Layout 1

Is Constraint Induced

Movement Therapy

(CIMT) a feasible

treatment option in

an inpatient

rehabilitation

environment within

the NHS?

Use of Botulinum

toxin in the treatment

of elbow flexor

spasticity in acute

stroke

Pusher Syndrome: a

relevant issue in

stroke rehabilitation

Spring/Summer 2012

www.acpin.net

JOURNAL AND NEWSLETTER OF THE ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS IN NEUROLOGY

SYNAPSE Spring 2012 28/05/2012 11:21 Page C1

SYNAPSE Spring 2012 28/05/2012 11:21 Page C2

ACPIN’S AIMS

1. To promote and facilitate

collaborative interaction between

ACPIN members across all fields

of practice including clinical,

research and education.

2. To promote evidence informed

practice and continuing

professional development of

ACPIN members by assisting in

the exchange and dissemination

of knowledge and ideas within

the area of neurology.

3. To provide encouragement and

support for members to participate

in good quality research (with a

diversity of methodologies) and

evaluation of practice at all levels.

4.To maintain and continue

to develop a reciprocal

communication process with the

Chartered Society of Physiotherapy

on all issues related to neurology.

5.To foster and encourage

collaborative working between

ACPIN, other professional groups,

related organisations ie third

sector, government departments

and members of the public.

Syn’apse

JOURNAL AND NEWSLETTER OF THE

ASSOCIATION OF CHARTERED

PHYSIOTHERAPISTS IN NEUROLOGY

Spring/Summer 2012

ISSN 1369-958X

CONTENTS

From the Chair 2

Editorial

Participate or perish (President’s address from the

2012 ACPIN national conference and AGM) 3

Article 1

Constraint Induced Movement Therapy (CIMT) –

a feasible treatment option in an inpatient rehabilitation

environment within the NHS? 4

Article 2

Use of Botulinum toxin in the treatment of elbow

flexor spasticity in acute stroke – a case report 10

Article 3

Pusher Syndrome:a relevant issue in stroke rehabilitation 16

The backbone of neurology

ACPIN national conference and AGM 2012

• Lecture abstracts 20

• Workshop sessions 25

• Speed updates 26

• Poster winners’ abstracts 27

• ACPIN AGM 2012 30

Sharing good practice

• Writing a case report 34

• Functional stroke training – evaluating a

community-based programme 35

• Sharing ‘local’ practice 36

• A novel technique to attach Velcro straps

to fibreglass splints 37

Resources of interest 38

Focus on…

• Paralympic classification 39

• Steve Brown – Wheelchair rugby captain – GB Team 40

• Jane Petty – national programme

physiotherapy lead for the MS Society 41

• The life of a PhD student 43

Reviews

BOOK: Physical management for neurological conditions 45

COURSE: Step into research 45

News 46

Articles in other journals 49

Regional reports 59

Writing for Synapse 63

Regional representatives 64

SYNAPSE Spring 2012 28/05/2012 11:21 Page 1

Current Executive Committee

President

Margaret Mayston

[email protected]

Honorary chair

Gita Ramdharry

g.ra[email protected]

Honorary vice chair

Jakko Brouwers

[email protected]

Honorary treasurer

Jo Kileff

joandivan@kileff.co.uk

Honorary secretary

Anne Rodger

Anne.rodg[email protected]

Honorary research officer

Jane Petty

jpetty@mssociety.org.uk

Honorary membership officer

Sandy Chambers

[email protected]

Honorary minutes secretary

Emma Procter

[email protected]s.uk

Honorary PRO

Adine Adonis

Adine.adonis@imperial.nhs.uk

Synapse coordinator

Lisa Knight

lisaknig[email protected].com

Diversity officer

Lorraine Azam

lorrainepetre@hotmail.com

iCSP link and Move for Health

Champion

Chris Manning

christopher.manning@sgul.kingston.ac.uk

Committee member 1

Ralph Hammond

Ralph.hammond@sompar.nhs.uk

Committee member 2

Jennifer Barber

Jennifer[email protected]

Welcome to the Spring/Summer 2012

edition of Synapse!

As usual sitting down to write From the

Chair makes me reflect on the hard

work of the exec and think of our plans

for the year ahead!

The last Chair’s address I had written

was full of despondency at the thought

of the health and social care bill being

passed and the implications that

would have for physiotherapists,

however although it was passed last

week I am feeling much more

optimistic!

I have just returned from the 2012

residential conference in Northampton,

The backbone of neurology, which was

a complete sell-out and unfortunately

we even had to turn people away. The

buzz and enthusiasm at the conference

was amazing. Judging by the silence

and complete attention in the lectures,

the chatter at breaks and the dancing

’til the wee small hours everyone had a

great time and the feedback from the

delegates has been fantastic. We even

got a mention in The Times by Melanie

Reid, whose full presentation can be

listened to on the website. For those of

you who were unable to attend we

also have a short video to give you an

overview of the day and the speakers’

presentations are also available on the

website.

We have also adopted our new

constitution and are fully affiliated

with the CSP as a professional network

within the neurological alliance.

An account of all our links with other

organisations is more fully described in

the conference abstracts and on the

website and thanks to Jo Tuckey, Cherry

Kilbride, Bhanu Ramaswarmy and Dr

Fiona Jones for their involvement on

behalf of ACPIN.

I can hardly believe that my two years

as Chair has passed and it is time to

step down. Thank you for allowing me

to have the honour of being chair of

such a dynamic and enthusiastic group

of professionals, I have enjoyed every

minute and made lovely friends along

the way!

Signing off!

Siobhan MacAuley

FROM THE CHAIR

Syn’apse

●

SPRING/SUMMER 2012

Thank you to Siobhan for being

such a fantastic Chair. She has

shown so much dedication and

enthusiasm throughout her term

and she will be very much missed.

ACPIN Committee

SYNAPSE Spring 2012 28/05/2012 11:21 Page 2

EDITORIAL

These may sound like strong words,

but in these uncertain times we all

need to be prepared to make an

active contribution to the ongoing

discussions and processes, whether

they be about the economy, the NHS

or, the future of physiotherapy.

In particular, participation is needed

in the discussions about the role of

ACPIN and where it fits into the new

Professional Network structure (CSP)

and its interaction with the wider

world of neurology. We know from the

International Classification of

Functioning Disability and Health (ICF),

that a focus on participation is key to

successful rehabilitation and habilita-

tion. It is also essential for the future of

our profession.

As I am embark on my fourth and

final year as President of ACPIN I have

cause to reflect on where the physio-

therapy profession is at, the healthcare

structure and physiotherapy education.

We learnt in March of the long awaited

decision of the NHS London review of

physiotherapy education, which is

supported in the capital financially by

the NHS. A decision has been made to

support only three of the central

London schools: Kings, Brunel and

St Georges, and of course places have

been cut significantly nationwide. How

has this come about? – was the

expansion of education the result of

poor consultation, or has this come

about because of the financial crisis in

which the world finds itself? I suspect

both factors. The NHS reform discus-

sions and implementations will

continue, and the only outcome from

these will be further reduction in

budgets, less service provision, over-

worked healthcare professionals and

fewer jobs available for qualified

physiotherapists (already a significant

concern especially for new graduates).

The knock–on effect is less money

available for CPD and possibly a reduc-

tion in skill development. Will our

speciality of neurophysiotherapy

perish? I am confident we will continue

despite these cuts and changes, but it

requires our active participation – all

of us.

At times, more so in these recent

times of global recession and blind

insistence on evidence based practice

or nothing, I do feel despondent about

the vision of physiotherapy and what

might happen to the profession, and

rather pleased that I can retire soon!

But, when I look at this specific interest

group there is cause to feel confident

for the future and to continue. ACPIN

goes from strength to strength, has

well over 2,000 members and all

events are well attended. This is in

large part thanks to the dedicated work

of the executive who give their time

freely and enthusiastically, and to the

membership in general who want to

develop their skills and be the best

therapist that they can for the clients

they treat, and also to have pride and

confidence in the work that we do.

