midline orientation of the head – does achieving this

> Midline orientation ofthe head – doesachieving this improveability to maintainunsupported sitting inthe stroke patient?

> Elective spinal patients –the implementation ofweekend physiotherapyat Kings College Hospital

> Late stage physiotherapy– rehabilitationfollowing severetraumatic brain injury –a case report exploring aclient with severephysical impairmentsfour years post injury

Autumn/Winter 2009

www.acpin.net

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

AUTUMN/WINTER 2009

ISSN 1369-958Xwww.acpin.net


SYNAPSE Autumn 2009 4/11/09 18:35 Page C4

ACPIN’S AIMS1. To encourage, promote and

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

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

3. To encourage members to participate in research activitiesand the dissemination of information.

4.To develop and maintain a reciprocal communication processwith the Chartered Society ofPhysiotherapy on all issues relatedto neurology.

5. To promote networking withrelated organisations and professional groups and improvethe public’s perception of neurological physiotherapy.

Syn’apseJOURNAL AND NEWSLETTER OF THE

ASSOCIATION OF CHARTERED

PHYSIOTHERAPISTS INTERESTED

IN NEUROLOGY

AUTUMN/WINTER 2009

ISSN 1369-958X

CONTENTSFrom the Chairs 2

President’s address 3

Article 1Midline orientation of the head – does achieving this improve ability to maintain unsupported sitting in the stroke patient? 5

Article 2Elective spinal patients – the implementation of weekend physiotherapy at Kings College Hospital 10

Article 3Late stage physiotherapy– rehabilitation following severe traumatic brain injury – a case report exploring a client with severe physical impairments four years post injury 13

Articles in other journals 19

Sharing good practiceResponse from BBTA and MRP to article ‘What do student physiotherapists perceive the Bobath concept and Motor Relearning Programme to be and do they feel confident to use these approaches in stroke rehabilitation?’ (Pinguey & Levis) 22

ACPIN news 26

General news 27

ACPIN @ Congress 2009Abstracts and speaker biographies 28

Five minutes with…Louise Ada 33

Focus on…Wales 34

ReviewsCOURSE: Are the arms and legs connected during locomotion? 37COURSE: Welsh Stroke conference 2009 37COURSE: Classic pilates clinical application for neurological patients 38COURSE: Outcome measures study day 38

Regional reports 39

Guidelines for authors 43

Regional representatives 44

SYNAPSE Autumn 2009 4/11/09 18:29 Page 1

Current Executive Committee

PresidentMargaret [email protected]

Honorary chairsCherry [email protected]

Jo [email protected]

Vice chairSiobhan [email protected]

Honorary treasurerJo [email protected]

Honorary secretaryAnne [email protected]

Honorary research officerJulia [email protected]

Honorary membership officerSandy [email protected]

Honorary minutes secretaryLouise [email protected]

Honorary PROAdine [email protected]

CIG liaison representativeGita [email protected]

Synapse coordinatorLouise [email protected]

Diversity officerJakko [email protected]

Committee memberLorraine [email protected]

Committee memberChris [email protected]

Committee memberEmma [email protected]

Welcome to Synapse Autumn2009!

We hope you will find this edition aninteresting and useful read; it may bejust what you need as we move intothe long nights of winter followingour long hot BBQ summer!

It seems like only yesterday thatwe were putting finger to keyboardto write for the spring edition, butthey say time flies when you areenjoying yourself; we can’t believethat this is our penultimate ‘From theChairs’ and that come March 2010 wewill be handing over the ‘Chairship’to our very capable and experiencedVice chair Siobhan MacAuley. As ourPresident Dr Margaret Mayston willhave been in post for a year by thenwe are very confident that we won’tbe missed at all! Don’t worry we willsave our reminiscing until the nextedition of Synapse, bet you can’twait!

Siobhan has also been our ACPINCSP Congress link person for the lastcouple of years and yet again she hasdone another marvellous job and wehope you agree that the Liverpoolprogramme was excellent. As alwaysthe standard and content of presen-tations was very high, and ACPINwere delighted to have been able tostart the proceedings off with suchan eminent neurological physiother-apist as Professor Louise Ada. A bigthank you to all our speakers!

ACPIN has been busy on manyfronts since the last Synapse; one ofthese has been the eagerly awaitedsplinting guidelines. Don’t get tooexcited as we are in the very earlystages but definite progress has beenmade! Firstly ACPIN has joined forceswith the specialist neuro section ofthe College of OTs with the aim ofproducing a document that is fit forpurpose across the professions. Manyof you will have already participatedin our stakeholder engagement exer-cise by filling in the Survey Monkeyquestionnaire about where we arecurrently with splinting – thank youto all who have done this as it con-stitutes one of the steps of the formal

process of guideline developmentstipulated by the CSP. We hope toreport the initial findings of the sur-vey in the next Synapse. As you cansee from this edition (and previous)ACPIN has also been involved in thedevelopment of other guidance.Bhanu Ramaswamy has yet againcomes up trumps with her work withthe Parkinson’s Disease Society toname but one area. Promoting andcontributing towards evidenceinformed physiotherapy practiceremains a key strand of ACPIN.

ACPIN have also joined forces withthe CSP and the Move for Healthexercise agenda. Chris Manning haskindly stepped forward to be ACPIN’sMove for Health champion and welook forward to seeing him lead byexample! The importance of exercisefor all is reflected in the 2010 ACPINConference and AGM (again in oursecond home at the NorthamptonHilton) on the 19th and 20th Marchand titled ‘Fit for Life? Exercise andNeurology’. Please see the advert inthis edition and of course visit ourwebsite on www.acpin.net whereyou can also download an applica-tion form.

Well that seems more than enoughfrom us, and it just leaves us to say“Hope to see you all in Glasgow forthe UK Stroke Forum” – do come andjoin us in December to round offanother great year for ACPIN.

Jo and Cherry

FROM THE CHAIRS

Syn’apse ● AUTUMN/WINTER 2009


PR

ESIDEN

T’S AD

DR

ESS

3

Do you remember that songrecorded by Liza Minnelli – I thinkit was from the musical Cabaret?

The relevance of this comes later. As Iwrite this, the London ACPIN groupare about to hold their annual wineand cheese evening, and in a fewweeks the CSP congress in Liverpoolwill take place. ACPIN as usual havean exciting programme set up withan international speaker, ProfessorLouise Ada from Sydney, Australia,who I am really looking forward tohearing and meeting again. Boththese events are examples of thehard work that takes place to ensurethat ACPIN members are wellrewarded for their membership.

Since taking on the role ofPresident in March this year, I havebeen introduced to the behind thescenes workings of the ACPIN execu-tive and regional representatives.This dynamic group of people do anastonishing job in driving neurologi-cal physiotherapy forwards andworking to provide the membershipwith high quality continuing educa-tion and support.

I have just spent this afternoontrying to get the new software work-ing for a practical session on theHoffmann reflex (H-reflex), whichwe do with our second year under-graduates in biosciences at UniversityCollege London (UCL). Most of youwill know what it is – the electricallyelicited reflex which is the analogueof the stretch reflex. The H-reflexprovides a way to examine theexcitability of the alpha motorneu-rone and the circuitry of the stretchreflex while bypassing the muscle

spindle. It is a commonly used toolin neurophysiological research ofspinal control mechanisms, includ-ing the study of spasticity. The UCLsystem has been running on DOS(most of you will be too young toknow what this is), and I decided itwas high time to get it into the 21stcentury and able to be run usingWindows. I have had to do this withno budget allowance– relying on afew people’s good will and somecreative side-stepping. As I was com-pleting this task, I was also wonder-ing about what I would have to sayin this edition of Synapse. The shoe-string way of updating this softwareled me to consider the current finan-cial crisis and the implications of thisfor health workers.

Times are tough everywhere, serv-ices are being cut, budgets are beingslashed, particularly in educationand the health service. For example,UCL has become very IT minded and Inow have to print out my own pay-slip if I want one! This saves them thecost of printing and distributing thesaid document. Only yesterday it wasreported in the The Daily Telegraph(not my usual paper) that thenational debt is at a staggering £1.4trillion – it is hard to imagine whatthat really looks like. The article wenton to say that the current govern-ment will have to make hard choiceson public spending and that the NHSwill be included in the drive to makesavings. Even the Tories have indi-cated that if they come to power theywill cut the NHS budget even moreseverely than the current LabourGovernment – who will not in anycase give us their plan for health

beyond 2010-2011 (The DailyTelegraph, 9th September 2009).Cuts, cuts, cuts – that is all we hear.

What does this mean for the neu-rophysiotherapy services within theNHS system, indeed for all healthprovision, and what will it mean forthe clients who need our services? Inparticular, services for people withneurological disabilities, especiallythose with a chronic disability, seemto get a raw deal. How far have wereally progressed with what we offerto our neurological patients? In com-parison to those who require care forcancer, the neurological patientseems like the poor relative. Hugeresources have been poured intocancer care and research- of course itis an emotive life/death issue and assuch attracts attention and vastfinancial support. I am reminded ofa comment in an editorial byDromerick (2003), who stated thatpatients do not die from bad reha-bilitation as they might from ineffec-tive drugs or poor surgical techniquesand as such there is less urgency toresearch the best way of dealing withit. I am not saying that neurophysio-therapists are providing a bad serv-ice, what we lack is sufficientresources to give a better one. Whena patient with a chronic neurologicaldisability is admitted to a Londonteaching hospital medical ward withan infection but receives no therapyfor his neurological disability andends up unable to walk after a threeweek inpatient stay one has to stopand ask what is going on here. Is themedical profession only responsiblefor treating the primary impairment,or might there be a person who

requires some kind of integratedservice based on need. Seems somecreativity might help in this situa-tion- or might it even be a good doseof common sense?

I can see two issues. The first isthat there will need to be a greatdeal of creativity in the way thatservices are provided as there will nodoubt be constraints on what can beoffered in comparison with the cur-rent provision. Secondly, there willbe a greater need for us to justifywhat we do with our clients and forhow long we provide a service. Thismeans that we need to be keepingup to date with current develop-ments, evaluating what we do andas much as possible referring toavailable evidence and knowledgeto support our clinical reasoning.

In my inaugural address I talkedabout the six hats of deBono. Thistime I will mention his latest booktitled Think! Before It’s Too Late (DeBono, 2009). He says that you ‘cananalyse the past, but you mustdesign the future’ (Chapter 3). Therehas been much discussion in recenttimes in the journals and on iCSPabout best practice in neurophysio-therapy- to Bobath or not to Bobath,to provide hands on or only allowhands-off intervention, we mustonly implement evidence basedpractice with clients, etc… I amrather tired of it. There can be manycomplex descriptions and theories,but in the end, what practical differ-ence do they make? What can weoffer to our clients which will resultin the best practical outcome forthem? De Bono says that design isfundamental to everyone’s thinking.

PRESIDENT’S ADDRESS

Money makes the world go ‘roundMargaret Mayston AM FCSP PhD



4

We need to put together what wehave in order to deliver the valueswe want. We all want to deliver bestpractice – what is the best way todesign that? It might mean that weneed to take a blank sheet, thendraw on our knowledge, experi-mental evidence, clinical expertise,client preference and goals, work outwhat financial and human resourceswe have, and design a service whichtakes all of these into account.Rather than being concerned aboutwhat approach we might use, wewill continue to focus on the clientand their needs and goals. Given thefinancial constraints, creativity willcome to the fore; what about groupwork, self practice, accessing otherresources like the fitness centre andleisure activities. We can put on thesix hats and creatively find a wayforwards despite the pending cuts. Itcould even be quite exciting as newand different ways are found toprogress in these demanding and

challenging times.Within this context you can also

rely on ACPIN to continue its highquality programme and support. Thisrequires contribution in time andcreativity from all of its members inaddition to that of the incrediblyhard working committed groupwhich form the executive andregional representatives. Progresswill result from creativity and design– let’s have a melting pot of ideasand an explosion of constructivedesign!

REFERENCES

De Bono E (2009) Think! Before its TooLate Vermilion.

Dromerick AW (2003) Evidence-basedrehabilitation: The case for andagainst constraint induced therapyJournal of Rehabilitation, Research &Development 40 (1) ppvii-ix.

Introducing a new Masters degree course!

MSc in Physiotherapy(Neurorehabilitation)

at the University of Nottingham

This Masters degree course aims to provide students withspecialist and up to date knowledge in neurorehabilitation.The course consists of the specialist neurorehabilitationmodules below (these can be taken as stand aloneindividual modules, outside the Masters programme), aproject dissertation on a topic in neurorehabilitation andflexible choice of modules from the Masters programmeincluding research methodology, evidence for health andsocial care and clinical reasoning.

The new Innovations in Neurological Rehabilitation module(30 credits) is an opportunity to develop specialist expertise inseveral diverse areas of neurological physiotherapy includingthree areas related to stroke: balance/posture, reach-to-graspand sensory impairment; and an area related to cerebral palsy:rehabilitation of gait. This module is delivered by a team withsubstantial expertise and research publications in these areas.Students will learn about the latest research findings and willlearn first-hand how to use new innovative technology andmovement analysis measures in our state of the art humanperformance laboratory, improving their knowledge of thebiomechanics of movement and research methods on the way.

Our popular Movement science approach to strokerehabilitation module (30 credits) is the most substantialpostgraduate course on this topic in the UK, has been runningnow for eight years and is taught by tutors experienced in theapplication of this intervention. The course comprises amodern interpretation of the Motor Relearning Programme inaddition to application of other individual evidence-basedtreatments. It examines and illustrates the application of amovement science based approach to the analysis andtraining of the motor performance of neurological patients(numerous clinical sessions included). Topics include:

• Normal and abnormal biomechanics and motor control of functional movements.

• Strategies for retraining motor performance• Facilitation of motor skills acquisition• Causes of decreased force production and changes

in muscle tone• Prevention of secondary musculoskeletal changes• Self-monitored practice• Measurement of motor performance• Strength and cardiovascular fitness following stroke

Module convenors: Paulette van Vliet & Marjan Blackburn

For further information, including dates and fees, and application forms foreither individual modules or the MSc Physiotherapy (Neurorehabilitation)

contact: [email protected] information concerning content of modules, contact:

[email protected] or [email protected]

Postgraduate Course Secretary, Division of Physiotherapy Education,Clinical Sciences Building, City Hospital Campus, Hucknall Road,

Nottingham NG5 1PB Tel: 0115 82 31797, fax 82 31791e-mail: [email protected]


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The ability to sit unsupported is crucial toindependence as it frees the upper limbs forfunctional tasks. Following a cerebrovascularaccident (CVA) or stroke, the ability to remainbalanced whilst sitting is often impaired (Carrand Shepherd 2004, Nieuwboer et al 1995).Therefore, regaining independent sittingbalance is a common rehabilitation goal(Harley et al 2006). As many of the sensoryinputs required for postural control originatein the head and neck, it has been suggestedthat head position and orientation can affectthe ability to balance (Barberini andMacpherson 1998, DiFabio and Emasithi 1997).The aim of this study is to investigate whetherimproving head orientation will lead toimprovements in sitting posture and balance instroke patients.

LITERATURE REVIEW AND NEUROPHYSIOLOGYTo balance and interact with the environmenthumans need an accurate internal representationor ‘body schema’. This involves awareness ofwhere body segments are in relation to oneanother, where the body is positioned within theenvironment, and awareness of vertical orienta-tion and the effect of gravity (DiFabio and Emasithi1997). Having an intact ‘body schema’ is the basisof postural control which will allow the necessarypostural adjustments for control of body positionand movement within the environment.

There are three main sensory modalities thehuman body uses in postural control. These arevision, the vestibular apparatus, and somatosen-sory information (Vuillerme et al 2005, Ivanenkoet al 1999, Kavounoudias et al 1999).

Vision provides the body with information aboutthe environment and orientation within the envi-ronment. The importance of vision in the controlof balance is well documented (Wade and Jones

1997) When visual input is altered, standinghumans have demonstrated increased posturalsway (summarised in Wade and Jones 1997 andSchmidt and Lee 1999).

The vestibular apparatus provide the body withinformation about head orientation in space withrespect to gravity, and also directional movementthrough space (DiFabio and Emasithi 1997 andSchmidt and Lee 1999). Under experimental con-ditions it has been shown to influence posturalcontrol when artificial stimulation was applied tothe vestibular system in standing adults. The stim-ulation resulted in the body perceiving amovement and therefore producing a compensa-tory postural reaction in an attempt to restoreequilibrium (Ivanenko et al 1999).

Somatosensory information from all over thebody is used in postural control (Jeka 1997). In theliterature (Kavounoudias et al 1999), much atten-tion has been given to the role of proprioceptiveinformation in postural control which provides thecentral nervous system (CNS) with informationabout the position of body parts and their relation-ship with one another. Particularly the neck hasbeen focused on as an important source of propri-oceptive information as the muscles and joints inthe cervical region have a large density of proprio-ceptors, thought to provide the body withinformation on head position (Strupp et al 1998).Numerous studies have demonstrated posturalresponses to altered neck muscle proprioception,either by vibration or fatigue of the neck muscles(De Nunzio et al,2005, Ivanenko et al 1999,Kavounoudias et al, 1999 and Vuillerme et al2005). These studies all had small subject groups,reducing their individual validity. However, as theyproduced the same trend in results this gives theirresults concurrent validity.

Information from all three sensory systems isintegrated within the CNS to provide accurateinformation of body position in space and allow

Midline orientation of the headdoes achieving this improve ability to maintainunsupported sitting in the stroke patient?Emily McGough BSc (HONS) Team Leader Physiotherapist in Acute Neurosciences, University Hospital of Wales



6

postural responses for the maintenance ofbalance. What, then, is the effect of an impairmentof one of these sensory systems? Altered sensoryinput from the neck as a result of trauma or painhas been shown to impair postural control andalter the perception of verticality in randomisedcontrolled trials (Kogler et al 2000 and Grod andDiakow 2002). However, when visual andvestibular inputs are intact, these can compensatefor the reduced proprioceptive input to give anadequate representation of body position in space.For example, Bove et al (2004) demonstrated areduced sensitivity to neck muscle vibration inpatients with cervical dystonia when compared tocontrols and hypothesise that these patients usevision, vestibular input and proprioceptive inputfrom the trunk and paraspinal muscles to providethem with postural orientation in the absence ofaccurate neck proprioception. Similarly, whenvestibular input is impaired, for example in thosewith vestibular neuritis, increased posturalresponse to neck muscle vibration has beendemonstrated showing the increased importanceof neck proprioceptive information whenvestibular information is impaired (Strupp et at1998).

Different head positions will not only result inaltered proprioceptive information from the headand neck, but also altered visual and vestibularinput as the eyes and vestibular apparatus areboth sited in the head. Generally the intact CNSshould be able to compute the effects of alteredsensory inputs with a change in head position tomaintain postural equilibrium. Barberini andMacpherson (1998) found that in standing cats,changes in head position did not affect the efficacyof the postural response for maintaining equilib-rium. However as this research evaluates cats onecannot presume that the results would be thesame in humans.

The evidence so far is not conclusive regardingthe effect of head position on postural control inhumans. In a small study, Knox and Hodges (2005)demonstrated reduced accuracy of elbow jointposition sense in young adults with end rangepositions of the head and neck. They hypothesisethat this may be due to disrupted organisation ofthe proprioceptive information from the change inhead position. However the authors only looked atone joint movement and have a small sample size,so caution with interpretation must be exercised.

While much research has investigated theimportance of sensory inputs to postural control,this research has been carried out in young adultswho are healthy and when they are standing. Verylittle is known about how sensory information isintegrated within the CNS to produce postural

responses, and there were no studies investigatingthe effect of altered sensory inputs or changes inhead position on maintenance of sitting balance.So, what does the research show about posturalcontrol in seated stroke patients, where more thanone sensory input can be impaired?

Sitting is often affected following stroke, causingpatients to lean either to the left or to the right.Taylor et al (1994) studied 38 patients followingstroke and found that only 16 were able to sit inmidline after one week. Harley et al (2006) alsodemonstrated reduced postural control in seatedstroke patients compared to controls.

