPractice Order on Motor SkillLearning in Adults With ParkinsonDisease: A Pilot Study pp1120-1131.

• Wolf S Revisiting Constraint-Induced Movement Therapy: AreWe Too Smitten With the Mitten?Is All Nonuse ‘Learned’? and OtherQuandaries pp1212-1223.

• Lindquist A et al Gait TrainingCombining Partial Body-WeightSupport, a Treadmill, andFunctional Electrical Stimulation:Effects on Poststroke Gait pp1144-1154.

Volume 87:10

• Kegelmeyer D et al Reliability andValidity of the Tinetti Mobility Testfor Individuals With ParkinsonDisease pp1369-1378.

Volume 87:12

• Etnyre B and Thomas D EventStandardization of Sit-to-StandMovements pp1651-1666.

• Sullivan K et al Effects of Task-Specific Locomotor and StrengthTraining in Adults Who WereAmbulatory After Stroke: Resultsof the STEPS Randomized ClinicalTrial pp 1580-1602.

• Welmer A et al Determinants ofMobility and Self-care in OlderPeople With Stroke: Importance ofSomatosensory and PerceptualFunctions pp1633-1641.

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• Maring J and CroarkinPresentation and Progression ofFriedreich Ataxia and Implicationsfor Physical TherapistExamination pp1687-1696.

Volume 88:1

• Mossberg K et al CardiorespiratoryCapacity After Weight-SupportedTreadmill Training in PatientsWith Traumatic Brain Injury pp77-87.

• Schenkman M et al EnduranceExercise Training to ImproveEconomy of Movement of PeopleWith Parkinson Disease: ThreeCase Reports pp63-76.

Vol 88 (2)

• Di Fabio R et al Gaze Control andFoot Kinematics During StairClimbing: Characteristics Leadingto Fall Risk in ProgressiveSupranuclear Palsy pp240-250.

• Paltamaa J et al MeasuringDeterioration in InternationalClassification of FunctioningDomains of People With MultipleSclerosis Who Are Ambulatorypp176-190.

PHYSIOTHERAPY RESEARCHINTERNATIONALVolume 12:3

• Pyöriä O et al Validity of the pos-tural control and balance forstroke test pp162-174.

• Glinsky J et al Efficacy of electricalstimulation to increase musclestrength in people with neuro-logical conditions: a systematicreview pp175-194.

PHYSIOTHERAPY THEORYAND PRACTICE Volume 23:6

• Bohannon R Knee extensionstrength and body weight deter-mine sit-to-stand independenceafter stroke pp 291-298.

STROKEVolume 39:2

• Pollock et al PhysiotherapyTreatment Approaches for Strokepp519-520.

• Wu H et al Acupuncture for StrokeRehabilitation pp517-518.


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I would like to share with you some of myexperiences with physiotherapy since mystroke in 2001. I was in England at the time,and spent seven months in hospital and reha-bilitation.

After the acute phase, once I got into a good rehabcentre, physiotherapists became among the mostimportant people in my life for a while.

There are two early experiences I’d like to tellyou about, concerning what it felt like losing thesensations and movement of one half of my body.The first sounds comical when I tell it, but wasvery perplexing at the time. I remember wakingup in a hospital bed and finding a body part whichseemed to have nothing to do with me, in my bed!I had found somebody’s breast! It could not bemine as I could only feel it with my good hand – Ireasoned that if it had been part of my own body,surely I would have known that I was touching it?That was the beginning of knowing that I could nolonger trust the sensory input from the left side ofmy body to my brain.

The second incident that stays with me is that ofthe ‘phantom hand’: some time later I had beenput in a chair at a table. An object rolled off thetable and my left hand shot out reflexively to catchit… or so I thought. I felt it, and was sure that myhand went out… and the object fell right throughit! That was amazing because, not only did I feelmy hand go out, but I was pretty sure I’d seen ittoo. However, on looking down, and feeling for itwith my right hand for confirmation, I found myleft hand lying inert in my lap. So no magic; mybrain had tricked me again. This had beenanother indication that I would have to learn newways of knowing what was going on with the leftside of my body.

Around this time I had my first physiotherapysessions. I remember being asked to move my left

arm. I tried desperately and nothing happened.The same when I was asked to move my leg. It feltlike I was looking down into the left side of mybody into a hollow, empty darkness, searching forsomething to use to make it move. There wasnothing inside it, no mechanisms to move my armor leg with. My right side, in contrast, felt full oflife.

So that was where I started on this interestingjourney of life after stroke.

What were the things that helped?Most of all the wonderful and constant support ofmy husband and family. Coming a close secondhas been the help I have received from a numberof physiotherapists.

Though not so much to begin with. As I said, Iwas in England when I had my stroke and unfor-tunately for me my local hospital was one of twowhich had been rated as the worst hospitals in thecountry. There seemed to be a physiotherapyprogram I should slot into and a right and wrongto each exercise. My efforts never seemed to besatisfactory, however hard I tried. I seemed to dis-appoint my physiotherapists.

Then I was moved to a specialist rehab centrewhere the physiotherapy approach seemed to bevery different and I heard for the first time, theterm Bobath.

It was here I had my ‘standing on no leg’ experi-ence: I remember being supported at ankle, knee,hip and torso as I was stacked up on my left leg,which once I couldn’t see it, simply ceased to exist!It had no connection with my brain, so I couldn’tknow what it was doing without seeing it. This wasvery frightening – I felt a sense of vertigo as if Iwere up somewhere really high and dangerous.As I was helped to stand on my left leg and per-suaded to lift up my right foot (I took a lot ofpersuading!) I remember feeling terrified butlaughing aloud with astonishment, joy and amaze-

FOCUS ON…

Listen to our voicestelling our stories to physiotherapistsWorld confederation for Physical Therapy International Congress

Carolyn Carter stroke survivor

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ment! This was a fantastic moment for me – I hadexperienced being upright and could reallybelieve, that one day I would achieve it without ateam of people supporting me. Only because I haddeveloped a strong, trusting relationship with theteam of physiotherapists was I able to overcomemy fear enough to allow that breakthrough tohappen.

Later, the same team of physiotherapists had aBobath Instructor visiting and I was lucky enoughto have her working with me for a session. I hadthe wonderful experience of ‘walking’ with thehelp of two people who seemed to be able to facili-tate movements by initiating physical responsesthat reminded my body and brain how to do thiswalking thing again. I couldn’t do it alone, but itgave me a feeling of what I could work towards.It gave me hope.

When asked what barriers I faced, there were acouple of encounters with medical professionalswho earnestly felt obliged to give me a ‘realisticprognosis’ which did not give me hope of contin-uing improvement. Each time, this was verydepressing and demoralizing for me.

Another barrier for me, is when physiotherapistscommunicate primarily through verbal instruc-tions. I find my attention focused on languageprocessing and not on being aware of sensory per-ception. I think this is why I have made greater

progress when working with people whose com-munication has also been through their hands,directly to my body. Because this is where myattention should be: If I’m figuring out what thephysiotherapist is telling me to do, and then wor-rying about whether I’ve got it right, I will not bepaying attention to what is going on inside myown body and I won’t remember the feel of thatmovement and what went before it.

In conclusion I would like to say that I feel veryfortunate to have been treated by some greatphysiotherapists since I moved to Vancouver, BC:Cathy Eustace and Libby Swain, who are bothBobath Instructors.

Having made most progress with Bobath trainedphysiotherapists in England, I sought out someonehere who would use a similar approach and I wasvery lucky to be put in touch with Cathy, who hastreated me ever since, though I see her much lessnow. I have been very busy with volunteer work inthe last couple of years and last year founded theVancouver Younger Stroke Survivor peer supportnetwork.

Although the changes are slower now, six yearson I am still aware of continued improvements inmy physical abilities, and I still set myself targets.Currently I’m working on walking without mystick. Now, when I see Cathy it’s with a focus onimproving the way I am doing this.


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ACPIN AGM 2008

MinutesOpened at 12.30pm

1. PresentJackie Sharp, Jakko Brouwers,Louise Rogerson, Nicola Hancock,Julia Williamson, Emma Forbes,Sandy Chambers, Cherry Kilbride,Jo Tuckey, Ros Cax, Siobhan MacAuley, Sue Mawson.

2. ApologiesAnne Rodger, Jo Kileff, LouiseGilbert, Fiona Wallace, Jill Fisher,Helen Dawson, Caroline Graham,Jo Jones, Carol Carr, JaniceChampion, Pam Thirlwell, HelenDawson.

3. Minutes of AGM 2007Accepted as an accurate account –proposed Chris Manning,Seconded Jackie Sharp.

4. President’s addressSue Mawson

5. Chair’s addressNicola Hancock

6. Treasurer’s addressvoting in of accountants for2008/09 – voted in by majority

7. Election of re-standing executiv committee members• Siobhan MacAuley Hon PRO –voted in by majority• Jakko Brouwers Diversity Officer– voted in by majority• Louise Rogerson Hon MinutesSecretary – voted in by majority

8. Election of new officers/committee members• Chris Manning iCSP co-ordinator – voted in bymajority• Adine Adonis committee member – voted in by majority•Gita Ramdharry committee mem-ber – voted in by majority

9. AOBnone

Meeting closed at 12.55pm

President’s addressSue Mawson MCSP BSc (Hons) PhD

The translational gapI’m sure many of you have heard thewords translational research, appliedresearch that takes theoreticalknowledge and tests it in a clinicalenvironment. An example of transla-tional research for us would be takingthe experimental work undertaken inthe field of sport science aroundknowledge of results and knowledgeof performance into the therapeuticmodels for stroke rehabilitation. Theexperimental findings from normalsubjects must be translated into clini-cal research with stroke subjects whodo not have a normal CNS. Indeed,resent work by Winstein (2007) wouldsuggest that learning paradigmsattributed to normal motor learningmay in fact be inappropriate for peo-ple who have had a stroke.

However, what does the term‘translational gap’ mean and is therea conflict between NHS policy andcurrent practice. The Cooksey review(2006) identified that whilst the UK isa leader in basic science research,there is a significant delay in takingthe results from research activity intoboth new innovations and intochanging health care practices. This‘second gap’ described by Cooksey, intranslating new ideas into clinicalpractice and new products into thecare pathway must be a significantdriver for clinical therapists in neu-rology as we seek to provide the bestevidence based care to our patientsand carers.

We know for example that tar-geted physiotherapy has beenshown to promote recovery followingbrain injury (Pomeroy and Tallis,2002). We also have evidence thatrepetitive shoulder movements per-formed soon after the stroke improveupper limb function (Fey et al 1998)and that reaching tasks in sitting hasan effect on standing from sitting(Dean, 1997). It is my belief that inthe world of neurological rehabilita-tion we have in fact translated scien-tific knowledge into changing

practice. We as physiotherapy practi-tioners have, for a number of years,taken evidence from the ‘bench tothe bed side’, ‘lab to lounge’ in myown area, phrases used to describethis Cooksey concept.

Since the early 1900s (Lawes, Musaand Kidd, 1994) we based our inter-ventions on the theories of neuro-plastic adaption however it wasn’tuntil 2000 that a study was pub-lished demonstrating, for the firsttime, that physiotherapy post strokecould result in reorganisation withinthe CNS with enlargements of themotor cortex following stimulation(Liepert 2000). A further study in 2002using fMRI showed clear signs ofincreased activity in the cortex afterrehabilitation (Johansen et al 2002).

However, there is a major problemwith this concept of translating evi-dence into practice because of a con-flict within the current NHS with afinancial model that dictates a bal-anced budget and payment by results.All Foundation Trusts now have majorproductivity and efficiency pro-grammes with cost savings year onyear that are having a huge impact onour ability to deliver evidence basedpractice. At our own ACPIN conferencehere in 2006 Kwakkle presented anextensive review of rehabilitation out-comes concluding that task orienta-tion, intensity and frequency were thekey factors for effective intervention.However in my own Foundation Trust,therapy frequency and intensity hasbeen reduced over the past year fromten sessions a week to five on ourstroke unit. We have therefore twoconflicting drivers, the need to trans-late evidence into practice and theneed to achieve a balanced budget forour Trust board. It is at times difficult tosee how we can fight such cuts in ourservices when we have the evidence toback the need for more therapy.

Perhaps if we look at a new reportof the High Level Group on ClinicalEffectiveness published in October 2007by Professor Sir John Tooke we mayfind a glimmer of hope for the future.This document clearly identifies theneed to revisit the evidence based

clinical effectiveness (EBCE) agenda.The report supports my view that thecurrent policy climate emphasisesaspect of trust performance other thanthose related to clinical effectivenesswith resulting disincentives for seniormangers. There are a number of fur-ther issues identified not least the lackof investment in the agenda and thelack of critical appraisal skills amongstall clinicians.

Tooke makes two points that Ihave been raising in Synapse overthe past three years. Firstly, that theNHS is a data poor organisationwhich lacks rigorous evaluations ofclinical effectiveness and secondly,the issue of a ‘paradigm war’ wherethe debate about the credibility ofevidence is challenged from a disci-plinary perspective rather than a sci-entific one. In 2005, 2006 and 2007 Idescribed and discussed the conceptof evidence, the problem of using anevidence hierarchy and the conflictbetween statistical significance andclinical significance. I also presentedto the reader the difference betweencentral tendency theorists whoaggregate outcome data to the groupmean and the concept of varianceswhere individual variations inresponse to interventions areanalysed to provide more valuabledata on which to base clinical andmanagerial decisions. In 2007 I sug-gested that perhaps the greatestvalue could be gained within theNHS if we undertook well designedservice evaluations using tools suchas the TELER method.

Whilst it is essential that we con-tinue to undertake pragmatic appliedresearch particularly in the areas ofcomplex interventions and servicedelivery we must also undertakegood evaluations of evidence basedpractice. Furthermore we must pro-vide valid evidence of how reduc-tions in service delivery are affectingthe quality of care we are providing.We are not translating research evi-dence into practice on our strokeunit. We must use aggregated indi-vidual data on changes in physical,psychological and social well being to

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provide evidence that these reduc-tions are having a major impact onthe quality of care we are providing.

The way to ensure that we under-take translational research and trans-late research findings into practice isthrough closer links with academia.Undergraduate and post graduateeducation is crucial if we are tochange the way we provide, interpretand use evidence in the field of neu-rological rehabilitation. Senior clini-cians must be given and take theopportunity to work in closer collabo-ration with university partners, as vis-iting lecturers, secondees, andcurriculum advisers. On the one handthe academic institution may beworld renounced for work on musclearchitecture or kinematic analysis in alaboratory setting on the other clini-cians have the experiential knowl-edge and serendipitous observationsthat become research questions thatare clinically relevant to patients andcarers. It is the clinician that translatesthe science into changed behaviour,do not underestimate your value butlearn to harness your skills as expertpractitioners in the fight to provideevidence of poor care that is resultingfrom reduced NHS resources for neu-rological rehabilitation.

ReferencesFey HM, de Weerdt W, Seltz BE, Cox-Steck GA, Spichiger R, Vereeck LE,Putman KD, Van-Hoydonck GA (1998)Effect of a therapeutic interventionfor the hemiplegic upper limb in theacute phase after stroke: a singleblind, randomised controlled multicentre trial Stroke 29 pp785-792.

Johansen-Berg H, Dawes H, Guy C,Smith S, Wade D, Matthews P (2002)Correlation between motor improve-ments and altered fMRI activity afterrehabilitative therapy Brain 125pp2731-2742.

Liepert J, Bauder H, Miltner W, Taub E,Weiller C (2000) Treatment–inducedcortical reorganisation after stroke inhumans Stroke 31 pp1210-1216.

Pomeroy VM, Tallis RC (2002)Restoring movement and functionalability post stroke: now and thefuture Physiotherapy 88 pp3-17.

Tooke J (2007) Report on the Highlevel group on Clinical EffectivenessDepartment of Health.

Chairs addressNicola Hancock MCSP BSc (Hons)

As usual, the ACPIN year proceeded atgreat pace. Despite reviewing andchanging their structure in order toreflect the goals of our organisationmore fully, National and Executivecommittee meetings actually seemedthe easy bit this year, as so many ofus were involved in other projectsand activities during the monthsbetween our meetings at the CSP.These contributions on your behalfare far too numerous to mention infull here, though I have includedsome to give you an idea of what wehave been up to.

You will no doubt be aware of thelaunch of the National Stroke Strategyin December. Members of the com-mittee were involved in peer reviewand in the PR for its launch, includ-ing articles in Frontline in both theconsultation and publication stages.Consultation on the NICE acute strokeguidelines has just closed and RhodaAllison has played a lead role for usin the process, supported by CherryKilbride and I continue to representACPIN on the RCP intercollegiatestroke working party, alongsideSheila Lennon and Chris Fitzpatrick,with new National Stroke Guidelinesdue this summer.

You are all aware, I am sure, of thenew, online membership system andI hope have all now tapped in yourdetails. This has been a huge changefor ACPIN and it would be facile toeven attempt to sum up the workput in by Jo Tuckey, who is about tobecome co-chair, and Mary Cramp-yes, that’s the same Mary Cramp whoresigned a year ago! Genuine thanksare due to them both and to all ofyou, for your patience with the newsystem.

Our reputation for excellent pro-fessional events continues, and weare a key group involved in Congressin Manchester later this year –Siobhan MacAuley has facilitated atruly fantastic programme for theneurology strand, and I am sure youare all aware of Anne Shumway Cookas a key note speaker, amongst manyothers. Thanks are also due toSiobhan for this excellent work.

