medical practitioners using acupuncture had only had two to three days of training themselves in this very complex modality.

We were proud to be able to talk about the scope of practice in the UK and of our CSP validated acupuncture course about to be launched giving a thorough theoretical and practical training in both western and traditional acupuncture.

NADIA ELLIS MSc MCSP Chairman

MAUREEN LOVESEY MCSP ONC Vice-chairman Acupuncture Association of

Chartered Physiotherapists

Teachers Untaught MADAM - I have just returned from the Spring study course of the Association of Teachers at the CSP at Abergavenny, entitled 'Four boundaries of knowledge'. This was an excellent course with well-known lecturers of national standing dealing with important, if unusual material. It was quite evident that those who went thoroughly enjoyed themselves due to the interesting and challenging material as well as the good food and good company.

What I find saddening was the fact that only seven physiotherapy schools were represented. The numbers were swelled by two psychology lecturers, an occupational therapy teacher, private practitioners, and a student.

Some of the material presented at this course could be characterised as being at the frontiers of knowledge - in fact one presentation may well turn out to be an early description of work of the greatest significance for cell biology and, ultimately, therapy.

While the organisers are to be congrat- ulated it seems a pity so many teachers were willing to avoid such an intellectually stimulating course.

JOHN LOW BA MCSP DipTP London SE1

Face-mask CPAP and Acute Asthmatics MADAM - I am at present carrying out a small retrospective study on the use of face- mask continous positive airway pressure in acute severe asthma to prevent intubation and/or mechanical ventilation.

This particular subject was briefly mentioned in a discussion at the November study day of the Association of Chartered Physiotherapists in Respiratory Care and I realise it is a very controversial technique to use with this particular group of patients. There were one or two other physio- therapists at the meeting, however, who had obviously been using CPAP with acute asthmatics and had met with the same success as 1 have.

I would be very interested to hear from anyone who has had experience of using CPAP with non-intubated acute asthmatics. I can be contacted at the address below.

Physiotherapy Department East Surrey Hospital Three Arch Road Redhill, Surrey RH1 5RH (tel 0737 768511 ext 2123 or bleep 465)

EVA DEMBINSKA-FOSTER MCSP

Were the Old Ways So Bad? ROBERT GARRETT MCSP MAPA Private Practitioner, Sydney

THIRTY years ago I qualified as a physical training instructor in the Royal Air Force and specialised later on as a parachute jumping instructor. I was therefore involved in the physical conditioning of service personnel from recruits to the elite paratroopers and Special Air Service.

The principles of instruction were hammered home to me then and are still relevant to instructors and physiotherapists who conduct classes today:

OThe instructor must have a good voice and intonation and should speak to the rear of the class so all can hear.

0 He/she should never speak above a noise. (Some present-day aerobic instructors shout instructions over loud music. Most of the class are unable to hear the words, therefore the response is poor.)

0 All movements should be demonstrated correctly, then broken down into sections, then a further complete demonstration is given, followed by class practice with the instructor moving among the class correcting where necessary.

This individual correction is often lacking in some aerobic classes today, especially when there is only one instructor taking a large class with noisy background music. This is when the injuries occur due to poor instruction and incorrect techniques.

0 Be firm but fair. Separate 'mates' who keep fooling around and disrupting the flow of the class.

0 Don't be over-critical, and give credit where it is due, but only when it has been earned. (Don't keep saying 'good' or 'well done' to everything - after a while it will be meaningless.)

OAvoid constantly picking on a class member, especially if heishe is poorly co- ordinated or overweight, etc. Avoid having favourites and try to give each class member a fair share of your attention.

0 Aways maintain a sense of humour and enjoy a joke at your expense and be able to accept criticism.

0 Stand where the class can see you and you them. Never turn your back on the class or stand in the centre of a circle.

0 Always have a 'trick' up your sleeve if the class is getting bored - eg tell them a joke, break the boredom, get their attention and maintain it.

0 Encourage and coach rather than bully. Spend more time with the less co-ordinated but not if you have to neglect the rest of the

class. See them afterwards and suggest a slower or lower fitness level programme.

0 Never use words like 'force', 'crush', or 'to the limit'. 'No pain, no gain' might be used for the elite but not for the less fit and certainly not in a rehabilitation class.