One of the many privileges in being

President is that I have had the oppor-

tunity to work with three Chairs over

my term, and to work with a large

number of committee members and

regional representatives. I have to say

that they make a formidable team.

However, I need and want to make one

plea on their behalf. The Chair,

formerly Siobhan and now, Gita, needs

to have prompt replies to their queries

from the committee members and

regional representatives about the

ACPIN response to a whole range of

matters: media releases, the Stroke

Forum, possible conference speakers,

through to who will assemble the

conference packs late at night, or make

sure that all the sandwich wrappers

and disposable coffee cups are in the

rubbish bin when the meeting is over.

The Chair did not take on the job to be

an autocrat and values and needs your

responses, and requires them in good

time without needing to send

reminders. Please respond in a timely

fashion. For the wider membership,

please make your contribution by

joining the executive, becoming a

regional representative, contributing to

Syn’apse, participating in surveys when

requested, and of course attending

meetings whether they be local,

national, or in support of ACPIN at the

national CSP conference.

That’s my grumble finished. Over

2,000 members can make a highly

significant contribution to the devel-

opment and progression of

neurophysiotherapy. Be a part of it!

This was the President’s address at the 2012

National ACPIN conference and AGM.

Participate or perish

Margaret Mayston AM FCSP PhD ACPIN President

SYNAPSE Spring 2012 28/05/2012 11:21 Page 3

Syn’apse

●

SPRING/SUMMER 2012

Following a stroke, many different factors

make the use of an affected upper limb diffi-

cult. One such factor which may be overlooked

as pure motor weakness is learned non-use.

This phenomenon commences with the

inability to use the affected upper limb in the

acute phase after stroke, when the ischaemic

penumbra is maximal. The resultant feeling of

failure and the ability to manage with use of

the unaffected limb reinforces the compensa-

tory use of the unaffected side. This can result

in the person with hemiplegia no longer trying

to use the affected upper limb, even once the

penumbra has resolved and activity is

returning (Taub et al 1999).

One treatment technique which seeks to address

learned non-use is constraint induced movement

therapy (CIMT). Traditional CIMT involves mitt

wear, by way of constraint, on the unaffected

upper limb for 90% of waking hours and six hours

a day of task practice and shaping exercises for

two weeks. Suitable patients are required to have

active finger and wrist extension and have suffi-

cient cognition to take on board the demands of

the programme (Wolf 2006, 2008). CIMT was first

developed in America by Dr Edward Taub and has

been tested by more than 120 studies in various

versions from traditional to modified forms, (Taub

et al 2006) including the rigorous, randomised,

controlled, multicentre EXCITE trial which

involved 220 participants over a two year follow

up period (Wolf et al 2006, 2008).

CIMT is one of the most evidence based forms of

upper limb rehabilitation available for stroke

patients, and yet, anecdotally, it appears to be min-

imally utilised as part of routine clinical practice

by physiotherapists within the NHS. The reason for

this is unclear and is the subject of current investi-

gation amongst ACPIN members who await the

publication of survey findings. The main issues

appear to be staffing levels, lack of consensus of

how to carry out CIMT and strict inclusion criteria.

In the National Clinical Guidelines for Stroke (RCP

2008) the importance of patient commitment to a

CIMT programme is reinforced because of the

‘considerable health resource’ required to provide

this intervention. As an NHS clinician this recom-

mendation highlights one of the major barriers to

CIMT – not enough time. NHS occupational thera-

pist (OT) and physiotherapist (PT) to patient ratios

are recommended as one to five (BSRM 2009,

BASP 2010) and actual average figures fall below

these guidelines (RCP 2007, Rudd et al 2009). The

provision of six hours of supervised exercise daily

seems overwhelming and impossible in services

which are struggling to see their patients for 45

minutes, five days a week per discipline, in order

to meet published guidelines (NICE 2010).

In addition to the time factor, is the issue of a

lack of standardisation of the approach (Tuke

2008). Despite the publication of articles that have

attempted to characterise the intervention pro-

tocol (Morris 2006), specifically what sort of

exercises to carry out, has remained unclear.

Some clarity has been provided by the EXPLICIT

study (Kwakkel et al 2008) which supplied a

detailed and repeatable protocol including photo-

graphs of specific exercises used within CIMT, for

their five year research programme, the results of

which have not yet been published.

Finally, strict inclusion criteria apply in many of

the studies, particularly around mobility levels.

Current guidelines for stroke (RCP 2008) state

that CIMT should be offered to appropriate

patients who are independently mobile. In an

inpatient environment patients are rarely mobile

at admission and, in the author’s experience, are

often primarily concerned with their mobility

levels over their reduced upper limb function and

prefer to set their goals around walking in order

to facilitate discharge. A recent study by Hartigan

Constraint Induced

Movement Therapy (CIMT)

– a feasible treatment option in an inpatient

rehabilitation environment within the NHS?

Rebecca Bradshaw Bsc (Hons) MCSP

SYNAPSE Spring 2012 28/05/2012 11:21 Page 4

ARTICLE 1

et al (2010) showed that the majority of stroke

patients with both upper and lower limb affected

identified either mobility or active tasks such as

gardening as their main goals.

This article, therefore, seeks to give an account

of a real life, NHS inpatient unit’s efforts, to incor-

porate this highly evidenced intervention into a

rehabilitation programme, in order to encourage

other practitioners to trial CIMT within their client

groups.

DRIVING FORCE

In our regional neurorehabilitation unit, CIMT had

not been used as described in the literature, except

as a highly modified version trialled within treat-

ment sessions and occasionally a modified version

of forced use involving only the constraint element

during specific functional tasks. For example a

patient eats two meals a day while their unaffected

upper limb is constrained. However, as a small unit

(eight neurorehabilitation beds) with a full comple-

ment of multi-disciplinary team members,

including assistant staff, we considered ourselves

well placed, to be implementing one of the most

evidence based forms of upper limb rehabilitation.

The physiotherapy team chose to present CIMT to

our area’s professional group quarterly meeting in

April 2010 and we therefore researched the subject

in depth, drawing together multiple articles

including several randomised controlled trials

(RCTs) examining the efficacy of CIMT. Studies not

only showed immediate effects after only a two

week intervention, but effects that were lasting up

to two years later (Wolf 2008). We felt that, as a

unit, we should be able to offer CIMT as a treatment

option to appropriate patients in order to ensure

that our practice is both up to date, evidence based,

and in line with national guidelines for stroke.

WHAT INFLUENCED OUR CHANGE IN PRACTICE?

The EXCITE trial was one of the most recent and

powerful of the CIMT studies available (Wolf et al

2006, 2008), and its two week, intensive pro-

gramme fitted in well within our unit which

admits patients for an average of three months.

We therefore decided to base our intervention on

their protocol with the clearly laid out exercises

from the EXPLICIT trial (Kwakkel et al 2008) as a

photographic resource to ensure that the inter-

vention would be clear and easy to follow by any

member of our multidisciplinary team (MDT).

In January 2011 several members of the MDT

attended the first course in the country entitled

‘How to do CIMT?’ (Harrison Training 2010). The

trainers presented a case study of CIMT in the

community and gave many examples of the types

of exercises and activities involved as well as pro-

viding examples of how to set up a CIMT

programme with the types of paperwork required.

We adapted this paperwork to make it suitable for

our unit.

CASE REPORT

Our first opportunity to use CIMT came with a 47

year old patient admitted to our unit five weeks

after a left middle cerebral artery infarct which

was thrombolysed. We introduced the idea of the

two week intensive programme from an early

stage in order to prepare the patient. We agreed

with the patient to complete the programme in the

final two weeks of his nine week admission once

his mobility had improved (at admission he was

mobile with assistance of two and a stick, by the

time of his CIMT programme he was independent

unaided). A behavioural contract was drawn up in

which certain tasks were excluded from mitt wear

ie stairs, drinking/pouring hot drinks and show-

ering (because the mitt wasn’t waterproof) and

certain tasks were highlighted as possibly

requiring extra help eg dressing. Both the patient

and his wife signed witnessed written agreements

to formalise the process and ensure he under-

stood the commitment required of him, having

been provided with written information on the

programme a few days before. His two week pro-

gramme consisted of:

• Mitt wear for 90% of waking hours.