I suppose that leads neatly into theinevitable, but none the less essen-

tial part of my address, that ofthanking those not already men-tioned.

Sue Mawson, our President,remains a constant source of inspira-tion and support, and I am sure youwill all join me in congratulating heron her recent appointment to Chairof Rehabilitation at Sheffield – sohere’s to the Prof!

Thanks to all members supportingACPIN on other groups include AnnAshburn at the UK Stroke Forum,Rhoda Allison on the NICE workingparty, Jill Fisher who represented uson the Manual Handling group at theCSP, and Chris Manning and all themoderators for their roles with iCSP.

Louise Dunthorne continues to doan inspired job in producingSynapse, thank you Louise from usall.

The regional reps continue to pro-vide a hub for contact from and tothe regions via the national commit-tee so thanks to them all for theirservice this year.

It is time to say goodbye to somevery long serving ExecutiveCommittee members. Jackie Sharpleaves us after ten years of service,and we are also very sad to be losingRos Cox, Emma Forbes, and LouiseGilbert. It is impossible to quantifytheir roles but we do have somesmall gifts to represent how gratefulwe are and how much we will missthem.

This means, that as I also depart,the committee really does havesomething of a fresh start, and wewill vote on our new members in aminute. I am really happy to be

leaving things in the very safe andexperienced hands of Jo Tuckey andCherry Kilbride, who will take on theChair’s seat together and I wish themboth the very best in their new roles.

And what of the future? Well, Ithink that we have a responsibility toengage further in the researchprocess, particularly in initiating anddriving forward work that is transfer-able and clinically relevant,acknowledging of course the terrificwork already done and that which isunderway. We must continue as anorganisation to have a loud andpowerful voice, as it is only from thevast clinical, educational andresearch expertise within the ACPINcommunity that change will happenin the direction we know it should:not only in terms of direct clinicalpractice, but in service commission-ing and development, and invest-ment in research and training. Whilstthe erosion of neurorehabilitationservices remains a reality, largely dueto the short-term political agenda,there remain many opportunities forfurther development and investmentand it is the duty of us all to ensurewe refute the former and insist onthe latter.

And for me personally, as I tendermy resignation to the Executive, thelong, ACPIN-free evenings loom! Ihave had a wonderful time in my tenyears of involvement and have beentruly honoured to serve as Chair since2004. I wish you all my very best,and look forward to seeing you atnext year’s AGM, from my vantagepoint in the very back row!

Nicola Hancock (centre) the outgoing Chair with the two new co-Chairs, CherryKilbride(left) and Jo Tuckey.


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Treasurer’s reportJackie Sharp

I will now present a summary of thefinancial accounts for National ACPINfor the year end 31st December 2007.

The total income (Figure 1) was£47,222, an decrease of £25,681. Thiswas mainly due to a substantiallyreduced income from conferences. Weonly held the Spring Conference inMarch 2007 and charged the member-ship at discounted rates. We made aloss on this conference but felt it was agood opportunity to put some of themonies back into the membership.

costs due to revamping the member-ship process. There has also been aslight increase in travelling expenses.

The website has cost more toupdate this year due to a change inthe way we are managing the site.Monthly updates have now startedand this results in a yearly expendi-ture of £1,400. Courses are also adver-tised on the website which adds tothe costs of maintaining the site.

Costs for 2007 continue to arisefrom the UK Stroke Forum. ACPINhave a representative on this forumand fund two committee membersto attend the annual conference witha view to holding programmes at thisevent in future years.

Delegate reportSam Botting Physiotherapy NeuroExpert Lead Portsmouth City teachingPrimary Care Trust

As a neurophysiotherapist with aspecial interest in acquired braininjury I was eager to attend thisACPIN conference, it promised a goodrange of presentations from acutemedical management to communitymild brain injury management.

There was a good representation ofphysiotherapists from across the UKand it was great to catch up with oldfriends and colleagues as well as toshare ideas, developments andreflect upon changes within the pro-vision of services across the country.

Over the two-day programmespeakers provided information on upto date clinical practice, currentresearch and addressed some of thechallenges we face when dealingwith this highly complex group ofpatients.

The lectures on day one reviewedthe acute management of the patientwith acquired brain injury.

Dr Martin Smith addressed theacute medical management ofpatients following traumatic braininjury on ITU, including current prac-tice on the monitoring and treatmentof patients with reference to thepathophysiology of primary and sec-ondary brain trauma. This was nicelyfollowed by an informative talk fromAdrian Capp he covered the physio-therapy management of thesepatients. He highlighted the impor-tance of active dynamic physiother-apy in the maintenance orpre-rehab acute phase to help pre-vent patients developing secondarycomplications.

The afternoon session began withBernie Lyons demonstrating howmuch hard work goes into aCochrane review and how specificresearch has to be to meet its strictcriteria. She gave us positive evidenceas to the effectiveness of botulinumtoxin for the management of upperlimb spastictiy.

The poster presentations followedgiving us a snap shot of work that isbeing done across the UK, it wasgood to see the use of rehabilitationassistances in different contexts.

In the final afternoon lecture

Dr Nigel Harris told us about a for-ward thinking and innovative devel-opment by the SMART rehabilitationconsortium, they have been devel-oping a new interactive assistivetechnology system for upper limbrehab, there was much enthusiasmabout this especially when we saw itin action.

The second day addressed therehab management of thesepatients. Dr Richard Greenwoodhighlighted the need for specificacute BI units/teams and addressedhow effective management improvesoutcome, giving us some ammuni-tion to go back to our commissionerswith.

Jo Tuckey followed this giving usan overview through case presenta-tions of how we might unstick thestuck patient. This was a very positivelook at how we can make significantfunctional changes with patientswho may initially appear unre-habable. Gina Sargeant went on totalk about those patients who pres-ent with challenging behaviours andgave us some really useful take homemessages on dealing with thesebehaviours, early, proactively andwith the IDT.

Nick Hedley then kept us alertbefore lunch with an insightful andentertaining account of his journeyfollowing a head injury.

In the final afternoon, AnneMcSherry told us about her role indeveloping services for the manage-ment of mild brain injury which somany of us rarely see as they oftenget missed but may have significantdebilitating problems and benefitfrom our input.

Finally Sue Mawson called us toresearch and encouraged us to regis-ter our interest in submitting a pro-posal for the NIHR ResearchProgrammes specifically the‘Research for patients benefit’.Through her rousing presentationand skiing photos a number of peo-ple may have gone home to startwriting their proposal.

Finally these two day offered agreat opportunity to network findout whats new and best practise inthe management of acquired braininjury and also to thank NicolaHancock for all her hard work beforeshe stepped down as chair. ■

2006 2007£ £

Course fees 35,937 8,925

Membership 32,687 33,653

Capitation 2,536 2,698

Synapse 420 110

Database 300 117

Bank interest 1,023 1,659

Total 72,903 47,222

Figure 1 Income

2007 Income Expenditure£ £

Marchconference 8,925 9,733

Figure 3 Courses

2006 2007£ £

Courses 28,053 11,333

Synapse 8,128 7,454

Travel 6,248 7,182

Administration 6,793 7,163

Capitation 5,288 5,272

Website 589 1,561

Research bursary 488 0

UK Stroke Forum/Stroke guidelines 580 306

Accounts, banksundry 1,543 1,837

Total 57,710 42,108

Figure 2 Expenditure

£Reserves broughtforward 51,818

Surplus/deficit 5,053

Reserves carriedforward 56,871

Figure 4 Reserves

Expenditure (Figure 2) for 2007 wasdown by £15,602 compared to 2006.This was primarily due to thedecrease in CSP Conference expendi-ture. There were also a smalldecrease in the cost of producing anddistributing Synapse, but increases inwebsite expenses and administration

Figure 3 divides the course incomeand expenditure up for the confer-ence that ACPIN held this year.

In 2006 the March two day residen-tial conference, our silver jubilee, wasprojected to make a profit with fullattendance but made an unexpectedlylarge profit. This was due to a numberof reasons we could not anticipate.This money has been used to subsidisethe conferences in 2007 and 2008 bykeeping the delegate rates down.

The balance sheet (Figure 4) on the31st December 2007 showed a profitof £5,053 and we were able to carryforward reserves of £56,871 into 2007.

Copies of accounts 2007Full copies of the ACPIN accounts areavailable on request

Vote for accountantsVote to retain the current accountantsfor 2008: Langers, 8-10 Gatley Road,Cheadle, Cheshire, SK8 1PY.

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Communications/EventsEmma Forbes and Jo Tuckey

The former sub groups joinedtogether during the last meeting. Theresidential conference in March 2008was briefly discussed and it was con-firmed that 2 sponsors would beattending each day.

CSP congress 2008 was discussedbut this is very capably being organ-ised by Siobhan MacAuley and thediscussion was indeed brief.

Most of the discussions involvedthe planning of the National ACPINstudy day in March 2009. A looseworking title and location wasdecided upon with members to sug-gest speakers in time for the nextmeeting. At time of printing we areinvestigating the option of the studyday being hosted in Leeds and thetitle to involve the ‘upper limb’.Details are scant at the moment withthe plans to be given substance atthe next meeting. ■

Feedback from EAregion membersAnna Colbear and Nic Hills

East Anglia ACPIN recently sent out aquestionnaire to their regionalmembers to seek feedback on whatmembers wanted to gain from theirmembership locally. Eighty ques-tionnaires were sent out, either bypost or email, according to expressedpreference of the individuals. 23responses were received, giving aresponse rate of 29%

Thank you to all the members whoreplied. We value your feedback andhave compiled this summary ofresponses, which will shape ourplans for the future programme.

Question 1 What would you likeout of East Anglia ACPIN?

%

Study days 21

Evening lectures 13

Weekend courses 9

Half study days 20

Networking meetings 15

Summary of national meetings 22

Committee comments: It is great tosee that people are once again inter-ested in study days, after a year ofrestricted study leave and funding,which meant that several courseshad to be cancelled due to lack ofapplicants.

Question 2 Would you be interested in summaries ofnational meetings?

%

Yes 96

No 4

Committee comments: Our RegionalRep (Nic Hills) is happy to compile asummary of the main relevant pointsfrom the national meetings, whichare held three times a year. Thesecan either be posted, or electronicallysent to interested members.

Question 3 Where would youtravel to for a course?

%

Ipswich 17

Colchester 14

Norwich 16

Bury 20

Peterborough 12

Cambridge 21

Committee comments: This is alwaysa consideration in our region, whichcovers a large geographical area.Many members highlighted two orthree different locations, which hasresulted in a fairly even distribution.

Question 4 Which courses wouldyou be interested in?

%

Saboflex 11

Lycra 14

Eureka 14

Spasticity 17

Update 14

Gym ball 12

Balance 18

Committee comments: These prefer-ences will be considered when com-piling the future programme ofevents

Question 5 What time and whenwould you prefer courses tobe run?

%

Midweek 47

Evening 24

Weekend 29

Committee comments: This shows aclear preference for midweekcourses, which the committee willreact to.

Question 6 Are there any othertopics or speakers you areinterested in?

Committe comments: This produceda significant list of ideas and optionsfor courses, which gives the commit-tee some great additional ideas forprogramme planning.

Question 7 Would you be interested in neurophysio peersupport?

%

Yes 81

No 19

Committee comments: The majorityof respondents would be interested,and the committee would like to setup a coherent network of contacts formembers throughout the region,perhaps focusing on the regions’hospitals? If anyone is interested indeveloping or contributing to thisidea further, please make contactwith our Chair, or any committeemember.

The committee felt that they receivedsome valuable information duringthis exercise, and felt it helpedregional members to be moreinvolved with their ACPIN region.Thank you again to all whom con-tributed. ■


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Our stroke unit wrestles with theusual challenges of very acute med-ical care and long term rehabilitationwithin the geographical context ofone 28 bedded unit and one team.

In 2007 the unit won the Meggittexcellence award for ward with themost innovations. This was a culmi-nation of two years hard work froman experienced and specialist multi-disciplinary team with a strong and

dynamic physiotherapy representa-tion. Some of the innovations madewhere as follows:• The introduction of thrombolysis

for appropriate patients involvingconsiderable teamwork and acompetency audit.

• A ‘Tell your story’ group for patientsto discuss their experience ofstroke, run by the speech therapistswith assistance from psychologists.

• An ‘Upper Limb’ group for workwith the less able arm in a socialclass setting with relatives assistingrun by the occupational therapistsand physiotherapists.

• A revised goal setting processinvolving the patient more fullyand documenting weekly goalswhich are then displayed by theirbedside to include relatives andother staff members.

• An education group for patientsand relatives to gain a betterunderstanding of the nature of astroke and prevention measures;run by the stroke liaison nurse.

• Piloting the system of one namedtherapist for each discipline to fol-low the patient through theirinpatient journey. A patient satis-faction survey identified high lev-els of patient satisfaction with this.

• Weekly therapy timetables for dis-play by the bedside.

• The design, completion and gooduse of a therapies gym areaincluding adjustable sink andquiet room.

The publicity and recognition fromthe award had an extremely positiveaffect of staff morale and the reputa-tion of the ward. As neurologicalphysiotherapists, we tend to considerthese projects as an everyday part ofour continuing professional develop-ment but I can recommend publicis-ing them to the management of yourtrust and beyond! ■

NEWS GENERAL

Poole Hospital stroke unit wins Meggitt Excellence AwardNaomi Gibson Senior physiotherapist

The re-write of the Royal College ofPhysicians guidance entitled Themanagement of adults with spastic-ity using botulinum toxin: A guide toclinical practice was started inOctober 2006 and is progressing well.The overall aim of the document is toprovide practical advice on the use ofbotulinum toxin in the managementof spasticity in adults.

The document is a multidiscipli-nary document, which gives current‘best practice’ advice on manage-ment of spasticity with botulinumtoxin. It places this in the context ofwider rehabilitation and therapyinvolvement in the process. The doc-ument also provides specific adviceon the involvement of non-medicalinjectors particularly physiothera-pists, including involvement in

administration of botulinum toxin. Substantial progress on this work

has been made with a final draft ofthe document to be completed at theend of this month. The documentwill then be sent for peer review tobe undertaken by the CharteredSociety of Physiotherapy, The RoyalCollege of Physicians, British Societyof Rehabilitation Medicine and TheAssociation of British Neurologists.

Development group• Professor Lynne Turner-Stokes,

Consultant in RehabilitationMedicine, Northwick Park Hospital,Harrow, Middlesex; HerbertDunhill Chair of RehabilitationMedicine, King’s College London(Chair and lead editor)

• Mr Stephen Ashford, Clinical

Specialist and ResearchPhysiotherapist, RegionalRehabilitation Unit, NorthwickPark Hospital, Harrow, Middlesex;Honorary Research Fellow, King’sCollege London

• Professor Bipin Bhakta,Charterhouse Professor ofRehabilitation Medicine, Universityof Leeds, Leeds

• Ms Kate Heward, Senior Lecturer inOccupational Therapy, SheffieldHallam University, Sheffield;Private Practitioner

• Dr Peter Moore, Senior Lecturerand Consultant Neurologist, TheWalton Centre for Neurology andNeurosurgery, Liverpool.

• Mr Adrian Robertson, ClinicalSpecialist Physiotherapist, MidYorkshire NHS Trust

• Dr Anthony Ward, Consultant inRehabilitation Medicine, NorthStaffordshire Rehabilitation Centre,Stoke-on-Trent; Honorary SeniorLecturer, Keele University

Many thanks to all those involved ininputting in one form or another tothe document so far; in particular tothe UK Adult Physiotherapy SpasticityForum as well as colleagues in thepaediatric field and to those whohave commented on initial drafts ofthe document to date. Special thanksto Toni Power, York St JohnUniversity, and the group involved inthe literature review by the UK AdultPhysiotherapy Spasticity Forum. ■

The management of adults with spasticity using botulinum toxin: A guide to clinical practiceUpdate to the document published July 2002. Progress Report February 2008Steve Ashford Clinical Specialist and Research Physiotherapist (on behalf of the development group)

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In 2003 an ACPIN grant helped me todevelop a stroke self-managementworkbook tested in a series of single-case studies as part of my PhD whichI then completed in 2005. Little did Iknow then what a well-timed grantof £432.00 would lead to.

Results from my first study com-pleted in 2005 showed a significantchange in self-efficacy and perceivedcontrol following introduction of theworkbook (n=10) (paper in press).Changes were also seen in activity,participation and mood but thesewere not statistically significant. Theconcept of a one-to-one stroke self-management intervention was newbut despite these promising resultsclearly more work was needed torefine and test the intervention witha larger group. The idea of applyingfor more grants and starting theprocess again seemed a dauntingone; the completion of a PhD for meseemed a good time to stop!

Spurred on by positive commentsabout the workbook from stroke sur-vivors, carers and colleagues andsome possible over inflation of theevidence base on self-managementinterventions I started the process oftrying to get more funding. The beliefthat ‘one-size does not fit all’ withself-management interventions hascontinued to keep me going, espe-cially when reflecting on the com-plexities involved for each individualliving after stroke

Stepping Out is now not just aworkbook.The ACPIN grant helped me produceand test the workbook, but I alsorecognised that this was a complexintervention, and the active ingredi-ent could be more to do with the thepartnership between the practionersand the stroke survivor. There was aclear need to develop suitable train-ing for practitioners working withstroke survivors at any stage of thepathway to enable successful self-management skills.