Several authors have investigated possiblecauses of this impaired sitting balance. One com-monly cited explanation is that some patientsfollowing stroke have an altered perception of thevertical or ‘subjective visual vertical’ (SVV) (Yelniket al 2002, Snowdon and Scott 2005 and Brandt etal 1994). Brandt et al (1994) studied 52 patientswith middle cerebral infarcts and found that 23had an altered SVV. These 23 patients were foundto have infarcts involving the parietal insular,which is an area which responds to vestibularstimulation. The authors suggest that this areamay be responsible for integration of propriocep-tive, visual and vestibular inputs to producerepresentation of vertical.

Snowdon and Scott (2005) found no direct corre-lation between size of disturbed SVV anddisturbed body posture in sitting. However, theydid find that if trunk lean was present it wasalways in the same direction as the perceived ver-tical. This is supported by research by Yelnik et al(2002) who also found the subjective visual ver-tical was altered in stroke patients compared tocontrols when the head was tilted 20 degrees tothe non-hemiplegic side. They suggest that someof the perception of vertical may be mediated bystretching of the somatosensory receptors of theneck. Perennou et al (1998) found improvedability to sit on a laterally tilting platform in hemi-plegic patients when TENS was applied to theneck muscles. These two studies suggest that neckmuscles could be an important source of sensoryfeedback in sitting in the stroke population.

Within stroke rehabilitation literature muchemphasis is placed on the importance of gainingactive, selective trunk control when working onsitting balance (Carr and Shepherd 2004, Davies1985 and Mudie et al 2002). However, despite therecent influx of information on the importance ofneck proprioceptors to postural control, no spe-cific studies directly examining the effect of headposition and orientation on balance in the strokepopulation were found. Davies (1985) emphasisesthe importance of restoring movements of the


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head, and Di Fabio and Emasithi (1997) hypothe-sise that therapy aimed at improving head controlmay improve postural responses. This is not yetsupported by research.

MR A Mr A is an 81 year old male who collapsed athome. A CT scan a day later showed lacunarinfarcts in both basal ganglia. Mr A also had anMRI scan which showed a left sided infarct in theposterior medulla. He was transferred to thestroke unit 20 days later for rehabilitation.

On assessment, Mr A was found to have fullactive movement of all limbs with ataxia and amild weakness on the left. He had an asymmetricalsitting posture with increased weight-bearingthrough the left hip and a feeling of being ‘offbalance’ when positioned in midline. He used hisupper limbs for support in sitting, limiting func-tional abilities. He also demonstrated reducedrange of movement in the neck associated withpain. He sat with the head held in right sideflexion. It was hypothesised by medical staff hehad a whiplash-type injury from his collapse.Figure 1 demonstrates initial sitting posture.

TREATMENT STRATEGIESActive and assisted neck stretches in sitting Mr A had lost neck range of movement in all direc-tions, especially into left side flexion due to tight,overactive trapezius and scalene muscles on the

right. Scapular muscle fatigue has been shown todecrease postural control (Vuillerme et al 2004)and body leanings were found after strong iso-metric contraction of neck muscles (Duclos et al2004). It was hoped that by decreasing the activityof the overactive trapezius and scalene muscles,improved postural control would result. Treatmenttherefore involved active eccentric lengthening ofthe right neck side flexors with facilitation whenthe head was positioned in left side flexion

Active and passive neck stretches were carriedout in all directions, with gentle manual pressureat end of range to improve range of movementand increase the proprioceptive input from theneck muscles and joints. It was hoped that thiswould also result in reduced neck pain which hasbeen shown to affect perception of vertical (Grodand Diakow 2002).

Independent ExercisesTo ensure carryover between treatment sessionsMr A was given neck exercises to do independently.

Visual FeedbackA mirror was used in activities both in sitting andstanding. Exercises and stretches were carried outwith the patient’s eyes closed. He would intermit-tently check his posture in the mirror to see if hehad achieved midline. Bonan et al (2004) hypothe-sise that by removing vision during treatment youallow improved awareness of somatosensory andvestibular inputs.

Weight transference activities Davies (1985) emphasises the importance of prac-ticing activities aimed at transferring weightsideways to improve balance. As Mr A was unableto maintain balance when weight was transferredto the right, functional activities such as reachingfor objects on the right side were facilitated to tryand retrain balance.

Outcome measures 1. Analysis of posture in sitting is difficult.Nieuwboer et al (1995) demonstrated low inter-rater reliability for visual analysis of posture. Thisis concurred by Carr et al (1999). In the absenceof other ways to evaluate trunk and head posture,visual analysis was used in the form of photo-graphs.

2. A balance performance monitor (BPM) wasused to measure weight distribution in unsup-ported sitting. These are thought to havereasonable validity for this purpose (Mudie et al2002 and Harley et al 2006).

Figure 1 A diagram to illustrate the initial sitting posture of Mr A

Neck side flexedto right

Trunk convex tothe left side

Plinth

Pelvic obliquity, up on the right causingincreased weight bearing on the left hip

Posterior view



8

3. In the absence of validated measures of sittingbalance (highlighted by Nieuwboer et al, 1995),the Motor Assessment Scale (MAS) was chosen. Ithas a subsection for sitting balance. It also reflectsphysical performance in a range of activities andhas been shown to be reliable (Poole and Whitney,1988).

4. Active range of movement measurements of theneck were taken using a goniometer. This has limi-tations as these readings have poor reliability. Thesame person took measurements each time toreduce inter-rater error.

There were several improvements following thesetreatments (See Table 1). Active neck rangeimproved as did the ability to sit unsupported(demonstrated by the MAS and BPM). During onetreatment period, active/assisted neck stretcheswere carried out with the patient sitting on theBPM. Interestingly, with no interventions but theneck stretches, the patients weight shifted from +2to the left to 0 (equal weight-bearing). This may bedue to improved proprioceptive input from theneck, a reduction in neck pain helping to nor-malise the perception of vertical, or as yetunknown mechanisms.

However, despite performance improvements,Mr A still tended to sit with the head and trunk inright side flexion. It was hypothesised that thiswas a compensatory strategy to help maintain

balance due to weakness in the left trunk and hip.The patient demonstrated difficulty with movingthe trunk selectively, tending to use his head toinitiate movements.

Treatment was modified accordingly. Active andassisted neck stretches were continued, but treat-ment progressed to working on increasedselectivity of the left hip, pelvis and trunk. Theseinterventions brought further improvements inposture and function (Table 1 and Figure 2).

CONCLUSIONS Improvements were seen in sitting posture whenstrategies were employed to address midline ori-entation of the head. When neck stretches alonewere carried out, this resulted in more equalweight-bearing in sitting. This strongly suggeststhat input from the head and neck is indeedimportant in postural control and orientation, aswas highlighted in the literature search. It may bethat stretching and correcting the muscle imbal-ance of the neck muscles to allow the patient togain midline position improved the proprioceptiveinput as well as positioning the eyes and thevestibular apparatus in an optimum position tointerpret incoming sensory information.

However, improvements were also seen in headalignment from working on selective trunk andhip control as it allowed a reduction in compensa-tion from the head to maintain balance. Head andtrunk position are almost certainly interrelatedand it is probably simplistic to analyze head andneck movements separately from trunk move-ments as sensory information from the trunk may

Outcome measure

MAS total score

MAS balanced sitting score

Balance performancemonitor score

Active Neck Range

Left rotation Right rotation Left side flexion Right side flexion

Initial Ax

28

2

+2to the leftincreasedweight

bearing to left

27° 28° 15° 18°

After 13 days

33

4

0Equal weight

bearing ofboth sides

45° 40° 20° 22°

45 days postinitial Ax

39

5

0Equal weight

bearing ofboth sides

45°48° 20° 30°

Figure 2 A diagram to illustrate the final sitting posture of Mr A

Table 1 Outcome measures for Mr A showing measures followingtreatment to address head position (day 13), and after thechange in treatment strategy to also address selectivity of pelvicand trunk movements (day 45)

Head and necknear midlinealignment

Improved trunksymmetry

Plinth

Reduced pelvic obliquity and equal weight bearing

Posterior view


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be just as important when trying to improve pos-tural control.

This is an area which has been given little atten-tion in physiotherapy literature and certainlywarrants further study. Many references used inthis article are older due to a lack of recent arti-cles on this subject. Suggestions for futureresearch include: evaluating the effect of changesin head position in the stroke population in bothsitting and standing; examination of the mosteffective treatment strategies to address issueswith head position and control and, the effect oftrunk mobilisation on head position in sitting.

influence of spoken outputJournal of Neurology,Neurosurgery and Psychiatry 77 (5)pp674-676.

Ivanenko Y, Grasso R andLacquaniti F (1999) Effect of gazeon postural responses to neckproprioceptive and vestibularstimulation in humans Journal ofPhysiology 591 (1) pp3Ol-314.

Jeka J (1997) Light touch contact asa balance aid Physical Therapy77(5) pp 476- 486.

Kavounoudjas A, Gilhodes J andRoll R (1999) From balanceregulation to body orientation:two goals for muscleproprioceptive informationprocessing? Experimental BrainResearch 124 (1) pp80-88.

Knox J and Hodges P (2005)Changes in head and neckposition affect elbow jointposition sense Experimental BrainResearch 165 (1) ppl07-113.

Kogler A, Lindfors J, Odkvist L andLedin T (2000) Postural stabilityusing different neck positions innormal subjects and patients withneck trauma Octolaryngologica 120(2) pp151-155.

Mudie M, Winzeler-Mercay U,Radwan S and Lee L (2002)Training symmetry of weightdistribution after stroke: arandomized controlled pilot studycomparing task-related reach,Bobath and feedback trainingapproaches Clinical Rehabilitation16 pp582-592.

Nieuwboer A, Feys H, De Weerdt W,Nuyens G and De Corte E (1995)Developing a clinical tool tomeasure sitting balance afterstroke: A reliability study.Physiotherapy 81(8) pp439-445.

Perennou D, Amblard B, Leblond Cand Pelisser J (1998) Biasedpostural vertical in humans withhemispheric cerebral lesionsNeuroscience letters 252 pp75-78.

Poole J and Whitney S (1988)Motor Assessment Scale for StrokePatients: Concurrent Validity andInterrater Reliability Archives ofPhysical Medicine andRehabilitation 69(3) pp195-197.

Schmidt R and Lee T (1999) Motorcontrol and learning: abehavioural emphasis HumanKinetics.

Snowdon N and Scott O (2005)Perception of vertical and posturalcontrol following stroke: a clinicalstudy Physiotherapy 91 pp165-170.

Strupp M, Arbusow V, Dieterich M,Sautier W and Brandt T (1998)Perceptual and oculomotor effectsof neck muscle vibration investibular neuritis: Ipsilateralsomatosensory substitution ofvestibular function Brain 121pp677-685.

Taylor D, Ashburn A and Ward C(1994) Asymmetrical trunkposture, unilateral neglect andmotor performance followingstroke Clinical Rehabilitation 8pp48-53.

Vuillerme N, Pinsault N andVaillant J (2005) Postural controlduring quiet standing followingcervical muscle fatigue: effects ofchanges in sensory inputsNeuroscience Letters 378 (3) pp135-139.

Wade M and Jones G (1997) Therole of vision and spatialorientation in the maintenance ofposture Physical Therapy 77 (6)pp619-628.

Yelnik A, Lebreton F, Bonan I, Colle F, Meurin F, Guichard J andVicaut E (2002) Perception ofverticality after recent cerebralhemispheric stroke Stroke 33pp2247-2253.

REFERENCES

Barberini C and Macpherson E(1998) Effect of head position onpostural orientation andequilibrium Experimental BrainResearch 122 (2) pp175-184.

Bonan I, Yelnik A, Colle F, Michaud C, Normand E, Panigot B,Roth P, Guichard E and Vicaut E(2004) Reliance on visualinformation after stroke. Part II:Effectiveness of a balancerehabilitation program withvisual cue deprivation after stroke:A randomized controlled trialArchives of physical medicine andRehabilitation 85 pp274-278.

Bove M, Brichetto G, Abbruzzese G,Marchese R and Schieppati M(2004) Neck proprioception andspatial orientation in cervicaldystonia Brain 127 (12) pp2764-2778.

Brandt M, Dieterich M and Danek M(1994) Vestibular cortex lesionsaffect the perception of verticalityAnnals of Neurology 35 (4) pp403-412.

Carr E, Kenney F, Wilson-Barnett Eand Newham D (1999) Inter-raterreliability of postural observationafter stroke Clinical Rehabilitation13 pp229-242.

Carr E and Shepherd R (2004)Stroke Rehabilitation Oxford,Butterworth Heinemann.

Davies P (1985) Steps to follow: Aguide to the treatment of adulthemiplegia. Berlin, Springer-Verlag.

De Nunzio A, Nardone A andSchieppati M (2005) Headstabilisation on a continuouslyoscillating platform: the effect of aproprioceptive disturbance on thebalance strategy ExperimentalBrain Research 165 (2) pp261-272.

Di Fabio R and Emasithi A (1997)Ageing and the mechanismsunderlying head and posturalcontrol during voluntary motionPhysical Therapy 77 (5) pp458-473.

Duclos C, Roll A, Kavounoudias Aand Roll J (2004) Long-lastingbody leanings following neckmuscle isometric contractionsExperimental Brain Research 158pp58-66.

Edwards S (Editor) (1996)Neurological Physiotherapy: Aproblem-solving approachLondon Churchill Livingstone.

Grod J and Diakow P (2002) Effectof neck pain on verticalityperception: a cohort studyArchives of Physical Medicine andRehabilitation 83 (3) pp412-415.

Harley C, Boyd J, Cockburn J, Collin C, Haggard P, Wann J andWade D (2006) Disruption ofsitting balance after stroke:



10

Spinal decompression is being performed withincreasing frequency (Mannion et al 2007).Throughout the UK there is a general agree-ment with regards to the provision of inpatientphysiotherapy for lumbar discectomy surgerywithin the NHS, with 96% of patients beingassessed day one post-surgery, and thenumber of therapy sessions ranging from 1-6(Williamson et al 2007).

Rehabilitation initiated immediately after electivespinal surgery has been found to promote a rapidreturn to work (Sjolinder & Nota 1994), preventfurther de-conditioning (Kjellby-Wendt & Styf1998) and shortened sick leave without increasedcomplications (Carragee et al 1996). Mobility andeducation were the most common themes withintreatment in preparation for discharge (93%), andthe most common type of exercises prescribedwere spinal stabilisation (Williamson et al 2007).Spinal stabilisation exercises have not yet beenvalidated in the post-surgical group (Williamson etal 2007), however multifidus muscle wasting isevident after lumbar spine decompression surgery(Gejo et al 1999), indicating the importance ofthese exercises. Carragee et al (1996; 1999)removed all postoperative restrictions and foundno increase in complication rates, therefore froma healing perspective, postures and mobility,which stress the healing tissues, promote repairand maintain flexibility (Provenzano et al 2003).

In June 2004 the NHS improvement plan set anambitious target. By 2008 there will be amaximum wait of 18 weeks from GP referral totreatment in hospital, if required (DOH 2006). Tohelp achieve this target for elective spinal surgerypatients Kings College Hospital neurosurgicalphysiotherapy department moved away from tra-ditional hours of work to eliminate anyunnecessary delays. A Saturday morning physio-

therapy service was introduced in September 2007for a period of six months to reduce the length ofhospital stay for elective spinal surgery patients.

Prior to the introduction of a physiotherapist onSaturday, patients undergoing surgery fromMonday to Thursday were assessed by the physio-therapist the following day, and if appropriate,attended the back class. They were then dis-charged if they successfully completed the class.Patients undergoing surgery on Fridays did notsee the physiotherapist until Monday and conse-quently were not discharged until Mondayafternoon. Some of the patients operated onThursdays were not fit for the class on the Fridayand suffered similar delays in discharge as Fridayoperations. To support these observations retro-spective data collection was carried out for July2007, and found that a large number of patientshaving surgery on a Thursday or Friday were dis-charged after back class on a Monday. Thisindicated the need for further data collection inAugust, which found similar results. The Augustbank holiday further prolonged the length of hos-pital stay, which could have been prevented forsome patients if physiotherapy had been availableat the weekend. Therefore a change of service wasdevised to see if implementing a Saturday physio-therapy service reduced length of stay, promoteddischarges over the weekend and allowed admis-sions for surgery on the Monday.

PROCESSA single therapist worked Tuesday through toSaturday coordinating back patients care and dis-charge planning to increase continuity of care andstreamline service. Awareness of admissions wasachieved using the pre-planned admissions listand liaising with the multidisciplinary neurosur-gical team.

Pharmacy is not a six-day service and to preventcreating too much extra work for the team a brief

Elective spinal patientsthe implementation of weekend physiotherapyat Kings College HospitalKarly Dunmall (Band 5 physiotherapist)


Average per month

Month

JulyAugust

SeptemberOctoberNovemberDecemberJanuaryFebruary

Totalpatientstreated

Saturday00

162020181414

Total Saturdaysin month

43

344543

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meeting on Friday mornings was arranged todecide which patients would definitely requiremedication in order to go home at the weekend.Prediction of patients being discharged at theweekend was based on patient age, type of opera-tion and pre-morbid level of mobility. It was alsoessential to liaise with the spinal nurse andmedical team to ensure all discharge documenta-tion was completed prior to the weekend.

Patients included were all patients having elec-tive spinal surgery, to include, laminectomies,instrumental fixations, microdiscectomies and discectomies. The majority were lumbar spinebecause cervical spine patients are not routinelyseen post-operatively. However, the few cervicalspine patients seen by physiotherapy were alsoincluded in the study.

RESULTSSee Tables 1 and 2 above.

ANALYSISA reduction was shown in median post-operativelength of hospital stay for patients operated onThursdays from 5.0 days to 3.0 days (Mean 5.0 to2.5 days), and Fridays from 4.0 days to 3.0 days(Mean 4.0 to 3.33 days) (Figure 1). An average of6.3 bed days were saved per month (rangebetween 2.0–13.0 days) (Figure 2), and it isassumed that a shorter inpatient stay was thoughtto decrease hospital costs.

DISCUSSIONSince September the introduction of a Saturdayphysiotherapist has produced positive results.November saw 13 bed days saved from the eightweekend discharges, which reduced length of hos-pital stay and we also assume a reduction inhospital costs, along with freeing beds for electiveadmissions.

The number of weekend discharges declined inthe last three months. Over the Christmas andNew Year period the main elective spinal surgeryward was closed for two weeks, therefore, onaverage fewer patients were treated on aSaturday. In December 55% (10) of patients wereday one post-op and 17% (3) were on bed restprior to the Saturday, so treatment was often

Day of Surgery

Monday Thursday Friday

July–AugustNumber of patients 15 14 6Mean (days) 2.80 5.00 4.00Range (days) 1–9 2–14 3–6

October–NovemberNumber of patients 6 8 16Mean (days) 2.00 2.75 4.10Range (days) 1–3 1–5 1–8

December–FebruaryNumber of patients 9 4 18Mean (days) 3.70 2.50 3.33Range (days) 2–7 1–3 1–6

Table 1 Summary of results for elective spinal surgery weekend discharges.Pre-weekend service: July–August. Post-weekend service: September–February.

Table 2 The range, mean and median length of post- operative hospital stays for patients being operated on three different days.

Saturday00

69126226.20

Saturday00

2352002.00

Sunday00

2332222.33

Monday36

634662

Tuesday31

531342

Averagedischarges

perweekend

00

1.331.502.000.800.400.671.10

Totalbed days

saved

00

69136226.30

Monday812

3316

102

DischargePhysiotherapy

DischargeHospital

Data was collected for three different time periods: one prior to theintroduction of the Saturday physiotherapy service (July–August), andtwo with the Saturday physiotherapy service (October–November andDecember–February).

Three different operating days were analysed, Monday, Thursday andFriday. To compare the mean and median lengths of post-operativehospital stay during each time period.

The introduction of the Saturday physiotherapy service demonstrated areduction in length of hospital stay for both patients being operated onThursday and Friday.



12

limited by pain. Three patients also had to returnto their local hospital for further input, which pro-longed the inpatient stay.

In January 65% of the patients treated on aSaturday either had complex surgery involvinginstrumentation and fixation, or had previouslyhad spinal surgery. These patients appeared tohave more pain and were more cautious withregards to progressing therapy post-operatively.In February 36% of the patients seen on Saturdayswere day one post operatively, all were multi-levelor instrumented fixations, which normallyprogress more slowly. There were also three cer-vical surgery patients which are not normallyreferred to physiotherapy unless the patient hadpoor mobility prior to surgery.