• Three hours of supervised intervention by the

therapy team every weekday.

• One hour intervention supervised by his wife

every weekday.

• Two hours independent shaping and task prac-

tise every weekday.

• Each hour long session consisted of four tasks –

a mixture of strength, range of movement and

dexterity tasks, each completed for 15 minutes.

• The programme started on a Wednesday in

order to provide an early break (mitt wear only

at weekends) after the first three days. See

Appendix 1 for examples of exercises used.

WHAT MEASUREMENTS DID WE USE?

Having reviewed upper limb outcome measures

used in the CIMT research papers, we felt that the

most evidence based and clinically relevant for us

and for our patient were the Nine hole peg test

(NHPT) (Kellor et al 1971, Heller et al 1987,

Mathiowetz 1985) and the Jebsen test of hand

function (Jebsen et al 1969, Bovend’Eerdt et al

2001) for dexterity, and dynamometry for power

(Heller et al 1987, Sunderland et al 1989). The

Canadian occupational performance measure

(COPM) (Bodiam 1999, Cup et al 2003) was used

to measure the patient’s perception of his upper

limb use, including identification of key functional

tasks and self-rating of their current performance

SYNAPSE Spring 2012 28/05/2012 11:21 Page 5

Syn’apse

●

SPRING/SUMMER 2012

level and degree of satisfaction with their current

performance. Each component is scored out of ten

with ten being the most satisfied. The measures

were completed twice in the two week pro-

gramme, the day prior to commencing the

programme and the day after completion. We also

video recorded the patient, to review the interven-

tions, and observe any changes in the quality of

movement. See Table 1 below, for results of the

above outcome measures used.

WHAT RESOURCES DID WE NEED?

To provide the level of input required we needed a

full complement of OTs and PTs: at our unit this

reflects the BSRM (2009) and BASP (2010) recom-

mendations of one therapist to five patients, as well

as full time OT and PT assistants. We also relied on

flexibility from the rest of the MDT as the two week

period involved the equivalent of full time work for

the patient on only his arm. Speech and language

therapy and psychology therefore had to largely

withdraw. This was discussed and agreed within

our multi-disciplinary team meeting. For this

patient, no dilemma arose, as he was receiving

minimal input from other disciplines with his out-

standing goals being physical. In a different case

where other disciplines were more heavily

involved, more flexibility maybe required and

perhaps a more modified CIMT approach adopted.

The most significant resource was time – not only

during the treatment period but also in set up – we

needed to designate protected CPD time and work

was also completed during the therapists’ own time

in order to prepare and set up the programme.

However, now this has been done once, the work-

load for the next patient will be significantly less.

Minimal equipment was required – only standard

upper limb rehab equipment/functional equipment

and games such as those found around the unit in

the kitchen, garden, bathroom etc.

WHAT DID WE LEARN ABOUT THE PROCESS?

Preparation/timing

• CIMT does appear to be a feasible treatment

option within an NHS setting but it does require

a lot of preparation and organisation both prior

to the programme and during it.

• Providing the intervention at the end of the

patient’s stay was very effective for us – not only

from a mobility point of view but it also allowed

the team to get to know the patient before

starting the programme. This is essential to

know when to push them, when rest is required,

when to abandon an exercise because it is too

hard and when to persevere because the

challenge they’re undergoing is part of the

process of improvement.

A flexible approach

• Flexibility is required by the therapists involved

in order to adapt quickly to early changes and

improvements – exercises that were challenging

on day one were easy by day three.

• Not every session goes ahead as planned.

Although independent sessions were timetabled,

OUTCOME MEASURE

COPM

ased on writing, toilet hygiene,

feeding himself and holding a

steering wheel.

Jebson test of hand function

NHPT

average of three attempts.

Dynanometry

gross grip, average of three

attempts.

PRE CIMT

Performance: 2/10

Satisfaction: 1.4/10

(standard deviations from

normal).

54.9 seconds

no drops.

41.3 pounds

POST CIMT

Performance: 6

.4/10

Satisfaction: 7.4/10

(standard deviations from

normal) between -2 and 2

considered to be within normal

range.

28.9 seconds

no drops.

56.6 pounds

SIGNIFICANCE

A change of two or more points

is considered clinically significant

(Law et al 2004) as cited in

Bodiam 1999).

This degree of improvement

represents an increase in speed

to perform seven dextrous,

functional tasks of between 110

and 141.2 seconds.

Normative values would be

completion within 18.8 seconds

(Mathiowetz 1985). Minimal

clinically important difference

has not been established.

Normative values would be

109.9 pounds.

Table 1

Outcome measure scoring pre and post CIMT

SYNAPSE Spring 2012 28/05/2012 11:21 Page 6

ARTICLES IN OTHER JOURNALS

they were not always completed, and certainly

not for a full hour, because of fatigue and frus-

tration. In addition the sessions supervised by

the patient’s wife were not always completed –

on reflection the team would not use a patient’s

partner in an inpatient setting again. Although

she was very keen to help, what our patient

needed when she visited was someone to offload

to about the frustrations of his day and how hard

the exercises were. In future we hope one

session each evening could be completed by a

rehabilitation assistant during a quiet period to

keep the supervised sessions to four hours a day.

This would also be better for a patient with no

regular visitors.

The intervention

• Very close communication between all those

working with the patient is vital to ensure the

programme is pitched at the correct level

throughout.

• CIMT is essentially a hands-off approach. As

Bobath influenced therapists, this is quite a chal-

lenge. Abnormal movement patterns are highly

likely to be employed by the patient but through

exploring the use of their upper limb and

problem solving for themselves on how to com-

plete tasks, neuroplastic changes are facilitated

and the patient’s movement should begin to nor-

malise. As physically helping the patient is

avoided, pitching the activities at the right level

is important so that tasks are difficult but not

impossible.

• The element of competition is vital – timing tasks

and racing against a target as dictated by the

shaping activities is crucial in maintaining the

interest of the patient. Even with the knowledge

that repetition is vital for plasticity (Kleim et al

1998, Kleim & Jones 2008, Sadowski 2008) and

improvement, boredom is potentially a major

problem. In our experience the greater the

variety of tasks and exercises that have been

prepared, the better because although repetition

is key, novel tasks have also been shown to

promote cortical plasticity (Adkins 2006). See

Appendix 1 for some examples of exercises used.

Outcomes

• Our outcome measures demonstrated substan-

tial improvements but most telling were the

videos of the intervention showing change in the

quality of movement in the tasks/exercises com-

pleted on day one compared with day fourteen.

With hindsight we would video and time one or

two of the tasks identified in the COPM to show

an objective change in the tasks that were most

relevant to the patient.

• Subsequent to the described CIMT programme

we have provided MDT in-service training on

what CIMT is and fed back the experiences high-

lighted here. This has increased our MDT’s

awareness of CIMT as a treatment tool and the

roles they can play within it ie encouraging the

patient, watching for mitt wear, being supportive

during functional tasks – nursing staff may need

to help a patient more with ADLs during their

CIMT period than they had been previously.