The theoretical basis of SteppingOut began with Social CognitionTheory (Bandura 1997), and chronicdisease self-management research

(Lorig, Sobel et al. 2001). But thedevelopment is strongly influencedby a body of qualitative research,exploring coping and adjustmentpost stroke (Pound, Gompertz et al1999; Bendz 2003; Cott, Wiles et al2007; Ellis-Hill, Payne et al 2007;Jones, Mandy et al 2007).

Although the policy context inself-management has been movingat a pace particularly in the last fouryears, the research on self-manage-ment in stroke has barely started(Bury, Newbould et al 2005; Jones2006; DH/Vascular Programme/Stroke2007; Johnston, Bonetti et al 2007;Kendall, Catalano et al 2007;Department of Health February2006). However, Chapter 3 of thenew stroke strategy published lastDecember now advocates the needto expand the number of self-man-agement activities (DH/VascularProgramme/Stroke 2007). It is clearthat Stepping Out needs to fit withboth the concept of new managedstroke networks and with moreestablished policies for self-manage-ment and long-term conditions.

In January and February 2007,three pilot sites were introduced toStepping Out programmes. 45 practi-tioners attended workshops inInverness, Christchurch and London.Over 150 workbooks were distributedto attendees of the workshops. InMay 2007, focus groups were held atthe three pilot sites to gain feedbackabout both the workshop and theworkbook. Following this, a secondversion of the workbook has beendeveloped to reflect comments madeby practitioners, stroke survivors andcarers.

What did practitioners say?‘We found automatically patientssearched for stories of other individ-uals experiencing similar issues aftertheir stroke, and found people whowere of a similar age and back-ground to themselves.’

‘The workbook was used in differentways by different patients, for exam-ple one person used the stories toreinforce to himself that his recovery

from the stroke was in fact muchbetter, and he was more fortunatethan he had first perceived himself tobe.’

‘There are some timing issues withusing the workbook, and somepatients did have difficulty filling inthe target setting section, it may bebetter to have a longer timeframerather than weekly targets, they likedthe scoring though, even though forone patient his wife ended up fillingit in.’

‘It can be helpful when an individualfinds it difficult to set anything otherthan a very ambitious long term goal- I worked with a woman and herhusband to problem solve and breakdown their long term goals into shortterm targets , this helped us all to bemore positive and focus on what shecould be able to do rather than whatshe couldn't do at present.’

Practitioners agreed that overall theworkshops had helped them tounderstand the background evi-dence in relation to self-manage-ment and self-efficacy. Thoseworking in acute settings had moredifficulties implementing the work-book and felt that the Stepping Outprogramme became more relevant asindividuals went through the transi-tional phases when discharged fromhospital, and later from communityrehabilitation. They also highlightedthe need to practice different strate-gies of facilitating target setting par-ticular for those individuals that findit difficult to come up with short termtargets, and may have some level ofcognitive impairment.

A project advisory group nowinforms on the continued develop-ment of Stepping Out. Our multipro-fessional group consists of strokesurvivors, carers, stroke consultant,occupational therapist, physiothera-

pist, nurse consultant, psychologistand advisors from Connect (UKCharity for people with aphasia). Thegroup meets three times per year andhas been closely involved in the pro-gramme since January 2007. SteppingOut has consulted communicationadvisors from Connect throughoutthe project. A further focus group isbeing held in February 2008, inwhich we will seek feedback regard-ing the second version of the work-book.

The final version of the workbookwill be completed by the beginningof March and we are now starting totake booking for workshopsthroughout 2008. Stepping Out willsoon become a registered independ-ent charity, but is currently a pro-gramme run from within the Facultyof Health and Social Care St George’sUniversity of London and KingstonUniversity.

A phase one study to furtherinvestigate proof of concept and effi-cacy is planned to start in Belfast inspring 2008. Further studies areplanned to develop and test anaccompanying carers resource pack,this work is expected to start inMarch 2008.

In December 2007 we had a standat the UK Stroke Forum ideas fair, andwere able to gain more valuablefeedback and comments from a mul-tiprofessional group. We have a reg-ular newsletter called Stride and ourwebsite www.steppingoutuk.org.ukwas launched in June 2007 to coin-cide with WCPT. Our dedicated emailaddress for enquiries [email protected]

And now…Writing this progress report forSynapse has made me reflect on the'steps' (no pun intended) made sincemy first grant received from ACPIN. I

Update on a new stroke self-management programme: ACPIN grant and beyondFiona Jones PhD MSc MCSP Principal lecturer


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would like to thank all the strokesurvivors, carers and colleagues thathave provided such support andmotivation to continue. But just anote of caution if you are consideringapplying for an ACPIN research grant… small ideas can sometimes get outof hand!

Supporting references:Bandura A (1997) The nature andstructure of self-efficacy. Self-effi-cacy: the exercise of control NewYork, WH Freeman and Company.

Bendz M (2003) The first year of reha-bilitation after stroke - from two per-spectives. Scand J Caring Sci 17pp215-222.

Bury M, J Newbould et al (2005) Arapid review of the current state ofknowledge regarding lay-led self-management of chronic illness.

Cott CA, R Wiles et al (2007)Continuity, transition and participa-tion: preparing clients for life in thecommunity post-stroke DisabilRehabil 29(20-21) pp1566-74.

Department of Health (February2006) Supporting people with longterm conditions to self care: a guideto developing local strategies andgood practice London, DHPublications Orderline.

DH/Vascular Programme/Stroke (2007)National Stroke Strategy Departmentof Health London, DH Publications.

DH/Vascular Programme/Stroke (2007)A new ambition for stroke: a consul-tation on a national strategy.

London Department of Health.

Ellis-Hill CSL, Payne S et al (2007)Using stroke to explore the LifeThread Model: An alternativeapproach to understanding rehabil-itation following an acquired dis-ability Disabil Rehabil 1-10.

Johnston M, D Bonetti et al (2007)Recovery from disability after strokeas a target for a behavioural inter-vention: results of a randomizedcontrolled trial Disabil Rehabil 29(14)pp1117-27.

Jones F (2006) Strategies to enhancechronic disease self-management :how can we apply this to stroke?Disability and Rehabilitation 28(13-14pp841-847.

Jones F, Mandy A et al (2007) Reasonsfor recovery after stroke: a perspectivebased on personal experiencesDisability and Rehabilitation.

Kendall E, Catalano T et al (2007)Recovery following stroke: the role ofself-management education SocialScience and Medicine 64 pp735-746.

Lorig K, D Sobel et al (2001) Effect of aself-managment program onpatients with chronic diseaseEffective Clinical Practice 4(6) pp256-262.

Pound P, Gompertz P et al (1999)Social and practical strategies usedby people living with stroke Healthand Social Care in the Community 7(2)pp120-128.

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A ‘Clinical Information Management’InteractiveCSP network has just beenlaunched to help members deal with21st century requirements for clinicaland business information manage-ment that underpins the organisa-tion and delivery of modern patientcare.

Developments in e-health arechallenging physiotherapists to re-examine how they deliver efficientand effective patient care. LordDarzi’s report Our NHS, Our Futureidentifies the need to ensure the‘Connecting for Health’ programmebrings about real clinical benefit.National information managementand technology programmes in thefour countries are delivering signifi-cant changes to practice in areas suchas the rollout and use of clinical sys-tems to record patient contact, theuse of standardised clinical terminol-ogy within clinical systems, multidis-ciplinary record keeping in theelectronic environment, andtelemedicine developments andtheir impact on local serviceredesign. In private practice one ofthe challenges will be around con-necting to NHS based systems toreport on patient care being carriedout on behalf of the NHS. This net-work aims to provide members witha focus for discussion and knowledgesharing on this topic.

Karen Middleton (Chief HealthProfessions Officer) recently identifieddata collection and management asone of the four current challenges for

AHPs. She is concerned that not allAHPs are equipped with the rightdata to successfully make the case fortheir service, to support serviceredesign and to inform the commis-sioning process. The impact of nothaving the right information couldbe that services may not be commis-sioned causing the loss of physio-therapy jobs. This new network aimsto help members deal with thesechallenges by providing a forum todiscuss developing and usingdatasets to demonstrate the value ofphysiotherapy, and collecting man-agement information to meet thechallenges of waiting time initiatives,making a business case, and dealingwith the financial reforms.

The network was devised and ismoderated by the CSP InformationManagement and Technology (IM&T)Group. The group is concerned withensuring the profession informsnational information managementand e-health developments so sys-tems and practices are fit for purpose.Margaret Hastings, Chair of the IM&Tgroup hopes the new network will‘provide a focus for all who need toprovide evidence of the value of theirservice to managers and commis-sioners. We need to identify thestandard data items physiotherapistsshould collect and ensure that thehealth service provides the clinicalsystems to extract the data from thephysiotherapy record.’

For further information see:http://www.interactivecsp.org.uk ■

Information management and technology revolutionNew iCSP network helps members embrace changeAndrea Peace Head of Professional Policy and Information, The Chartered Society of Physiotherapy

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The provision of Early Supported Discharge(ESD) following acute stroke is a key compo-nent in the National Stroke Strategy (DOH2007). In the South West Locality of SurreyPCT, we have been running such a service sinceOctober 2003. Our team covers a semi-ruralarea based around Guildford of between 1000-1200 sq miles and a population of 250 000.

The team is a specialist branch of IntermediateCare and was formed as part of a whole systemworking group expanding acute and communityservices for stroke during 2002-3. It was devel-oped from scratch and follows governmentrecommendations (DOH 2001, 2005) and theNational Clinical Guidelines for Stroke (RCP2004). The model adopted is that set out in theCochrane Review of ESD schemes (Langhorne et al2005), which essentially showed that as good carecould be provided by specialist teams in the com-munity and reduce inpatient length of stay byeight days. Funding was achieved through thedrive to reduce hospital bed days and as suchforms a crucial part of the Stroke Pathway in ourarea. Up to twelve weeks rehabilitation andsupport at home can be provided, with visits pos-sible several times per day between 8.00am and8.00pm.

ADMISSION CRITERIAIt is essential that clinicians recognise that not allservices are suitable for all patients and we knowthat the more severely affected patients will farebetter in an inpatient rehabilitation facility(Langhorne et al 2005). Successful rehabilitationin the community following acute stroke demandsstrict admission criteria to determine suitability(Figure 1). Many patients live alone, and since themajority of visits are conducted by lone workers,our criteria must be robust. We do not offer 24-

hour care. In a few cases we have made a clinicaldecision to accept patients who did not fully meetthese criteria, particularly with regard to trans-fers. Without exception, these cases have resultedin considerable logistical difficulties. We nowendeavour to adhere to criteria for all referrals.

SHARING GOOD PRACTICE

Establishing and runningan Early Supported Discharge (ESD) rehabilitationteam for Stroke: four years experienceAnna Dunkerley MSc BSc(Hons) MCSP Advanced Physiotherapy Practitioner Stroke Team 4 Early Discharge (STED)

South West Locality, Surrey PCT, Milford Hospital, Tuesley Lane, Milford, Surrey GU7 1UF

• Confirmed stroke diagnosis and scan

• Medically stable

• Rehabilitation potential

• Would remain in hospital (or require admission) without the service

• Patient/carer agreement for early supported discharge

• Independent transfers if alone / minimal assistance with spouse or carer

Figure 1 Admission criteria

The majority of our ESD referrals are generatedfrom the acute stroke unit (Royal Surrey CountyHospital), with smaller numbers from the nearbyrehabilitation hospitals. Referrers are encouragedto identify patients quickly and inform our team.Liaison continues so that discharge is facilitatedas soon as possible, with the patient generallyseen at home on the same day. A large number ofpatients are only a week post-stroke when dis-charged home.

We also accept occasional admission avoidancereferrals for patients not admitted into the acutestroke unit for whatever reason. Best practiceindicates that optimum stroke managementincludes full investigations and comprehensivemedical assessment, including scanning. This canbe undertaken in the fast track TIA/Stroke Clinicand, if appropriate, referral made to the team.

Our early discharge scheme is firmly embeddedinto the Stroke Pathway. Strong links are main-


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tained with our partners in the acute sector,enabling us to dovetail complementary services.Management of complex referrals is discussed col-laboratively in conjunction with our localconsultant stroke physician.

MULTIDISCIPLINARY TEAMOur specialist Multidisciplinary Team (MDT) isstaffed for a caseload of 20 concurrent patients(Figure 2). The average caseload is 17. Most staffare part-time and, with careful planning, we canprovide good cover across disciplines throughoutthe year.

We set no upper age limit and have treatedpatients ranging in age from 22-94 years (mean74 years). The vast majority of our patients areESD referrals (91%) with just 9% admission avoid-ance. This is in accordance with best practice:patients with suspected acute stroke are optimallymanaged by hospital admission initially (DOH2007).

Our case mix (Figure 4) indicates a broad spreadof stroke subtypes. Outcomes demonstrate thatthe service can offer input to patients with all pre-sentations, not just those with the highest level offunctional ability. However it is apparent from theliterature that the severely dependent patients areleast likely to benefit from ESD services(Langhorne et al 2005).

• Occupational Therapists x 1.5 WTE(2 posts – x 1 Band 7, x 0.5 Band 6 non-rotational)

• Physiotherapists x 1 WTE(2 posts – Band 7, Band 6 neurology rotation)

• Speech and Language Therapist x 0.5 WTE(Band 7)

• Stroke Nurses x 1 WTE(2 posts – Band 7 job-share)

• Rehabilitation Support Workers x 2 WTE(3 posts – Band 3)

Figure 2 Staffing

Classification %

Partial Anterior Circulation Stroke (PACS) 55

Lacunar Stroke (LACS) 21

Posterior Circulation Stroke (POCS) 11

Total Anterior Circulation Stroke (TACS) 6

Primary Intracerebral Haemorrhage (PICH) 2

Brainstem 2

Subarachnoid Haemorrhage 1

Subdural Haematoma 1

Unclassified 1

Figure 4 Case mix

Year Admissions

2004 - 2005 59

2005 – 2006 75

2006 – 2007 82

2007 – 2008 70 to date(projected 86)

Figure 3 Admissions

In addition we fund an additional SupportWorker post in Intermediate Care to cover visitsrequired after 4.00pm and at weekends.

ANNUAL EVALUATIONSince our service began we have collected data onall patient episodes for comprehensive evaluation.Admission numbers have steadily risen (Figure 3).

Demographics and clinical information arerecorded in addition to standard outcome measures(Functional Independence/Assessment MeasureFIM/FAM, Visual Analogue Self Esteem Scale VASES,Carer Strain Index CSI) scored at admission, dis-charge and 6/12 post-stroke. Some outcomes fromthe last financial year are detailed below.

Our mean length of stay is between eight to nineweeks, with 93% patients remaining at home ondischarge from the team. Last year there werethree re-admissions of which only one was stroke-related. From admission to discharge and throughto review, FIM/FAM scores increased, CSI scoresdecreased and VASES scores increased and weremaintained. Patient satisfaction has been excel-lent – it has been particularly encouraging for theteam to receive positive feedback in formal anony-mous satisfaction surveys (78% response rate) andanecdotally in clinic or by letter, including thosesent to the local paper.

SERVICE IMPROVEMENTSWe continue to review our service and actively

encourage feedback from staff and serviceusers/carers. A number of changes and improve-ments have been implemented as a result:• Clinical Governance meetings – service review

held quarterly with the MDT and consultantstroke physician, to discuss and implement newideas.

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• Referral process – use of flow charts and check-lists to assist management of referrals.

• Educational meetings with the acute service –held every two months to develop andstrengthen our links. Usually includes threeshort case studies of patients referred from theacute stroke unit, with contributions from staffin both teams.

• Patient information – includes staff roles andphotographic identification. The dischargeprocess is explained at the start of our involve-ment – patients are well-prepared andarrangements made for ongoing services in goodtime if needed.

• Post Stroke review – introduced a 3/12 post dis-charge review for those patients who are morethan 6/12 post stroke.

• Shared information – community matrons andGPs are copied on reviews to aid monitoring ofpatients in the long term.

• Physiotherapy follow-up – we are able to offeroutpatient physiotherapy on a reducing basis forpatients requiring less regular input.

• Presentations – staff have been invited to deliverpresentations at local, regional and national (UKStroke Forum 2006, Best of Health 2008) levelwhich has kept the team at the forefront of pio-neering best practice for stroke in accordancewith the available published evidence.

STAFF DEVELOPMENTEstablishing and running this service has createdopportunities for professional and personal devel-opment for all members of our team. We havedeveloped a rich opportunity for broadening ourscope of practice and enjoy cross-disciplineworking, problem solving and pushing boundaries.Students from all disciplines regularly undertakepractice placements within the team.

CONCLUSIONWe have demonstrated through annual evaluationover the last four years that our service provideseffective early supported discharge/admissionavoidance and effective home-based rehabilitation.Analysis has shown a substantial reduction inlength of stay in the acute sector, from 49 to 19days in the last Sentinel Audit. The place of ourteam in the Stroke Pathway has been a factor, andin achieving this we offer a high quality economicalservice. We have shown consistent positive clinicaloutcomes, low onward referral rates (includingsocial care), low re-admission rates and high levelsof patient satisfaction. We are hopeful that theservice will soon be expanded to provide equityacross a wider geographical area, resulting fromreorganisation and formation of a larger Trust.