The number of bed days saved did fluctuate on amonthly basis, however the results were positivefor the entire six months, and with a permanentSaturday service are likely to improve even further.

Patients having surgery on Mondays initiallyshowed no reduction in length of post-operativestay when the Saturday service was introduced, infact the average length of stay actually increasedwithin the final three months of the trial. However,56% of the Monday surgery patients duringDecember to February were either admitted to theHigh Dependency Unit or were on bed rest post-operatively, which would account for theincreased length of stay.

Initially the Friday operations did not see areduction in post-operative length of stay.Collectively in July and August only six operationswere performed on a Friday, of which 33% weredischarged by Monday, whereas October andNovember had a total of 16 operations, of which44% were discharged by Monday. As the trial con-tinued the median length of post-operative staydid reduce from four days to three, with a greaterpercentage of patients (61%) being discharged byMonday for a greater number of operations.

CONCLUSIONThis service development audit has shown a reduc-tion in post-operative length of hospital stay forelective spinal surgery patients. There have been anumber of problems since the introduction of aSaturday physiotherapist, most came from poorawareness of the service initially, and are likely tounderestimate the potential of this service atpresent. These issues were addressed as theyarose, demonstrated by the initial steady increasein weekend discharges and reduction in length ofstay. As a result of this audit funding has beenapproved for a further twelve months to continuethe Saturday physiotherapy service. A new targethas also been set to further reduce post-operativestay to two days.

Num

ber o

f day

s

Monday Thursday Friday

5

4

3

2

1

0

July–August

October–November

December–February

Figure 1 Length of median post-operative hospital stay beforeand after the introduction of the Saturday physiotherapy service.

Num

ber o

f day

s

Sept Oct Nov Dec Jan Feb

12

10

8

6

4

2

0

Saturday discharges

Sunday discharges

Total bed days saved

Figure 2 Total weekend discharges and bed days saved for each month.

REFERENCESCarragee E, Han M, Yang B, Kim D,Kraemer H, Billys J (1999) Activityrestrictions after posterior lumbardiscectomy Spine 24 pp2346-2351.

Carragee EJ, Helms E, O’Sullivan G(1996) Are postoperative activityrestrictions necessary afterposterior lumbar discectomySpine 21 pp1893-1897.

Gejo R, Matsui H, Kawaguchi Y,Ishihara H, Tsuji H (1999) Serialchanges in trunk muscleperformance after posteriorlumber surgery Spine 24 pp1023-1028.

Kjellby-Wendt G, Syrf J (1998)Early active training after lumbardiscectomy. A prospective,randomized and controlled studySpine 23 (21) pp2345-51.

Mannion AF, Denzler R, Dvorak J,Muntener M, Grob D (2007) Arandomised controlled trial of

post-operative rehabilitation aftersurgical decompression of thelumbar spine European SpineJournal 16 pp1101-1117.

Provenzano P Martinex D,Grindeland R, Dwyer K, Turner J,Vailas A, Vanderby R (2003)Hindlimb unloading altersligament healing Journal ofApplied Physiology 94 pp314-324.

Sjolinder PO and Nota DF (1994)Early Return to Work Following anAggressive Rehabilitation ProgramInitiated One Day After SpineSurgery Journal fo OccupationalRehabilitation 4 ( 4) pp211-228.

Williamson E, White L, Rushton A(2007) A survey of post-operativemanagement for patientsfollowing first time lumbardiscectomy European SpineJournal 16 pp795-802.


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There is a growing body of evidence to suggestthat significant motor recovery followingsevere traumatic brain injury (TBI) can con-tinue for several years post injury1,3,6,7,8,9. Thisevidence tends to focus on intervention leadingto successful motor recovery9, however there islimited evidence documenting the interventionwhere motor recovery is limited. Time investedwith such clients to assist with postural man-agement is invaluable.

This case study came about following work with aclient who had severe physical limitations fol-lowing a TBI and was in rehabilitation at theQueen Elizabeth’s Foundation, Brain InjuryCentre, Surrey. Although he made some progress,functional gains were minimal. The gains he didmake were relatively small and some were diffi-cult to measure objectively, however there was agreat deal to learn from him. The success was inhis postural management and the small, but sig-nificant, progression of his postural abilities.

This case study aims to describe the variety ofequipment and treatment options explored inmanaging his severe postural requirements.

THE PATIENTIn July 2004 at the age of 18 Ben suffered a severeTBI, in a road traffic accident as a cyclist. He sus-tained severe brain stem injuries, diffuse axonalinjuries and cerebral oedema and was in a per-sistent vegetative state for several months. Bencommenced rehabilitation at the Brain InjuryCentre in May 2007 due to the closure of his pre-vious rehabilitation unit. He presented with severephysical difficulties including: increased tone, nofunctional movement throughout his left side, over-activity of his right lower limb, no sitting balanceand joint restriction in his left elbow, ankle andright hand (see posture examples, Figure 1).

He required the assistance of two with personalcare, bed mobility and low-level crouch transfersand three to stand to a standing frame. Ben hadcomplex behavioural and speech difficulties. Hewas not open to using communication strategiesand his voice was unreliable. The only reliableform of communication was movement of his righthand for ‘yes’ and shaking his head for ‘no’.Cognitively he had severe anterograde amnesiaand lacked insight, often denying his TBI.Subsequently, his ability to comply with therapywas extremely limited and had a significantimpact on his ability to change functionally.

THE INTERVENTIONInitially the possibility of Ben changing function-ally was explored. However, following apreliminary period of rehabilitation it was evidentthat any functional changes would be minimal.Thus, the focus moved more towards posturalmanagement and to allow him to participate asmuch as possible in movement. This involvedimproving range of movement and activity in histrunk and pelvis, increasing range distally in hisleft side and improving his ability to movebetween and access a variety of postural sets.

Late stage physiotherapyrehabilitation following severe traumatic braininjury – a case report exploring a client withsevere physical impairments four years post injuryHannah L Dearlove MCSP Senior Physiotherapist Brain Injury Centre, Queen Elizabeth’s Foundation, Surrey

Figure 1 Posture examples in lying and sitting



14

During this time exploring seating options was asignificant factor in his postural management.

Treatment very much depended on Ben’s behav-iour, the equipment and the experience andnumber of staff available. Risk assessment was anongoing process. He required a 2:1 ratio in mostsessions and occasionally a 3:1 ratio due to hisphysical limitations and unpredictable behaviour.He was only ever seen on a 1:1 basis once set upin a position of safety.

He often actively resisted the movement trying tobe gained and frequently did the opposite of whatwas being asked. At times this could be used effec-tively to gain what was required, but he was notalways consistent with this. Despite these difficul-ties, Ben enjoyed exploring movementopportunities.

IMPROVING RANGE AND ACTIVITY IN TRUNK AND PELVISIncreasing the range and activation in Ben’s trunkand pelvis was explored utilising a variety ofequipment and treatment techniques. He requiredinnovative approaches to keep him engaged andmanage his behaviour. Through exploration it wasascertained that we could be more experimentalin treatment than initially thought. This is bestdemonstrated through the use of photographs, seeFigures 2 to 8.

Figure 2 Lateral trunk elongation working from side lying tositting. Carried over functionally with carers whengetting out of bed.

Figure 5 Trunk mobilisation and activation with large gym ball. Used in supine and prone.

Figure 6 On crash mat to explore trunk mobilisation and varying postural sets to activate trunk. Use of harness with roll on crashmat to explore four-point kneeling.

Figure 7 Trunk activation onroll (Sammons Preston Rolyanroll) – Ben moving roll withpelvis sitting astride andanatomy quiz using skeletonfor trunk rotation.

Figure 8 Soft tissuemobilisation on blue roll.

Figure 3 Inversionwith assistance of two.To mobilise trunk and gain central stability in a novel framework. Reducing hispreconcieved ideas of extension.

Figure 4 Meywalkframe with assistance oftwo. Exploring steppingand postural extensionagainst gravity.


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THE ABILITY TO MOVE BETWEEN AND ACCESS A VARIETY OFPOSTURAL SETSFollowing work to increase the activity and rangein Ben’s trunk he became increasingly able toexplore moving between postural sets. Withencouragement he was able to roll to the left andright, assist with lying to sitting (see Figure 2) androll over to prone (see Figures 11 and 12). He alsodemonstrated an improved ability to movebetween sitting and standing and maintain astanding position with reduced support (Figure 9).However, for prolonged periods of standing anelectric standing frame was considered the bestoption (see Figure 10).

It is evident from changes in outcome measurescores that Ben’s postural abilities improved (seeTable 1). His trunk and pelvis activity and ability tomove between and access postural sets had pro-gressed following intervention. Having a largerrepertoire of postural sets and being able to assistwhen moving between them increased his pos-tural activity, thus reducing the possibility ofdeterioration.

INCREASING RANGE DISTALLYThe restrictions in Ben’s left ankle and elbow hada significant impact on his alignment in all pos-tural sets. Improving range was challenging dueto the severity of his tone. It was achieved invarious ways: exploring a variety of splints,Botulinum Toxin, soft tissue release, anti-spasticitymedication and dosage review, serial casting, soft-scotch casts and regular standing to assist withankle range. His left elbow was progressed from90 degrees to 75 degrees flexion (with forearm in¾ pronation). His ankle was progressed from 45degrees to 30 degrees plantarflexion.

Increasing elbow range assisted with personalcare and also enabled him to position his left armover the edge of the bed when lying prone. Therange gained at his ankle improved his alignmentin sitting and standing and improved his ability toweight-bear in crouch transfers. Finding long-term splints that were strong enough to maintainrange was challenging. Following trials of severalsplints the long-term solutions were a CDS anklebrace4 and a bespoke polythene arm gutter withan elbow cap.

EXPLORING SEATINGAs Ben’s right side and trunk became stronger, hisability to alter his position increased but this hada negative impact on his posture. He used a massextensor pattern, pushing through his right leg.This was usually a result of a behaviouralresponse. Several footplates were broken as aresult of this movement pattern.

When assessed in sitting, if Ben’s pelvis wasanchored in neutral, he gained lumbar extensionand improved alignment throughout his trunk andneck. Many adjustments were made to his current

Figure 11 Rolling from supine toprone over the right side withminimal assistance.

Figure 9 Exploring standing.

Table 1 Outcome measures.

Figure 10 Ben in electricstanding frame (Quest 88)with thoracic and headsupport.

Figure 12 With left armpositioned over edge of bed,Ben would relax in prone andoften fell asleep.

On Admission FollowingIntervention

PosturalAssessment Scale 2 10/36 15/36

Trunk Control Test 5 0/100 24/100



16

seating in order to secure his pelvis, howeverthese were all ineffective. To maintain andimprove his sitting posture and prevent deteriora-tion, correct seating was integral. Whilst at TheCentre Ben was assessed in a moulded seatingsystem (see Figure 13) and for specialist seating.He is awaiting casting for a moulded seat insert,which should maintain his pelvis in neutral andsustain his posture for longer periods. Exploringseating was a long and protracted process due toa number of factors, including funding issues.

Throughout his time at The Centre, all staff com-pleted low level crouch transfers with Ben withthe aim that he would gradually become moreinteractive and reliable with them. However, theseremained unpredictable due to his behaviour andcognitive difficulties. For this reason and for thefuture provision of a moulded seating system, itwas felt hoisting was the most appropriate long-term option.

DISCUSSIONBen was a challenging client with complex diffi-culties. His cognitive and behaviouralimpairments have had a profound effect on hisrehabilitation potential. Owing to this, the way inwhich we worked with him had to be innovativeand varied in order to manage his behaviour,engage him in sessions and reduce his pre-con-ceived ideas of movement. Liaison with family toestablish his interests and history was integral inengaging him effectively in sessions.

Having the staff available and suitable equip-ment was essential to explore fully his potentialand activate his trunk in a variety of novel ways.The equipment enabled us to work with him safelyin many positions, which would otherwise nothave been possible, due to his unreliable behav-iour. The time he spent at The Centre also gave us

the opportunity to loan and trial several pieces ofequipment for Ben, such as splints and standingframes, prior to their purchase.

A consistent multi-disciplinary approach wasfundamental with managing behaviour and moreimportantly managing behaviour in regard tomanual handling. As Ben became stronger anddeveloped a degree of movement control, behav-ioural issues when assisting him with movementbecame more prominent. All manual handling wascompleted in conjunction with behavioural guide-lines and, with experience, staff were able tomanage any behavioural issues confidently andeffectively. This was vital as it enabled care staff tocarry through elements of his physical rehabilita-tion throughout the day, such as using thestanding frame and assisting him with lying tositting.

Over time, Ben improved in his pelvis and trunkactivity (including rotation) and alignment. Thisenabled him to assist and resist movement (notalways in a positive way), alter his posture, reachfurther with his right arm and move between andaccess an increased variety of postural sets.Owing to limited insight and communication diffi-culties, it was not possible to determine thedifference this made to Ben’s quality of life.However, he now has more movement choices anda degree of control. Family have been able toexplore more movement options with Ben andhave reported the level of support he requiresphysically has gradually reduced.

If Ben hadn’t had the opportunity to access reha-bilitation, his posture is likely to have beenextremely difficult to manage in the community,due to staffing, environmental constraints andequipment availability. He is at a level now wherehis posture is much more manageable and he hasmore movement control. As a result of this, hisrisk of deterioration or developing secondarycomplications has greatly reduced.

Overall, Ben’s motor recovery was limited.However, investing time in his rehabilitation hasenabled him to make small, but significantchanges, ultimately reducing his complex posturalrequirements and is likely to have increased hisquality of life, now and in the future.

CONCLUSIONBen presented with severe physical, cognitive andbehavioural difficulties following his TBI. He pre-sented a challenge in rehabilitation due to his lackof insight and unreliable behaviour. Despitelimited motor recovery, he made significantprogress in his postural abilities, reducing hislong- term postural requirements. In being experi-mental with our equipment and therapy Ben was

Figure 13 Left, Ben’s current seating system. Right, assessingBen in a chair with a moulded seat insert (He chose not to wearfootwear on right foot and would remove it immediately if puton).


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able to explore activating his trunk in a variety ofsafe and novel ways and which ultimately led toprogression. Without input, he is likely to havebeen extremely difficult to manage in the commu-nity because of complex postural requirements,and his posture would be more likely to deterio-rate leading to secondary complications.

KEY MESSAGES• Being innovative in treatment, not only to main-

tain focus and manage behaviour, but to exploreactivating the trunk in a variety of ways.

• When motor recovery is limited it is essential toinvest rehabilitation time in improving posturalabilities and managing complex posture for thelong term.

• Having the right equipment and number of staffavailable if you work with such clients is integralto fully explore their potential in a safe andnovel way.

• Improving proximal activity to provide a stablereference point for posture and movement.

• A strong multi-disciplinary approach is essential to ensure consistency in all areas ofrehabilitation.

ACKNOWLEDGEMENTSI would like to thank the patient described and hisfamily for giving their permission to give thisaccount. Thanks also go to my colleagues whowere involved in his care and management. Thepatient’s real name was changed for this account.

REFERENCES

1 Burke D, Alexander K, Baxter F,Connell K, Diggles S, Feldan K,Horny A, Kokinos M, Moloney Dand Withers J (2000)Rehabilitation of a person withsevere traumatic brain injuryBrain Injury 14 (5) pp463-471.

2 Benaim C, Alain Pérennou D,Villy J, Rousseaux M, Yvon PelissierJ (2000) Validation of aStandardized Assessment ofPostural Control in Stroke PatientsStroke 30 pp1862-1868.

3 Butler P, Farmer S and Major R(1997) Improvements in gaitparameters following late stageintervention in traumatic braininjury: a long-term follow-upreport of a single case ClinicalRehabilitation 11 pp220-226.

4 CDS ankle brace (online image)(2009) Available atwww.albrechtgmbh.com/sprachen/de/produkte/fuss/cds-sprunggelenk.php

5 Franchignoni F, Tesio L, Ricupero C, Martino M (1997) TrunkControl Test as an Early Predictor ofStroke Rehabilitation OutcomeStroke 28 pp1382-1385.

6 Hitchcock R, Watson M 2004)Recovery of walking late after asevere traumatic brain injuryPhysiotherapy 90 pp103-107.

7 Wales L, Bernhardt J (2000) A case for slow to recoverrehabilitation services followingsevere acquired brain injuryAustralian Journal ofPhysiotherapy 46 pp143-146.

8 Watson M, Bailey B, Trebble H(2003) Later stage recoveryfollowing severe traumatic braininjury? Identifying the evidence.Synapse Autumn pp5-9.

9 Watson M (2007) Feasibility offurther motor recovery in patientsundergoing physiotherapy morethan 6 months after severetraumatic brain injury: Anupdated literature review PhysicalTherapy Reviews 12 pp21-32.



18

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AMERICAN JOURNAL OF PHYSICALMEDICINE AND REHABILITATIONVolume 88:3

• Carter SE, Richardson JK, Thies S,DeMott T, Ashton-Miller JA The relationship between frontalplane gait variability and anklerange of motion in middle-agedand older persons with neuropathy. pp210-215.

• Facchin P, Rosa-Rizzotto M, Turconi AC, Pagliano E, Fazzi E,Stortini M, Fedrizzi E The Gipci StudiGroup: Multisite trial on efficacyof constraint-induced movementtherapy in children with hemiplegia: study design and methodology pp216-230.

• Miyamoto S, Kondo T, Suzukamo Y,Michimata A, Izumi S-I Reliabilityand validity of the manual function test in patients withstroke pp247-255.

Volume 88:4

• Hahn A, Duisberg B, Neubauer BA,Stephani U, Rideau Y Non-invasivedetermination of the tension-time index in Duchenne musculardystrophy pp322-327.

• Miller M, Flansbjer U-B, Lexell JVoluntary activation of the kneeextensors in chronic poststrokesubjects pp286-291.

Volume 88:7

• Park JY, Chun MH, Kang SH, Lee JA,Kim BR, Sin MJ Functional outcomein poststroke patients with orwithout fatigue pp554-558.

Volume 88:8• Park JH, Chun MH, Ahn JS, Yu JY,Kang SH Comparison of gait analysis between anterior andposterior ankle foot orthosis inhemiplegic patients pp630-634.

Volume 88:9Kim JH, Jang SH, Kim CS, Jung JH, YouJH Use of virtual reality toenhance balance and ambulationin chronic stroke: A double-blind,randomized controlled studypp693-701.

Volume 88:10

• Kim DY, Ohn SH, Yang EJ, Park C-I,Jung KJ Enhancing motor perform-ance by anodal transcranial directcurrent stimulation in subacutestroke patients pp829-836.

• Lakse E, Gunduz B, Erhan B, Celik ECThe effect of local injections inhemiplegic shoulder pain: aprospective, randomized, con-trolled study pp805-811.

ARCHIVES OF PHYSICAL MEDICINEAND REHABILITATIONVolume 90:2

• Ana Cristina R, Camargos ACR,Rodrigues-de-Paula-Goulart F,Teixeira-Salmela LF The effects offoot position on the performanceof the sit-to-stand movementwith chronic stroke subjectspp314-319.

• Mudge SN, Stott S Timed walkingtests correlate with daily stepactivity in persons with strokepp296-30.

Volume 90:3

• Gerrits KH, Beltman MJ, Koppe PA,Konijnenbelt H, Elich PD, de Haan A,Janssen TW Isometric muscle function of knee extensors andthe relation with functional performance in patients withstroke pp480-487.

• Manns PJ, Tomczak CR, Jelani A,Cress ME, Haennel R Use of the continuous scale physical func-tional performance test in strokesurvivors pp488-493.

• Rimmer JH, Rauworth AE, Wang EC,Terry LN, Hill B A preliminary studyto examine the effects of aerobicand therapeutic (nonaerobic)exercise on cardiorespiratory fitness and coronary risk reduction in stroke survivorspp407-412.

• Tyson SF, Rogerson L Assistive walking devices in nonambulantpatients undergoing rehabilita-tion after stroke: the effects onfunctional mobility, walkingimpairments, and patients’ opinion pp475-479.

Volume 90:4

• Hirsh AT, Turner AP, Ehde DM,Haselkorn JK Prevalence andimpact of pain in multiple sclerosis: physical and psychologiccontributors pp646-651.