0 Always look the part. The class will not respect you if you are scruffy, overweight or have poor posture. You must try to exemplify that which the class has to work to attain. Always have goals and make the programme competitive.

The Physical Training Class The class was usually conducted by two

instructors; one out front demonstrating the movements and giving commands and timing, which was usually at an average pace according to the fitness level of the class. The other instructor moved around the class giving individual encouragement and correction. Classes lasted 45 minutes and consisted of:

1. introductory Activity. Small ball or partner game to wake the class up and get them in the mood.

2. Warm-up. Ballistic 5 minutes stretching.

3. Strength and Endurance. Twenty minutes of activities. Circuit training was very popular with recruits - some could perform one chin-up or push-up while others could perform 20 or more. Circuit activities catered for all individuals regardless of their fitness level.

4. Game and Warm-down. The last 15 minutes were spent playing a game involving skill and co-ordination. Sometimes the class would be split into groups, each group spending a few minutes practising lay-up basketball shots, header tennis, gymnastic activities, volley ball, etc, on a rotational basis.

Most youngsters dislike formal exercise but give them a ball and a challenge and they will give maximum effort.

The class was terminated by a couple of minutes slow jogging combined with gentle arm and shoulder movements and deep breathing.

Modern Observations

Having closely observed the current boom and public awareness of the many benefits regular exercise has to offer, it is pleasing to see the concern being expressed to instructors on the dangers of some exercises and the care and caution taken with the unfit exerciser.

However, the list of 'dangerous' exercises

388 Physiotherapy, June 1991, vol 77, no 6

is growing daily and very soon there will not be many exercises which are considered safe. There is a deal of confusion as to which movement is dangerous and which is safe. Strict rules should be adhered to when instructing beginner exercisers but many of the 'dangerous' exercises can be utilised when dealing with the fitness training of the conditioned sportsperson and should be if the movement is used in his/her sport.

Most of the aerobic class movements listed as 'dangerous' are used repeatedly on the track and sportsfield.

Lumbar Hypertension This is used extensively in gymnastics,

diving, volleyball, basketball, high jump, weight lifting and so on.

Most of the hypertension movements are carried out in the weight-bearing positions which accentuate the compression and load on the lower lumbar intervertebral discs and the ilio-lumbar ligaments which stabilise the fourth and fifth lumbar vertebrae on the ilium and sacrum. The stresses performed in lumbar hyperextension in the prone position will do no damage to the discs or the lumbo-sacral junction in the majority of advanced exercisers, provided the performer does not have a hyperlordosis, spondylolis- thesis or kissing spine, or hypermobility.

Thirty years ago few people owned a TV or car or sat slumped in front of or in them for hours a day. Most people walked much more than they do nowadays.

There was far less flexion abuse to the lumbar spine with lumbar lordosis loss compensating thoracic kyphosis and increased cervical lordosis. The incidence of spinal pain was far less than the estimated 70% of back sufferers in the western world today.

Daily exercises of hypertension in the prone position would combat the posterior migration of the nucleus pulposus, caused by years of slumped sitting, and keep it in the centre of the disc away from the sensitive posterior spinal structures. The long and short stabilising spinal muscles would maintain and strengthen the natural

~~

lumbar lordosis which in turn would correct the increased thoracic kyphosis and cervical lordosis.

Ballistic Stretching These 'bouncing' stretches are at present

considered 'dangerous' because vigorous stretching elicits the neuromuscular spindles in the muscle fibres to cause a reflex muscular contraction at spinal cord level. The exerciser is then stretching his/her muscle against a reflex contraction which can cause damage to the muscle fibre.

The amount of reflex contraction brought about by vigorous stretch stimulation of the neuro-muscular spindles is controlled by the neurotendinous 'golgi' organs found a t the musculo-tendinous junction. These become excited when the muscle contracts vigorously and act as a 'safety net' by inhibiting the motor neurones of the muscle and reducing tension, thus regulating contraction.

Ballistic movements thus have protection and should be perfectly safe provided the muscle has been pre-warmed and are far more conducive to the functional stretching the muscles will go through during the programme or game which will be mostly ballistic-type stretch movements.