ReferencesDepartment of Health (2001) TheNational Service Framework forOlder People London DH.

Department of Health (2005) TheNational Service Framework forLong Term Conditions London DH.

Department of Health (2007)National Stroke Strategy LondonDH.

Langhorne P et al (2005) EarlySupported Discharge Services forStroke Patients: a meta-analysisof individual patients’ data Lancet365 pp501-506.

Royal College of Physicians (2004)National Clinical Guidelines forStroke, 2nd Edition, prepared bythe Intercollegiate Stroke WorkingParty, London RCP.

Address for [email protected]


Lecture abstractswith references and speaker biographies

Intensive care management

of traumatic brain injury

Dr Martin Smith The National Hospital for Neurology and Neurosurgery, University College

London Hospitals

There has been a marked decline in mortality from severetraumatic brain injury (TBI) in adults over the last twodecades because of improvements in resuscitation andpre-hospital care1. There have also been simultaneousadvances in our understanding of the pathophysiology ofbrain injury and in monitoring and imaging techniques.This has allowed the development of evidence basedintensive care management of patients with TBI2.

PATHOPHYSIOLOGYHead injury is a heterogeneous diagnosis, encompassinga wide range of pathologies including diffuse axonalinjury, focal contusions and space occupyinghaematomas. If the initial (primary) injury is notimmediately fatal, it is usually exacerbated by secondaryevents that lead to secondary brain injury. This developsover the subsequent minutes, hours and days and has anadverse effect on outcome. The primary injury activatesan auto-destructive cascade of ionic, metabolic,inflammatory and immunological changes that renderthe brain more susceptible to secondary physiologicalinsults and ultimately results in irreversible cell damageor death. Secondary insults arise from both systemic andintracranial changes that initiate or propagatepathophysiological processes and fatally damageneurones already rendered susceptible to injury by theprimary insult. Systemic hypotension and hypoxemia arethe major causes of secondary brain injury and primarydeterminants of adverse outcome after TBI3.

MONITORINGGeneral monitoring allows maintenance of optimalsystemic physiology but will not detect changes in thebrain. Cerebral monitors allow measurement of CPP andassessment of the adequacy of oxygen delivery to thebrain and guide therapy to target specific physiologicalchanges to maintain a balance between cerebralmetabolic supply and demand4.

Intracranial pressure5 ICP cannot be reliably estimatedfrom any specific clinical feature or CT finding and mustactually be measured. Measurement of ICP via a

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ventricular catheter offers the gold standard for ICPmonitoring but several less invasive devices are available.Fibreoptic and microtransducer devices are miniatureprobes that can be inserted into the brain parenchymavia a burr hole at the bedside. ICP monitoring allowsdetermination of CPP (CPP = MAP - ICP) and detection ofabnormal ICP waveforms.

Cerebral oxygenation Several methods have beendeveloped to detect brain ischaemia and guidemanagement6. A catheter placed in the jugular bulballows sampling of venous blood draining from the brainand provides a global assessment of the balance betweencerebral oxygen supply and demand. Jugulardesaturation (SjvO2 < 50%) is associated with increasedmortality after TBI and worsened outcome in survivors.However, because SjvO2 is a global measure, a normalvalue does not exclude significant regional ischaemia.Focal brain tissue oxygen tension (PtiO2) can be measuredusing small microprobes. Initial low values rise over thefirst 24 hours after injury and both the depth andduration of hypoxia are related to outcome.

Brain tissue biochemistry Cerebral microdialysis (MD) is awell-established laboratory tool that is increasingly usedas a bedside monitor to provide on-line analysis of braintissue biochemistry during neuro-intensive care8. MD hasthe potential to provide early warning of impendingcerebral hypoxia/ischaemia.

Multi-modal monitoring Individual monitoringtechniques provide information about specific aspects ofcerebral physiology but all have disadvantages and mostsuffer from significant artefact. Decisions to treat aretherefore not usually based on a change in one variablealone. Monitoring of several variables simultaneously(multimodal monitoring) allows cross validation betweenmonitors, artefact rejection and greater confidence tomake treatment decisions4.

INTENSIVE CARE MANAGEMENTThe intensive care unit is where rigorous and continuousmonitoring and treatment are delivered to patients withTBI with the sole objective of minimising secondary braininjury2,9. The ICU management of TBI has undergoneextensive revision as evidence accumulates thatlongstanding and established practices are not asefficacious or innocuous as previously believed10. Theprimary goal of identifying and treating intracranialhypertension has been superseded by a focus onprevention of secondary brain ischaemia by a multi-faceted neuroprotective strategy of maintenance ofcerebral perfusion pressure (CPP) and cerebral oxygendelivery. It is likely that specialist neuro-critical care, withprotocol guided therapy, improves outcome in patientswith severe head injury9. Consensus, expert guidelines areavailable to assist management after TBI11,12.

Ventilation Control of PaO2 and PaCO2 are essential tomaintain favourable cerebral haemodynamics andoxygenation. Mechanical ventilation is therefore a keypart of the treatment of severe TBI. Patients with isolatedhead injury can be managed with standard ventilatorytechniques but those with co-existing chest pathology orsevere head injury are at high risk for developing acutelung injury. The classic teaching of no or low levelpositive end expiratory pressure (PEEP) to prevent rises inICP is inappropriate because ventilation without PEEPoften fails to correct hypoxaemia. With adequate volumeresuscitation PEEP actually decrease ICP because ofimproved cerebral oxygenation.

Cardiovascular support Even short periods ofhypotension (MAP < 90mmHg) are associated withadverse neurological outcome and should bemeticulously avoided13. Higher mean pressures may benecessary to maintain an adequate CPP in the presence ofraised ICP and this may be achieved with volumeresuscitation and vasopressors/inotropes as required.Euvolaemia is the primary resuscitative goal for patientswith severe TBI and different fluids may be used tosupport CPP, with the emphasis on preserving adequateintravascular volume1,2. There is no ideal fluid for patientsafter severe TBI and both crystalloids and colloids aresuitable. Glucose containing solutions should be avoidedbecause the free water liberated following themetabolism of glucose can worsen cerebral oedema and,in the anaerobic brain, glucose is metabolised to lactatewhich worsens secondary injury14.

ICP and CPP guided therapy Conventional approaches tothe management of TBI have concentrated on a reductionin ICP to prevent secondary ischaemia despite theabsence of controlled randomised studies thatdemonstrate outcome benefits. However, over the lastdecade there has been a shift of emphasis from primarycontrol of ICP to a multi-faceted approach ofmaintenance of CPP and brain protection. Although thereis debate about the optimal level for CPP, there is aconsensus that it should be maintained between 50-70mmHg12 as higher targets are often achieved only at theexpense of significant complications15.

Management of intracranial hypertension ICP should betreated when > 20 mmHg5,12.i) Position Elevation of the head reduces ICP, whilstrotation of the head and flexion of the neck increase it.The patient should be positioned with moderate head-up tilt (up to 45°) and a neutral position of the head andneck but care must be taken to ensure that the head-updoes not cause a reduction in MAP.ii) Hyperventilation was once the cornerstone of ICPcontrol after TBI but over the last decade has come undermore fire than any other therapy. Empirical and excessivehyperventilation is associated with adverse neurological


36

outcome16 because regional ischaemia may beworsened17. The routine use of hyperventilation isdiscouraged and current guidance recommend PaCO2targets of 4.0 - 4.5 kPa12. Modest hyperventilation may beindicated to control intracranial hypertension in selectedcases but should only be undertaken in conjunction withcerebral oxygenation monitoring in order to detectcerebral ischaemia.iii) Osmotic therapy Mannitol is a standard of care in thetreatment of intracranial hypertension, although it hasnever been subject to a randomised controlled clinicaltrial against placebo. Mannitol (0.5g/kg) effectivelyreduces elevated ICP and increases CPP and cerebral bloodflow in certain settings of intracranial hypertension. ICP-directed treatment is more beneficial than treatmentdirected by neurological signs or physiologicalindicators18. There is substantial experimental data tosupport the use of hypertonic saline solutions (HSS) aseffective alternative treatment of elevated ICP. Thebeneficial effects of HSS are likely to be related not onlyto an osmotic effect but also to haemodynamic,vasoregulatory, immunological and neurochemicaleffects19. Whilst there can be little doubt that HSS areeffective treatments of elevated ICP, there are no large,randomised comparisons with conventional osmoticagents or long-term functional outcome studies.iv) Barbiturates reduce ICP and have protective effects inthe context of focal ischaemia because of suppression ofcerebral metabolism and associated reduction in CBF,effects on vascular tone and free radical scavenging.However, the clinical use of barbiturates for the control ofintracranial hypertension unresponsive to othertreatments is highly contentious and any potentialbeneficial effects may be offset by side-effects,particularly hypotension12.v) Surgical methods Drainage of CSF via an EVD is aneffective means of reducing ICP. Another option fortreating refractory intracranial hypertension isdecompressive craniectomy, an operation to remove alarge area of skull to increase the volume of the cranialcavity and thus decrease its pressure2. There is dividedopinion on the relative benefits and risks of thisprocedure and these are currently being addressed by amulti-centre, randomized controlled outcome trial - theRESCUE-ICP study [http://rescueicp.com/].

Glycaemic control Severely head-injured patientsfrequently develop hyperglycaemia and this exacerbatessecondary injury and worsens neurological outcome1,14. Themechanisms underlying this effect include hyperosmolality,lactic acid production, alterations in neuronal pH andincreases in excitatory amino-acids. Tight glycaemic controlmay therefore improve outcome after TBI.

Therapeutic hypothermia Although beneficial in animalmodels, the results of moderate hypothermia (33-35°C) inhuman trials have been disappointing. A prospective,

randomised study of moderate hypothermia (33°C) in TBIwas terminated early because of increased morbidity inpatients over 45 years of age treated with hypothermia20.There was possible benefit to patients who presentedalready hypothermic but older patients had such highrates of medical complications that hypothermia wasdetrimental regardless of their admission temperature.However, moderate hypothermia is an effective methodof reducing raised ICP and remains a treatment option inyounger patients2. Hyperthermia worsens outcome afterTBI and should be treated aggressively21.

SUMMARYOver the last decade there have been improvements inthe ICU management of patients with severe TBI that havebeen guided by better understanding of thepathophysiology of brain injury and by new andimproved monitoring techniques. There has been a shiftof emphasis from primary control of ICP to a multi-faceted approach to maintenance of cerebral perfusionand oxygenation. The development of protocols andtreatment guidelines is to be welcomed but must notprevent tailored therapy. The days of nihilism in themanagement of severe TBI have been replaced by thebeginnings of evidence based practice.

REFERENCES

1. Moppett I (2007) Traumatic braininjury: assessment, resuscitation andearly management Brit J Anaesth 99pp18-31.

2. Helmy A, Vizcaychipi M, Gupta A(2007) Traumatic brain injury:intensive care management Brit JAnaesth 99 pp32-42.

3. Chesnut RM, Marshall LF, KlauberMR, et al (1993) The role of secondarybrain injury in determining outcomefrom severe head injury J Trauma 34pp216-222.

4. Tisdall M, Smith M (2007)Multimodal monitoring in traumaticbrain injury: current status andfuture directions Brit J Anaesth 99pp61-67.

5. Smith M (2008) Monitoring intra-cranial pressure in traumatic braininjury Anesth Analg 106 pp240-248.

6. Nortje J, Gupta A (2006) The role oftissue oxygen monitoring in patientswith acute brain injury Brit J Anaesth97 pp95-106.

7. Tisdall M, Smith M (2006) Cerebralmicrodialysis: research technique or clinical tool? Brit J Anaesth 97 pp18-25.

8. Smith M (2004) Neurocritical care:has it come of age? Brit J Anaesth 93pp753-5.

9. Roberts I, Schierhout G, Alderson P(1998) Absence of evidence for the effectiveness of five interventionsroutinely used in the intensive caremanagement of severe head injury:a systematic review J NeurolNeurosurg Psychiatry 65 pp729-733.

10. Maas AI, Dearden M, Teasdale GMet al (1997) EBIC-guidelines for management of severe head injuryin adults Acta Neurochir (Wien) 139pp286-294.

11. Brain Trauma Foundation (2007)Guidelines for the management ofsevere traumatic brain injury 3rdEdition J Neurotrauma 24 (Suppl 1)ppS1-S106.

12. Chesnut RM (1997) Avoidance ofhypotension: conditio sine qua nonof successful severe head-injurymanagement J Trauma 42 ppS4-S9.

13. Lam AM, Winn HR, Cullen BF et al(1991) Hyperglycaemia andneurological outcome in patientswith head injury J Neurosurg 75pp545-551.

14. Robertson CS, Valadka AB,Hannay HJ et al (1999) Prevention ofsecondary ischemic insults aftersevere head injury Crit Care Med 27pp2086-2095.

15. Muizelaar JP, Marmarou A, WardJD et al (1991) Adverse effects ofprolonged hyperventilation in

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patients with severe head injury. Arandomized clinical trial J Neurosurg75 pp731-739.

16. Coles JP, Minhas PS, Fryer TD et al(2002) Effect of hyperventilation on cerebral blood flow in traumatichead injury: clinical relevance andmonitoring correlates Crit Care Med30 pp1950-1959.

17. Wakai A, Roberts I, Schierhout G(2005) Mannitol for acute traumaticbrain injury Cochrane Database SysRev CD001049.

18. White H, Cook, D, Venkatesh B(2006) The use of hypertonic salinefor treating intracranial hypertensionafter traumatic brain injury AnesthAnalg 102 pp1836-1846.

19. Clifton GL, Miller ER, Choi SC et al(2001) Lack of effect of induction of hypothermia after acute brain injuryN Engl J Med 344 pp566-63.

20. Marion D (2004) Controllednormothermia in neurologicintensive care Crit Care Med 32 ppS43-S45.

Dr Martin Smith is a consultant inneuroanaesthesia and neurocriticalcare and Director of NeurosurgicalCritical Care Services at the NationalHospital for Neurology andNeurosurgery, University CollegeHospitals London, UK. He is also aclinician scientist and honoraryreader in anaesthesia and criticalCare at University College London. Hisclinical interests lie particularly in themanagement of acute brain injuryand his research interests focus onthe development and assessment ofbedside optical techniques tomonitor cerebral haemodynamics,oxygenation and cellular metabolicstatus at the bedside. Dr Smith is thechair of the Neurocritical CareStakeholder Forum, immediate pastpresident of the NeuroanaesthesiaSociety of Great Britain and Ireland, a director of the Society of Neuro-anaesthesia and Critical Care and amember of the editorial board of theJournal of NeurosurgicalAnaesthesiology.

joint range. This ‘maintenance phase’ is crucial to allowthe patients to access the rehabilitation/mobilisationphase with the minimal amount of preventableimpairment. The ‘rehabilitation/mobilisation phase’ensures that the patient is given the opportunity toappropriately interact with their environment in order tofacilitate their functional recovery. Due to the nature ofthis patient group, low arousal level, fluctuating tone &challenging behaviour, the therapist must be aware ofthe any manual-handling implications, so sound clinicalreasoning linked to robust risk assessment, is ofparamount importance to ensure the safety of bothpatient and therapist.

Physiotherapy management

In early brain injury:

practical, proactive

intervention

Adrian Capp MCSP

The timing of the acute mobilisation/rehabilitationphase of patients following severe traumatic braininjury (TBI) remains controversial. There are two distinctphases within the neurocritical care setting,maintenance and rehabilitation. Currently, there islimited evidence based guidance to aid the clinician intheir decision making processes as to when tocommence this intervention or the effectiveness ofinterventions. Comparisons have been made betweenstroke and TBI regarding the secondarypathophysiological effects, especially the concept of theischaemic penumbra. The use of current physiologicalthinking, best available evidence and expert opinioncan assist in the choice of early interventions and theirefficacy. Initially, during the acute phase, physiotherapyintervention concentrates on the maximisation ofpulmonary function, maintenance of muscle length and

REFERENCES

Carr J, Shepherd R (2002)Neurological rehabilitation –optimizing motor performanceOxford Butterworth Heinemann.

Chang A (2004) Standing withassistance of a tilt table in intensivecare: a survey of Australianphysiotherapy practice AustralianJournal of Physiotherapy 50 pp51-54.

Coles J, Fryer T, Smielewski P,Chatfield D, Steiner L, Johnston A,Downey S, Williams G, Aigbirhio F,Hutchinson P, Rice K, Carpenter T,Clarke J, Pickard J, Menon D (2004)Incidence and mechanisms ofcerebral ischemia in early clinicalhead injury

Edwards S (2002) NeurologicalPhysiotherapy London:ChurchillLivingston.

Gerber C (2005) Understanding andmanaging coma stimulation: Are wedoing everything we can? Criticalcare nursing quarterly 28 (2) pp94.

Journal of Cerebral Blood Flow andMetabolism 24 pp202-211.

Leker R, Shohami E (2002) Cerebralischemia and trauma – different etiologies yet similar mechanisms:neuro-protective opportunities BrainResearch Reviews 39 pp55-73.

Marik P, Varon J, Trask T (2002)Management of head trauma Chest122 (2) pp699-711.