• Kayes NM, Schluter PJ, McPhersonKM, Leete M, Mawston G, Taylor DExploring actical accelerometersas an objective measure of physical activity in people withmultiple sclerosis pp594-601.

• Massie C, Malcolm MP, Greene D,Thaut M The effects of constraint-induced therapy on kinematicoutcomes and compensatorymovement patterns: anexploratory study pp571-579.

• Morris DM, Taub E, Macrina DM,Cook EW, Geiger BF A method forstandardizing procedures inrehabilitation: use in the extremity constraint inducedtherapy evaluation multisite randomized controlled trialpp663-668.

• Widener GL, Allen DD, Gibson-Horn C Balance-basedtorso-weighting may enhancebalance in persons with multiplesclerosis: preliminary evidencepp602-609.

• Williams G, Morris ME, Schache A,McCrory PR Incidence of gaitabnormalities after traumaticbrain injury pp587-593.

Volume 90:5

• Fatone S, Gard SA, Malas BS Effectof anklefoot orthosis alignmentand foot-plate length on the gaitof adults with poststroke hemiplegia pp810-818.

• Gao F, Grant TH, Roth EJ, Zhang L-QChanges in passive mechanicalproperties of the gastrocnemiusmuscle at the muscle fascicle andjoint levels in stroke survivorspp819-826.

• Krassioukov A, Eng JJ, WarburtonDE, Teasell R Spinal cord injuryrehabilitation evidence researchteam. A systematic review of themanagement of orthostatichypotension after spinal cordinjury pp876-885.

Volume 90:6

• Boonsinsukh R, Panichareon L,Phansuwan-Pujito P Light touchcue through a cane improvespelvic stability during walking instroke pp919-926.

• de Leon MB, Kirsch NL, Maio RF,Tan-Schriner CU, Millis SR,Frederiksen S, Tanner CL, Breer MLBaseline predictors of fatigue oneyear after mild head injurypp956-965.

• Epstein-Lubow GP, Beevers CG,Bishop DS, Miller IW Family functioning is associated withdepressive symptoms in care-givers of acute stroke survivorspp947-55.

• Falvo MJ, Earhart GM Six-minutewalk distance in persons withParkinson Disease: a hierarchicalregression model pp1004-1008.

• Frykberg GE, Åberg AC, Halvorsen K,Borg J, Hirschfeld H Temporal coor-dination of the sit-to-walk taskin subjects with stroke and incontrols pp1009-1017.

• Melzer I, Tzedek I, Or M, Shvarth G,Nizri O, Ben-Shitrit K, Oddsson LESpeed of voluntary stepping inchronic stroke survivors under

ARTICLES IN OTHER JOURNALS



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single and dual-task conditions:a case-control study pp927-933.

Volume 90:7

Datta S, Lorenz DJ, Morrison S,Ardolino E, Harkema SJ A multivari-ate examination of temporalchanges in Berg Balance Scaleitems for patients with ASIAImpairment Scale C and D spinalcord injuries pp1208-1217.

Volume 90:8

• Allet L, Leemann B, Guyen E, Murphy L, Monnin D, Herrmann FR,Schnider A Effect of different walking aids on walking capacityof patients with poststroke hemiparesis pp1408-1413.

CLINICAL REHABILITATIONVolume 23:4

• Haworth J, Young C, Thornton E The effects of an 'exercise andeducation' programme on exercise self-efficacy and levels ofindependent activity in adultswith acquired neurologicalpathologies: an exploratory, randomized study pp371-383.

• McPherson KM, Kayes N, Weatherall M on behalf of all mem-bers of the Goals-SR Research GroupA pilot study of self-regulationinformed goal setting in peoplewith traumatic brain injurypp296-309.

• Playford ED, Siegert R, WilliamLevack L, Freeman J Areas of consensus and controversy aboutgoal setting in rehabilitation: aconference report pp334-344.

• Turner-Stokes L Goal attainmentscaling (GAS) in rehabilitation: apractical guide pp362-370.

• Wade DT Goal setting in rehabili-tation: an overview of what, whyand how pp291-295.

Volume 23;5

• Brogårdh C, Flansbjer U, Lexell JWhat is the long-term benefit ofconstraint-induced movementtherapy? A four-year follow-uppp418-423.

• Hammer A, Lindmark B Is forceduse of the paretic upper limb beneficial? A randomized pilotstudy during subacute post-strokerecovery pp424-433.

Volume 23:6

• Iwarsson S, Horstmann V, CarlssonG, Oswald F, Wahl HW Person—environment fit predicts falls inolder adults better than the consideration of environmentalhazards only pp558-567.

• Jones F, Mandy A, Partridge CChanging self-efficacy in individuals following a first timestroke: preliminary study of anovel self-management intervention pp522-533.

• Katsuhiko T, Yohei O, Koji S,Tomoaki S Does assessing error inperceiving postural limits by testing functional reach predictlikelihood of falls in hospitalizedstroke patients? pp568-575.

• Kayes NM, Schluter PJ, McPherson KM, Taylor D, Kolt GS The Physical Activity and DisabilitySurvey — Revised (PADS-R): anevaluation of a measure of physical activity in people withchronic neurological conditionspp534-543.

Volume 23:7

• Babyar SR, Peterson MGE,Bohannon R, Pérennou D, Reding MClinical examination tools for lat-eropulsion or pusher syndromefollowing stroke: a systematicreview of the literature pp639-650.

• Katsuhiko T, Yohei O, Koji S,Tomoaki S Does assessing error inperceiving postural limits by testing functional reach predictlikelihood of falls in hospitalizedstroke patients? pp568-575.

Volume 23:8

• Borisova Y, Bohannon RWPositioning to prevent or reduceshoulder range of motion impairments after stroke: ameta-analysis pp681-686.

• Glinsky J, Harvey L, van Es P, Chee S,Gandevia SC The addition of electrical stimulation to progres-sive resistance training does notenhance the wrist strength ofpeople with tetraplegia: a randomized controlled trialpp696-704.

GAIT AND POSTUREVolume 29:3

• Balasubramanian CK, Neptune RR,Kautz SA Variability in spatiotem-poral step characteristics and itsrelationship to walking perform-ance post-stroke pp408-414.

• Jonsdottir J, Recalcati R, Rabuffetti M,Casiraghi A, Boccardi S, Ferrarin MFunctional resources to increasegait speed in people with stroke:Strategies adopted compared tohealthy controls pp355-359.

• Williams G, Morris ME, Schache A,McCrory P Observational gaitanalysis in traumatic braininjury: accuracy of clinical judgment pp 454-459.

Volume 29:4

• Motoyoshi M, Kazu A, Tadamitsu M,Yumiko A, Ryusuke Y, Takashi BAnalysis of dynamic sitting balanceon the independence of gait inhemiparetic patients pp530-534.

Volume 30:5

• Bleyenheuft C, Cockx S, Caty G,Stoquart G, Lejeune T, Detrembleur CThe effect of botulinum toxininjections on gait control in spastic stroke patients presentingwith a stiff-knee gait pp168-172.

• Chihiro M, Shohei O, Satoru MAnalysis of stroke patient walkingdynamics using a tri-axialaccelerometer pp60-64.

• Nardone A, Godi M, Grasso M,Guglielmetti S, Schieppati MStabilometry is a predictor of gaitperformance in chronic hemipareticstroke patients pp5-10.

INTERNATIONAL JOURNAL FORREHABILITATION RESEARCHVolume 32:1

• Keresztényi Z, Cesari P, Fazekas G,Laczkó J The relation of hand andarm configuration varianceswhile tracking geometric figuresin Parkinson's Disease: aspects forrehabilitation pp53-63.

Volume 32:2

• Snögren M, Sunnerhagen KSDescription of functional disability among younger strokepatients: exploration of activityand participation and environmental factors pp124-131.

• Wolfenden B, Grace M Returningto work after stroke: a reviewpp93-97.

PHYSICAL THERAPYVolume 89:2

• Jette DU, Halbert J, Iverson C, MiceliE, Shah P Use of standardized outcome measures in physicaltherapist practice: perceptionsand applications pp125-135.

• Wulf G, Landers M, Lewthwaite R,Töllner T External focus instructionsreduce postural instability in individuals with Parkinson Diseasepp162-168.

Volume 89:3

• Harting J, Rutten GMJ, Rutten STJ,Kremers SP A qualitative applicationof the diffusion of innovations theory to examine determinants ofguideline adherence among physical therapists pp221-232.

• McGinnis PQ, Hack LM, Nixon-CaveK, Michlovitz SL Factors that influence the clinical decisionmaking of physical therapists inchoosing a balance assessmentapproach pp233-247.

Volume 89:4

• King LA, Horak FB Delaying mobility disability in people withParkinson Disease using a sensorimotor agility exercise program pp384-393.


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• Siengsukon CF, Boyd LA Does sleeppromote motor learning?Implications for physical rehabilitation pp370-383.

Volume 89:5

• Beissner K, Henderson Jr CR,Papaleontiou M, Olkhovskaya Y,Wigglesworth J, Reid MC Physicaltherapists’ use of cognitive-behavioral therapy for olderadults with chronic pain: anationwide survey pp456-469.

• Kahn JH, Hornby TG Rapid andlong-term adaptations in gaitsymmetry following unilateralstep training in people withhemiparesis pp474-48.

Volume 89:6

• Hammer AM, Lindmark B Effects offorced use on arm function in thesubacute phase after stroke: arandomized, clinical pilot studypp526-539.

• Musselman KE, Fouad K, MisiaszekJE, Yang JF Training of walkingskills overground and on thetreadmill: case series on individuals with incompletespinal cord injury pp601-611.

• Ries JD, Echternach JL, Nof L,Blodgett MG Test-retest reliabilityand minimal detectable changescores for the timed ‘up and go’test, the six-minute walk test,and gait speed in people withAlzheimer Disease pp569-579.

• Salbach NM, Veinot P, Rappolt S,Bayley M, Burnett D, Judd M, Jaglal SBPhysical therapists’ experiencesupdating the clinical manage-ment of walking rehabilitationafter stroke: a qualitative studypp556-568.

Volume 89:7

• Hancock M, Herbert RD, Maher CGGuide to interpretation of studiesinvestigating subgroups ofresponders to physical therapyinterventions pp698-704.

• Stemmons Mercer V, Freburger JK,Shuo-Hsiu C, Purser JL Measurementof paretic–lower-extremity load-

ing and weight transfer afterstroke pp653-664.

• Tomey KM,Sowers MR Assessmentof physical functioning: a conceptual model encompassingenvironmental factors and individual compensation strategies pp705-714.

Volume 89:8

• Beninato M, Portney LG, Sullivan PEUsing the international classifica-tion of functioning, disability andhealth as a framework to exam-ine the association between fallsand clinical assessment tools inpeople with stroke pp816-825.

• Jau-Hong Lin, Miao-Ju Hsu, Ching-Fan Sheu, Tzung-Shian Wu, Ruey-Tay Lin, Chia-Hsin Chen,Ching-LinHsieh Psychometric comparisons of four measures for assessingupper-extremity function in people with stroke pp840-850.

• Lewek MD, Cruz TH, Moore JL, RothHR, Dhaher YY, Hornby TG AllowingIntralimb kinematic variabilityduring locomotor training post-stroke improves kinematic consistency: a subgroup analysisfrom a randomized clinical trialpp829-839.

PHYSIOTHERAPY RESEARCH INTERNATIONALVolume 14:1

• Mccormack E, Liddiard H Home oraway? Community rehabilitationfollowing traumatic brain injury:a case report p 66-71.

• Piriyaprasarth P, Morris ME, DelanyC, Winter A, Finch S Trials needed to assess knee proprioception following stroke pp6-16.

• Wilson D, Williams M, Butler DLanguage and the pain experience pp 56-65.

Volume 14:2

• Durham K, Van Vliet PM, Badger F,Sackley C Use of information feed-back and attentional focus offeedback in treating the personwith a hemiplegic arm pp 77-90.

PHYSIOTHERAPY THEORY AND PRACTISEVolume 25:1

• Bezerra de Figueiredo KMO, Costa deLima K, Maciel ACC, Guerra ROInterobserver reproducibility ofthe Berg Balance Scale by noviceand experienced physiotherapistspp30-36.

Volume 25:2

• Amusat N Assessment of sittingbalance of patients with strokeundergoing inpatient rehabilitation pp138-144.

• Langhammer B, Stanghelle JK,Lindmark B An evaluation of twodifferent exercise regimes duringthe first year following stroke: arandomised controlled trial pp55-68.

Volume 25:3

• Rindflesch AB A grounded-theoryinvestigation of patient educationin physical therapy practicepp193-202.

Volume 25:4

• Smith JM, Sullivan SJ, Baxter GDTelephone focus groups in physio-therapy research: potential usesand recommendations pp241-256.

Volume 25:5 and 6

• Dean E Physical therapy in the21st century (Part I): toward practice informed by epidemiology and the crisis oflifestyle conditions pp330-353.

• Dean E Physical therapy in the21st century (Part II): evidence-based practice within the contextof evidence-informed practicepp354-368.

• Rhodes RE, Fiala B Building motivation and sustainability intothe prescription and recommen-dations for physical activity andexercise therapy: The evidencepp424-441.

Volume 25 Issue 7 2009

• Karin H, Filip S, Jo G, Bert AObstacles to the implementationof evidence-based physiotherapyin practice: a focus group-basedstudy in Belgium (Flanders)pp476-488.

• Jenkins S, Cecins N, Camarri B,Williams C, Thompson P, Eastwood PRegression equations to predictsix minute walk distance in middle-aged and elderly adultspp516-522.



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From the British Bobath TutorsAssociation (BBTA)

Thank you for asking BBTA to respond to thisinteresting synapse article exploring under-graduate physiotherapy students’ perceptionsof the Bobath Concept and the MotorRelearning Programme, and confidence inusing these approaches in stroke rehabilitation.

Although there are a number of methodologicallimitations within this study, we will not commenton these in this response.

As might be expected the majority were not con-fident in using either approach in their clinicalpractice.

More important than in depth understanding ofspecific approaches, the undergraduate physio-therapy student needs to have a foundation builton anatomy, biomechanics, movement analysis,neurophysiology, neuropathology, principles ofmotor control and motor learning. This knowledgethen forms the basis of and confidence in assess-ment, treatment interventions and overall patientmanagement. They also need to be aware thatthere are a number of different approaches in thetreatment of patients with neurological problemsbut that developing in depth knowledge and confi-dence to practice comes with extensivepostgraduate experience, specific training andongoing reflective practice.

It is recognised by BBTA and other IBITAmembers that undergraduate training dependsupon publications and over the last few years theyhave worked to disseminate the developments inthe Bobath Concept within the literature ratherthan purely on postgraduate courses. Someexamples of this would include; Raine, Meadowsand Lynch-Ellerington 2009, Gjelsvik 2008,

Raine 2007, Luke, Dodd and Brock 2004,Vaughan-Graham et al 2009.

These publications enable those within the uni-versity environment to access the currenttheoretical underpinning and clinical practice ofthe Bobath Concept.

REFERENCESGjelsvik BE (2008) The Bobath Concept in Adult Neurology ThiemeStuttgart.

Luke C, Dodd KJ and Brock K (2004) Outcomes of the Bobath Concept onUpper Limb Recovery following Stroke Clinical Rehabilitation 18 pp888-898.

Raine S (2007) Current Theoretical Assumptions of the Bobath Concept asdefined by the members of BBTA Physiotherapy Theory and Practice 23(3) pp137-152.

Raine S, Meadows L and Lynch-Ellerington M (2009) Bobath Concept;Theory and Clinical Practice in Neurological Rehabilitation Wiley-Blackwell Oxford.

Vaughan-Graham J, Eustace C, Brock K, Swain E and Irwin-Carruthers S(2009) The Bobath Concept in Contemporary Clinical Practice Topics inStroke Rehabilitation 57 (12).

SHARING GOOD PRACTICE

Article responsesto ‘What do student physiotherapists perceive the Bobath concept andMotor Relearning Programme to be and do they feel confident to usethese approaches in stroke rehabilitation?’ (Pinguey and Levis) in Synapse Spring 2009


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From the motor relearning programme (MRP)

This is a very interesting study investigatingphysiotherapy students’ understanding of andconfidence in using the two most prevalenttreatment approaches to stroke in the UK.

It was found that students had a poor under-standing of both treatments and authors suggestsome good reasons to explain this. Students alsofelt more confident in using MRP. This is rathersurprising as the most commonly used approach inthe UK is the Bobath approach so it would beexpected that students would receive a greateramount of expert tuition in this treatment thanMRP on their neurological clinical placements. Soit will be very interesting to find out more aboutwhy students felt more confident in using the MRP.For example, reasons may include the fact that theapproach to analysis of the movement problems issystematic and easy to follow, or the fact that thereis current literature widely available to describehow to implement the approach. This informationmight be more easily elicited from subjects via oneto one interviews or focus groups and thesemethods should be included in future studies asthe questionnaire alone does not seem to have produced enough explanatory information.

The next point is perhaps a minor one, but thetreatment framework described by Carr andShepherd has not been named the ‘MotorRelearning Programme’ in recent texts from theseauthors. A more appropriate name would be a‘movement science based approach’ to strokerehabilitation. This is because, although the treat-ment does emphasis the patient as an activelearner, there are other foundations for the treat-ment, apart from motor learning, that haveemerged from the movement science literature. Ibelieve the authors are correct in describing thistreatment as involving ‘optimisation of motor per-formance and functional abilities through taskoriented rehabilitation, which should be contextspecific’ and several core principles are listedwhich I would agree are key. The description couldbe more detailed however, perhaps includingimportant elements such as the underlying biome-chanical basis for analysis of movement, anunderstanding of how the brain controls the func-tional movements, the repetitive nature of thepractice and how practice and feedback are usedin a structured manner to enhance learning.There are also analyses of the content of thistreatment from independent authors such as

Lettinga (Lettinga 1999 #11) that could be incor-porated into the description.

In this study, it was found that 87.5% of studentschose an eclectic approach and that they tailoredrehabilitation to the patient. This seems a verypositive sign, as the time for rigidly applying oneapproach or the other is fast disappearing, drivenby the emergence of a rich evidence base aboutspecific interventions for stroke, such as con-straint-induced therapy or robotics, that do notnecessarily align with a particular complex inter-vention. In the future, it may be more useful toexpand this type of inquiry to students’ confidenceand understanding of specific interventions suchas these, whilst still exploring attitudes to thecomplex interventions that physiotherapists cur-rently apply. In other words we need both topdown approach where we study the wholecomplex intervention as well as a bottom upapproach where individual components of treat-ment are assessed, as advocated by Marsden andGreenwood (Marsden 2005 #808).

The point is made in the discussion that a lack ofBobath teaching at undergraduate level is abarrier to students’ knowledge. It would be inter-esting to explore this hypothesis further, as thismay also be the case for the movement sciencebased treatment. At postgraduate level, it seemsthat Bobath teaching is more widely availablethan teaching on the movement science basedintervention, so a investigation of teaching at bothlevels via survey methods could inform thishypothesis.

I would like to thank the editor of Synapse foroffering the opportunity to comment on this study,which raises some thought provoking ideas abouteducation of physiotherapy students in this field.

Paulette van Vliet Division of Physiotherapy Education, School ofNursing, Midwifery and Physiotherapy, University of Nottingham

NB There is postgraduate teaching available onthe Movement Science base approach to strokerehabilitation (9 day course, 30 credits) at theUniversity of Nottingham, within the MScPhysiotherapy (Neurorehabilitation). This partic-ular module can be taken alone, withoutregistering for the masters degree. Enquiries to:[email protected].



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ACPIN National Conference and AGM 2010Northampton Hilton

Friday 19th and Saturday 20th March

Go to www.acpin.net for further details and an application form.

fitlife?for

exercise& neurology


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This two day residential

conference will provide an

overview of the essentials

of exercise physiology related

to strength, cardiovascular fitness

and neuroplasticity. Best practice

and insights on how to promote

exercise in people with Multiple

Sclerosis, Parkinson’s Disease,

Stroke and Spinal Cord Injury

will be shared by experts in

this growing and important

area of neurophysiotherapy.

?



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ApologyEmma Heathcote and Jo Pierce

We wish to apologise for the absenceof the third named author in theabstract (see below) that was sub-mitted for conference in March 2009(printed in Synapse Spring 2009).Charlie Winward’s contribution wasfundamental to the completion ofthis piece of work.