PROS AND CONS AND PATIENT SELECTION

Trialling CIMT within our unit following the

EXCITE trial example (Wolf et al 2006, 2008) has

highlighted to the team several areas for further

consideration – particularly regarding the inclu-

sion criteria:

• The EXCITE trial (Wolf 2006, 2008) actually has

lower level mobility criteria (independent toilet

transfer, independent sit to stand and two

minutes independent standing balance) than

many other studies which require the patient to

be independently mobile (van der Lee et al

1999). A high level of mobility proved beneficial

for CIMT in our experience, as it meant less time

spent with the mitt off (ie if a walking aid is

required, the mitt cannot be worn while

walking – this would limit use of the affected

upper limb in automatic tasks like opening

doors, turning on light switches etc). Having a

mobile patient also increased the scope for a

greater variety of exercises ie more dynamic

tasks like throwing a ball against the wall and

picking it up off the floor when dropped, as well

as dynamic standing tasks. Despite this, the team

felt that CIMT could be adapted for a wheelchair

user. This may tax the imagination of the thera-

pist and patient more, in order to come up with

sufficient variety of tasks, but a CIMT pro-

gramme in our experience may well serve to

improve a patient’s trunk and therefore, poten-

tially, their functional level, by increasing the

involvement of the affected side in activities of

daily living.

• Conversely, within an inpatient service, if the

patient has the potential to improve their

mobility it is difficult to completely prioritise (as

is required for traditional CIMT) the upper limb

over mobility – from a discharge planning point

of view as well as from the patient’s perspective.

Perhaps for this type of patient, CIMT would be

better provided within the community at a later

stage or perhaps a modified version of CIMT

could be considered, involving fewer hours of

massed practice daily. This might be particularly

relevant in light of recent protocol changes now

being employed by the originators of CIMT in

America. They now favour three hour training

programmes rather than six hours although mitt

wearing continues to be aimed at 90% of waking

SYNAPSE Spring 2012 28/05/2012 11:21 Page 7

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SPRING/SUMMER 2012

hours (Morris 2011). This training schedule may

make CIMT easier to apply in the inpatient NHS

environment.

• The majority of articles on CIMT thus far, have

studied patients with stroke. Various studies

have looked at patients at different lengths of

time post-stroke and some other patient groups

have been studied eg multiple sclerosis (Mark et

al 2008) and traumatic brain injury (TBI)

patients (Page 2003). TBI patients are now eli-

gible, alongside stroke patients, for Dr Edward

Taub’s Therapy Clinic. In addition to these

patient groups, CIMT could perhaps be applied

to others eg post excision of a space occupying

lesion, or patients with an encephalopathy or

infection. Anyone presenting with unilateral

upper limb weakness that is motivated, cogni-

tively intact and has some return of functional

movement and has the potential to improve

could, in theory, benefit.

CONCLUSION

As a unit we now feel confident and are set up,

ready to provide a two week intensive CIMT pro-

gramme for appropriate patients. This article has

detailed our first experience of applying CIMT to

an inpatient setting within the NHS. We faced the

day to day difficulties of real-life NHS work rather

than the controlled environment of a research

trial. What I have strived to do is share our quali-

tative experience of the practicalities including

the barriers and difficulties of trying to apply

evidence based practise into our clinical work in

the hope that it will encourage readers to also try

the approach because the effects were quite

extraordinary.

ACKNOWLEDGEMENTS

The author wishes to thank Annie Meharg for her many helpful

comments and Stephanie Andrews for joint preparation of our CIMT

programme.

British Society of Rehabilitation

Medicine (2009) Standards for

Rehabilitation Services Mapped

onto the National Service

Framework for Long-Term

Conditions Royal College of

Physicians. London, UK [online]

Available at:

http://www.bsrm.co.uk/

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and Kleim JA (2006) Motor

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specific patterns of plasticity

across motor cortex and spinal

cord Journal of Applied

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Johansen-Berg H and Wade DT

(2001) Evaluation of the Modified

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the University of Maryland Arm

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Physicians (2010) Stroke Service

Standards Clinical Standards

Committee [online] Available at:

http://www.basp.ac.uk/Link

Click.aspx?fileticket=%2FKYTI

cgdxg0%3D&tabid=653&mid

=1053 [Accessed 14 July 2011]

SYNAPSE Spring 2012 28/05/2012 11:21 Page 8

ARTICLE 1

Party (2007) National Sentinel

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(organisational audit) 2006

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Evaluation Unit, Royal College of

Physicians London, UK [online]

Available at:

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contents/d1301a83-729b-4342-

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17 July 2011].

Royal College of Physicians (RCP)

Intercollegiate Stroke Working

Party (2008) National Clinical

Guidelines for Stroke 3rd Edition.

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Evaluation Unit, Royal College of

Physicians London, UK [online]

Available at:

http://bookshop.rcplondon.ac.uk/

contents/6ad05aab-8400-494c-

8cf4-9772d1d5301b.pdf [Accessed

18 July 2011].

Sadowski B (2008) Plasticity of

the Cortical Motor System Journal

of Human Kinetics (20) pp 5-21.

Sunderland A, Tinson D, Bradley L

and Langton Hewer R (1989) Arm

function after stroke. An

evaluation of grip strength as a

measure of recovery and a

prognostic indicator Journal of

Neurology, Neurosurgery and

Psychiatry (52) pp 1267-1272.

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(2006) A Placebo-Controlled Trial

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EXCITE Trial: Retention of

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Receiving CI Movement Therapy

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EXERCISE

Mini Solitaire

ck up Sticks

Counters and jar

Counters

Nut and bolt

Cards

Marbles

Keys

Writing

Cupboard and fridge

DESCRIPTION

Dexterity task focusing on pincer grip – picking up and

ving small pegs between holes on a board.

Dexterity task focusing on pincer grip accuracy, trying to

pick up sticks without moving the other sticks around it.

Picking up counters from a jar and placing them on the

table and vice versa.

In hand manipulation – pick up counters one at a time,

gradually increasing the number held in the hand -

release one at a time.

Flower press with wing nuts on bolts, patient screws the

nut down then back up.

Turn over individual playing cards.

In hand manipulation – as counters task.

In hand manipulation of key to undo locks of

cupboards/drawers at various heights therefore also

range of movement and strength.

Writing grip.

Open and close cupboards/fridge and unload then

reload items in and out of cupboards/fridge.

SHAPING TASKS

Increase speed by timing, change height of board

ie pl

ace on a block, change distance from patient.

Speed, change distance moved, change size of sticks

eg matchsticks

Change height of jar, speed, change type of counter –

use coins, change distance of jar from patient.

Use coins or smaller counters, release into a target of

varying size, pick up from different surface / container,

distance from patient.

Speed, use standard nut rather than wing nut, distance

of press from patient.

Speed, distance of pack from patient, size of cards, lay

cards out individually or in a pile.

Use different size marbles, use different shape objects

such as pens or paperclips.

Start with low cupboards and build up to higher ones,

vary number of keys on key ring, speed, distance patient

stands from cupboard.

Follow pattern with index finger if writing too difficult,

adapted pens, start with large patterns/letters and

reduce size, mazes.

Start with lower shelves/cupboards and build up to

higher ones, different size, weight and shape items, vary

distance patient stands from cupboard.

Appendix 1

Examples of exercises

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ABSTRACT

This case report describes the use of botulinum toxin A (BT-A) in the treatment of elbow flexor spasticity in a 69 year

old male, who suffered a large right middle cerebral artery infarct. The patient had BT-A administered eight weeks

post stroke, alongside 45 minutes daily physiotherapy and a splinting regime, as an in-patient on the stroke unit. A

variety of measurement tools, including goniometry, Tardieu Scale, Numeric Graphic Rating Scale, photography and

Goal Attainment Scale (GAS), were used before BT-A, and repeated on day 14 and day 28 post injection, to assess the

different components of spasticity and its impact on function. BT-A was found to be safe and efficacious in reducing

elbow flexor spasticity in this case. Improvement in patient centred goals was found, with better than expected GAS

scores at 28 days post BT-A, including a 40° increase in passive range of movement, a reduction in pain, greater

tolerance of splinting, reduction in carer burden and improved positioning. The integrated multi disciplinary team

involvement essential for best practice in spasticity management makes it difficult to distinguish the effects of

separate therapeutic components in relation to the outcomes. Clinical trials investigating the use of BT-A early post

stroke remain scarce and further research is warranted.