NICE Clinical Guidelines (2003) HeadInjury

Pryor J, Prasad A (2001) Physiotherapyfor respiratory and cardiac problemsAdults and Paediatrics Edinburgh:Churchill Livingstone.

Royal College of Physicians, BritishSociety of Rehabilitation Medicine(2003) Rehabilitation followingacquired brain injury NationalClinical Guidelines, London.

Sirois MJ, Lavoie L, Dionne C (2004)Impact of transfer delays torehabilitation in patients with severetrauma Archives of Physical Medicineand Rehabilitation 85 pp184-191.

Smith M (2004) Neurocritical care:has it come of age? British Journal ofAnaesthesia 93 (6) pp753-755.

Stiller K, Phillips A (2003) Safetyaspects of mobilising acutely illinpatients Physiotherapy Theory andPractice 19 pp239-257.

Turner-Stokes L, Disler PB, Nair A,Wade DT (2005) Multi-disciplinaryrehabilitation for acquired braininjury in adults of working age TheCochrane Database of SystematicReviews Issue 3 Article no CD004170pub 2 DOI: 10.1002/14651858.CD004170.pub2.

Adrian Capp has worked extensivelywithin the field of neurology andneurosurgery in New Zealand andLondon for eleven years. During thelast seven years he has gained furtherexperience in the management ofcomplex patients in critical care andon the neurosurgical and neurologywards at The National Hospital forNeurology and Neurosurgery, London,UK (NHNN). He completed an MSc inAdult Critical Care at Imperial CollegeLondon in 2005 and has subsequentlyspecialised in neurorehabilitation inthe acute setting. He has fostered theintegration of physiotherapy within atransdisiplinary tracheostomy teamfor neurological patients at NHNN. Hehas taken part in an internationalbench marking process regardingtracheostomy care in Australia and theUK. He teaches regularly onphysiotherapy and head injurymanagement to undergraduate andpost graduate students and hasrecently written a book chapter onrespiratory considerations inneurology.


38

Cochrane review: botulinum

toxin for adult spasticity

after stroke or non-

progressive brain lesion

Bernie Lyons MCSPMoore AP, Bhakta BB, Bamford JM, Cardwell C, Logan I

BACKGROUNDIn most of Europe, botulinum toxin type A is now licensedto treat spasticity in the forearm finger and wrist flexorsin people with stroke. Italy has extended this further andis also licensed to use botulinum toxin to treat lower limbspasticity.

OBJECTIVESThe objective of this review is to evaluate the efficacy ofbotulinum toxin in the treatment of limb spasticity afterstroke or non-progressive brain lesion.

METHODSThe following databases were searched;• Cochrane Stroke Group Trials Register, the Cochrane

Injuries Group and the Cochrane Infectious DiseasesGroup to request a search of their trials.

• Ovid electronic databases: Evidence Based MedicineReviews, MEDLINE , EMBASE CINAHL and AMED. Furtherpublished studies were identified using citationtracking. Authors and researchers active in this fieldwere also contacted and included abstracts and articlesin all languages.

SELECTION CRITERIATypes of studies All published and unpublishedunconfounded randomised controlled trials wherebotulinum toxin type A or B was used to treat limbspasticity were considered.

Participants Adults with stroke or non-progressive braininjury, with limb spasticity.

Interventions All studies investigating comparisons oftreatment with botulinum toxin versus placebo, or opencontrol treatment. All studies investigating treatmentwith botulinum toxin type A, or B with placebo.

Outcome measures Impairment based and functionaloutcome measures as well as adverse events, and deathsfrom all causes were measured.

Primary outcome measure The patient/carers' subjectiveglobal assessment of improvement/benefit.

Timing of outcome measurements• 4 to 8 weeks post injection• 12 to 16 weeks post injection.

Data collection and analysis After screening all identifiedtitles and abstracts only interventional studies on adultswere included. Two review authors independentlyconsidered all interventional studies that met previouslydefined inclusion criteria for eligibility. Two reviewauthors also independently assessed each includedarticle for relevant data extraction. Disagreements wereresolved by discussion with a third party.Statistical analysis Cochrane Review Manager softwarewas used for all analyses. Continuous outcome measureswere summarised using mean differences and standarderrors of mean differences. Ordinal outcome measureswere summarised as dichotomised data. A qualitativedescription of adverse events was conducted.Heterogeneity was considered using the I 2 statistic andchi-squared tests and publication bias was investigatedfor the primary outcome measure using a funnel plot.

Subgroup analyses Sensitivity analyses were performedto assess the impact of only trials that: had adequaterandomisation; were double blind; adequateconcealment of randomisation and adequate follow up.

RESULTSThe search resulted in 1036 hits following removal ofduplications. Following application of inclusion/exclusioncriteria, 17 randomised controlled trials were included inthe review. Data analysis is ongoing and preliminaryresults will be discussed.

REFERENCES

Included studies

Bakheit AMO, Thilman AF, Ward AB,Poewe W, Wissel J, Muller J, BeneckeR, Collin C, Muller F, Ward CD,Neumann C (2000) A randomized,double-blind, placebo-controlled,dose-ranging study to compare theefficacy and safety of three doses ofbotulinum toxin type A (dysport)with placebo in upper limb spasticityafter stroke Stroke 31 pp2402-2406.

Bakheit AMO, Pittock S, Moore AP,Wurker M, Otto F, Erbguth, Coxon L(2001) A randomized double-blindplacebo-controlled study of theefficacy and safety of botulinumtoxin type A in upper limb spasticityin patients with stroke EuropeanJournal of Neurology 8 pp559-565.

Bhakta BB, Cozens JA, ChamberlainMA, Bamford JM (2000) Impact ofbotulinum toxin type A on disabilityand carer burden due to armspasticity after stroke: a randomised double-blind placebo-controlledtrial J Neurol Neurosurg Psychiatry 69pp217-221.

Brashear A, Gordon MF, Elovic E,Kassicieh VD, Marciniak C, Do M, LeeC, Jenkins S, Turkel C (2002)Intramuscular injection of botulinumtoxin for the treatment of wrist and finger spasticity after stroke NewEngland Journal of Medicine 347:6pp395-400.

Brashear A, McAfee AL, Kuhn ER, FyffeJ (2004) Botulinum toxin type B inupper limb poststroke spasticity: Adouble-blind, placebo-controlledtrial Archives of Physical Medicine &Rehabilitation 85(5) pp 705-709.

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Burbaud P, Wiart L, Dubos JL, GaujardE, Debellleix X, Joseph PA, MazauxJM, Bioulac B, Barat M, Lagueny A(1996) A randomised double-blindplacebo-controlled trial of botulinumtoxin in the treatment of spastic footin hemiparetic patients J NeurolNeurosurg Psychiatry 61 pp265-269.

Chen FJ, Chen ZY, Liang XZ, Lin HF(2003) Botulinum toxin type A forlimb function recovery in highspasticity patients with stroke[Chinese] Zhongguo LinchuangKangfu 7(25) pp3478-3479.

Childers MK, Brashear A, Jozefczyk P,Reding M, Alexander D, Good D, Walcott JM, Jenkins SW, Turkel C,Molloy PT (2004) Dose-dependentresponse to intramuscular botulinumtoxin type a for upper-limb spasticityin patients after a stroke Archives ofPhysical Medicine & Rehabilitation85(7) pp1063-1069).

Cui Li-hua, Zhang Tong. Domesticbotulinum toxin type A injection inthe treatment of post stroke patientswith upper extremeity spasticityChinese Journal of Neurology 39 (7)pp463-465.

Hesse S, Reiter F, Konrad M, JahnkeMT (1998) Botulinum toxin type Aand short term electrical stimulationin the treatment of upper limb flexorspasticity after stroke: a randomised,double blind placebo controlled trialClinical Rehabilitation 12 pp381-388.

Kong KH, Neo JJ, Chua KS (2007) Arandomized controlled study ofbotulinum toxin A in the treatmentof hemiplegic shoulder painassociated with spasticity ClinialRehabilitation 21 (1) pp28-35.

Simpson D M, Alexander DN, O'BrienCF, Tagliati M, Aswad AS, Leon JM,Gibson J, Mordaunt JM, MonaghanEP (1996) Botulinum toxin type A inthe treatment of upper extremityspasticity: A randomized, double-blind, placebo-controlled trialNeurology 46 pp1306-1310.

Smith SJ, Ellis E, White S, Moore AP(2000) A double-blind placebo-controlled study of botulinum toxinin upper limb spasticity after strokeor head injury Clinical Rehabilitation14 pp5-13.

Suputtitada A, Suwanwela NC (2005)The lowest effective dose ofbotulinum A toxin in adult patientswith upper limb spasticity Disability& Rehabilitation 27(4) pp176-184.

Yelnik AP, Colle FM, Bonan IV, Vicaut E(2006) Treatment of shoulder pain in

spastic hemiplegia by reducingspasticity of the subscapular muscle:A randomized, double-blind,placebo-controlled study ofbotulinum toxin A J NeurolNeurosurg Psychiatry.

Excluded randomised and pilotstudies

Bakheit AM, Sawyer J (2002) Theeffects of botulinum toxin treatmenton associated reactions of the upperlimb on hemiplegic gait – a pilotstudy Disability & Rehabilitation24:10519-22.

Bayram S, Sivrioglu K, Karli N, OzcanO (2006) Low-dose botulinum toxinwith short-term electricalstimulation in poststroke spastic dropfoot: A preliminary study AmericanJournal of Physical Medicine & Rehabilitation.

Carda S, Molteni F (2005) Tapingversus electrical stimulation afterbotulinum toxin type A injection forwrist and finger spasticity. A case-control study Clin Rehabil 19 (6)pp621-626.

Childers MK, Stacy M, Cooke DL,Stonnington HH (1996) Comparisonof two injection techniques usingbotulinum toxin in spastichemiplegia American Journal ofPhysical Medicine & Rehabilitation75(6) pp462-469.

Fock J, Galea MP, Stillman BC,Rawicki B, Clark M (2004) Functionaloutcome following botulinum toxinA injection to reduce spastic equinusin adults with traumatic brain injuryBrain Injury 18(1) pp 57-63.

Francisco GE, Boake C, Vaughn A(2002) Botulinum toxin in upper limbspasticity after acquired brain injury:A randomized trial comparingdilution techniques American Journalof Physical Medicine & Rehabilitation81(5) pp355-363.

Grazko MA, Polo KB, Jabbari B (1995)Botulinum toxin A for spasticity,muscle spasms, and rigidityNeurology 45 pp712-717.

Hyman N, Barnes M, Bhakta B,Cozens A, Bakheit M, Kreczy-Kleedorfer M, Poewe W, Wissel J,Bain P, Glickman S, Sayer A,Richardson A, Dott C (2000)Botulinum toxin (Dysport) treatmentof hip adductor spasticity in multiple sclerosis: a prospective, randomised,double-blind, placebo-controlled,dose ranging study Journal ofNeurology, Neurosurgery andPsychiatry 68 pp707-712.

Johnson CA, Wood DE, Swain ID,Tromans AM, Strike P, Burridge JH(2002) A pilot study to investigate thecombined use of botulinumneurotoxin type A and functionalelectrical stimulation, withphysiotherapy, in the treatment ofspastic dropped foot in subacutestroke Artificial Organs 26(3) pp263-266.

Johnson CA, Burridge JH, Strike PW,Wood DE, Swain ID (2004) The effectof combined use of botulinum toxintype A and functional electricstimulation in the treatment ofspastic drop foot after stroke: Apreliminary investigation Archives ofPhysical Medicine & Rehabilitation 85(6) pp902-909.

Kirazli Y, On AY, Kismali B, Aksit R(1998) Comparison of phenol blockand botulinus toxin type A in thetreatment of spastic foot after stroke:A randomized, double-blind trialAmerican Journal of PhysicalMedicine and Rehabilitation 77 (6)pp510-515.

Mancini F, Sandrini G, Moglia A,Nappi G, Pacchetti C (2005) Arandomised, double-blind, dose-ranging study to evaluate efficacyand safety of three doses ofbotulinum toxin type A (Botox) forthe treatment of spastic footNeurological Sciences 26(1) pp26-31.

On AY, Kirazli Y, Kismali B, Aksit R(1999) Mechanisms of action ofphenol block and botulinus toxinType A in relieving spasticity: electro-physiologic investigation andfollow-up American journal ofphysical medicine & rehabilitation/Association of Academic Physiatrists78(4) pp344-349.

Reiter F, Danni M, Lagalla G, CeravoloG, Provinciali L (1998) Low-dosebotulinum toxin with ankle tapingfor the treatment of spastic

equinovarus foot after stroke Archivesof Physical Medicine & Rehabilitation79(5) pp532-535.

Richardson D, Sheean G, Werring D,Desai M, Edwards S, Greenwood R,Thompson A (2000) Evaluating therole of botulinum toxin in themanagement of focal hypertonia inadults Journal of Neurology,Neurosurgery & Psychiatry 69(4)pp499-506.

Snow BJ, Tsui JKC, Bhatt MH, VarelasM, Hashimoto SA, Calne DB (1990)Treatment of spasticity withbotulinum toxin: A double-blindstudy Ann Neurology 28 pp512-515.

Verplancke, D et al (2005) Arandomized controlled trial ofbotulinum toxin on lower limbspasticity following acute acquiredsevere brain injury ClinicalRehabilitation 19(2) pp117-125.

Bernadette Lyons qualified as aphysiotherapist in 1990 University ofUlster at Jordanstown NorthernIreland. She has worked in the RoyalGroup of Hospitals from July 1990 topresent time. She is currently aSenior 1 physiotherapist in the ElliottDynes Rehabilitation Unit working inthe stroke unit and day hospital.From 2000-2004 she received aBursary from the R&D office to carryout a part time MSc in AdvancedPractice of Physiotherapy. In 2005-2007 she had a career break to workas a research associate on a multi-centered RCT involving strokepatients in Northern Ireland. From2005- 2007 she received a CochraneFellowship to carry out a Cochranesystematic review examining the useof Botulinum toxin to treat spasticityin patients with non progressivebrain injuries. She is married toJeremy and has two children.


40

New technologies for

rehabilitation of traumatic

brain injury

Dr Nigel HarrisConsultant Clinical Scientist, Royal Mineral Water Hospital, Bath and School

for Health, University of Bath

This work is presented on behalf of the SMART rehabilita-tion consortium and Bath Neuro Rehabilitation Services.

There have been considerable advances in micro-electronics and motion sensor technology in the last fiveto ten years1,2. These devices, along with multimedia PC’sand video cameras are now widely available at relativelylow cost. This technology, which can track limb and bodyposition, that had previously only been found inspecialist biomechanics laboratories is now available foruse in a clinical or home environment. There areconsiderable practical and organisational difficulties thatneed to be overcome, before this type of technology canbe used to support or deliver therapy3. However, thebiggest challenges remain around the interface betweenthe therapy platform, the clinician and the patient, as wetry to work out how best to use the technology tofacilitate motor relearning.

The SMART rehabilitation project (http://research.shu.ac.uk/chscr/smart/) was a three year package of work toinvestigate the use of technology to support homerehabilitation of patients following stroke. The system wasintended to support motor relearning by providingfeedback (knowledge of performance) during task specificrepetitive practise of reach and grasp and hand to mouthexercises. A key feature of the work was the involvementof a multidisciplinary team of clinicians and engineers,patients and carers, from the earliest stages of theproject4. Evaluation of the prototype system was carriedout during therapy sessions and independently by strokepatients at home. The hardware uses two MTX inertialsensors (Xsense Technology, Enschede) attached to theupper and lower arm, these are connected to a wirelessinterface that transmits data to a computer. Customisedsoftware was developed for data collection, dataprocessing and to provide knowledge of results viasummary measures and a 3D computer representation.

We have carried out preliminary work to assess thefeasibility of using the system with patients within aneuro-rehabilitation unit following traumatic brain

injury or with Locked in Syndrome. Three patients usedthe system daily for one to two weeks, with the assistanceof a therapist. During the rehabilitation sessions thepatient performed a reach exercise as directed. Humanfactors issues were assessed with structured interviewswith the therapist and patient. Kinematic data wererecorded by the system and then replayed using computeranimation, along with summary variables, such as elbowflexion/extension and length of reach. The SMARTrehabilitation system was able to provide measurablechanges in the range of functional movement in allpatients, even though these were quite small. Positivehuman factor issues were that patients could see andunderstand their movements and could describe thedifferences and partake in goal setting. Patients foundthat observing the small movements they achieved wasvery motivational and that they could follow changes intheir movement over time. The system could be usedconcurrently with other therapy devices. Negative issueswere the robustness of the motion tracking system, whichneeded to be improved and the feedback of knowledge ofresults was poor ie graphs and charts

We have shown that commercial motion tracking devices,coupled with suitable software, can be successfully usedin a clinical rehabilitation setting. Subtle changes inmovement patterns and ranges, which may not bereflected in routine functional outcome measures, can bequantified. The system is currently being re-developed toallow full wireless operation of the inertial sensors,further work is needed on the most appropriate means ofpresenting results back to therapists and patients/carers.

REFERENCES

1. Zheng H, Black ND, Harris ND (2005)Position-sensing technologies formovement analysis in strokerehabilitation Medical and BiologicalEngineering and Computing 43 (4)IEE, ISSN 0140-0118 pp413-420.