GRASPING THE CONCEPT:SAEBOFLEX® AT THE OXFORD CENTREFOR ENABLEMENT (OCE)Emma Heathcote, Jo Pierce andCharlie Winward

Abstract:BACKGROUND AND PURPOSE –Following a neurological injury, theprognosis of recovery in the arm andhand is generally poor. The currentOxford Centre for Enablement (OCE)approach to upper limb rehabilita-tion includes a functional upper limbgroup for patients with a RivermeadMotor Assessment (RMA) score of ≥3/15 (arm). However, many patientsdo not fulfil this criteria and to date,for those individuals with littlepower or functional return in theirhand, therapy options are oftenreduced. Recently a novel treatmentapproach called the SaeboFlex®became available. This uses adynamic hand splint designed toposition a patient’s hand at a biomechanical advantage, so thatgrasp and release activities are possible and can be practiced inde-pendently. A clinical service auditwas conducted to determine theaddition of this hand splint to upperlimb rehabilitation at OCE.

METHODS – An audit cycle providedthe framework for criteria setting,data collection and analysis ofresults. Patients were included ifthey fulfilled the physical parametersfor SaeboFlex® training and wantedto participate. Baseline measureswere recorded for all SaeboFlex®users prior to upper limb training,the Modified Ashworth Scale (MAS)9,

RMA arm and Motricity Index (MI). Allmeasures were then repeated at sixmonths. In addition, training inten-sities were recorded.

RESULTS – Over a twelve monthperiod, 23 patients commencedSaeboFlex® training. Eleven com-plete sets of data were collected (sixmale, five female, six left, five right,mean age 55.8 years (s 11.7). Beforetesting RMA mean 4.5 (s 3.5), MImean 58.4 (s 21.1) and MAS mean 2.5(s 2.3). Post testing RMA mean 6.7 (s3.5), MI mean 77.3 (s 14.4) and MASmean 3.4 (s 2.5). The mean trainingintensity was seven sessions perweek (s 3.9), 39 minutes per session(s 10.4). Having trained with theSaeboFlex®, two patients whowould had previously beenexcluded, were then eligible toattend the upper limb group.

CONCLUSIONS – More patients wereable to access the upper limb groupthan previously. The increase in boththe RMA and MI are indicative of anincrease in function for SaeboFlex®users. An increase in MAS was alsonoted. Robust research is necessary todetermine the effect of SaeboFlex® inupper limb rehabilitation.

Interactive CSP updateChris Manning iCSP link moderatorfor neurology

iCSP is going from strength to strengthand is a valuable tool for members toshare ideas and documents. Theneurology network, owned by ACPIN,now has 7,692 registered users.

Most of the items submitted to theneurology network are discussionsthese allow exchange of ideas andviews as well as request for informa-tion. Do search the network to checkif there is already a discussion on atopic and remember only to use theemail members option if an urgentreply is needed. If you have anexample of good practice or yourown research you wish to communi-cate use the ‘sharing practice’ area.

Exercise has featured frequently inrecent discussions eg balance exer-cises, Pilates, the use of the NintendoWii® in rehabilitation and exercisegroups in the community. Other com-mon themes include: outcome meas-ures, goal setting, information forpeople with newly diagnosed neuro-logical conditions and walking aids. Ifyou have opinions on any of thesetopics look up the discussion andshare your views.

There have been some really usefuldocuments added to the site, particu-larly guidelines, outcome measures,and interesting and relevant research.

To make the links between theACPIN executive and iCSP moreapparent and interdependent thecontent fron iCSP wil be used toinform the topics for future events.Exercise is the theme for the ACPINresidential conference in March andthe discussions highlighted abovecan enlighten our debate.

The 4th UK Stroke forum is beingheld in Glasgow from 1-3 December2009. See iCSP for details and to sub-mit related content.

www.interactivecsp.org.uk

NEWS ACPIN


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Latest issue of StrokeMatters now available

Produced by The Stroke Association,Stroke Matters is a quarterly e-publi-cation for professionals with aninterest in stroke. It covers interestingand accurate news on stroke issues,carefully selected by an expert multi-disciplinary editorial board compris-ing of leading stroke specialists.

This issue includes updates onstem cells in stroke, childhood stroke,the use of telemedicine and skillstraining for stroke care, along withresearch updates across the strokecare pathway.

The fourth issue is now available.To subscribe for free, please visitwww.stroke.org.uk/strokemattersand complete the online subscriptionform.

Spasticity in adults:management usingbotulinum toxinNational guidelines

These new guidelines published bythe Royal College of Physicians (ACPINwere involved in the development),provide clinicians with the knowl-edge and tools to use BT effectively. Ifused according to the guidance, BTcan improve the lives of those suffer-ing from spasticity and of those car-ing for them, as well as reducing theoverall costs of ongoing care.

The guidance is essential readingfor all clinicians dealing wIth strokepatients, people with multiple scle-rosis and patients with severe trau-matic brain injury.

The guide costs £20.00. For moreinformation and to purchase onlineplease visit: www.rcplondon.ac.uk/pubs/brochure.aspx?e=272

Launch of QuickReference Cards:UKfor physiotherapists working with people withParkinson’s DiseaseBhanu Ramaswamy MCSP

In 2004 the Royal Dutch Society forPhysical Therapy (KNGF) publishedthe Guideline for Physical Therapy inpatients with Parkinson’s Disease(Keus et al 2004), guidelines whichprovide the best available evidencefor use in clinical practice.

An innovative feature of the KNGF‘Dutch’ guidelines is the inclusion offour Quick Reference Cards designedto directly support clinical practice atany stage of Parkinson’s Disease, inthe clinic, on the ward or in commu-nity settings. These are of particularimportance as most physiotherapistsdo not work in specialist centreswhere they have the opportunity ofworking with large numbers ofpatients with Parkinson’s Disease

The UK version of the QuickReference Cards (QRC: UK) waslaunched at the recent NationalConference on Parkinson’s Diseasehosted by AGILE in Glasgow inOctober 2009 and are an adaptationof the KNGF guidelines making themmore appropriate for clinical use inthe UK.

The development of the UK guide-lines was initiated by the Parkinson’sDisease Society in the UK and takenforward by a group of nationallyrecognised clinical, research andacademic physiotherapists. BhanuRamaswamy, ConsultantPhysiotherapist has led the group inher role as Project Officer forParkinson’s Disease for both AGILE(Chartered physiotherapists workingwith older people) and ACPIN. Bhanuis also currently part of a nationalgroup hosted by the PDS and BritishGeriatric Society involved in planninga national audit tool for physiothera-pists working with people withParkinson’s Disease in preparation toreview implementation of the NICEGuidelines for PD published in 2006.

The QRC: UK will provide a means

of standardised guidance for physio-therapists. They relate to best practicein Parkinson's Disease and cover thediagnostic processes (QRC 1: History-taking; QRC 2: Physical examination),and the therapeutic processes (QRC 3:Specific treatment goals and QRC 4:Treatment strategies). The cards areso designed that each of the fourareas under examination fit on asingle page of A4. The clinician canprint and laminate, and hence placethe cards in an accessible area forquick reference.

The QRC: UK can be accessed fromboth the ‘Neurology’ and the ‘OlderPeoples’ networks on interactive CSPat www.interactivecsp.org.uk/

Similarly from the Parkinson’sDisease Society website in the sectionon publications for the Professionalsat www.parkinsons.org.uk/for_professionals.aspx

The UK guidance notes should alsobe read in conjunction with the

original guidelines found atwww.fysionet.nl/dossier_files/uploadFiles/Eng_RichtlijnParkinsonsdisease_251006.pdf as these providea full explanation of how to use theoriginal guidelines, a glossary ofterms, examples of the measurementtools considered, and, suggestedstrategies to aid movement.

ReferencesKeus S, Hendriks H, Bloem B, Bredero-Cohen A, de Goede C, van Haaren M,Jaspers M, Kamsma Y, Westra J, deWolff B, Munneke M (2004) Clinicalpractice guidelines for physical therapyin patients with Parkinson’s diseaseSupplement of the Dutch Journal ofPhysiotherapy; 114 (3).

National Institute of Clinical Healthand Excellence (2006) CG35:Parkinson's Disease: diagnosis andmanagement in primary and second-ary care London, RCP.

NEWS GENERAL


The CharteredSociety ofPhysiotherapy

Congress 2009 was held on16-17 October 2009 at the BTConvention Centre, Liverpool.

The full programme covered six main areas of content. ACPINwas involved in organising theneurolgy part of the programme.

FRIDAY SESSION 1Contribution of motor impairments to physical activity after strokeProfessor Louise Ada Associate Professor, University of Sydney

AbstractA major concern of neurological physiotherapists is the relativecontribution of the positive versus negative impairments toactivity limitations in neurological conditions. It is now com-monly understood that the major contribution to disabilityafter stroke is not the result of the positive impairments, ie spasticity, but rather the negative impairments, ie loss ofstrength and dexterity. This has lead to a shift in focus of rehabilitation towards the treatment of weakness and incoor-dination. Recent descriptive studies suggest that weakness is amore important contributor to disability after stroke thanincoordination. Furthermore, there is increasing evidence,summarised in a recent systematic review, that strength can beincreased after stroke, with a positive effect on function andwithout increasing spasticity. Yet, it is possible that insufficientattention is given to strength training in rehabilitation of indi-viduals after stroke because of the commonly-held assump-tions that not only is spasticity the most important contributorto disability but that resisted exercise will increase spasticity. It now remains to identify the most effective methods ofincreasing strength early after stroke, especially at short muscle lengths. It is important for physiotherapists to understand as much as possible about the nature of theseimpairments in different neurological conditions as well theirrelative contribution to activity limitations in order that rehabilitation has a sound scientific basis.

BiographyLouise Ada is a physiotherapist who is an associate professor in the Disciplineof Physiotherapy at The University of Sydney with an interest in neurologicalrehabilitation. She is particularly interested in the relative contribution ofimpairments to disability as well as the efficacy of physiotherapy interven-tions and the design of environments to promote the active participation ofpeople undergoing rehabilitation.


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ACPIN @ CSP Congress 2009

Professor Louise Ada (far left, our keynote speaker) with (from left to right) Dr Sarah Tyson(invited speaker), Dr Cherry Kilbride (ACPIN co-chair), Jo Tuckey (ACPIN co-chair) andSiobhan MacAuley (ACPIN vice-chair and organiser of this year’s neurology strand.


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The role of the neurological physiotherapist as an expert witness in medico-legal practice

Sue Edwards Director of Edwards Associates and part-time clinical specialistphysiotherapist, National Spinal Injuries Unit, Stoke Mandeville Hospital

AbstractNeurological physiotherapists have a vital role to play as expertwitnesses in the medico-legal process. This may be in deter-mining issues of liability with regard to whether or not a treat-ing physiotherapist has been negligent in their practice (this isonly a small proportion of the work) or, more commonly iden-tifying the current and on-going physiotherapy needs inrespect of quantification of the claim following appropriateassessment.

This presentation aims to:· Provide an overview of the medico-legal process· Discuss what attributes are required to be an expert witness· Clarify what the lawyers and others expect from the expert

physiotherapy report

BiographySue Edwards qualified as a physiotherapist in 1971 from the Robert Jones andAgnes Hunt Orthopaedic Hospital, Oswestry. Her exposure to the treatment ofspinal cord injured people during her training led her to pursue a career spe-cialising in neurology. Her current posts include: expert witness in medico-legal cases of adults and children with neurological disability and part-timeclinical specialist, Spinal Injuries Unit at Stoke Mandeville Hospital.

Sue is the author of Neurological Physiotherapy: A Problem-solvingApproach. The first edition was published in 1996 and the second in 2002.She has also contributed chapters to several other neurological texts.

She taught extensively from 1980 to 2006 both nationally and internation-ally. Topics included:· Treatment and management of hypertonia / spasticity· Treatment and management of patients with incomplete spinal cord injury· Treatment and management of patients following acquired brain injury· The use of splinting for adults and children with neurological disability· Treatment and management of children with cerebral palsy· Analysis of normal movement

She became a committee member of the Medico-legal Association ofChartered Physiotherapists in 2005 and is currently the Vice Chair of this group.More recently she has lectured on courses relating to medico-legal practice.

She was awarded a Fellowship of the Chartered Society of Physiotherapy in1995 and was President of the Association of Chartered Physiotherapists withan Interest in Neurology (ACPIN) from 1998 to 2002.

FRIDAY SESSION 2Some thoughts on the measurement of spasticity

Professor Michael Barnes Honorary Professor of Neurological Rehabilitation,Newcastle University

AbstractSpasticity is difficult to measure. The lack of a clear definitionclearly hinders precise measurement.

In a clinical setting the Ashworth or Modified Ashworth scaleis the most commonly used and indeed these scales are by farthe most common quoted in the research literature. However,there has been significant criticism that the Ashworth scale isnot entirely reliable, is not good at measuring milder spasticity

and is not a good tool to measure ongoing clinical change. Analternative is the Tardieu scale. This is a composite measure ofspasticity but, once again, it is difficult to perform and relia-bility has been questioned.

An alternative approach is to use biomechanical measure-ments, such as the Wartenberg pendulum test. This is reason-able to use but is really only relevant in cases of mild spasticitywhen a limb can swing freely. There are other powered sys-tems that have been used but these are not practical in a clini-cal setting. Indirect biomechanical approaches can also beused, such as gait analysis. Gait analysis has a role in themanagement of some aspects of spasticity, such as the rele-vance of orthotics but is clearly impractical for most day-to-day spasticity treatment. There are a number ofneurophysiological approaches to spasticity measurement,such as analysis of tendon jerks, H reflexes and F waves butthese are really only useful in a research setting.

As spasticity is a subjective phenomenon then it makes sensefor the patient’s own perception to be taken into account.There is emerging literature of the usefulness of simple tools,such as visual analogue scales to monitor the patient’s per-ception of their own spasticity. If an individual is not able tocomplete such a scale (such as in the context of severe braininjury) then the measured opinion of the key family memberor carer can be used.

I will discuss the merits and drawbacks of these measure-ment techniques and come to the conclusion that we shoulduse subjective measures as the mainstay of our clinical man-agement of spasticity.

BiographyMike Barnes is an accredited neurologist and rehabilitation physician. Hisclinical work has, for the last 20 years, focused entirely on the rehabilitationof people with severe and complex disabilities. He has a particular interestand expertise in the management of dystonia and spasticity and the use ofbotulinum toxin. He was responsible for the development of Walkergate Park,International Centre for Neurorehabilitation and Neuropsychiatry (formerlyHunters Moor Regional Neurological Rehabilitation Centre) – a brand new,state of the art, nationally and internationally recognised centre of excellencefor people with neurological problems, particularly following traumatic headinjury. Walkergate Park has one of the largest botulinum toxin services in theUK. In December 2007, he retired from the National Health Service to concen-trate on setting up and running Hunters Moor Neuro Rehab Ltd and HuntersMoor Residential Ltd (www.huntersmoor.com) – a rehabilitation service pro-vided into client’s homes and, in the near future, in a network of high qual-ity residential treatment centres across the UK.

He is recognised at a national and international level in the field of neuro-logical rehabilitation. He is Founder/Past President of the World Federation forNeuroRehabilitation (www.wfnr.co.uk) – a global organisation for profes-sionals with an interest in the field of neurorehabilitation. He is currentlyChairman of the United Kingdom Acquired Brain Injury Forum (UKABIF). Hehas been President of the British Society of Rehabilitation Medicine (1994-1996) and Chairman of the Royal College of Physicians of London JointSpeciality Committee for Rehabilitation Medicine.

He has produced over 100 articles for peer review journals and has writtenor edited nine books in the field of neurological rehabilitation and has pro-duced many chapters for such books. He has presented widely on the subjectof neurological rehabilitation both nationally and internationally. He is onthe Editorial Board for many journals in the field.



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Spasticity in adults: management and practiceimplications for using botulinum toxin

Stephen Ashford Clinical Specialist & Research Physiotherapist, NorthwickPark Hospital and Honorary Research Fellow, Department of Palliative Care,Policy and Rehabilitation, King’s College London

AbstractSpasticity is over activity in muscles, which can follow braininjury. Damaged parts of the brain, which would normallycause muscles to ‘relax’, no longer work in the same way andinstead muscles may contract when not required to do so 1.

In addition muscles, which contract most of the time, arelikely to become short and stiff. This makes stretching themuscle much more difficult. If left untreated, the muscle canbecome permanently shorter leading to secondary problems.For example if spasticity in the arm and hand are not man-aged in some cases this will lead to inability to open the handand clean the palm or cut finger nails 1.

Principles of spasticity managementSpasticity management requires a 24-hour approach· Maintaining and changing body positions to avoid muscle

shortening· Supporting the body where needed in a wheelchair or in bed· Avoiding aggravating factors such as pain, infection or

constipation

Botulinum Toxin InjectionBotulinum toxin (BT) is a treatment that weakens or paralysesspecific muscles to reduce spasticity and make it easier tostretch the muscles. The effects of BT are usually greatest twoto six weeks following injection and usually fade completelyafter three to six months. In general, BT cannot be used totreat widespread severe spasticity, since the amount of drugrequired to bring about meaningful functional improvementswould need to be greater than the currently recommendedmaximum dose. BT is used in spasticity management as anadjunct to physical management intervention such as posi-tioning or splinting and should be viewed as a combined orcomplex intervention with these other modalities.

Outcome measurementThe guidelines for the management of spasticity with botu-linum toxin have highlighted the importance of measuring theimpact of interventions at the level of improved function andreduction of the impact of spasticity on patients and their car-ers 1. Goal Attainment Scaling and the Arm Activity Measure areboth methods of measuring outcomes following botulinumtoxin intervention. Both these measures have been shown tobe useful in demonstrating functional improvements ofimportance to patients following BT 1.

Reference1. Spasticity in adults: management using botulinum toxin. National guide-lines. London: RCP, 2009. (http://www.rcplondon.ac.uk)

BiographySteve trained in Physiotherapy at Salford University and qualified in 1993. Hecompleted an MSc in Neurorehabilitation at Brunel University in 1998. Thenundertook a Post Graduate Certificate in Education through the University of

Greenwich while working at the Royal Hospital for Neurodisability, Putney.He subsequently became part-time lecturer and course director for the MScNeurorehabilitation at Brunel University from 2001 until 2003, while workingclinically at the Regional Rehabilitation Unit, Northwick Park Hospital.

Since 2003 Steve has been full-time clinical specialist and research physio-therapist at the Regional Rehabilitation Unit, Northwick Park Hospital andHonorary Research Fellow, Department of Palliative Care Policy andRehabilitation, King’s College London. Steve is currently part way through aPhD at King’s College London investigating the measurement of arm functionfollowing focal interventions, such as botulinum toxin for arm spasticity.Steve has published a number of peer-reviewed papers in the rehabilitationliterature as well as book chapters and clinical guideline contributions.

FRIDAY SESSION 4What the commissioners want

Louise Rogerson Service Reform Lead for Clinical Pathways

AbstractThis lecture will provide an overview of the current paymentmechanisms for services in the community and hospital set-ting using practical examples relevant for our practice. Thecompetency framework from World Class Commissioning willbe explained, along with the PCT performance measurementincluding this year’s targets and performance framework. Bydemonstrating the broader context in which the PCT operates,the prioritisation of commissioning decisions will be exploredalongside the process of commissioning redesign.

The second half of the lecture will focus on the practicalimplications of these processes. This will include examples ofservice reform to demonstrate how clinician’s can guide thisredesign whilst achieving the commissioning expectations. Itwill also provide insight on who to involve in these projects,how to identify political drivers and outcomes to build a busi-ness case, and provide practical advice on the type of informa-tion that commissioners can relate to. Opportunities to placeneurological services on the commissioning agenda will beexplored within the current healthcare agenda.

BiographyLouise Rogerson qualified as a physiotherapist from the University of EastLondon in 1995. After junior rotations at the Royal London Hospital, she spe-cialised in neurology, working at the Regional Neurorehabilitation Unit inHomerton, and then moving to work at the University Hospital of SouthManchester in 2000. After working privately in the community and complet-ing masters level research at the University of Salford, Louise started workingat South Manchester PCT as a service improvement manager with a focus ontier two interface services. Following an 18 month secondment Louise hasnow secured a permanent post as the service reform lead for clinical path-ways within the commissioning directorate at Trafford PCT. Her work involvesperformance management of several key PCT targets including the large CVDagenda (including prevention and rehabilitation), diabetes management,cancer, and palliative care. Louise also continues to work privately as a neu-rophysiotherapist, and is currently the Honorary Minutes Secretary forNational ACPIN.