Key words: Botulinum toxin A, spasticity, stroke, elbow flexors.

Collateral nerve sprouting eventually enables the

nerves to re-innervate the muscle. In clinical terms

the effects of the BT-A injection last around three

to four months (Moore et al 2003). There is strong

evidence from randomised control trials (RCTs)

that BT-A reduces upper limb (UL) spasticity post

stroke (Childers et al 2004, Bakheit et al 2000,

Smith et al 2000, Simpson et al 1996). There is also

a growing body of evidence demonstrating how the

reduction of spasticity translates into functional

benefits in terms of reduction in disability, carer

burden and improvements in goal achievement

(McCrory et al 2009, Francis et al 2004, Brashear

et al 2002, Bhakta et al 2000).

In routine clinical practice BT-A tends to be given

once the clinical signs of spasticity have become

established which is usually several months post

stroke. By this time secondary complications such as

pain and contractures are likely to become estab-

lished (Cousins et al 2010). The RCP guidelines (2009)

suggest appropriate use of BT-A in the early phases

of rehabilitation may prevent soft tissue shortening

and potentially help to avoid learned disuse and facil-

itate neurological recovery. Early treatment may also

reduce the costs of long term care.

Use of Botulinum toxin

in the treatment of elbow flexor spasticity

in acute stroke – a case report

Emma Bretherton Senior physiotherapist, University Hospitals of Leicester

Spasticity is defined as ‘a velocity-dependent

increase in tonic stretch reflexes’ (Lance

1980). It can be painful, distressing, and a

potentially costly cause of disability. It may

contribute to secondary complications

including impaired function, contracture,

pressure ulcers and reduced quality of life

(Moore et al 2003). Nineteen percent of

patients after stroke are reported to have

spasticity at three months and thirty-eight

percent after one year (Watkins et al 2002).

Recent data suggest that spasticity may

develop within a week following stroke

(Malhotra et al 2008).

BT-A is recommended as an effective treatment

for focal spasticity, without affecting sensation or

the associated systemic side-effects of other anti-

spasmodic agents (RCP 2009). A meta-analysis of

36 studies has demonstrated both its efficacy and

safety (Naumann and Jankovic 2004). BT-A aims

to reduce spasticity by blocking acetylcholine

release at the neuromuscular junction, thereby

inducing muscle weakness (Barnes 2003).

SYNAPSE Spring 2012 28/05/2012 11:22 Page 10

ARTICLE 2

In order to evaluate the effectiveness of treat-

ment intervention it is important to record valid

and reliable data about spasticity and its effects

on function. Much debate exists in the literature

regarding the measurement tools available and

their clinical relevance (Haugh et al 2006, Morris

2002). The RCP guidelines (2009) suggest the use

of a battery of tools to address the different com-

ponents of spasticity and its impact on function.

This case report aims to demonstrate the early

use of BT-A in the treatment of UL spasticity eight

weeks post stroke. The measurement tools used

include, goniometry, Tardieu Scale, Numeric

Graphic Rating Scale, Photography and Goal

Attainment Scale.

PATIENT CASE PRESENTATION

Patient A, is a sixty-nine year old male who suf-

fered a large right middle cerebral artery infarct

resulting in a dense left (L) hemiplegia. He had no

significant past medical history and was fully

independent prior to his stroke. He was an in-

patient on the stroke unit for a total of fourteen

weeks where he was under the care of a stroke

specialist multi-disciplinary team (MDT). Eight

weeks post stroke, he was making good progress

in some aspects of rehabilitation and was able to

stand and transfer with assistance of one.

However, his (L) UL remained non-functional, with

no selective voluntary activity. He developed pain

and spasticity in his (L) UL. The impact of the UL

spasticity will be the focus of this case report and

has been classified according to the International

Classification of Functioning, Disability and Health

(ICF) (WHO, 2001), see Table 1 below.

CLINICAL EXAMINATION

On examination eight weeks post stroke the

muscle involvement in the spasticity appeared rel-

atively focal to the elbow flexors. On palpation

biceps brachii and brachioradialis felt particularly

overactive.

Initial spasticity management involves excluding

any aggravating factors such as, constipation,

infection or pain. This is because spasticity results

partly from the abnormal processing of sensory

input and nociceptive stimuli, therefore such

factors can exacerbate spasticity and make it

harder to treat (RCP 2009). Patient A complained

of pain at the site of biceps brachii and therefore

regular paracetamol was given for analgesia, no

other aggravating factors were found. However,

despite reducing the pain, the spasticity remained

unchanged. The MDT agreed that a predominantly

neural component was evident at the elbow

flexors because the resistant to passive elbow

extension was velocity dependent. This was differ-

entiated from the non-neural component ie the

mechanical restraint of soft tissues, by assessment

of slow and fast passive range of movement and

recorded with the Tardieu Scale.

MEASUREMENTS

The Tardieu Scale (Haugh et al 2006) was selected

to measure spasticity as it has been suggested that

it provides higher intra-rater and inter-rater relia-

bility compared with the Modified Ashworth Scale

(Mehrholz et al 2005). The Tardieu Scale also aims

to measure the relative contribution of the velocity-

dependent neural mechanisms ie spasticity (V3)

and the mechanical restraint of soft tissues ie

passive range of movement (PROM (V1)). It is

therefore suggested as a more valid spasticity scale.

However, a key criticism is that it is time-con-

suming; rating was therefore limited to V1 and V3

as recommended (RCP 2009). The position of the

patient was standardised in sitting on each test and

range of movement was measured with goniometry.

Arm pain around biceps brachii was graded

using the Numeric Graphic Rating Scale (NGRS)

(RCP 2009) where by; 0 = no pain and 10 = most

severe pain.

PATIENT GOALS

Four priority goals were determined through col-

laborative agreement with the patient and MDT

before the injection therapy. Please refer to Table 2.

IMPAIRMENTS

• (L) elbow flexor spasticity.

• Decreased passive range of movement (PROM) (L) elbow extension.

• No voluntary active movement throughout (L) UL.

• Pain in (L) arm around biceps brachii.

• Associated reactions into (L) elbow flexion during effortful tasks.

ACTIVITIES: PASSIVE FUNCTION

• No functional use (L) UL.

• Difficulty putting (L) arm through sleeve and dependent on carer

for assistance with dressing.

• Unable to tolerate elbow extension splint; causing pain and

redness on the skin with pressure markings as the arm pulled into

elbow flexion against the splint.

• Difficulty achieving or maintaining good positioning of the (L) UL

in bed and when sitting in the wheelchair.

PARTICIPATION

• Dependent on a carer for (L) UL dressing and positioning.

• Reduced tolerance sitting out in wheelchair, greater time in bed

and decreased social interaction.

Table 1

ICF

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SPRING/SUMMER 2012

The Goal Attainment Scale (GAS) (Ashford and

Turner-Stokes 2006) was selected as it provided an

individualised measurement approach. The validity

and reliability of the scale has been demonstrated

in other settings and preliminary studies support

that it provides a useful measure of functional

gains in response to treatment of spasticity with

BT-A (Ashford and Turner-Stokes 2006). The goals

were reviewed with the patient and measured

weekly. The numerical rating of the goals helps

clearly identify areas of progression, plateau or

deterioration. The patient’s goals were also dis-

cussed at weekly MDT care planning meetings as

part of the integrated team-work approach in spas-

ticity management during stroke rehabilitation.

INTERVENTION

The MDT agreed that BT-A would be an appro-

priate treatment selection for Patient A’s focal

spasticity. Following patient written consent, BT-A

was injected intramuscularly into biceps brachii

and brachioradialis. Although BT-A is reported to

diffuse into active neuromuscular junctions within

the muscle, endplate targeting has been reported

to potentiate BT-A effects (Gracies et al 2002).