2. Zhou H, Hu H, Harris N,Hammerton J (2006) Applications ofwearable inertial sensors inestimation of upper limb movementsJournal of Biomedical SignalProcessing and Control 1 pp22-32.

3. Islam N, Harris ND, Eccleston C (2006) Does technologyhave a role to play in assisting stroketherapy? A review of practical issuesfor practitioners Quality in ageing 7(1) January.

4. Mountain GA, Ware PM,Hammerton J, Mawson SJ, Zheng J,Davies R, Black N, Zhou H, Hu H,Harris N, Eccleston C (2006) TheSMART project: a user led approachto developing applications for

domiciliary stroke rehabilitation InClarkson P, Langdon J, and RobinsonP (eds) Designing AccessibleTechnology, Springer-Verlag London.

Dr Nigel Harris joined the RoyalNational Hospital for RheumaticDiseases (RNHRD) in 2001 as Head ofClinical Measurement and Imagingand senior lecturer in the School forHealth at the University of Bath. He isa fellow of the Institute of Physics andEngineering Medicine and member ofthe Council of the Society for Researchin Rehabilitation and the BathInstitute for Medical Engineering. TheRNHRD specialises in the treatment ofpeople with long term conditionsfocusing on rheumatic diseases,neurorehabilitation and painmanagement. The ClinicalMeasurement and Imaging teamprovide a range of specialistinvestigations including: bonedensitometry, thermography, laserdoppler imaging and capillaroscopy.

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Nigel has a particular interest inphysiological measurement,ambulatory monitoring andbiomedical engineering. Currentprojects include measurement of freeliving activity in people with longterm conditions, mechanisms ofcomplex regional pain syndrome anduse of new technologies for neuro-rehabilitation. His research interests

have led to a joint project withSheffield Hallam University in SMARTrehabilitation entitled ‘Technicalapplications for use in the home withstroke patients'. This researchexamines the appropriateness andeffectiveness of technology to supporthospital or home based rehabilitationprogrammes for people with stroke.

7. National Service Framework forLong Term Conditions Department ofHealth, London.

Dr Richard Greenwood is aconsultant neurologist to theNational Hospital for Neurology andNeurosurgery, Queen Square, andthe Homerton University Hospital; hehas been a consultant neurologistsince 1983. He is Director of the

Homerton Regional NeurologicalRehabilitation Unit, and leadclinician for the Acute Brain InjuryService at the National Hospital. Hisparticular clinical interest is in thenatural history and rehabilitation ofsingle-incident brain injuryincluding head injury, and hisresearch interests are focussed onrestorative neurology and drivers ofbrain plasticity after brain injury.

Service provision in ABI

rehabilitation: current

drivers

Dr Richard GreenwoodConsultant Neurologist, National Hospital for Neurology & Neurosurgery,

Queen Square and the Homerton University Hospital

The overall economic consequences of traumatic braininjury (TBI) rival those of stroke1, 2. The incidence of newlydisabled adult survivors one year after TBI is 100-150 per100,000 of the population3. Most survivors are young andhave a near-normal life expectancy4; thus the burden onpublic health and social care is substantial.

The beds that these patients occupy in ‘usual’ care arenot utilised appropriately and their recovery is inevitablysuboptimal5. Studies of TBI in the UK have confirmed thata major ‘bottleneck’ in the clinical pathway is a lack oforganised inpatient AR, after patients have beendischarged from acute neurosurgical or intensive care butprior to their participation in either early inpatient orcommunity rehabilitation6. Many patients are ‘stuck’ oninappropriate wards, acquire avoidable complications,fail to make optimal gains and fall through the net; lackof timely and appropriate rehabilitation results in poorlong-term outcome7. At present, organised inpatient ARfacilities in the UK are extremely scarce. They are unlikelyto become widespread unless their effectiveness isdemonstrated.

REFERENCES

1. Thurman DJ et al (1999) J HeadTrauma Rehabil 12 pp1027-54.

2. The Comptroller and Auditor General, National AuditOffice (2005) Reducing braindamage: faster access to better strokecare House The Stationery Office,London.

3. Thornhill S et al (2000) BMJ 320pp1631-35.

4. Brown AW et al (2004)NeuroRehabilitation 19 pp37-43.

5. Greenwood RJ et al (2004) Brit JNeurosurg 18 pp462-466.

6. Pickard JD et al (2004) J R Soc Med97 pp384-389.

‘Unsticking the stuck’:

physiotherapy challenges

in post acute brain injury

rehabilitation

Jo Tuckey MCSP

The challenges faced in post acute brain injuryrehabilitation are invariably highly complex requiring aninterdisciplinary team approach. One of the manyphysical impairments that a large majority of braininjured patients face is the loss of joint range and softtissue length in their limbs ie they become ‘stuck’.

This presentation discusses not only why physiotherapistsshould address this impairment, but also how this can beachieved. It focuses on the differing pathologies whichmay be the cause of this impairment, includingheterotopic ossification, hypertonia and motor andsensory dysfunction. It then goes on to discuss some ofthe combined therapy and medical interventions used intreatment, including splinting, exercise, antispasticitymedication and surgery.

Case examples and referenced literature are used todescribe the clinical reasoning processes which have beenused in the treatment of patients with the differingpathologies described. In so doing, the wider physical,cognitive and behavioural challenges are also highlighted.

REFERENCES

Citta-Piettrolungo TJ, Alexander MA,Steg NL (1992) Early detection ofheterotopic ossification in youngpatients with traumatic brain injuryArchives of physical medicine andrehabilitation 73 pp252-262.

Edwards (2002) Neurologicalphysiotherapy – a problem solving

approach 2nd Edition ChurchillLivingstone Edinburgh

Garland DE (1991a) A clinicalperspective on common forms ofacquired heterotopic ossificationClinical Orthopaedics and RelatedResearch 263 pp13-29.

Garland DE (1991b) Surgicalapproaches for resection of


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heterotopic ossification in traumaticbrain injury in adults ClinicalOrthopaedics and Related Research263 pp59-70.

Grissom SP, Blanton S (2001)Treatment of upper motor neuronplantarflexion contractures by usingan adjustable ankle-foot orthosisArch Phys Med Rehabil 82 pp270-273.

Knight LA, Thornton HA, Turner-Stokes L (2003) Management ofneurogenic heterotopic ossificationPhysiotherapy 89:8 pp471-477.

Mortenson PA, Eng JJ (2003) The useof casts in the management of jointmobility and hypertonia followingbrain injury in adults: a systematicreview Physical Therapy 83 (7)pp648-658.

Moseley AM (1993) The effect of aregimen of casting and prolongedstretching on passive ankledorsiflexion in traumatic head-injured adults Physiotherapy Theoryand Practice 9 pp215-221.

Moseley AM (1997) The effect ofcasting combined with stretching onpassive ankle dorsiflexion in adultswith traumatic head injuries PhysicalTherapy 77 (3) pp240-247.

Safaris KA, Karatzas GD, Yotis CL (1999)Ankylosed hips caused by heterotopicossification after traumatic braininjury: A difficult problem TheJournal of Trauma: Injury, Infectionand Critical care 46 (1) pp104-109.

Sheean G (1998) Spasticityrehabilitation ChurchillCommunications Europe Ltd London.

Subboro JB, Garrison SL (1999)Heterotopic ossification: diagnosisand management, current conceptsand controversies Journal of SpinalCord Medicine 22 (4) pp273-283.

Jo Tuckey qualified with a graduatediploma from King’s College HospitalSchool of Physiotherapy in 1990. Shehas specialised in neurology since1992. Since qualifying she hasworked in several NHS hospitalsincluding The National Hospital forNeurology and Neurosurgery, King’sCollege Hospital and the RegionalNeurological Rehabilitation Unit,Homerton Hospital, where she wasthe clinical specialist physiotherapistin neurology for five years. Inaddition she has worked at aspecialist neurorehabilitation clinicin Germany. She completed amasters degree inneurorehabilitation at BrunelUniversity in 2000. In 2006 shestarted a neurophysiotherapy serviceworking full time through a NorthLondon private practice, which shealso leads. Her clinical work is nowmainly domiciliary and shecontinues to teach on a variety ofpostgraduate and MSc courses.

establish working relationships with them and use goalsto direct their rehabilitation. Through theimplementation of a variety of approaches and skills wecan engage with the ‘Changed Person’ and family at anystage of their recovery, maximising the outcome of ourphysiotherapy interventions, and assisting them inachieving success.

Throughout the patient journey we need to measure bothrecovery and outcome, so we need to appreciate howbehaviour impacts on traditional neuro outcomemeasures and still be able to provide evidence for ourpractice. Physiotherapy services too, must acknowledgechallenging behaviour ensuring we provide both qualityand safety to all those involved.

In conclusion, Gina suggests why as physiotherapists weare well equipped to manage challenging behaviour andhow we can play an essential role within aninterdisciplinary team that includes the family andpatient when faced with the challenge of behaviour.

Challenging Behaviour

after Brain Injury: The

Physiotherapists role

Gina Sargeant MCSP

Within this presentation Gina aims to explore; ourperceptions of challenging behaviour. How does it restricta patient’s ability to engage in physiotherapy and how itcan ultimately impact on a patient’s recovery from atraumatic brain injury?

By considering the perspectives of all those affected bychallenging behaviour, physiotherapists can aim tounderstand and respect both the patient and family;

REFERENCES

Bach L, David, A (2006) Self-awareness after acquired andtraumatic brain injuryNeuropsychological Rehabilitation 16(4) pp397-414.

Frenisy M et al (2006) Brain injuredpatients versus multiple traumapatients: some neurobehaviouraland psychopathological aspects JTrauma, 60 (5) pp1018-1026.

Course notes from: Institute forApplied Behavior Analysis (2000) Apositive approach to challengingbehavior London ref address: 5777West Century Boulevard and Suite 675Los Angeles, California 90045 USA.

Course notes from: Ylvisaker M (2007)Rehabilitation after traumatic braininjury – enabling patients to achievemeaningful rehabilitation goalsusing a positive, holistic andcollaborative approach Bath refaddress: BNRS, RNHRD, UpperBorough Walls, Bath, BA1 1RL.

Lequerica A et al (2007) Agitation inacquired brain injury: impact onacute rehabilitation therapies J HeadTrauma Rehabil 22 (3) pp177-183.

Levack W et al (2006) Is goalplanning in rehabilitation effective?A systematic review ClinicalRehabilitation 20 (9) pp739-755.

Lippert-Gruner M et al (2006)Neurobehavioural deficits aftersevere traumatic brain injury (TBI)Brain Injury 20 (6) pp569-574.

Lombard L, Zafonte R (2005) Agitationafter traumatic brain injury:considerations and treatmentoptions Am J Phys Med Rehabil 84(10) pp797-812.

McAvinue L et al (2005) Impairedsustained attention and errorawareness in traumatic brain injury:Implications for insightNeuropsychological Rehabilitation 15(5) pp569-587.

Marsh N, Kersel D Frequency ofbehavioural problems at one yearfollowing traumatic brain injury:Correspondence between patient and caregiver reports NeuropsychologicalRehabilitation 16 (6) pp684-694.

Medd J, Tate R (2000) valuation of ananger management therapyprogramme following acquiredbrain injury: a preliminary studyNeuropsychological Rehabilitation 10(2) pp185-201.

Niemeier J et al (2005) Acutecognitive and neurobehaviouralintervention for individuals withacquired brain injury: preliminaryoutcome data NeuropsychologicalRehabilitation 15 (2) pp129-146.

Nyein K, Thu A, Turner-Stokes L (2007)Complex specialized rehabilitationfollowing severe brain injury: a UK perspective J HeadTrauma Rehabil 22 (4) pp239-247.

Obonsawain M et al (2007) A modelof personality change after traumaticbrain injury and the development ofthe Brain Injury Personality Scales

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Journal of Neurology, Neurosurgeryand Psychiatry 78 (1) pp1239-1247.

O’Callaghan C, Powell T, Oyebode J(2006) An exploration of theexperience of gaining awareness ofdeficit in people who have suffered atraumatic brain injuryNeuropsychological Rehabilitation 16(5) pp579-593.

O’Neill H (2005) Managing angerafter brain injury Series 3: practicalhelp after brain injury UK: Headway– the brain association.

O’Neill H (2006) Managing angerSecond edition West Sussex: WhurrPublishers.

Ponsford J et al (1996) Traumaticbrain injury rehabilitation foreveryday adaptive living East Sussex:Psychology Press.

Schonberger M et al (2006) Workingalliance and patient compliance in brain injury rehabilitation and theirrelation to psychosocial outcome Neuropsychological Rehabilitation 16(3) pp298-314.

Schonberger M et al (2006) Patientcompliance in brain injuryrehabilitation in relation toawareness and cognitive andphysical improvementNeuropsychological Rehabilitation 16(5) pp561-578.

Sivaraman N (2003) Life goals: theconcept and its relevance torehabilitation Clinical Rehabilitation17 (2) pp192-202.

Staff Training booklet RNHRD (2007)Managing Difficult Behaviour BNRSref address: BNRS, RNHRD, UpperBorough Walls, Bath, BA1 1RL.

Wilson B et al (1999) Evaluation ofoutcomes in brain injuryrehabilitation NeuropsychologicalRehabilitation, special edition 9 (3-4) pp225-544.

Wilson B, Herbert C, Shiel A (2003)Behavioural approaches inneuropsychological rehabilitationoptimising rehabilitation proceduresNew York: Psychology Press.

Wood R, McMillan T (Eds) (2001)Neurobehavioural disability andsocial handicap following traumaticbrain injury East Sussex: PsychologyPress.

Gina Sargeant qualified from Salfordin 1994, and has worked with headinjured patients in the acute hospitalsetting for nearly all of her career.She is currently clinical specialist atBath Neuro Rehabilitation Services atthe Royal Mineral Water Hospital,Bath and ‘challenging behaviour’ inits various guises has been a part ofthat puzzling patient presentationthroughout. Gina once noted thatwhen being introduced at the localuniversity, the head of schooldescribed the role of physiotherapyin head injury as ‘extreme –physio’something that initially alarmed her,however on reflection – is itdangerous? – not really; is itdifficult? – at times yes; does itrequire patience, skill and cunning?– definitely – and that can be downto both complexity of patient need,behaviour exhibited and therapist;Whether that behaviour ischallenging or not remains to beseen…

patient in particular has confident presentation skills andis able to articulate himself well, and a strong vein ofhumour runs through his outlook on the experiences hehas coped with since his traumatic complex brain injury.

A patients perspective

Nick Hedley

A talk about my full brain injury ‘experience’, from apersonal patient’s perspective, whose views andperceptions of the events and the medical environmentaround him during the brain injury treatment/recoveryprocess will hopefully illuminate or increaseunderstanding of the perceptions of a patient. This

Nick Hedley is 26. In 2001 he starteda three year BA (Hons) in primaryteacher training. He also workedpart-time and was quite adept atmanaging time. He was also at thistime very physically fit. However, on23rd August 2003, he was foundunconscious in a supermarket carpark in the early hours of themorning, with some quite severe

head injuries and damage to hisbrain. Assault was suspected, butdue to a lack of witnesses and theamnesia resulting from swelling ofthe brain, he has no memory ofwhat occurred on that night. Aftertwo hospitals and a stint at RehabUK, he returned to university, and iscurrently there now.

Discharged and forgotten:

managing the effects of

minor brain injury

Anne McSherry

Physical recovery following brain injury is very muchviewed as the primary role for the physiotherapist. Thereare many challenges presented to our profession when itcomes to the management of clients with mild braininjury, whose clinical presentation are more often relatedto behavioural or social functioning deficits.

This presentation hopes to provide an insight into thesequelae of mild brain injury and present theimplications for clinical practice using current evidence,and will include some innovative interventions given thespeakers clinical background.

REFERENCES

King NS (2003) Post-concussionsyndrome: clarity amid thecontroversy The British journal ofPsychiatry 183 pp276-278.

Wong Wai-kei (2006) PostConcussional Syndrome The HongKong Medical Diary 11 (12) pp15-17.

Ponsford et al (2002) Impact of earlyintervention on outcome followingmild brain injury in adults Journal ofNeurology Neurosurgery andPsychiatry 73 pp330-332.

De Kruijk et al (2002) Prediction ofpost-traumatic complaints after mildbrain injury: early symptoms andbiochemical markers Journal ofNeurology, Neurosurgery andPsychiatry.London 73 (6) pp727-734.

Wade et al (1998) Routine follow upafter head injury: A secondrandomised controlled trial Journalof Neurology, Neurosurgery andPsychiatry 65 (2) pp177-184.

Moore et al (2006) Mild traumaticbrain injury and anxiety sequelae: Areview of literature Brain Injury 20 (2)117-132.


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Bryant R, Harvey A (1998)Relationship between acute stressdisorder and Post Traumatic StressDisorder following mild brain injuryAmerican journal of Psychiatry 155pp625-629.

Gemmell C, Leathern J (2006) A studyinvestigating the effects of Tai ChiChuan: Individuals with traumaticbrain injury compared to controlsBrain Injury 20 (2) pp151-156.