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SATURDAY SESSION 1A framework for physiotherapy interventions inHuntingtons Disease: the ongoing processes

Monica Busse PhD MSc (Med) BSc (Med) Hons BSc (Physio) Department ofPhysiotherapy, Cardiff University

AbstractPhysiotherapy is being more frequently recommended forpeople with Huntington’s Disease (HD) although literaturereviews have highlighted the need to utilise appropriate outcome measures and to document interventions providedacross the spectrum of the condition. The Cardiff PhysiotherapyGroup (CPG) alongside the European Huntington’s DiseaseNetwork (EHDN) Physiotherapy working group has utilised astaged process to develop a Framework for PhysiotherapyInterventions for people with HD.

A series of qualitative studies have been undertaken to characterize current physiotherapy practice and guide provi-sion of interventions in this group of people. Further cross-sectional studies evaluating potential physiotherapy outcomemeasures for use in HD were also conducted. The findings ofthis exploratory work was presented to the EHDNPhysiotherapy working group during the recent developmentprocess of the Guidance Document for Physiotherapy.Physiotherapy expert sub-groups were formed to interpretcurrently available literature and incorporate consensus as tobest practice guidelines. A draft document was distributed tothe entire membership of the working group, to other healthcare professionals of EHDN to elicit feedback and comments.Feedback was incorporated into the final document.

A guidance document covering eight specific areas pertaining to physiotherapy management of HD has now beendeveloped. During this presentation, the staged processtowards developing a Physiotherapy Framework and Guidancefor Physiotherapy Interventions in HD will be described.

BiographyMonica Busse works as a lecturer and researcher in the Department ofPhysiotherapy, Cardiff University. Her research focuses specifically on neu-rodegenerative conditions and the related physiotherapy issues. This includesthe assessment and management of mobility problems and has strong linkswith the specialist Huntington’s disease (HD) Clinic based in Cardiff. HD servesas a paradigm for neurodegeneration – although it a relatively rare condition,it is a good model for investigating treatments in that is can be isolated to asingle gene, can be diagnosed in life and results in focal degeneration.Current projects include the development of home based interventions forpeople with HD at risk of falls, investigation of respiratory function in peoplewith HD as well as evaluation of utilisation of rehabilitation services acrossEurope. Other projects are linked to the European Huntington’s DiseaseNetwork (EHDN) Physiotherapy Working Group for defining physiotherapypractice, developing guidance for physiotherapists working with HD anddetermining best outcome measures to assess efficacy of physiotherapy interventions.

Bladder and bowel dysfunction in the neurological patient

Dr Doreen McClurg NMAHP Research Unit, Glasgow Caledonian University

AbstractBladder and bowel dysfunction are a common symptom ofmost neurological conditions often with significant detrimen-tal impact on overall quality of life. For example up to 98% ofpeople with multiple sclerosis will have bladder problems atsome stage during the course of their disease, be it as an initial symptom or later when mobility is impaired. Followinga CVA incontinence can occur either as a result of impairedmobility or impaired awareness and often defines discharge tohome or long-term residential care with hugh economic costimplications. It is important that during rehabilitation physiotherapists are aware of the incidence, causes, socialimplications and potential therapies which may be used toreduce the severity of symptoms and improve quality of life.During this talk simple strategies for educating patients andcarers are outlined as are posible referral pathways for thosewith more severe problems.

BiographyDr Doreen McClurg worked for many years as a Women's Health physiotherapist in the Belfast City Hospital, undertaking the post-graduateDiploma in Continence in 2000. An interest in multiple sclerosis and continence problems developed and a PhD was completed in 2006. A ClinicalSpecialist post in Continence followed and more recently a move to theNursing Midwifery and Allied Health Professions Research Unit at GlasgowCaledonian University has allowed her to further develop an interest inresearch and continence.

SATURDAY SESSION 2Understanding the neurologically unexplainedsymptoms

Dr Mike Dilley Consultant Neuropsychiatrist, CNWL NHS Foundation Trust andNational Hospital, Queens Square

AbstractUnexplained symptoms are commonplace in patients attend-ing neurology services. Practitioners are often at a loss as tohow to ‘explain the unexplained’, let alone develop treatmentstrategies and management plans that result in functionalimprovements. This lecture will introduce the concepts behindneurologically unexplained symptoms and provide some prac-tical advice about how to approach patients and answer theirquestions.

BiographyDr Mike Dilley trained at King’s College and completed his specialist trainingat The Maudsley Hospital, Institute of Psychiatry and National Hospital forNeurology & Neurosurgery. He continues to hold an Honorary ConsultantNeuropsychiatrist appointment at Queens Square and The Blackheath BrainInjury Rehabilitation Centre. He is a member of the Executive Committee ofthe Section of Neuropsychiatry, Royal College of Psychiatrists.



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Practical considerations for a physical rehabilitation approach to unexplained neurological symptoms

Sarah Edwards Highly Specialised Physiotherapist, National Hospital forNeurology and Neurosurgery

AbstractKey features of clinical presentation relevant to physiotherapy· Principles of assessment and treatment· Relevant outcome measures· Top management tips

BiographySarah Edwards qualified as a physiotherapist in 1999 from the University ofEast London. She has specialised in adult neurology for the past eight yearsand has been working as a senior physiotherapist at the National Hospital forNeurology and Neurosurgery, Queens Square, London for the last five years.Over the past two years she has worked as the lead physiotherapist for theneuropsychiatry service gaining extensive experience working with patientswith unexplained neurological symptoms.

SATURDAY SESSION 3Rehabilitation after stroke: how should it bedelivered?

Professor Louise Ada Associate Professor, University of Sydney

AbstractRehabilitation for the person after stroke involves labour-intensive treatment. Investigations in the 1980’s found thatpatients spent the majority of their day alone and inactive andthat therapy occupied a small percentage of the day.Disappointingly, the findings of recent investigations intophysical activity in rehabilitation units identified a similar sit-uation, ie, most of the time outside therapy was spent aloneand inactive while most physical activity occurred in the ther-apy area where patients spent only a small proportion of theday. These findings suggest that, currently, rehabilitation unitsdo not function as learning environments and that the therapyarea is an isolated area of physical activity. There is a need tointroduce interventions that will increase the amount of prac-tice undertaken because the amount of physical activityundertaken in rehabilitation has been shown to be related tooutcome. Furthermore, interventions should be implementedin a way that does not solely rely on increasing the numbers oftherapists.

BiographyLouise Ada is a physiotherapist who is an Associate Professor in the Disciplineof Physiotherapy at The University of Sydney with an interest in neurologicalrehabilitation. She is particularly interested in the relative contribution ofimpairments to disability as well as the efficacy of physiotherapy interven-tions and the design of environments to promote the active participation ofpeople undergoing rehabilitation.

SATURDAY SESSION 4Research trial: acute management of whiplash injuries

Professor Sallie Lamb Director, Warwick Clinical Trials Unit, Warwick Medical School

AbstractTo evaluate the effectiveness and cost-effectiveness of treat-ments used in the management of acute whiplash injuries.Methods: We recruited over 3000 participants from 16 emer-gency departments across England. Departments were randomised to provide either usual care advice or active management advice and a copy of the Whiplash Book.Participants who reported they were struggling to recover atthree weeks were randomised a second time to receive either asingle session of advice from a physiotherapist or up to six sessions of a physiotherapy package comprising manual therapy, exercise and advice. Participants were followed up for12 months, using a range of disease specific and generic healthoutcome measures. A cost evaluation and qualitative studywas run in parallel alongside the main trial.

ResultsThere was no difference in the outcomes between the advicepackages. The active management advice and whiplash bookcost more than usual care advice, without securing additionalclinical benefit. There was some evidence that the intensive physiotherapy package was associated with slightly largersymptomatic benefit at four months, but there was no impacton health related quality of life nor on longer term clinicaloutcomes. The intensive physiotherapy package was not costeffective at current levels of willingness to pay.

ConclusionsThis trial was commissioned by the NHS to determine theeffectiveness and cost-effectiveness of acute treatments forwhiplash. We will describe how trials are used to determinecost effectiveness for the NHS, and importantly, how we mightbuild on this work to design and deliver effective and cost-effective treatments for the management of whiplash inthe future.

BiographyProfessor Lamb qualified in 1986 from Salford School of Physiotherapy, andhas worked in the UK, Australia, New Zealand and the United States. She wasawarded an MSc in Rehabilitation with Distinction from SouthamptonUniversity in 1991, and a DPhil from Oxford University in 1998. She wasawarded a Harkness Fellowship in 1995 to study fall and disability preventionin older people in the United States of America. She is a member of theChartered Society of Physiotherapy and a Fellow of the Royal StatisticalSociety. Her current position at the University of Warwick is that of Director ofthe Clinical Trials Unit and Professor of Rehabilitation. In addition she holdsthe Kadoorie Professorship of Trauma Rehabilitation at the University ofOxford. She was awarded a National Institute of Health Research SeniorInvestigator Award in 2008 in recognition of outstanding contributions topatient centred research in the National Health Service. Professor Lamb'sresearch intrests span clinical trials methodology, with particular applicationin gerontology, musculo-skeletal sciences, physiotherapy and more latterly,critical and emergency healthcare.


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A clinician's guide to the ins and outs and highs and lows of doing research

Dr Sarah Tyson Senior Research Fellow, Centre for Rehabilitation and Human Performance, University of Salford

AbstractWith the advent of Best Research for Best Health leading toThe Government’s focus on applied clinical research anddevelopment of the National Institute for Health Research,there has never been more opportunity for physiotherapiststo get involved in research.

This presentation will consider how you can get involved,from dipping one’s toe to pushing back the frontiers of science. It will consider the political context, the whys andwherefores and give topical tips, handy hints and adversityavoidance strategies.

BiographyDr Sarah Tyson is a physiotherapist and Senior Research Fellow in theCentre for Rehabilitation and Human Performance Research and thePhysiotherapy Directorate at the University of Salford where she leadsresearch programmes into clinical outcome measures and postural controland mobility problems in neurological conditions. She uses a wide rangeof methodologies to develop new measurement tools, explore the use ofmeasurement tools in clinical practice, characterise and understandpatients' postural control and mobility problems, evaluate the effective-ness of physiotherapy and assistive devices and develop novel interven-tions and measurement tools. She has over fifty peer-reviewedpublications and has received over £2.5 million in research funding fromthe Department of Health, research councils, medical charities and professional bodies. Outside the University, Sarah is President-elect for theSociety of Research in Rehabilitation, President of the PhysiotherapyResearch Society and Chair of the North West Stroke Research Network'sSteering Group, an associate faculty member of the National Institute ofHealth Research and works closely with the Greater Manchester Cardiacand Stroke Clinical Services Network to re-design and improve strokeservices.

What/who have been key influences on your clinical practice?

Obviously being taught by Janet Carrand Roberta Shepherd and workingwith them for 20 years has been a biginfluence on my career.

They taught me to questionassumptions and test hypotheses.They also inspired my love for train-ing patients and teaching physio-therapists.

How has neuro physiotherapychanged since you first qualified?

The major change is the incorpora-tion of movement science into thetheoretical framework underlyingphysiotherapy. No longer is ourintervention based solely on neuro-physiological concepts, but includesa wide range of other relevant sciences, such as biomechanics,motor learning, muscle biology, andcognitive psychology. The process ofderiving clinical implications fromresearch has provided us with inter-ventions which can be tested in randomised controlled trials andmore recently, evidence based practice has come to the fore.Science- and evidence-based neurological physiotherapy is nowthe norm.

If you were to give a physio onesmall piece of advice…

I have two!1. Develop skill in analysing the

contribution of impairments todisability so that your interventionis most likely to be effective.

2. Develop the attribute of perseverance. There are no quickmagic cures in neurological physiotherapy.

What research has the potentialfor the greatest clinical impact?

Research that has the potential tochange our fundamental assump-tions, such as the research done overthe past few decades that challengedthe assumption that spasticity wasthe major determinant of physicaldisability which paved the way toincrease the focus on strength andtask training.

What do you think the futureholds?

Firstly, more sharing of ideas andresources. For example, every country,if not every state, seems to be devel-oping clinical practice guidelines. This is an incredible amount of dupli-cation which seems unnecessary giventhe current ability to share informa-tion using the internet. It is to behoped that the scope and availabilityof online resources (such aswww.physiotherapyexercises.com – afree website developed by physiother-apists in Sydney for assisting physio-therapy students, physiotherapistsand patients) will be expanded.

Second, further development andtesting of technology designed toenhance intervention, such as neu-roprostheses, robotic therapy andcomputer games used to encouragephysical activity.

What would be on your wish listfor the future?

To walk into any neurologicaltherapy area and see every patientpracticing.

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Developing Stroke Research inWales: the OPAN Stroke ResearchInterest Group

Dr Allison Cooper Stroke Research PortfolioDevelopment Fellow

Research should be an integral part of allstroke services to help develop the evidencebase for the ongoing benefit of staff andpatients, yet participation in stroke research islow in Wales. A key objective of the OlderPeople & Ageing Research & DevelopmentNetwork (OPAN Cymru), one of the ThematicResearch Networks within the ClinicalResearch Collaboration Cymru (CRC Cymru), isto develop stroke research in Wales. The OPANStroke Research Interest Group (SRIG) hasbeen set up to address this priority.

The SRIG brings together a multidisciplinary teamof stroke practitioners from NHS Wales and aca-demic researchers from Swansea, Cardiff, Bangorand Glamorgan universities. The first full meetingtook place in Cardiff on 19th April 2007. The SRIGmeets three times per year. A web presence for theSRIG has been built into the existing OPAN website: www.opanwales.org.uk and a regular emailbulletin is distributed to anyone who is interestedin research with details of funding sources,research training, conferences and the latest published research (to join the email distributionlist send your details to the SRIG coordinator,Christine Stock at: [email protected] or telephone 01792 513269.)

The key aim of the SRIG is to increase researchcapacity in Wales by:• Enhancing the quality and volume of research• Improving the integration of policy, practice and

research around stroke care• Improving the coordination of research both

across and within health, social care and clinicalspecialisms

• Strengthening research collaborations acrossand within sectorsThere is a close relationship between the SRIG

and the Welsh Stroke Alliance (WSA), a multidisci-

plinary alliance of stroke professionals in Walesthat serves as a reference group to the WelshAssembly Government Stroke ServicesImprovement Programme Project. This relation-ship aims to ensure that there are strong linksbetween stroke research and the developments instroke policy and practice in Wales.

Wales is involved in a number of national stroketrials, for example, ENOS, Stroke-INF, LoTS-Care,AVERT, CADISS, CARS, SOS, CLOTS, IST3, andVITATOPS. More details on these studies can befound on the UK Stroke Research Network(UKSRN) web site www.uksrn.ac.uk. Practitionersand researchers in Wales are actively engagingwith further national trials and these discussionswill result in additions to the current portfolio. Theportfolio is now supported by CRC CymruResearch Professional Network Clinical StudiesOfficers and Research Nurses who assist withpatient and carer recruitment and follow up.

A number of Research Development Groups(RDGs) have been established by the SRIG todevelop clinical research questions related tostroke care into funding submissions. These RDGscover topics related to post-stroke shoulder pain,benchmarking to improve knowledge translation,screening for depression and anxiety post-stroke,measurement of patient activity in hospital reha-bilitation environments and stroke patients’experiences of transitions from hospital to com-munity based rehabilitation. Opportunities to formmore RDGs are available as it is important thatWales increases home-grown research studies,and builds collaborative working relationshipswith the UKSRN Clinical Studies Groups (CSGs) inEngland.

The SRIG has been successful in three fundingapplications:

1. ARRREST – Action Research to ReduceRepetition of Stroke, PhD studentship funded byWales Office of Research & Development(WORD),2. Stroke Research Portfolio Development Fellowpost, jointly funded by The Stroke Associationand WORD, and3. A realistic synthesis of integrated health andsocial care funded by WORD.In 2008, Dr Allison Cooper joined OPAN as

Stroke Research Portfolio Development Fellow.Based at Swansea University and jointly funded by

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the Stroke Association and WORD, this post isdesigned to build stroke research capacity inWales. Allison works specifically with the SRIG tofacilitate the development and submission of highquality collaborative clinical research proposalsinformed by the group’s research priorities as wellas linking with the UK Stroke Research Networkto enhance Welsh involvement in multicentrestroke studies and continuing to develop hercareer as a stroke researcher. Until starting thispost Allison was a clinical specialist physiothera-pist in Gwent Healthcare NHS Trust where shespecialised in neurological, stroke and vestibularrehabilitation for over 20 years. Allison completedher PhD at the School of Healthcare Studies,Cardiff University in 2006 supported by a WORDpersonal bursary. Her research aimed to furtherknowledge of the nature of neurological impair-ments following stroke, in particular, those relatedto the causes of muscle weakness, the relationshipof spasticity and muscle contracture and muscleactivation patterns during gait. Her researchinterests continue in the field of gait patterns andmuscle weakness following stroke and also intothe causes and prevention of post-stroke shoulderpain.

Allison would be interested in talking to anybodywithin Wales who has a research idea that theywould like to develop or to anybody within oroutside Wales who is interested in collaborating todevelop stroke research. She can be contacted [email protected] or telephone07717 576108.

Programme manager for All Wales Stroke ServicesImprovement Collaborative

Michelle Price

I am currently the programme manager of theAll Wales Stroke Services ImprovementCollaborative (AWSSIC). It is a twelve monthprogramme, led by National Leadership andInnovation Agency for Healthcare (NLIAH),focussed on improving the reliability of caredelivered to stroke patients in the first sevendays following stroke by introducing carebundles. I have been seconded to NLIAH fortwelve months from my substantive post asClinical Specialist Physiotherapist in the NeuroInflammatory Team for South West Wales.

The collaborative is one work stream of the over-arching Stroke Services Improvement Programme(SSIP), being delivered in partnership by theNational Public Health Service (NPHS), WelshCentre for Health (WCfH) and NLIAH.

The AWSSIC is based on the Institute ofHealthcare Improvement Breakthrough SeriesModel. Fourteen multidisciplinary teams repre-senting the 18 acute stroke services in Wales havebeen involved.

The collaborative was launched in November2007 at the first learning session. Teams wereintroduced to four care bundles. These are:• First Hours Bundle – rapid recognition of symp-

toms and diagnosis within three hours.• First Day Bundle – Emergency treatment for

people with stroke within 24 hours.• First Three Days Bundle – Early mobilisation

following stroke – within three days.• First Seven Days Bundle – Patient centred and

goal orientated specialist care following stroke –within seven days.There are between three and five specific inter-

ventions in each bundle, which largely map to thestandards of care set out in the RCP and NICEGuidelines. To achieve compliance with the bundlea patient must receive all of the interventions inthe bundle in the appropriate timeframe.

Teams were also introduced to service improve-ment methodology and a data tool that had beendeveloped to allow teams to monitor their per-formance against these bundles on a patient,weekly and monthly basis and inform and eval-uate any service developments.

There have been three Wales wide events overthe past nine months to enable teams to sharewhat they have achieved and learn from eachothers experiences.

By July 2009 all acute stroke sites had startedcollecting prospective data on every stroke patientadmitted hospital. Twelve teams are using AWSSICdata tool. Nine teams have almost completedatasets. Ten teams have completed at least onetest of change. One team have tested and imple-mented over ten small changes which they havebeen able to show have improved the reliability ofpatient care.

My role as programme manager entails sup-porting all of the teams and facilitating thesharing of learning and service developmentthrough:• monthly site visits,• bimonthly meetings for those designated as

project leads for each team,• bimonthly telephone conferences,• maintaining an intranet site to enable teams to

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programmes that have been developed.I have been overwhelmed by the enthusiasm and

commitment of all the clinicians involved in acutestroke care in Wales. The collaborative has pro-vided a focus for service improvement andprovided a framework for clinicians to identifywhich aspects of the care they provide they needto address and evaluate the impact of the changesthey make. It has helped improve communicationwithin and between multidisciplinary teams, andhas led to service improvements being made morequickly than if the teams were all working inde-pendently.