Deshpande et al (2006) described the endplates of

biceps brachii as an inverted V-shaped band just

below the midpoint of the humerus. Utilising this

and knowledge of anatomical landmarks, 60 units

of Botox® was injected between two sites targeting

both heads of biceps brachii. Electromyography

(EMG) injection guidance, as recommended for

muscles more difficult to locate (Wissel et al 2009),

was used for brachioradialis where 40 units of

Botox® was injected at a single site. Relatively low

doses within the recommended range (RCP 2009)

were selected due to this being the initial treat-

ment and the acute nature of the stroke. A dilution

volume of 2mls per 100 units of Botox® was

selected due to muscle size.

Brachialis was not injected as it has been sug-

gested that it has weaker elbow flexion power and

provides muscular protection of the joint, ensuring

contact between the articular surfaces over the

flexor aspect (Huber and Heck 2008). Mayer et al

(2008) interestingly found reduced activity in

brachialis post injection of biceps brachii and bra-

choradialis, suggesting leakage of the toxin to

adjacent muscles.

The clinical effect of BT-A occurred gradually

over seven days as expected (Barnes 2003). It is

widely recognised and emphasized throughout the

national guidelines that BT-A should be used in

parallel with an integrated MDT management

plan (RCP 2009). Indeed Giiovanelli et al (2007)

suggest that physiotherapy in combination with

BT-A can significantly improve overall response.

Patient A attended forty five minute daily physio-

therapy sessions, Monday to Friday, throughout

his fourteen week hospital stay. Following RCP

(2009) spasticity guidelines, (L) elbow extension

stretching exercises and splinting were carried

out, despite the controversy in the literature that

exists with regards to their benefit (Katalinic et al

2011; Bovend’Eerdt et al 2008). Physiotherapy

also played an important role in advising the MDT,

patient and family on careful handling and posi-

tioning, contributing to the maintenance of muscle

length, control of pain and spasticity.

An elbow extension splint was made on day

seven post BT-A as recommended (RCP, 2009).

Splinting provides a prolonged stretch aiming to

KEY: +2 Much better than expected +1 Better than expected 0 Expected target goal -1 Worse than expected -2 Much worse than expected

GOAL 1: PROM

Increase PROM of (L) elbow

xtension by 30°

Increase PROM of (L) elbow

extension by 20°

Increase PROM of (L) elbow

extension by 10°

Maintain PROM of (L) elbow

extension at 140°

Decrease PROM of (L) elbow

extension to less than 140°

GAS SCORE

-1

-2

GOAL 2: PAIN

Achieve a reduction in pain

ore by 5 or more points

Achieve a reduction in pain

score by 3 to 4 points

Achieve a reduction in pain

score by 1 to 2 points

Achieve no change in pain

score (7/10)

Achieve an increase in pain

score by 1 or more points

(>7/10)

GOAL 3:DRESSING

Put (L) arm through sleeve

ndependently with ease

Put (L) arm through sleeve

independently with difficulty

Put (L) arm through sleeve

with minimal assistance of 1

Put (L) arm through sleeve

with moderate assistance of 1

Put (L) arm through sleeve

with maximum assistance

of 1

GOAL 4: SPLINTING

Tolerate (L) arm splint for

reater than 6 hours per day

Tolerate (L) arm splint for

6 hours per day

Tolerate (L) arm splint for

4 hours per day

Tolerate (L) arm splint

2 hours per day

Not able to tolerate (L)

arm splint

Table 2

GAS Scale

SYNAPSE Spring 2012 28/05/2012 11:22 Page 12

ARTICLE 2

improve muscle length. Optimal duration is

unclear, however, some evidence suggests splints

should be worn for at least six hours, therefore, it

was aimed that tolerance towards this would grad-

ually be reached (Tardieu et al 1988). Figure 1

displays the elbow extension splint in situ.

Nurses, occupational therapists and stroke

physicians are examples of other key members of

the MDT who were involved in the coordinated

management of spasticity. For example the occu-

pational therapists played an important role in

splinting and provision of seating. Nurses were

responsible for implementing positioning pro-

grammes and careful handling of the patient

throughout the 24-hour period, and the stroke

physician was involved in on-going medical man-

agement, including analgesic review.

RESULTS

Measurements were recorded prior to BT-A injec-

tions, on day 14 and day 28 post injection, in line

with follow-up recommendations (RCP 2009).

They were repeated at the same time of day and

by the same rater. Tables 3, 4 and 5 (overleaf)

display the assessment findings.

Photographs were taken to illustrate any changes

pre and post treatment, particularly with regards to

positioning of the (L) arm in bed and when sitting in

the wheelchair. The photographs displayed in

Figures 2 to 4 clearly illustrate the improvement in

positioning from pre- BT-A to day 28.

DISCUSSION

The injections were well tolerated and no adverse

effects were found in patient A, consistent with the

results of a meta-analysis by Naumann and

Jankovic (2004). A reduction in elbow flexor spas-

ticity was demonstrated by increases in the angle

at which the muscle reaction occurs (Y angle,

Table 3) and decreases in the spasticity angle on

the Tardieu Scale at day 14, with further improve-

ment found at day 28 post BT-A. This suggests that

Figure 1

Supine with elbow extension splint in situ

BT-A in conjunction with the integrated MDT

management was effective in reducing spasticity,

supporting previous RCT’s in stroke (Brashear et

al 2002, Bakheit et al 2000, Bhakta et al 2000

Figure 2

Supine: pre-BT-A

Figure 3

Supine: 28 days post-BT-A

Figure 4

Sitting in wheel chair pre-BT-A (left) and post-BT-A (right)

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SPRING/SUMMER 2012

Smith et al 2000, Simpson et al 1996). The large

difference of 50° found between V1 and V3 on the

Tardieu Scale pre-BT-A was suggestive of a large

dynamic and neural component; whereas smaller

differences have been suggested to represent a

more mechanical restraint of the soft tissues

(Morris 2002). It is important to note that the level

of pain around biceps brachii on passive elbow

extension (V1) was limiting PROM and hence

measurement of soft tissue length was difficult to

assess. The impact of decreased pain levels must

therefore be considered when viewing the

improvements found in PROM post BT-A. The

quality of muscle reaction (X = 2, Table 3)

remaining at day 28, shows no change in the

quality component of the measure, however this

should be analysed with caution. A systematic

review of the Tardieu Scale questioned the rela-

tionship of the categories to assess quality and

found that this part of the scale was not even used

in five of the ten papers reviewed (Haugh et al

2006).

The pain score reduced more than expected to

3/10 NGRS, by day 28 post injection, supporting

analgesic effects of BT-A (Barnes 2003). Relief of

spasticity and increased freedom of movement at

a joint have been reported to be likely contribu-

tors to pain relief (Bhakta et al 1996). However,

McCrory et al (2009) and Bhakta et al (2000),

found no significant improvement in pain fol-

lowing BT-A compared with placebo in their RCTs.

It is important to note that in this case report,

patient A’s analgesia was changed concomitantly,

with the inclusion of Buprenorphine (BuTrans®

10 patch). This makes assessment of BT-A’s contri-

bution to relief of pain difficult and is recognised

as a limitation.

A reduction in elbow flexor spasticity seemed to

correlate with increasing ease of putting arm

through sleeve and reducing carer burden. This

was demonstrated by improvement in goal three

to +1 on the GAS, thus supporting a RCT that

found a reduction in disability and carer burden

following BT-A (Bhakta et al 2000).