Anne McSherry qualified from UlsterPolytechnic now University of Ulster in1984 and completed the AdvancedBobath course in 1993. From 1994 to2004 whilst working as a Senior 1 inthe North & West Belfast YoungPhysically Disabled Programmeincluding Brain injury she developedan interest in the mind/bodyrelationship. In 1999 she completedan MA in Psychoanalytic Studies at

Queen’s University Belfast – herdissertation being: A psychoanalyticinsight into psychosomatic illness.During 2003-4 she was a ResearchAssociate in the University of Ulsterphysiotherapy pilot study comparingBobath therapy and gait specifictraining in acute stroke. From 2004 shehas worked as a Clinical Specialistpromoting the role of physiotherapy inthe treatment of post traumatic stressdisorder (PTSD) in the multi-disciplinary trauma team in the nowBelfast Trust. The team has presentedthe results of their innovative work onan international stage and has tworesearch papers pending. From August2006 to the present she was the actingco-ordinator of the Community BrainInjury team and is now the Senior 1physiotherapist in the team. Herpresent research interest is in theacknowledgement of PTSDsymptomology in mild brain injury.

The challenge of community

rehabilitation: an

interdisciplinary pathway

for acquired brain injury

Vicky Richards

The presentation will include a brief history of theCommunity Brain injury Team, its client group and typesof interventions available. The development of carepathways by the team and the difficulties and limitationsexperienced.

Examples will be shown of the teams process map and itspre-intervention documentation. Discussion of how ICP’shelp provide an equitable service, and allow goodcommunication. This ensures smooth team meetings andstaff induction, whist providing a tool for clinical audit.

Vicky Richards initially undertookRMN training in Cardiff, qualifying1982, then RGN at UHW qualifying1984. Following this she returned towork in psychiatry until 1987 whenshe commenced work as a communityliaison sister with the CommunityMemory Project. During this time sheundertook a Diploma in Counselling atthe University of Wales College in

Newport. In 1995 she returned towork in psychiatry as a clinical nursespecialist in neuropsychiatry. In 2000she completed MSc in family healthstudies at the University of Glamorgan.She has worked in her current positionas clinical nurse specialist andcoordinator of the Community BrainInjury team since the team wascommissioned in October 2001.

REVIEW

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ARTICLE

Stroke patients andlong term training: is it worthwhile?A randomized comparison of twodifferent training strategies afterrehabilitationLanghammer B, Lindmark B,Stanghelle JK (2006) ClinicalRehabilitation 21 pp495-510

Review by Nicola James, OxfordACPIN

TitleThe title accurately describes thestudy undertaken.

AuthorsThe first two authors appear to beacademics at physiotherapy depart-ments at Oslo University College inNorway and Uppsala University inSweden while the last authorappears to work at the SunnaasRehabilitation Hospital in Norway.

AbstractThe abstract clearly sums up themethod and results of the study.This research studied stroke patientsin their first year after inpatient reha-bilitation. It compared an intensivephysiotherapy led exercise pro-gramme with physiotherapy asrequired based on the patients’needs. Both groups improved signifi-cantly up to six months, at whichpoint function stabilised. The groupsdid not differ significantly whenretested at three, six and twelvemonths. Motivation and compliancewith exercise was high in bothgroups and all subjects maintainedtheir level of function.

IntroductionThe introduction is concise and thor-ough. It sums up the lack of studiesin the long term treatment of strokeafter discharge from a stroke unit aswell as putting the new study intocontext of the authors’ previous

research. The authors previouslystudied patients at one and fouryears after stroke. They conclude that‘there have been no longitudinalstudies of the effects of uninterruptedregular physical exercises in strokepatients from the acute phase up toone year after stroke’.

MethodThis study was a longitudinal ran-domized controlled stratified trial. Itdiffers from much physiotherapyresearch by attempting to be doubleblind: neither investigator norpatients knew to which group thepatients were being allocated.However it is not clear to what extentthe patients in the exercise groupswere blinded to which group theyhad been allocated. The subjectswere aware that there would be dif-ferences in intensity of physiotherapywithin the groups.

The subjects were patients withfirst ever stroke discharged from thesame acute hospital after havingreceived the same type of inpatientrehabilitation. Stratification was bygender and by hemisphere lesion.There were 35 patients in the inten-sive group and 40 in the regularexercise group and no significant dif-ferences between the groups regard-ing age, hemisphere lesion, maritalstatus or length of stay on the strokeunit. MAS, Barthel and grip strengthwere all higher in the regular groupbut these differences were not signif-icant.

Mean motor function at baselineas measured by the MAS was higherin the regular group (31.4) than forthe intensive group (26.7). TheBarthel was also higher at baseline inthe regular group (66) than theintensive group (56.6). Grip strengthwas also higher in the regular group.However, these differences were notsignificant. Length of stay betweenthe two groups was significantlylonger for the intensive group at 22days compared to 16 for the regulargroup. There was a greater improve-

ment in MAS total score and Bartheltotal score in the intensive groupfrom admission to discharge from theacute stroke unit; intensive group 7.5,regular group 1.7.

On discharge, rehabilitation for theintensive group was carried out byphysiotherapists in the communitywho had agreed in advance to treatthese patients to the intensive treat-ment protocol. These training proto-cols included high intensity exercisesuch as static bicycling, sit to standpractice and stair walking. Intensitywas monitored by the Borg scale orheart rate. The regular exercise groupreceived treatment if felt to require itbut were not treated to any specificprotocol. They did receive encour-agement to maintain a high level ofactivity.

The intensive group had a mini-mum of 20 hours every third monthduring the study year. These sessionsstarted immediately on dischargefrom the acute unit, two or threetimes a week if at home or daily ifthe patient was on a rehabilitationward. The regular group had followup physiotherapy treatment accord-ing to their needs as determined bythe stroke unit staff or communityteams.

ResultsThe patients had the MAS, Barthel,and grip strength measured by an‘experienced investigator’ blinded togroup allocation at admission, dis-charge from rehabilitation and three,six and twelve months after stroke. Itis not mentioned whether this inves-tigator was also a study author. Aunivariate analysis of variance(ANOVA) was used to compare thebaseline to one year change in theoutcome measures. The significancelevel was <0.05. The results areclearly set out and easy to under-stand.

Both exercise groups improved sig-nificantly from admission to threemonths in motor function, activitiesof daily living and grip strength as

measured with the MAS, Barthel andMartin vigorimeter. Between threeand six months improvement sta-bilised and there were no furthersignificant improvements in eithergroup.

Motivation in both groups washigh with compliance 80% in theintensive group and 78% in the reg-ular group. Both groups undertookapproximately the same amount ofexercise per week.

DiscussionTo the authors knowledge, this is thefirst randomized controlled study tocompare intensive exercise with reg-ular treatment for patients in theyear following their first stroke.

The authors feel that this improve-ment is because the reduction in sec-ondary complications due toinactivity are minimised, allowingimprovements to be due to sponta-neous recovery and rehabilitation.

The similarity in the intensity ofexercise between groups was felt tobe due to the motivation of havingtest occasions and regular contactwith a physiotherapist. The impor-tance of supervision and socialgroups in exercise programmes forpatients following stroke has alsobeen suggested by other authorssuch as Olney et al (2006).

One exciting result was the main-tenance and improvements in MAS,Barthel and grip strength results ayear after stroke. These improve-ments were larger than the authors’2003 study of patients who receivedlittle or no treatment after stroke,and to the authors’ knowledge, havenot been found in other studies.

The authors conclude that ‘afterinitial rehabilitation following stroke,planned regular exercise continuedover one year leads to a greaterimprovement in motor function thantreatment “as required”’. I feel theresults are not clear enough todemonstrate this. Using the meanMAS results, the only time the inten-sive group improved significantly

REVIEWS ARTICLES BOOKS COURSESReviews of research articles, books and courses in Synapse are offered by regional ACPIN groups or individuals in response to requests from the ACPIN committee. In the spirit of an extension of the 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 reviews reflect the opinions of the authors only. We give the authors of the original book or paper the opportunity to respond. We hope these reviews will encourage members to read the original article and not simply take the views of the reviewers at face value.


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over the regular group after dischargefrom rehabilitation was between sixmonths and one year: intensivegroup mean MAS 1.2 and regular -0.7(p=0.02).

ConclusionThis study has much to interest phys-iotherapists working with stroke sur-vivors after discharge from acuterehabilitation. It demonstrates theimportance of supervised exercise inmaintaining and improving function,and that physiotherapist led follow-up programmes are as beneficial as acompulsory exercise programme. It isencouraging to note the high level ofcompliance and motivation for exer-cise in the subjects. This study has aclear design and the use of familiaroutcome measures and statisticsmeant that it is easy for clinicians tounderstand. The treatment protocolappeared relevant and similar totreatments offered to this group ofpatients in the UK. The use of a largegroup of physiotherapists in manydifferent settings to treat the subjectsas part of a research project appearsinteresting as a way to design futurestudies in this area.

ReferencesThe reference list is appropriate for astudy of this type.

COURSE

24 hour postural management of theadult neurologicalpatient

Reviewed by Alison Burns clinicalspecialist physiotherapist, FarnhamHospital, Surrey PCT (SW locality) andKate Moffatt senior physiotherapist,Godwin rehabilitation unit, SurreyPCT (SW locality)

This was the second year this studyday course had been run within thesouth west locality of Surrey PCT.Expanded from the previous years’programme, it incorporated multi-disciplinary speakers from within thePCT. After an initial session definingpostural management regime, lec-tures included the medical manage-ment of increased tone, posture andseating, and the effects of splintingand passive stretches. In addition tothe previous year, speakers also covered the topics on the effects ofposture on swallow and communi-cation, tissue viability and funding oflong term disability.

This course was well received bythe multi-disciplinary participants,who attended from acute, primarycare and social care settings. It high-lighted the need for well plannedand pro-active postural manage-ment regardless of the locality of thepatients. The use of case studies atthe end of the day assisted in com-bining many of the points that hadbeen raised throughout the day,with time for questions and discus-sions around current practice.

With the ever growing populationof community dwelling adults withlong term neurological disease, thecourse raised awareness of theimportance of delivering timelyinterventions, the need for inte-grated working and a greater under-standing of the roles of otherdisciplines in optimising care.

We will be running this courseagain next year, using a similar pro-gramme.

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East AngliaNic Hills

Over the last few months we havebeen surveying the East Anglia ACPINmembers to gain feedback on whatthey wanted from ACPIN at a regionallevel. Thank you to everyone whotook the time to complete the ques-tionnaire, the results can be seen onpage 27. We really value the feedbackand will use the responses to planfuture courses. If anyone has yet tocomplete the survey, we will stillwelcome your replies.

Following the feedback from thequestionnaire we have planned thefollowing courses;• April Half day Spasticity course and

AGM Norwich and Norfolk Hospital• June Saboflex course ICANHO,

Suffolk• September Lycra and AtaxiaAs I touched upon in my last report,we are trying to get East Anglia ACPINback on the map. As the region cov-ers a large geographical area, wethought it would be useful to have arepresentative from each area withinthe region to aid communication anddissemination of information. If youare interested in this role please getin touch, I look forward to hearingfrom you.

KentJanice Champion

We have had another good year withmembership numbers staying highfor Kent and therefore our committeehas been strongly supported led byCathy Kelly-Jones, our chairperson.

Our 2008 programme started withthe AGM ‘UnderstandingNeuromuscular Disorders’ which washeld in March at Medway MaritimeHospital, Gillingham. We tried a dif-ferent format this year and started at3:30pm followed by the AGM. Wehad a fascinating talk by Dr MichaelRose MD FRCP, consultant and hon-orary senior lecturer in neurology,Kings College Hospital, London andJoanna Reffin, senior I physiothera-pist, Muscle Clinic, also from KingsCollege Hospital, London.

This was well attended andattracted therapists from other spe-cialities as well as ACPIN members.

Our plans for 2008 include a studyday on ‘Managing the post-neuro-surgical patient in a district generalhospital’ which is scheduled for Apriland we are planning a ‘Vestibularrehabilitation’ study day in conjunc-tion with our neighbouring Sussexregion in June. This will be a practicaland theoretical day and give partici-pants a chance to see the posturog-raphy equipment at MedwayBalance Clinic.

Any ideas from members for futurecourses are always welcome.

LondonLeigh Forsyth

2007 has been another strong year forthe region, both London ACPIN andthe committee have a healthy mem-bership and thanks to the new mem-bership database from National ACPINit has made it easier to contact all ofour members than before. This hasled to us establishing one emailaddress ([email protected]) so that all course queries can bedirected to one place throughout theyear so gone are the days of chasingafter one person for course enquiries!The majority of feedback we havebeen getting is positive however, ifthis isn’t the case and you are experi-encing problems then please do let usknow. We have been using iCSP moreto advertise our courses and we arealso planning to use the improvedACPIN website to hold details of theongoing annual programme.

Last years program was a combi-nation of evening lectures and studymornings which were very wellattended, topics included ‘Transitiontowards successful stroke manage-ment’ by Dr Fiona Jones; ‘Gettingthrough and getting on – feedbackand practice for stroke patients’ by DrPaulette Van Vliett; a fantasticevening of lectures, debate and wineto commemorate Sue Edward’sretirement from teaching and a fan-tastically well attended evening lec-ture on ‘Musicians Dystonia’.

We have been planning an excitingschedule for 2008 the most up to dateversion is available on the ACPINwebsite (acpin.net) and we will con-tinue using iCSP for regular remindersand post or email at the start of theyear. Thanks for all of your supportand please let us know of any topicsyou would like covered or any gen-eral comments via the feedback formsat the lectures.

We would like to welcome ournewest committee member SusannaNielsen from Kings College Hospital tothe London committee and we wishyou all of the best for the comingyear!

ManchesterHelen Dawson

Happy belated new year fromManchester ACPIN.

Thank you to all the speakers andeveryone involved for their hardwork to create a successful pro-gramme for the region in 2007.

With a strengthened committeewe have planned an exciting pro-gramme for 2008 following a suc-cessful start to the year with apopular Vestibular Rehab. lecture byNova Mullin.

The rest of this year’s programmelooks like this!• May Gym ball session• July MS- focus on cognition and

fatigue• September Splinting day course• November Open forum for ques-

tions/discussion with wine andcheese

New committee members are alwayswelcome so if you have an interest injoining us or to get an idea of whatwe do please get in touch.

If you any questions/comments/feedback let us know by email at:[email protected]

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Northern IrelandJoanne Wrigglesworth

NI ACPIN continues to be a dynamicand stimulating group with a goodmembership base from around theprovince. A huge thank you must goout to our retiring committee mem-bers, Siobhan MacAuley (retiringChair) and Maire Kerr (retiringTreasurer) for their hard work andenthusiasm over a number of years.Congratulations to one of our ‘careerbreak committee members’, JaneMcKeown, on the birth of her son. Bythe time this goes to press, we hopeto have recruited to our committee;however, interest in joining us at anytime of the year is always gratefullyreceived!

And now to business! Our 2007/2008 programme continues to bewell attended, with monthly lectureson a variety of topics, including themanagement of chronic pain and avery informative evening spent inour local gait laboratory. Our AGMand review of Spasticity andBotulinum Toxin, followed by lightworkshops on driving and disability,gym ball activity and Parkinson’s dis-ease complete the programme.

NI ACPIN has funded a place forboth our regional representative andanother member to attend the ACPINnational acquired brain injury con-ference. As a committee, we con-tinue to assess the budget andattempt to provide assistancethrough the running of reduced pricecourses or assisting with fundingwhere applicable.

Finally, we are beginning to collateideas for the 2008/09 programme,both for the format and titles/speak-ers. Any ideas are always receivedwith great delight! Many thanks foranother good year, enjoy the sum-mer break and we look forward toseeing you in September.

NorthernPam Thirlwell

As you read this the ACPIN pro-gramme for 2008 will be well under-way. On January 24th we had anevening lecture about the ‘RheastimFES cycling system’ which was heldas Chase Park Health Club. Thisinvolved a patient demonstration ofthe equipment which was wellattended and thought provoking.

On February 23rd/24th we held anexcellent ‘Hydrotherapy in neurol-ogy’ course at James Cook Universityhospital. The tutor was AlisonSkinner. The course went well and asusual we had an AGM by stealth lur-ing people in with a free lunch. Wewelcomed new committee membersGillian Scott, Emma Robinson, RosieSimms and Heidi Miller

Further plans for the year definitelyinclude • 13/14th September On the ball

course with Joanne ElphinstonOther ideas for courses include:• Autumn Spasticity and spasticity

management• July (possible) Musculoskeletal

techniques for neurophysiothera-pists

• July (possible) Movement sciencecourse

• Bobath course – planned for late2008 or early 2009 actual topic andvenue TBA

We plan to send out flyers of the fullprogramme once we have moredates confirmed

Thank you to all the committeewho continue to work hard arrang-ing all the courses. Please let usknow if there are any courses youwould like arranged or if anyonewould like to join the committee weare always happy to have newmembers.

OXFORDSophie Gwilym

Oxford region have enjoyed goodattendance at a varied programme ofevening lectures and courses withtopics including thrombolysis instroke, incomplete spinal cord injuryand functional neurological disabil-ity. We would like to thank ourspeakers and also our attendeeswhose comments, questions anddebate all add to the educationalvalue.

The committee remainsunchanged since the last edition ofSynapse, however committee mem-ber Claire Harris is now Claire Clarke.Congratulations to Mrs Clarke!

Forthcoming programme• 6th May 7.15pm SaeboFlex at the

OCE• June 14th Pain, the brain and the

real world with Lorimer Moseley,Nuffield Orthopaedic Centre,Oxford. A one day course coveringup to date pain theory and physi-ology, discussing treatment strate-gies and explaining concepts suchas CNS hardwiring and neuro-pathic pain – all this with refer-ence to the neurological patient!