It has been fascinating to see how once a teamstart collecting prospective data and are able tosee the shortcomings in the care they deliver, howresourceful they can be in developing and imple-menting improvements.

My broad clinical experience in neurosciencesfrom acute neurosurgery to community rehabilita-tion and long term support in the UK and abroadhas helped me understand the challenges faced bythe project leads and teams and facilitate some ofthe solutions. I feel privileged to have beeninvolved and have learnt so much about serviceimprovement methodology that will be transfer-able into any future roles I may have.

Neuronet-working

An informal group comprising of academicsand clinical staff was formed in October 2007.

The following objectives for the group were established:• To generate themes and priorities for research,• To develop collaborative teams,• To share expertise,• To disseminate information,• To provide a mechanism for communication,

such as email, video conferencing to facilitatecollaboration.Meetings are held monthly at Cardiff University.

Academic staff and former MSc students have pre-sented their research on topics, such as, corestability, FES, strength training, shoulder pain andclinical research priorities. It is hoped that a webpage will be established in 2009 to facilitatefurther links with clinicians in other parts ofWales.


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COURSES

Are the arms and legsconnected during locomotion?26th May 2009

A course led by Pam LoadmanResearch Associate at theRehabilitation NeuroscienceLaboratory, University of Victoria,Canada and a Clinical Specialist forthe Outpatient NeurologicalRehabilitation programme

Review by Charlie DorerEast Anglia ACPIN

On the 26th May, Pam Loadman gavea fascinating talk, based on her MScthat examined the potential neuralmechanisms of control in neurologi-cally intact individuals during rhyth-mical, automatic movement. It wasdiscussed whether humans mightmaintain similar residual interlimbco-ordination seen in quadrupedsduring locomotion and if there wasany potential to access these mecha-nisms in a clinical setting.

Pam used the H-reflex to see ifspecificity existed in interlimb SoleusH-reflex modulation during armcycling. It was found that rhythmicmovement of the arms created a rel-atively non-specific signal of gener-alised activity that was transferred to

Welsh StrokeConference 2009The 8th Welsh Stroke conferencewas held at the Riverfront Centrein Newport South Wales on 19thJune 2009

Review by Adelle Griffiths

The atmosphere of the conferencewas buoyant following a year ofinvestment, training and collabora-tive working in Welsh Services whichhas seen new posts and a commit-ment to new ways of working withstakeholders from a wide variety ofbackgrounds committed to improv-ing the journeys and outcome of thestroke population.

The morning session, From Benchto Bedside opened with ProfessorSteve Dunnett, director of the BrainRepair group at Cardiff Universitypresenting functional cell transplan-tation and emerging stem cell andgene therapy technologies.

Dr Michel of Lausanne UniversityHospital presented the Swiss model ofstate of the art management of acutestrokes. He showed how the highlevel of service organisation allows foradmission to thrombolysis time to be

thirty minutes and how the use ofhelicopters has increased thromboly-sis rates by 15%. Dr Michel advocatedthe use of telemedicine technology toenable a medic to assess patients intransit and spoke about the benefitsof using endovascular treatmentsboth in isolation and in combinationwith thrombolysis. Dr Michel spoke inpraise of the recent improvements inWelsh Services and emphasised thatthere are greater benefits to the strokepopulation from having high qualitybasic stroke care than from thrombolysis.

Dr Mark Bayley, Medical Director ofthe neurorehabilitation programmeat the Toronto Rehabilitation Institutespoke about the challenge of imple-menting research into practise andhis aim of providing a map for trans-lating knowledge into practise. DrBayley is currently a principle investi-gator on the Canadian StrokeNetwork SCORE trial (Stroke CanadaOptimisation of Rehabilitation byEvidence) and the Getting on withlife after Stroke trial. He spoke aboutsimple and achievable ways of get-ting rehabilitation messages acrosssuch as the use of publicity,reminders, pocket cards and bags forpatient equipment.

the leg muscles. The modulation ofthe H reflex was not phase depend-ent or related to the locus of move-ment, but higher frequencies andlarger excursions of the arms pro-duced a greater suppression of thereflex.

Mechanisms that control thisinterlimb reflex modulation are notfully understood but there is likely tobe a CPG component, as it is taskdependent and changes in rhythmlead to changes in its suppression.This could have important clinicalrelevance for physiotherapists facili-tating locomotion in that:1. Accessing automatic rhythmicity

of locomotion is likely to be important.

2. The arms are connected neurologi-cally to the legs when movingrhythmically.

3. The frequency and the size of therhythmic arm are important tomodulate leg neural circuitry.

This piece of research is likely to leadon to looking at what happens whenthe arms and legs are movingtogether and if similar results occur inpeople post stroke or SCI.

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.

The second session Achievingexcellence in service delivery openedwith a moving account from MrGeorge Smedley of his journeythrough Welsh Stroke Services, asobering story which cannot havefailed to touch every delegate at theconference and spur them to work todeliver a world class service in Wales.

Dr Damian Jenkins then took thefloor, describing the challenges ofredesigning stroke services and theimportance of clinical networks, DrJonathan Mant spoke about the roleof primary care in developing strokeservices and the importance of longterm support.

The annual Bhomick BursaryPresentation was an entertainingshowcase of an e-referral system thathas been introduced in Cardiff. TheBhomick Lecture was delivered byProfessor Marie Germaine Bousserwhose inspiring story telling left uswith the message that we can learnsomething from every patient.

Following an excellent lunch andan opportunity to view the thirtyposter presentations, the conferencedivided for the afternoon sessions.The medical programme focussedupon the management of hyperten-sion. The rehabilitation programme

opened with Professor Steven Wolf,presenting the implications of theEXCITE trial. Dr Jeremy Tree, discussedthe links between aphasia researchand practise, Professor Anthony Wardgave a clear update of the currentevidence for the use of BotulinumToxin in Stroke Rehabilitation.

The conference was brought to aclose with Dr Paulette van Vliet pre-senting evidence for the use ofextrinsic feedback for motor learningafter stroke. She showed that the aimof using feedback was to increase thelevel of skill achieved, speed uplearning, to sustain motivation andimprove skill mastery. Dr van Vlietemphasised the importance of givingspecific verbal feedback on perform-ance and consideration of internallyfocussed instructions versus exter-nally focussed instructions. The takehome messages were to ‘focus on thefocus’ and that it ‘is better to be sci-entific rather than subliminal aboutour feedback”.

The conference was sold out anddelivered a varied and interestingprogramme, we can now look for-ward to next years’ conference whenwe should be able to see the impactof the collaborative working groupsupon Welsh Stroke services.



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COURSES (CONTINUED)

Classic Pilates ClinicalApplication forNeurological patientsSussex ACPIN study day, 20th June 2009

A course led by Jo Gilmore, classical pilates instructor inadvanced mat work and senior neurophysiotherapist

Reviewed by Gemma Alder SeniorNeurophysiotherapist, Lilac StrokeRehabilitation Unit SouthlandsHospital Western Sussex andSussexACPIN regional representative

Jo Gilmore has been qualified as aClassical Pilates Tutor for the past fiveyears and has a particular interest inhow the Classical Pilates Concept canbe transferred to clients with a neu-rological dysfunction.

Pilates is a complete exercisemethod developed by Joseph Pilatesover the course of a lifetime dedi-cated to improving physical andmental health. Pilates focuses onbuilding your body’s core strengthand improving your posture througha series of low impact stretching andconditioning exercises.

The objective of the study day wasto challenge the participants under-standing of core stability, to takeaway the important concepts in thetraining of core stability and howthese concepts can be transferredinto clinical practice.

The format of this study dayincluded a suitable balance of boththeoretical and practical components.The practical component gave partici-pants the opportunity to experienceClassical Pilates themselves whichresulted in a more informed idea ofhow to facilitate this approach withclients with neurological dysfunction.The study day was well received withpositive feedback from all participants.

Jo says that ‘Pilates from a physio-therapeutic perspective could bedescribed as a system which trainsmovement in multiple synergisticpatterns that can assist in developingcontrol and coordination, improvealignment, address stability withmobility and can result in effort withease’.

The morning lecture concentratedon the ‘Theory behind the JosephPilates Concept’ followed by a practi-cal session where participantsanalysed core stability, alignmentand practised the facilitation of coremuscles.

Throughout the morning partici-pants were encouraged to review thefactors that cause problems with sta-bility in neurological dysfunctionsuch as disturbances of feedback/feedforward mechanisms, posturalcontrol mechanisms, tonal changes,posture and local changes to musclesin order to begin to formulate someideas that could be brought intoclinical practice.

The afternoon consisted again ofboth theory and practical lectureswhich focused on clinical applica-tion. Jo outlined how Pilates can beused as an adjunct to treatment or asan integral component of rehabilita-tion. This was complemented wellwith previous case studies thatdemonstrated how Pilates can assistin managing long term pain anddysfunction.

Appropriate clientele were dis-cussed and what adaptations wouldbe required to implement thisapproach affectively into the clinicalsetting. Jo continued to facilitate dis-cussion about the use of various pos-tural sets used in core stabilitytraining and how and when to con-sider progression. The day closedwith practical mat class for the group.

This course was beneficial forphysiotherapists working in a varietyof neuro fields with clients that havevarious functional abilities. The tutorand the structure of the programmeenabled an interactive day whichwas particularly well facilitated pro-viding plenty of food for thought.

As neurophysiotherapists we areconcerned with developing treat-ment plans which challenge ourclients postural control and increasetheir body awareness in order toenhance their functional independ-ence. This course provided me with anew treatment intervention that Ilook forward to implementing in myeveryday clinical practice.

Outcome measuresSurrey and Borders ACPIN study day,29th February 2009, PostgraduateMedical Centre at the Royal SurreyCounty Hospital, Guildford

Review by Emma Jones, ACPINcommittee member

The Outcome Measure Study wasorganised by Surrey and BordersACPIN Committee and was attendedby members from here and neigh-bouring ACPIN regions.

The day comprised of three spe-cialist guest speakers within the fieldof outcome measures. Dr Sara Tyson,Senior Research Fellow from theUniversity of Salford, Dr Sara Demainfrom the University of Southamptonand Dr Paula Kersten, Senior Lecturerat the University of Southampton.The format of the day involved lec-tures and study workshops todemonstrate both the theoreticaland practical application of usingphysiotherapy related outcomemeasures.

The study day commenced with alecture by Dr Sara Tyson on UsingRobust outcome measures in neuro-logical physiotherapy. This was anintroductory lecture into the topic ofoutcome measures, in particular whyoutcome measures are importantclinically, the different type of meas-ures to use and how we make thedecision of what we use and why.She also effectively dispelled themisconception that one measure issuitable for all and how we need a‘basket of measuring tools’ to coverall aspects of the physiotherapyassessment and treatment process.

Dr Sara Demain presented a lectureon Not everything that counts can bemeasured. This explored the qualita-tive aspects of using measurementtools. In particular discussing theimportance of how you may not beable to measure everything that isconsidered important within yourassessment. It was identified thatthese factors still need to be consid-ered as part of your managementplan as these may have influenceson the outcome of your intervention.This was discussed with reference toher recent research project.

The half day was concluded by alecture from Dr Paula Kersten onChoosing a valid measure and fol-lowed with practical workshops. Thisdiscussed considering the psychome-tric properties of outcome measuresand in particular the influences ofvalidity and reliability on ensuringappropriate and clinically soundconclusions are drawn. This wasrelated clinically to three commonlyused measures, The Barthel Index,the Functional Reach Test and Timed10 metre walk. This prompted dis-cussion within groups particularlythrough the variations between howoutcome measures were undertakenand interpreted. The importance ofunderstanding and correctly per-forming various measures wasstressed.

Feedback from the day identifiedthe course was good value for moneyand a success being run as a half day.Respondents also felt the informa-tion disseminated was clinically rele-vant, thought provoking and had agood balance between theoreticaland interactive practical sessions.


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East Anglia Nic Hills

2009 thus far has continued to besuccessful for East Anglia ACPIN. Thecommittee now has a good repre-sentation from across the region,thanks to Anna Farr, Charlie Dorerand a pool of members fromAddenbrookes joining the team. Ourmembership numbers haveremained high and this has seen ourcourses well attended and often oversubscribed.

Our programme so far has been:• February – Neuro-pilates study day.• May – Cognition and Memory study

afternoon combined with the AGM.• May –Evening lecture Do legs and

arms work together in locomotion?• September – Neuro-pilates study

day (re-ran due to populardemand).

Provisional programme for 2010• March – Balance course with Helen

Lindfield, Bobath Tutor at IpswichHospital.

• May – AGM with lectures from localexperts (title to be confirmed).

We would like to run another neuro-pilates study day, if anyone is inter-ested in running or attending thecourse please get in touch with me.

As ever, we like to hear what youas members would like to see in theEast Anglia ACPIN programme, so ifyou have any suggestions pleasecontact me. I look forward to seeingyou at our courses in 2010!

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.

Following our successful AGM lec-ture on neurolinguistic programming,we planned a follow-up workshopfor June but unfortunately we did notreceive enough applicants to make

this viable so we plan to re-schedulethe event for January 2010.

Our next study day will be TheBrain Gym which will be held onSaturday 14th November at the Kentand Canterbury Hospital and lunchwill be sponsored by Allergan.

The forthcoming programme willhopefully include a study day onpilates in neurology linked with theAGM in March 2010.

Any ideas from members for futurecourses are always welcome.

LondonAndrea Stennett

This is my first report as Regional Repfor London ACPIN, having succeededLeigh Forsyth in January 2009.

The Committee would like to takethis opportunity to say thanks toboth Leigh Forsyth and Dr GitaRamdharry for their invaluable con-tribution to London ACPIN, and wishthem all the best in their futureendeavours. We also would like towelcome the new committee mem-bers and Trudy-Ann Sinclair in hernew role as secretary.

So far this year we have had someexciting lectures. Dr Fiona Jones kickstarted the year in January withupdates on Self-efficacy followed byour AGM. May and June were quitebusy with Dr Emma Stack presentingon The Early Management ofParkinson’s Disease. Remember youcan get a free copy of theProfessional’s Guide to Parkinson’sDisease from the Parkinson DiseaseSociety. In June we teamed up withthe National Physiotherapy ResearchNetwork (NPRN) to host another suc-cessful event on the Management ofSpasticity. We received presentationsfrom Steve Ashford, Dr Amiee Pintoand Professor John Marsden.

In September there was anevening lecture on CognitiveBehavioural Therapy with Dr DiThompson followed by our annualwine and cheese reception!

The final event of the year will beheld in November, which will show-

case new research being done byphysiotherapists in our region.Application forms for all courses maybe found in the London Region partof the main ACPIN website.

We have been working very hardon the 2010 lecture programmes andjust to give you a sneak preview; wewill be hosting a study day inSeptember 2010 with AnneShumway- Cook! So keep checkingFrontline, iCSP or the ACPIN website(www. acpin.net) for updates.

Thank you for your continued sup-port to both our evening lectures andstudy mornings. Our lectures havebeen very successful which keeps ourbank balance quite healthy. As such,we have made an effort to keep thelectures at an affordable rate despitethis period of economic downturn.Additionally, we have launched anew initiative: ‘The London ACPINInternational Lecture Fund’. This wasset up to provide funding exclusivelyfor London ACPIN members who wishto present at international confer-ences. For more information pleasesee www.acpin.net under theLondon Region link.

As usual, if you wish to contact usdirectly or if you have any ideasabout future courses that you wouldlike us to organise please email us [email protected]

We look forward to working withyou over the upcoming months.

North TrentAnna Wilkinson

The new North Trent ACPIN committeehave met several times and since thesuccess of our evening lecture inFebruary we now hope to get therecently dormant North Trent back tolife a little again! I would like tothank the previous committee for alltheir hard work over several yearsand also to Emma Procter for steppingin temporarily as chair-person untilwe find another willing volunteer!

We are finishing the year with twolectures – one on October 27th withDr Tungland (Audiovestibular

Physician) speaking on a simplemodel of balance in relation tovestibular rehabilitation. We arehoping this will lead us into a 2008lecture on vestibular rehabilitationtreatment. On 9th December wewelcome Liz Mackay back to lectureat Sheffield Hallam University onPushing Syndrome – where to gowhen nothing seems possible.Hopefully, these two lectures willhelp end this year on a good note.

We are busy planning next year’sprogramme. If anyone has any ideasor events that they would like to seerun please let us know – contactdetails are on the website.

Northern IrelandJoanne Wrigglesworth

NI ACPIN continues as a successfuland thriving Clinical Interest Groupbranch. We have launched our 2009 /10 programme with ourNeurological Assessment workshop,which has become a fixture and fit-ting, kick starting everyone’s learningfor the year! NI ACPIN continues toprovide a monthly evening work-shop, with variable topics, bothpractical and theoretical.

The programme this year will becovering treadmill training, seatingand pressure mapping for patientswith neurological deficit, falls andbalance re-education and neuro-pathic pain. Practical workshops onairway clearance with cough assistequipment and a gym ball class arejust some of the spring highlights.

The NI ACPIN committee have beenconsidering organising a one or twoday course in 2010. Any topic sugges-tions would be received and consid-ered with thanks.

As always, the committee wouldlike to thank you all for the on goingsupport and attendance at the ACPINevents and we look forward to see-ing you all over the coming months.

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NorthernCatherine Birkett

Here in the Northern Region we havehad a few changes in our committee.We owe a huge debt of gratitude toPam Thirlwell, Alex Haugh and VickiGilman who have recently steppeddown after years of dedicated serviceand we wish them well. Naturally,this means we would welcome newcommittee members to come andjoin us. No experience necessary –just an interest in neurology andenthusiasm!

So far we are enjoying the year andfollowing feedback from our membershave tried to vary our programme toinclude a mix of weekend courses,evening lectures with discussion andweekday afternoon updates. So farthis has been well received. Our mostrecent events have included anevening lecture by Dr Eldabe onintrathecal baclofen at James CookUniversity Hospital. A Spasticity Updateafternoon given by Dr Macfarlane andSandra Stark at Walkergate Park forNeurorehabilitation, and a weekendcourse on Musculoskeletal techniquesin Neurology provided by LauraFinucane and Helen Lindfield andhosted by Chester-le-StreetCommunity Hospital. Thank you to allevent organisers and venues, and toour members for making these eventssuch a success.

Our programme for later this year isset to include AAPI Mat Level OnePilates for physiotherapists onSeptember 18th and 19th, and anevening of Outcome MeasureExchange in November. So far for2010 we are looking forward to aprogramme which includes PosturalControl with Linzi Meadows in March,Vestibular Rehabilitation and threeIntroductory Bobath Weekends. Wewelcome all feedback and sugges-tions from our membership and weare keen to know what events youwould like us to provide. All eventsare advertised by newletter and flyerto our membership and in Frontline,or you can find details on theNorthern Region page atwww.acpin.net

OxfordSophie Gwilym

At the time of writing (in a gorgeouslate blast of sunshine) theAutumn/Winter programme is stillbeing finalised. Over the past fewmonths we have enjoyed an inter-esting update from Professor Kischkaon spasticity and Professor Wade isdue to speak to us about neurologi-cal outcome measures. We are grateful to the therapists at StokeMandeville Hospital who rananother of their popular SCI work-shops earlier in the summer.

A big thank you to our memberswho continue to support our eveninglectures in good numbers, we arelooking forward to seeing you againafter our summer break.

We would welcome new commit-tee members, ideas or suggestions forfuture events. Please contact anymember of the committee directly oruse the email address [email protected]

ScotlandDorothy Bowman

We would like to thank ,JulieMcdonald who has retired as treas-urer and Lynn Haughy who hasretired as membership secretary fortheir contributions to the committeeand ACPIN Scotland. Welcome tonew members of the committee.

We have had several successfulcourses this year which have beenwell attended with good feedback.We always welcome new ideas andsuggestion. We try and ensure a geo-graphical spread of courses but obvi-ously covering such a huge area thisis difficult. If you would like to hosta course or are feeling left out let usknow!

Programme 2009/2010• November 21st 2009 Lower Limb

rehabilitation in patients with aneurological deficit Helen Lindfield(Bobath Tutor Raigmore HospitalInverness.

• January/February 2010 Rescheduledcourse. Orthotic management ofthe Lower Limb Ray BowersGlasgow tbc

• June 23rd-25th 2010 MuscleImbalance in the NeurologicalPatient Sarah Mottram (KineticControl), Woodend Hospital,Aberdeen.