V1:SLOW AS POSSIBLE

PROM ELBOW EXTENSION

140°

160°

180°

TIMESCALE

Pre BT-A

Day 14

Day 28

V3: FAST AS POSSIBLE

Y: ANGLE AT WHICH

MUSCLE REACTION OCCURS

90°

120

155°

V1 – V3

SPASTICITY ANGLE

50°

40°

25°

X: QUALITY OF

MUSCLE REACTION

Table 3

Tardieu Scale for (L) elbow flexors

GOAL 1:PROM

-1

TIMESCALE

Pre BT-A

ay 14

Day 28

GOAL 2: PAIN

-1

GOAL 3: DRESSING

-1

GOAL 4: SPLINTING

-2

Table 5

GAS scores

PAIN AT REST

0/10

TIMESCALE

Pre BT-A

ay 14

Day 28

PAIN ON PASSIVE ELBOW EXTENSION

7/10

4/10

3/10

Table 4

NGRS (L) arm pain

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ARTICLE 2

Patient A gradually increased tolerance to the

splint and the expected target was achieved for

goal 4 on GAS by day 28. Better than expected

changes in GAS scores were found for goals 1 to 3

at day 28. This suggests that the reduction in spas-

ticity translated into improving the ability to

achieve patient centred goals, supporting previous

findings (McCrory et al 2009, Ashford and Turner-

Stokes 2006). A probable reason for greater than

expected changes may be that alongside the

reduction in spasticity, other factors also improved

including reduction in pain, improved positioning,

greater tolerance of splinting and therapy. Greater

recovery expected in the acute stage post stroke

also needs to be considered. Research, however,

into the use of BT-A in the acute phase remains

scarce (Cousins et al 2009).

Patient A was discharged home from hospital,

following a 14-week stay, to care of the community

physiotherapy team, who provided ongoing follow-

up. The management plan was to review the

patient at the spasticity clinic in three to four

months post BT-A as recommended (RCP 2009), as

it was anticipated that the effects of the BT-A may

have worn off (Moore et al 2003). It would there-

fore be important to assess whether functional

levels had been maintained with ongoing physio-

therapy, splinting and positioning regimes. It

would also be prudent to consider whether further

injections are indicated, particularly with the

acute nature of the stroke and better than

expected achievements in GAS after 28 days.

Thorough re-assessment and use of outcome

measures are key to inform the clinical reasoning

at this point; repeated injections if indicated are

recommended at no less than three month cycles

(RCP 2009).

CONCLUSION

BT-A was found to be safe and efficacious in

reducing elbow flexor spasticity post acute stroke,

which translated into higher GAS scores. This was

reflected by an improvement in the ability to

achieve patient centred goals 28 days post BT-A,

including increased PROM, a reduction in pain,

greater tolerance of splinting, ease of putting

affected arm through sleeve, reduction in carer

burden and improved positioning. The integrated

MDT involvement essential for best practice in

spasticity management makes it difficult to distin-

guish the effects of separate therapeutic

components in relation to the outcomes in this

single case study design.

KEY POINTS

• BT-A used early post stroke may benefit patients

with focal spasticity.

• BT-A should be used in parallel with an inte-

grated MDT management plan.

• BT-A used alongside physiotherapy, splinting

and positioning regimes was beneficial in the

management of focal elbow flexor spasticity in

this individual.

• Valid and reliable outcome measures to address

the different components of spasticity and its

impact on function should be used.

• GAS captured personally relevant achievements

in response to treatment of spasticity with BT-A.

Conflict of interest

The author received financial support from Allergan to attend the

Injection Therapy Masters Module at the University of Coventry. Allergan

have had no involvement in the preparation of this case study.

Address for correspondence

Physiotherapy Department, Leicester General Hospital, Gwendolen

Road, Leicester, LE5 4PW

SYNAPSE Spring 2012 28/05/2012 11:22 Page 15

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SPRING/SUMMER 2012

Upon sitting upright the gentleman vigorously

extended his non-affected upper and lower

extremities, pushing upon the plinth as though

to resist an imminent fall towards his unaf-

fected side – despite the presence of a

reassuring physiotherapist sitting next to him.

This was what I witnessed during my first week

of a practice based learning placement within

an acute stroke unit, and I was left pondering

the behaviour of this patient who had suffered a

right-sided total anterior circulation stroke

(TACS). At first I could not fathom why the

person acted in this way – why would someone

with a marked left-sided hemiplegia be so deter-

mined to actively push his way onto his affected

side? I learned that the patients behaviour was

characteristic of something called ‘pusher syn-

drome’ – my immediate interest lead me to

investigate this phenomenon further, and was

nurtured over the course of a stimulating and

enjoyable placement. My experience has since

motivated me to write the following article.

The term ‘pusher syndrome’ (PS) as named by

Davies (1985) is used to describe the performance

of pushing behaviour towards the paretic side of

the body (contralateral to the cortical lesion) using

the unaffected upper and/or lower limbs, and is

commonly observed by neurological physiothera-

pists in hemiplegic stroke patients. Furthermore,

attempts by physiotherapists’ to manually correct

sitting posture in such circumstances are often

met with significant resistance from patients, who

have been reported to express a fear of falling

towards their non-affected side (Karnath et al

2000). Such ‘contraversive pushing’ may result in

loss of postural balance within the frontal plane,

causing the individual to fall laterally towards

their paretic side upon upright sitting, standing or

when performing transfers (Karnath et al 2000,

Karnath & Broetz 2003, Paci et al 2009). Indeed, it

is likely that physiotherapists are often among the

first health professionals to witness pusher behav-

iour (PB) in clinical settings, considering that

initial medical assessment upon patient admission

following acute stroke is often performed with the

patient in supine (Karnath 2007).

PS is often mistaken for similar postural disor-

ders associated with neurological injury, such as

‘listing’ whereby patients experience a loss of

sitting balance towards their paretic side sec-

ondary to muscular weakness, rendering them

unable to maintain static equilibrium (Karnath &

Broetz 2003). As these individuals are able to

recognise their loss of sitting balance they tend to

‘pull’ on objects using the non-paretic upper limb

in order to correct sitting posture – not ‘push’

(Karnath & Broetz 2003). The active PB, which

commonly manifests as abduction and extension

of the non-affected limbs, as well as resistance to

manual correction, differentiates PS from other

balance disturbances (Karnath 2007).

PATHOPHYSIOLOGY AND UNDERLYING MECHANISMS

The underlying epidemiology and aetiology of the

disorder remain poorly understood, despite the

topic receiving considerable focus within scientific

literature during the past decade. Previously

reported prevalence rates have varied extensively,

ranging from 10 – 60% (Paci et al 2009). There is

general consensus that PB can be attributed to a

disturbed perception of verticality (Paci et al

2009). Specifically, it is believed that PS arises

from an impaired perception of body orientation

relative to gravity or ‘behavioural vertical’,

derived from the processing of visual, vestibular

and somatosensory afferent information (Paci et

al 2009). The latter comprise the subjective verti-

cals, which are: subjective visual vertical (SVV);

subjective haptic vertical (SHV); and subjective

postural vertical (SPV) (Paci et al 2009).

Pusher Syndrome:

a relevant issue in stroke rehabilitation

Jordan Hepburn,BSc (Hons) Applied Sports Science MSc Physiotherapy (Pre-Registration)

Student Physiotherapist, Queen Margaret University

SYNAPSE Spring 2012 28/05/2012 11:22 Page 16

ARTICLE 3

The finding that patients with PS demonstrate

an intact SVV, evidenced by their ability to align

their body’s longitudinal axis with earth-vertical

using visual environmental cues, implies the exis-

tence of a second graviceptive system responsible

for processing afferent activity from the trunk

from which SPV is derived (Karnath et al 2000,

Karnath & Broetz 2003). Such afferent activity

may arise from somatosensory receptors in the

skin, golgi tendon organs and muscle spindles, as

well as impulses transmitted via the renal, phrenic

or vagus nerves generated from the inertia of

mass within the body. Furthermore, patients with

vestibular lesions who demonstrate a tilted SVV

are still able to orientate themselves with earth

vertical – implying the utilisation of an alternative

graviceptive system (Karnath 2007).

In a study by Karnath et al (2000), patients with

PS were found to perceive themselves as being

upright (SPV) when tilted 18° towards the ipsile-

sional side upon a rotational seating device. So

why then do patients with PS perform contraver-

sive pushing in the presence of an ipsileisional

bias of SPV? It is believed that PB arises as an

attempt to compensate between a disturbed SPV

and an intact SVV, as opposed to resolving this

problem with weighted summation (Karnath &

Broetz 2003). This notion is supported by the

observation that PB diminishes when patients are

deprived of visual input, thus eliminating the need

to compensate (Karnath & Broetz 2003).