• July 17th 6.00pm Summer socialpunting, Cherwell Boathouse,Oxford, followed by meal.

• August – summer break!• September 5th and 6th Ataxia,

Pam Mulholland. Two day course.• October 15th Cognitive changes in

MS, Dr Rachel Tams Psychologist,OCE

We welcome any volunteers for ourcommittee, ideas and suggestions fortalks and are also looking for addi-tional venues to host lectures. Feelfree to contact us informally to dis-cuss further.

SCOTLANDLindsay Masterton

2007 was another good year forScottish ACPIN with a varied range ofcourses/speakers. Membership num-bers remain healthy at about 78however we do have spaces on thecommittee so do contact me if youare interested.

Forthcoming programme• April 23rd AGM and Exploring the

Brain Dr Gilie McNeill in Glasgow• August 23rd Pauline Pope on

Positioning and Seating withNeurological Patients. Edinburgh

• September 27thNeurophysiotherapy ResearchForum Stirling. Panel includingMark Smith, Jackie Morris, JohnDennis and June Lawrie. Morespeakers to be confirmed.Opportunities for questions , dis-cussion groups etc.

• October 25/26th Debbie Strang(Bobath tutor ) Trunk and ShoulderRaigmore Hospital.

Further details about the abovecourses will be included in anewsletter together with other localnews.

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Surrey and BordersKate Moffatt

Firstly, thank you for all your supportover the gloomy winter months! Wehave yet again had a successful yearwith high membership numbers andan enthusiastic committee. AnnaDunkerley has settled into the role aschair very well and the committeecontinues to work at providing aninnovative and extensive list ofevening lectures throughout theyear.

By the time this issue of Synapse ispublished we will have had ‘Theneurological foot’ study day and ourannual AGM. We hope to have a newwave of committee members joiningus for this next year!

Many thanks to all of the speakersthis year who have given us food forthought!

Forthcoming programme• May Fatigue management• July Discharge from stroke physio-

therapy• September Robotics• October Developments in the

management of spinal cord injuryand the influence on physiother-apy practise.

All future events will be advertised inFrontline and on the ICSP website, sokeep your eyes peeled!

Please do not hesitate to contactme with any querieson:[email protected]

We look forward to seeing you allat future events!

SussexClare Hall

We have had a varied programme ofevents with really good attendance,in spite of the current squeeze onstudy time and budgets. A big thankyou to all the committee for theircontinued enthusiasm! We will con-tinue to provide at least four eventsper year in different venues.

The autumn programme last yearstarted with an absolutely fabulousday on ‘Pilates in neuro’ with JoKilmore (senior physiotherapist), atSouthlands Hospital, on October. Thebackground to the PEAK Pilatesapproach was given using theoryand practical sessions. Clear informa-tion and discussion about how tosafely use this in the neurologicalpatient population was also covered.

In November there was a‘Feedback Session’ by two seniorphysiotherapists from the 2007 ACPINconference on ‘Balance’, and from astudy day in Southampton on‘Parkinsons disease’.

Forthcoming programme• April Interpretation of MRI/CT scans

evening lecture, Firwood House,Eastbourne. Details TBC.

• Summer Vestibular study day, jointevent with Kent ACPIN. Details TBC.

• Autumn Effects of exercise follow-ing TIA, Margaret Hewett, ClinicalSpecialist in Neurology, ConquestHospital.

We are always seeking further ideasfor topics, speakers and venues.Please let us know about your wishesfor next year’s programme: contactdetails are on the website.

WessexMary Vincent

After a successful year in 2007, with awell attended programme Wessexcommittee are hoping to continue toorganise monthly evening lecturesthroughout 2008. We also hope toorganise a two day Pilates course inSeptember/November, which ofcourse will be discounted to ourmembers.

Forthcoming programme• May 20th Talk on thrombolysis,

Bournemouth• June 24th Talk on new drug devel-

opments in MS, PoolePlease look out for advertising flyersnearer the time for exact speaker,time and venue details.

Thank you to all the committee fortheir hard work in organising events.The Wessex Committee largelyremains unchanged, with JennyBaker as Chair, Marjon van Wees asSecretary and Heather Ross asTreasurer. Due to me commencingmaternity leave in April I would liketo thank Hayden Kirk who has kindlyoffered to take on my role as regionalrepresentative in my absence.

Lastly, a big thank you to all theregional members who support ourevents, we hope you continue tosupport us throughout 2008.

West MidlandsFiona wallace

West Midlands ACPIN Membershiphas remained strong in 2007 withover 100 members. The committeecontinues to be active with about tenregular attendees. Louise Nichols ourmembership secretary has moved topastures new and on behalf of thecommittee I would like to say a hugethank you for all her hard work.

In November 2007 we welcomedAlison Skinner to Good Hope Hospitalfor a hydrotherapy course which wasextremely well received. The 2007programme then drew to a close inDecember with Carron Sintler pre-senting an evening lecture on thenew national stroke strategy.

The 2008 Course Programme waskick-started in February atBirmingham Heartlands Hospital. Dr Sandler presented an evening lec-ture titled ‘Shaping Stroke services’ atthe regional AGM, this was wellattended and very informative.

We are currently busy organisingthis year’s courses and meetings,which will include the long awaitedPNF Course in September with NikiRochford at Birmingham HeartlandsHospital. All events will be advertiseddirectly to ACPIN members by post oremail.

If you are interested in becoming acommittee member or have any sug-gestions for topics or speakers pleasefeel free to contact me via [email protected] or telephone on 0121 424 2867.


50

YorkshireJill Fisher

The Yorkshire ACPIN programme hadbeen very well supported over thelast few months by members andnon members. People from a num-ber of disciplines attended theevening talk I gave in October‘Managing people with severeneuro-disability in the community’.

In November Denise Ross gave avery interesting talk describing aninnovative and exciting approach tophysiotherapy stroke assessmentbeing developed in some LeedsHospitals. In early December it wasgood to welcome back Debbie Neil totalk to us about her role as a consult-ant physiotherapist and ‘Enablingself-management’.

On February 23rd Mary Lynch-Ellerington led a study day on‘Functional recovery of the hand’.

On 13th of March Professor Bhakta,Sophie Makeover and Jane Savagegave a talk on ‘The development ofan intelligent robotic system to aidphysiotherapy in stroke’. The AGMwill be on 19th April combined witha day course related to gait. SarahDaniels will be leading a workshop,and an orthotist will be presentingsome research he has done related tothe use of ankle foot orthotics.

Other events in the pipelineinclude Dr Duffy talking on ‘Dystonia’and Dr Amanda Stroud on ‘Practicalstrategies for behaviour manage-ment’. Debbie Strang on August 15thwill be leading a day course on ‘Theshoulder’ and Janice Champion on25th September will be the tutor for acourse with special emphasis onhandling during assessment andtreatment in the context of the hos-pital setting.

The email address seems to behelpful for aiding communicationwith the committee members: [email protected].

Dear Colleague,

In March 2007 we published a letterin Synapse requesting contributionsof abbreviations used in neurologicalphysiotherapy to enable us to com-pile a standardised list of abbrevia-tions to be used at a local level. Thiswas following a physiotherapy notesaudit for neurology inpatients thathighlighted inconsistencies in termsand abbreviations used betweentherapists. The list of abbreviations isnow completed and in use in ourtrust. It will be used as the standardfor abbreviations in the next audit ofphysiotherapy notes. If you wouldwish to receive a copy for your ownreference then it is available by con-tacting myself.

Many thanks to the individualswho contributed their own lists ofabbreviations.

Jo GilmoreSenior II physiotherapistNeuro GymPhysiotherapyWorthing HospitalLyndhurst RoadWorthingSussexBN11 2DHt 01903 285206e [email protected]

LETTERS

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Synapse is the official newsletter ofACPIN. It aims to provide a channel ofcommunication between ACPIN members, to provide a forum to inform,instruct and debate regarding allaspects of neurological physiotherapy. A number of types of articles have beenidentified which fulfil these aims. Thetypes of article are:

Case ReportsSynapse is pleased to accept case reportsfrom practitioners, that provide informationwhich will encourage other practitioners toimprove or make changes in their ownpractice or clinical reasoning of how toinfluence a change or plan a treatment forthat condition. The maximum length is2000 words including references. An out-line is given as follows:

IntroductionState the purpose of the report and why thecase is worth reading about to include inshort sentences:• The patient and the condition.• How the case came to your

attention.• What is new or different about it.• The main features worth reporting.

The patientGive a concise description of the patientand condition that shows the key physio-therapeutic, biomedical and psychosocialfeatures. The patient’s perspective on theproblem and priorities for treatment areimportant. Give the patient a name in theinterests of humanity, but not the realname. Do not include any other identifyingdetails or photographs without thepatient's permission.

InterventionDescribe what you did, how the patientprogressed, and the outcome. This sectionshould cover:• Aims of physiotherapy.• Treatment, problems and progress.• Outcomes, including any changes in

impairment and disability.• Justification of your choice of treatment;

clinical reasoning• The patient’s level of satisfaction and the

outcome and the impact on quality oflife.

MethodThis should clarify what intervention tookplace and what measurements were taken.It should include:• Description(s) of outcome measures used

and reference• Interventions carried out (where, when,

by whom if relevant)

Implications for practiceDiscuss the knowledge gained, with refer-ence to published research findings and/orevidence about clinical effectiveness. Forexample:• Outcome for the patient.• Drawbacks.

• Insights for treatment of similar patients.• Potential for application to other

conditions.

SummaryList the main lessons to be drawn from thisexample.

ReferencesThese should be in the Harvard style (seesection on ‘Measurements’ below).

Further guidelines for writing case reportswere published in the Spring 2001 issue ofSynapse, page 19.

Abstracts of thesis and dissertationsAbstracts from research projects, includingthose from undergraduate or postgraduatedegrees, audits or presentations. Theyshould be up to 500 words and where pos-sible the conventional format: introduc-tion, purpose, method, results, discussion,conclusion.

Audit ReportA report which contains examination of themethod, results, analysis, conclusions andservice developments of audit relating toneurology and physiotherapy, using anymethod or design. This could also include aService Development Quality AssuranceReport of changes in service delivery aimedat improving quality. These should be up to2000 words including references.

Review of ArticlesA critical appraisal of primary source mate-rial on a specific topic related to neurology.Download the ACPIN information sheetReviewing research articles for furtherguidance from the ACPIN website.

Product NewsA short appraisal of up to 500 words, usedto bring new or redesigned equipment tothe notice of the readers. ACPIN andSynapse take no responsibility for theseassessments, it is not an endorsement ofthe equipment. If an official trial has beencarried out this should be presented as atechnical evaluation. This may include adescription of a mechanical or technicaldevice used in assessment, treatment,management or education to include spec-ifications and summary evaluation.

Review of books, software and videosShort reviews of up to 500 words to includedetails of availability, price and source forpurchasing.

Letters to SynapseThese can be about any issue pertinent toneurological physiotherapy or ACPIN. Theymay relate to material published in theprevious issue(s) of Synapse.

PREPARATION OF EDITORIALMATERIAL

Copy should be produced in MicrosoftWord. Wherever possible diagrams andtables should be produced in electronicform, eg Excel, and the software usedclearly identified.

Hard copies should be as close to journalstyle as possible, on one side of A4 paperwith at least a 25mm margin all around,consecutively numbered.

The first page should give:• The title of the article• The names of the author(s)• A complete name and address for corre-

spondence• Professional and academic qualifications

for all authors, and their current positions• For research papers, a brief note about

each author which indicates their con-tribution and a summary of any fundssupporting the work

All articles• The text should be well organised and

written in simple, clear correct English.The positions of tables, charts or photo-graphs should be appropriately titledand numbered consecutively in the text.

• All abbreviations must be explained.• Any photographs or line drawings

should be in sharp focus with good con-trast for best reproduction.

• All charts should be in black and whiteonly and captions should reflect this.

• References should be listed alphabeti-cally, in the Harvard style with punctua-tion as follows: Bloggs A, Collins B (1998)The use of bandages in treating headinjuries Physiotherapy 67,3 pp12-13.

• In the text, the reference should bequoted as the author(s) names followedby the date: Bloggs A (1994)

• Acknowledgements are listed at the end.

MeasurementsAs the International System of Units (SI) isnot yet universal, both metric and imperialunits are used in the United Kingdom indifferent circumstances. Depending onwhich units were used for the original cal-culations, data may be reported in imperialunits followed by the SI equivalent inparentheses, or SI measurements followedby imperial measurements in parentheses.If the article mentions an outcome meas-ure, appropriate information about itshould be included, describing measure-ment properties and where it may beobtained.

Permissions and ethical certificationProtection of subjects: Either provide writ-ten permission from patients, parents orguardians to publish photographs of recog-nisable individuals, or obscure facial fea-tures. For reports of research involvingpeople, written confirmation of informedconsent is required. The use of names forpatients is encouraged in case studies forclarity and humanity, but they should notbe their real names.

Submission of articlesThe disk and two hard copies of each arti-cle, should be sent with a covering letterfrom the principal author stating the typeof article being submitted, releasing copy-right, confirming that appropriate permis-sions have been obtained, or stating whatreprinting permissions are needed.

For further information, please contact theSynapse co-ordinator:Louise DunthorneManor Farm BarnManor RoadCloptonWoodbridgeSuffolk IP13 6SHTelephone 01473 704150 / 738421

Note: all material submitted to the admin-istrator is normally acknowledged withintwo weeks of receipt.

The Editorial Board reserves the right toedit all material submitted. Likewise,the views expressed in this journal arenot necessarily those of the EditorialBoard, nor of ACPIN. Inclusion of anyadvertising matter in this journal doesnot necessarily imply endorsement ofthe advertised product by ACPIN.

Whilst every care is taken to ensurethat the data published herein is accu-rate, neither ACPIN nor the publishercan accept responsibility for any omis-sions or inaccuracies appearing or forany consequences arising therefrom.

ACPIN and the publisher do not spon-sor nor otherwise support any substance, commodity, process, equipment, organisation or service inthis publication.

GUIDELINES FOR AUTHORS


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EAST ANGLIA

Nic HillsPhysiotherapy DepartmentIpswich Hospital NHS TrustHeath RoadIpswich IP4 5PDt 01473 704150e Nicola.hills@

ipswichhospital.nhs.uk

KENT

Janice ChampionMedway Maritime HospitalWindmill RoadGillinghamKent ME7 5NYt 01634 833959e [email protected]

LONDON

Leigh ForsythStamford Brook Centre14-16 Stamford Brook AvenueLondon W6 0YDt 020 8383 6414e [email protected]

MANCHESTER

Helen Dawsone [email protected]

MERSEYSIDE

Jo Jonest 0151 282 6000 ext 6117e [email protected]

NORTHERN

Pam Thirlwellt 01642 282640e [email protected]

NORTHERN IRELAND

Joanne WrigglesworthPhysiotherapy DepartmentBelfast City HospitalLisburn RoadBelfast BT9 7ABt 028 90329241 ext 2545e joanne.wrigglesworth@

belfasttrust.hscni.net

NORTH TRENT

Emma ProcterBrearly Physiotherapy DepartmentNorthern General HospitalHernes RoadSheffield S5 7AUt 0114 271 5088e [email protected]

OXFORD

Sophie Gwilyme [email protected]

SCOTLAND

Lindsay MastertonCRABISAbility CentreCarmondeanLivingstone EH54 8PTe [email protected]

SOUTH TRENT

Tina HutchinsonPhysiotherapy DepartmentDerby City General HospitalUttoxeter RoadDerby DE22 3NEt 01332 340131 bleep 1992e [email protected]

SOUTH WEST

Kate MossPhysiotherapy DepartmentCirencester HospitalGloucester GL7 1UYt 01285 884536e [email protected]

SURREY & BORDERS

Kate Moffatte [email protected]

SUSSEX

Clare HallPhysiotherapy DepartmentConquest HospitalThe RidgeSt Leonards-on-SeaEast Sussex TN37 7RDt 01424 755255 ext 6435e [email protected]

WESSEX

Mary Vincentt 02380 825050e [email protected]

WEST MIDLANDS

Fiona WallacePhysiotherapy Ward 23Birmingham Heartlands HospitalBordesley Green EastBirmingham B9 5SSt 0121 4242867e Fiona.Wallace@

heartofengland.nhs.uk

YORKSHIRE

Jill FisherNeurophysiotherapy4 St Helen’s LaneAdelLeeds LS16 8ABt 0113 2676365e neurophysiotherapy@

yahoo.co.uk

REGIONAL REPRESENTATIVES NOVEMBER 2007 Syn’apseAdministratorLouise Dunthorne

Editorial Advisory CommitteeMembers of ACPIN executive andnational committees as required.

Designkwgraphicdesignt 44 (0) 1395 263677e [email protected]

Printers MF Barnwell & Sons, Norwich

Address for correspondenceLouise DunthorneSynapse AdministratorManor Farm Barn, Manor Road,Clopton, WoodbridgeSuffolk IP13 6SHe louisedunthorne@

tiscali.co.ukt 44 (0)1473 738421

JOURNAL AND NEWSLETTER OF THE ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS INTERESTED IN NEUROLOGY

SPRING 2008

ISSN 1369-958Xwww.acpin.net

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