Thank you to all members for theircontinued support of ACPIN.

South TrentBecky Sammut

Welcome to our new members and abig hello to our existing members. Overthe past 18 months we have dwindledin regular attenders to the South Trentcommittee meetings. However, wehave recently recruited several newfaces and have representatives fromboth the Derby and Nottingham trustsnow and we look forward to providinga more action packed programme dur-ing the remaining 2009 and into 2010.We would really like to welcome newfaces to the committee, particularlyfrom other counties such asLeicestershire and Lincolnshire soplease drop me a line or email if youwould like any further details. Werotate the location of meetings to helpout with travelling.

We must say a huge thank you toour retiring minutes secretary KatePattinson for all her hard work andsupport.

We have run two evening lecturesover the summer months, IntrathecalBaclofen and the Role of thePhysiotherapist and Caloric Stimulation.Both evenings were well attended andprovided a great forum for discussion.We are very grateful to our speakersNatalie Gray and Ruth Sturt.

Please do not hesitate to contactme if you require any further infor-mation on upcoming events, becom-ing part of the committee team or ifyou have an idea for a lecture, course or speaker that youwould like us to organise.

Remaining programme for 2009• 14th/15th November 2009 Ataxia

Lynne Fletcher, NottinghamUniversity Hospital, City Campus.

Forthcoming Programme for 2010• 20th/21st February 2010 The Upper

Limb with a focus on the ScapulaClare Fraser, venue to be confirmed.

South WestKaty Moss

South West ACPIN has continued toremain an active group over thesummer season. We have held a suc-cessful study day on stroke guidelinescombined with an AGM whichattracted some new committeemembers. We have also held studydays and evening lectures on neu-roanatomy and an evening talk onthe use of dynamic orthoses in themanagement of ataxia incorporatinga summer social. Further coursesplanned include motivational inter-viewing and a balance after trau-matic brain injury study day. Courseswill be advertised via the ACPINwebsite www.acpin.net

Changes to committee membersincluding a change of chair andregional representative are plannedfor the autumn/winter season.

If anyone wishes to be involvedwith the ACPIN committee or hasideas/suggestions for courses pleasecontact [email protected]

Surrey and BordersKate Moffatt

Our membership remains healthyand I hope you have enjoyed thisyear’s programme so far. Moreregional members and committeemembers are always welcome!

As you may be aware, due tomembers’ feedback at last yearsAGM, we reduced the number ofevening lectures and trialed twohalf-day study days; OutcomeMeasures and FOTT. We have also hada recent evening lecture onAcupuncture in Neurology given byVal Hopwood, proving very popular.

Surrey and Borders ACPIN nowhope to provide at least five eventsper year, varying the venuesbetween RSCH, Farnham, FrimleyPark Hospital and WokingCommunity Hospital.

Forthcoming programme• November 2009 Pain of neurologi-

cal Origin Dr Markham (TBC).• February 2010 MS research project

feedback and the AGM.• April 2010 Further update by Sara

Demain re: Discharge from physio-


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therapy stroke services (TBC).• June 2010- Specialist Seating in the

Developing World DavidConstantine (TBC).

• September 2010 Gym Ball StudyDay (TBC).

• November 2010 Mental Rehearsal(TBC).

If you have further suggestions offuture lectures or courses please donot hesitate to contact me. Pleasecheck Frontline and iCSP for updateson our future programme.

SussexGemma Alder

There has been a few changes madeto the committee this year. We saidgoodbye to Margret Hewett and ClareHall as they stepped down as chairperson and regional rep. On behalfof Sussex ACPIN we would like tothank them for all their hard workand contributions to the regionalcommittee. We were delighted thatone of our proactive committeemembers Nora Bessant agreed to beour new chair. I have had an excitingtime as 2009 was my first year asregional rep.

By the time you receive yourautumn Synapse we will have com-pleted our course programme for2009. We have had an inspiring yearwith a variety of study days andevening lectures.

In February we held our AGM andMultiple Sclerosis Study Day onPostural and gait re-education. Thisincluded presentations from a MSspecialist nurse, two clinical special-ist physiotherapists in neurology,and two patient perspectives. Thiswas a fantastic day which wasextremely useful for furthering theaudience’s knowledge of MS.

In May we had an evening lectureon Understanding Impaired patientCognition within NeurologicalPhysiotherapy Treatment with MarkHawkes a senior occupational thera-pist in the community stroke setting.We had an excellent turn out – oneof our most successfully evening lec-tures so far. It certainly provided uswith a structure to work with withinphysiotherapy assessment and treat-ment. It also prompted some inter-

esting discussion regarding multi-disciplinary working and cognition.

In June we were thrilled that JoGilmore MCSP, Classical PilatesInstructor returned for a sequel afterinterest from the course she ran in2008. Again this was a very successfulday with very positive feedback fromparticipants and yet again Jo pro-vided us with some fresh treatmentideas to use with our clients withneurological dysfunction. To readmore about The Pilates Study Day –Clinical Application for theNeurological Patients refer to thisissue of Synapse under CourseReviews.

In September we held anotherevening lecture with Martin D vanden Broek who suggests that moti-vational interviewing may help thepatient to recognise the importanceof making psychological adjustmentsand practical adaptations.Subsequently the patient may beable to develop confidence in theirability to adjust and adapt to realisticgoals for their recovery. This was avery interesting and useful lecture.

Finally in October we weredelighted that Geralidine MannSpecialist Physiotherapist in FES fromSalisbury Hospital agreed to comeand talk to us. The Study Day con-centrated on the Upper Limb and thecourse was designed to give atten-dees a feel (literally) of what FES islike. The theory behind stimulation,and the evidence for and adjuncts toupper limb FES was covered, plushalf a day of practical. A course thor-oughly enjoyed by all.

The Sussex Committee are gratefulto all of the programme speakers foreducating and enlightening us overthe last year.

We have a selection of other studydays in the pipeline for 2010. Moreinformation and confirmation ofthese courses will be available on thewebsite in the near future.

As always your thoughts and ideasare important to us. They really aidus in shaping the course format forthe following year. Please feel free tocontact myself or any of the commit-tee members to share your ideas.

ACPIN National Conferenceand AGM 2010

Northampton HiltonFriday 19th and Saturday 20th March

fitlife?for

exercise& neurology

Call for postersDo you have a piece of work relating to

exercise with neurological clients that youwould like to share with your colleagues?

A pilot study or audit perhaps? Are you planning to set up such a group and would welcome peer reviewto help with outcome measures or benchmarking? Are

you a post-graduate student or recently graduatedphysiotherapist who would like to share

the results of your dissertation?

Then this is the forum for you.

Posters will be displayed during the conference and a £50 prize awarded to the best as judged by a selected panel.

It really is not as daunting as you think and may help you achieve your KSF

requirements! Advice and support can be offered in the development of your

idea although ACPIN cannot print the posters themselves.

Please contact Julia Williamson(Hon research officer) via

[email protected]

for additionalinformation.

Deadline for expressions of interest: 11 January 2010



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YorkshireJill Fisher

Our committee have been very activethis year producing a busy and excit-ing programme including a largenumber of day courses. Thanks go toHeather Dunbar at this time of herresignation, for all she has con-tributed to Yorkshire ACPIN over thelast three years, the last two as Chair.

We have had a very good responsefrom Yorkshire members who volun-teered to be part of the nationalmapping project, thank you.

In April our AGM day included talksabout Lycra Splinting and SleepSystems. In May, Patrick Doherty gavea very interesting talk, althoughunfortunately under attended, relat-ing to carrying out physiotherapyresearch. Emma Greenfield, in June,gave a well received talk on themanagement of spasticity. In July, Dr Salawa talked on cognition andphysical activity. In SeptemberAmanda Stroud, clinical psychologist,will talk on strategies for physiother-apists in addressing cognitive prob-lems. In October Caroline Brown gaveus a botulinum toxin update.

Forthcoming ProgrammeIn early November a two dayhydrotherapy course will be held atPinderfields Hospital, and on the 21stof November there will be a day –‘Introduction to PosturalManagement’ supported by the MSsociety. On the 20th of March 2010Janice Champion will be leading a‘Gym Ball’ day, and on the 5th ofJune 2010 Lyn Fletcher will be leadinga Ataxia course to respond to themuch enjoyed and oversubscribedcourse held in March 2009.

WessexHayden Kirk

2009 has been a very active year forWessex ACPIN. The new committeehas settled in well and our member-ship rose to a healthy 72. This yearthe committee tried a programme offewer but more targeted evening lec-tures which seemed to have a goodresponse in terms of attendance andfeedback. Topics included MNDmanagement and research, familyand carer interactions, return todriving, hemiplegic shoulder path-ways, head injury management andupper limb FES. For courses we ran asplinting weekend and this year wehosted our first one-day conferenceon spasticity management. Thisproved a very popular day and waswell supported by all the professionswith 150 delegates coming fromacross the country (and Ireland).

In order to maintain the momen-tum from 2009 we have made anearly start with the programme andwould encourage members to look atthe Wessex region page of the ACPINwebsite as all courses, bursary detailsand application forms will now beposted and regularly updated on thissite.

Finally, the usual committee plea!As a committee we try to understandthe membership needs and providea strong and inclusive programme. Itcan however be hard to reach allcorners of the region so please con-tinue to put forward any suggestionsor ideas that you have, either byemail or through a local committeemember. If you are brimming withenthusiasm then why not join thecommittee, new members arealways welcome, age and experienceare no barrier.

West MidlandsKatherine Harrison

2009 has been a very successful yearso far for west midlands ACPIN.Committee membership remainsstrong as does the number of mem-bers throughout the region.

Our first course of the year was thevery successful Parkinson’s Diseasestudy day run at BirminghamUniversity. The course involvedinformative lectures on many differ-ent aspects in Parkinson’s includingrecent research projects and was verywell received by a full house ofattendees!

Mary Lynch, Bobath tutor, ran apractical based course over oneweekend which was again fully sub-scribed and very interesting.

More recently an evening lecturewas done by the GBS society (free toACPIN members). As the lecture wasdone my someone who had sufferedfrom GBS it gave a new perspectiveon the condition and proved a suc-cess with a very full lecture theatre.

The next course on the agenda isthe much anticipated weekend PNFcourse by Nikki Rochford. This coursehad to be cancelled last year so it hasfilled up quickly. Due to its popularitywe may try to run another coursenext year!

On the 7th and 8th of Novemberwe are running a practical basedcourse on cerebral palsy. The coursewill be done by Bobath tutor ChrisBarber and will focus on the transi-tion period from child to adult. Dueto the courses practical content placeswill be limited so look out for advertising via email or on the ACPINwebsite.

Finally for 2009 we are planningan evening lecture on MND byProfessor Morrisson at BirminghamUniversity. This will take place in thefirst week of December, more detailsto follow soon.

If you have any questions aboutany of the courses or ACPIN in thewest midlands please us on katherine.harrison @ heartofengland.nhs.uk

I would like to thank the westmidlands committee members fortheir all their hard work and thewest midlands members for theircontinued support.


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Synapse is the official peer-reviewedjournal of the Association of CharteredPhysiotherapists in Neurology (ACPIN).Synapse aims to provide a forum forpublications that are interesting,informative and encourage debate inneurological physiotherapy and associated areas.

Synapse is pleased to accept submittedmanuscripts from all grades and experience of staff including students.We particularly wish to encourage‘novice’ writers considering publicationfor the first time and ACPIN providessupport and guidance as required. Allsubmissions will be acknowledgedwithin two working weeks of receipt.

Examples of articles for submission:

Case ReportsSynapse is pleased to accept case reportsthat provide information on interesting orunusual patients which may encourageother practitioners to reflect on their ownpractice and clinical reasoning. It is recog-nised that case studies are usually writtenup retrospectively. The maximum length is3,000 words and the following structure issuggested:

Title – this should be concise and reflectthe key content of the case report.

Introduction – this sets the scene givingbackground to the topic, and why you con-sider this case to be important, for examplewhat is new or different about it? A briefoverview of the literature or the incorpora-tion of a few references is useful so peoplecan situate the case study against whatalready is known.

The patient – give a concise description ofthe patient and condition that shows thekey physiotherapeutic, biomedical and psy-chosocial features. Give the patient a name,but not their own name. Photographs of thepatient will need to be accompanied byexplicit permission for them to be used. Onlyrelevant information to the patients’ prob-lem should be included.

Intervention/method – Describe what you did, how the patient progressed andthe outcome. Aims, treatment, outcomes, clinical reasoning and the patient’s level of satisfaction should be addressed.Indications of time scales need to be considered.

Implications for practice – Discuss theknowledge gained, linking back to theaims/purpose, and to published researchfindings. Consider insights for treatment of similar patients, and potential for application to other conditions.

Summary – List the main lessons to bedrawn from this example. Limitationsshould be clearly stated, and suggestionsmade for clinical practice.

References – the Harvard style of referenc-ing should be followed (please seePreparation of editorial material below).

Original research papersThese should not exceed 4,000 words andpapers should include the following headings:

Abstract – (maximum of 300 words)

Introduction

Method – to include design, participants,materials and procedure

Results

Discussion

Conclusion – including implications forpractice

References

Abstracts of thesis and dissertationsAbstracts from research (undergraduate andpostgraduate) projects, presentations orposters will be welcomed. They should beup to 500 words, and broadly follow theconventional format: introduction, purpose,method, result, discussion, conclusion.

Audit reportA report which contains examination of themethod, results, analysis, conclusions ofaudit relating to neurology and physio-therapy, using any method or design. Thiscould include a Service DevelopmentQuality Assurance report of changes in service delivery aimed at improving quality.These should be up to 2,000 words.

Sharing good practiceThis Synapse feature aims to spread theword amongst ACPIN members about innovative practice or service develop-ments. The original format for this piecestarted as a question and answer session,covering the salient points of the topic,along with a contact name of the authorfor readers to pursue if they wish.Questions were loosely framed around thefollowing aspects (this would be for anaudit)• What was the driving force to initiate it?• How did you go about it?• What measurements did you use?• What resources did you need?• What did you learn about the process?• How has it changed your service?

However recent editions have moved awayfrom this format, and provide a fuller picture of their topic eg Introducing a management pack for stroke patients innursing homes (Dearlove H Autumn 2007),An in-service development education pro-gramme working across three differenthospitals (Fisher J Spring 2006), A therapyled bed service at a community hospital(Ramaswamy B Autumn 2008) andEstablishing an early supported dischargeteam for stroke (Dunkerley A Spring 2008).

Product newsA short appraisal of up to 500 words, usedto bring new or redesigned equipment tothe notice of readers. This may include adescription of a mechanical or technicaldevice used in assessment, treatment

management or education to include specifications and summary evaluation.Please note, ACPIN and Synapse take noresponsibility for these products, it is not anendorsement of the product.

ReviewsCourse, book or journal reviews relevant toneurophysiotherapy are always welcome.Word count should be around 500. Thissection should reflect the wealth of events and lectures held by the ACPIN Regionsevery year.

OTHER REGULAR FEATURESFocus on…This is a flexible space in Synapse that features a range of topics and serves to offerdifferent perspectives on subjects.Examples have been a stroke survivor’sown account, an insight into physiotherapybehind the Paralympics and the topics ofresearch, evidence and clinical measure-ment.

Five minutes with…This is the newest feature for Synapse,where an ACPIN member takes ‘five min-utes’ to interview well-known professionalsabout their views and influences on topicsof interest to neurophysiotherapists. We arealways keen to receive suggestions of indi-viduals who would be suitable to feature.

PREPARATION OF EDITORIALMATERIAL

Copies should be produced in MicrosoftWord. Wherever possible diagrams andtables should be produced in electronicform, eg excel, and the software usedclearly identified.

The first page should include:• The title of the article• The name of the author(s)• A complete name and address for

correspondence• Professional and academic qualifications

for all authors and their current positions

For original research papers, a brief noteabout each author that indicates their contribution and a summary of any fundssupporting their work.

All articles should be well organised andwritten in simple, clear, correct English.The positions of tables and charts or photo-graphs should be appropriately titled andnumbered consecutively in the text.

All photographs or line drawings shouldbe at least 1,400 x 2,000 pixels at 72dpi.

All abbreviations must be explained.

References should be listed alphabetically,in the Harvard style. (see www.shef.ac.uk/library/libdocs/hsl-dvc1.pdf) eg:

Pearson MJT et al (2009) Validity and inter-rater reliability of the Lindop Parkinson’sDisease Mobility Assessment: a preliminarystudy Physiotherapy (95) pp126-133.

If the article mentions an outcome measure, appropriate information about itshould be included, describing measuringproperties and where it may be obtained.

Permissions and ethical certification;either provide written permission frompatients, parents or guardians to publishphotographs of recognisable individuals, orobscure facial features. For reports ofresearch involving people, written confir-mation of informed consent is required.

SUBMISSION OF ARTICLESAn electronic and hard copy of each articleshould be sent with a covering letter fromthe principal author stating the type of article being submitted, releasing copy-right, confirming that appropriate permissions have been obtained, or statingwhat reprinting permissions are needed.For further information please contact theSynapse coordinator:[email protected]

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.

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44

EAST ANGLIA

Nic HillsPhysiotherapy DepartmentIpswich Hospital NHS TrustHeath RoadIpswich IP4 5PDt 01473 702072e Nicola.hills@

ipswichhospital.nhs.uk

KENT

Janice ChampionMedway Maritime HospitalWindmill RoadGillinghamKent ME7 5NYt 01634 833959e [email protected]

LONDON

Andrea Stennete [email protected]

MANCHESTER

Helen Dawsone [email protected]

MERSEYSIDE

Jo Jonest 0151 282 6000 ext 6117e [email protected]

NORTHERN

Catherine Birkette [email protected] [email protected]

NORTHERN IRELAND

Joanne WrigglesworthPhysiotherapy DepartmentBelfast City HospitalLisburn RoadBelfast BT9 7ABt 028 90329241 ext 2545e joanne.wrigglesworth@

belfasttrust.hscni.net

NORTH TRENT

Anna Wilkinsone [email protected]

OXFORD

Sophie GwilymWitney Community HospitalWelch WayWitney OX28 6JJe [email protected]

SCOTLAND

Dorothy Bowmane [email protected]

SOUTH TRENT

Becky SammutPhysiotherapy DepartmentDerby City General HospitalUttoxeter RoadDerby DE22 3NEt 01332 786565e [email protected]

SOUTH WEST

Kate MossPhysiotherapy DepartmentCirencester HospitalGloucester GL7 1UYt 01285 884536e [email protected]

SURREY & BORDERS

Kate Moffatte [email protected]

SUSSEX

Gemma Aldere [email protected]

WESSEX

Hayden Kirkt 02380 811324e [email protected]

WEST MIDLANDS

Katherine HarrisonPhysiotherapy DepartmentSolihull Medical Day HospitalLode LaneB91 2PLt 0121 424 4660e katherine.harrison@

heartofengland.nhs.uke [email protected]

YORKSHIRE

Jill FisherNeurophysiotherapy4 St Helen’s LaneAdelLeeds LS16 8ABt 0113 2676365e neurophysiotherapy@

yahoo.co.uk

REGIONAL REPRESENTATIVES JULY 2009 Syn’apse

EditorLouise Dunthorne

Editorial Advisory CommitteeMembers of ACPIN executive andnational committees as required.

Designkwgraphicdesignt 44 (0) 1395 263677e [email protected]

Printers Henry Ling LimitedThe Dorset PressDorchester

Address for correspondenceLouise DunthorneSynapse EditorManor Farm Barn, Manor Road,Clopton, WoodbridgeSuffolk IP13 6SHe [email protected] 44 (0)1473 738421


> Midline orientation ofthe head – doesachieving this improveability to maintainunsupported sitting inthe stroke patient?

> Elective spinal patients –the implementation ofweekend physiotherapyat Kings College Hospital

> Late stage physiotherapy– rehabilitationfollowing severetraumatic brain injury –a case report exploring aclient with severephysical impairmentsfour years post injury

Autumn/Winter 2009

www.acpin.net


AUTUMN/WINTER 2009

ISSN 1369-958Xwww.acpin.net


SYNAPSE Autumn 2009 4/11/09 18:35 Page C4

midline orientation of the head – does achieving this

Documents