The lliopsoas Phobia This muscle has received much adverse

publicity and labelled the 'bad guy'. Supine straight leg lifts and sit-ups with straight legs are considered 'dangerous'. Because of i ts attachments to the lumbar spine and intervertebral discs, it can pull on the lumbar spine vigorously and increase the lumbar lordosis.

If the muscle becomes shortened then it can cause problems but if it is kept balanced by stretching it and working the antagonists then it will give no problems and it will be an asset to the lumbar spinal stability if it is kept strong.

I have seen a rugby player who avulsed the insertion of iliopsoas from the lesser trochanter and he could not walk even with crutches. The lesser hip flexors, ie rectus

femoris, sartorius, adductors and tensor fascia lata, were unable to flex the hip. So iliopsoas has a very important function.

Sit-ups with straight legs should not be classified as a dangerous exercise but obviously to work the abdominals more effectively and dampen down iliopsoas action the knees and hips should be flexed and the trunk raised to 30°.

Supine double straight leg raises are excellent dynamic iliopsoas exercises with the abdominals working isometrically as stabilisers. This exercise is best carried out resting on the elbows which flexes the low back, shortens the lever and reduces the pull on the lumbar vertebrae.

Conclusion Ballistic stretching, prone hyper-spinal

extension, supine double straight leg raising, burpees, straight leg sit-ups, windmill toe- touching, star jumps, hands behind the neck sit-ups, etc, were all part of the programme thirty years ago.

In my ten years as a PTI and five years as a physiotherapist with a professional soccer team, I cannot recall any injuries sustained through these types of exercises. This can be attributed to:

0 The youthful age and reasonable fitness of the class.

0 The sound training, organisation and control of the instructors.

OThe strong emphasis on correct tech- nique.

O A l l the class were warmed-up and mobilised before any of the 'banned' exercises were performed.

*There were far fewer and far less repetitive movements than there are now.

Nowadays, with many exercisers in their forties and older, the instructor has to be much more careful; but once middle-aged exercisers have reached a good standard of fitness and strong abdominals they should be capable of performing most of the so- called 'dangerous' exercises wi th no adverse effects.

Reports

Design for Disability, published by the Society of Designers in Ireland, 8 Merrion Square, Dublin 2, Ireland, 1990. Illus. 12 pages.

Glossily presented report of a European conference on design in the service of aged and handicapped people held in Dublin in April 1989. It contains reports of the six papers presented at the conference, and of the workshops which followed the papers.

Copies of the full conference proceedings are available at €50 including postage.

All Change - From hospital t o community care, published by the Department of Health, London, October 1990. 49 pages. Available from DHSS Store, Health Publications Unit, Site no 2, Manchester Road, Heywood, Lancashire OTlO 2PL.

This is the report of a small-scale community care inspection undertaken by the Social Services inspectorate in four

localities in England. It examined arrange- ments made to support and resettle former long-stay patients discharged to the community from mental illness and mental handicap hospitals. It found that many people did not have enough stimulating activity during the day, and too little work had been done on the costs of resettlement. A clear and agreed philosophy and co- ordinated planning of services were shown to be of primary importance for a successful transfer.

What Happens when Nurses Become Disabled? by P Moon. Published for the Association of Disabled Professionals, 1990. 23 pages. Available from the Royal Association of Disability and Rehabilitation, 25 Mortimer Street, London W1N 8AB. €5 including postage.

The author of this survey, herself a disabled nurse, compiled the report from 12 questionnaires completed by other nurses with disabilities. Themes which emerge are the lack of consideration by fellow pro- fessionals for their colleagues who work

under difficulties, especially those in managerial positions who tend not to consider them for responsible posts; and the degree of empathy with patients that experience on the receiving side of the health service gives to disabled staff. Parallels can easily be drawn with pro- fessionals in any other health care discipline who have disabilities.

Executive Summary of the First Report of the Chief Medical Officer's Group on the Medical Aspects of Air Pollution Episodes. Department of Health, London, May 1991. Five pages.

Ozone levels experienced in the UK during hot summer weather are unlikely to produce any permanent lung damage, and general warnings to the public are not justified, states this report. Some individuals sensitive to ozone may experience respiratory symptoms while taking vigorous exercise out of doors, however, and should be advised to reduce exposure.

Copies of this summary are available from the DOH but the full report will be published as soon as possible by HMSO.

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