Furthermore, this may explain the marked patient

resistance encountered by physiotherapists when

attempting to provide postural correction, as this

may interfere with active compensatory attempts.

It has also been suggested that PB may arise via

alternative mechanisms, such as when patients

experience lateral instability upon standing or

sitting upright secondary to aligning their body’s

longitudinal axis with an ipsilesional SPV

(Karnath & Broetz 2003). Pérennou et al (1998)

expressed that PS may arise from a cessation of

contralesional afferent activity and its respective

cortical processing, termed ‘graviceptive neglect’.

Although previous authors have implied a strong

association between PS and spatial neglect, con-

sensus indicates that neglect does not cause PS –

rather that PS is highly associated with neglect

and aphasia in right and left hemisphere lesions

respectively (Pederson et al 1996, Karnath et al

2000, Karnath & Broetz 2003). Clearly, establish-

ment of the exact underlying mechanisms of PS

awaits the results of future research, although

current evidence provides a theoretical platform

from which treatment strategies can be devised.

Previously considered as a relay station to other

structures, it has been postulated that the poste-

rior lateral thalamus is predominantly involved in

the control of upright body posture, and may rep-

resent the brain structure most commonly

affected in PS (Dietz et al 1992, Karnath et al

2000, Karnath et al 2005). Therefore, this area is

likely to be responsible for the processing of the

aforementioned postural afferent activity.

However, previous experimental studies have

identified other brain areas which may be impli-

cated in the disorder including the parietal and

insular cortex, suggesting the existence of a

complex processing loop with cortical as well as

sub-cortical elements responsible for controlling

upright body posture (Saj et al 2005, Paci et al

2009). Indeed, this multicomponential model may

explain the strong association of PS with spatial

neglect and aphasia (Paci et al 2009).

PHYSIOTHERAPY MANAGEMENT

Despite the potential disruption of PS to the imple-

mentation of physiotherapy interventions in

stroke rehabilitation, the disorder has a surpris-

ingly favourable long-term prognosis, with

previous studies having reported that such

patients demonstrate a complete resolution of

symptoms six-months following hospital admis-

sion (Karnath et al 2002). Although PS is not

considered to influence rehabilitation outcomes, it

can have a significant effect on the rate of

recovery post-stroke, particularly in the early

stages of rehabilitation. In the Copenhagen Stroke

Study, which examined 327 stroke patients over a

one year period, patients with PS took approxi-

mately four weeks longer to achieve the same

functional level as their unaffected counter-parts

(Pederson et al 1996). This delay in functional

recovery represents longer periods of hospital

stay and increased strain upon physiotherapy

resources, illustrating a clear rationale for physio-

therapeutic intervention specifically targeted at

treating the disorder (Karnath 2007).

The finding that the integrity of SVV is preserved

in patients with PS has led to the proposal of a

treatment approach which utilises this ability to

correct their disturbed postural body orientation

(Karnath & Broetz 2003). The ipsilesional bias of

SPV in patients with PS means that a perceived

‘upright’ body posture corresponds to a tilted

visual field – it is believed that this must be chal-

lenged primarily so that patients acknowledge

that their visual input is representative of reality,

and thus can identify their disturbed SPV

(Karnath & Broetz 2003). Karnath and Broetz

(2003) recommended the use of visual cues repre-

sentative of ‘earth vertical’ within the therapeutic

environment, such as the edges of window frames,

doors, or even the use of a therapist’s arm. Such

SYNAPSE Spring 2012 28/05/2012 11:22 Page 17

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●

SPRING/SUMMER 2012

cues serve to promote awareness of the patients

erroneous body posture and provide a reference

point to which their longitudinal body axis can be

aligned (Karnath & Broetz 2003). Once patients

are able to assume a correct upright body posture

using this method, the therapist may begin to

incorporate non-affected upper limb activities

such as reaching for objects, involving weight dis-

tribution to the ipsilesional side in order to

minimise abduction and extension of the non-

affected limbs (Karnath & Broetz 2003, Broetz et

al 2004). Upon mastery of the latter elements in

sitting and standing, these may then be combined

with distractive activities in order to progress to

an autonomous stage of skill learning (Broetz et al

2004). Although high quality scientific studies sup-

porting its efficacy are lacking, improvements in

PB when using this treatment approach have been

recorded by Broetz et al (2004), with eight acute

stroke patients being able to stand with therapist

assistance following 18 days of daily 30-minute

treatment sessions.

It would appear that this strategy follows the

motor re-learning approach to rehabilitation as

opposed to one incorporating the Bobath method,

and perhaps neglects the re-training of

somatosensory graviceptive pathways as previ-

ously described – although alternative approaches

have been suggested (Paci et al 2009). Panturin

(2004), for example, suggested performing move-

ment of the lower trunk upon a stationary upper

trunk in order to stimulate graviceptive receptors

involved in the control of SPV. The use of mirrors

to promote patient awareness of erroneous body

posture has also been described, although evi-

dence supporting the effectiveness of this

approach in PS is lacking (Trueland 2009).

A number of assessment tools exist, which can

be used by physiotherapists to both diagnose PS

and monitor patient progress through quantifica-

tion of PB. The ‘Scale for Contraversive Pushing’

(SCP) by Karnath et al (2000) comprises of an

ordinal scale which measures PB according to

three variables: spontaneous body posture; exten-

sion of the unaffected arm/leg to increase the area

of physical contact with the ground; and resist-

ance to passive correction of posture to an upright

position measured in both sitting and standing

(Baccini et al 2008, Babyar et al 2009). Patients

are considered to have PS if a score of 1 is

achieved for each of the latter variables (Karnath

& Broetz 2003). A recent systematic review of the

literature supported the reliability, validity and

clinical applicability of the SCP, as well as the

‘Modified Scale for Contraversive Pushing’ (MSCP)

and the ‘Burke Lateropulsion Scale’ (BLS) (Babyar

et al 2009). Furthermore, the MSCP and BLS were

considered to be most appropriate for monitoring

changes in PB secondary to their wider metric

ranges, whilst the SCP remained the most exten-

sively tested measure of the three (Babyar et al

2009).

CONCLUSION

In conclusion, PS is a problem that warrants inter-

vention during rehabilitation following stroke,

given its association with longer periods of hos-

pital stay and delayed functional recovery. The

need for future research is clear, especially to

establish the efficacy of the aforementioned treat-

ment approaches. Furthermore, having witnessed

how effective evidence based management of PS

by physiotherapists can accelerate functional

recovery in such patients during my own practice

based learning experiences, as a student physio-

therapist I am motivated to tackle this problem

upon entry into the profession.

Acknowledgements

I would like to express my gratitude to physiotherapists Fiona Genney

and Suzanne Offer of Raigmore Hospital Inverness for providing me with

an invaluable practice based learning experience which inspired me to

write the current article.

REFERENCE LIST

Babyar SR, Peterson MGE,

Bohannon R, Pérennou D and

Reding M (2009) Clinical

examination tools for

lateropulsion or pusher

syndrome following stroke: a

systematic review of the literature

Clinical Rehabilitation (23)

pp639-650.

Baccini M, Paci M, Nannetti L,

Biricolti C and Rinaldi LA (2008)

Scale for Contraversive Pushing:

Cutoff scores for diagnosing

‘Pusher Behaviour’ and construct

validity Physical Therapy 8 (88)

pp947-955.

Broetz D, Johannsen L and

Karnath HO (2004) Time course of

‘pusher syndrome’ under visual

feedback treatment

Physiotherapy Research

International 9 (3) pp138-143.

Davies PM (1985) Steps to Follow:

A Guide to the Treatment of Adult

Hemiplegia (Springer, New York).

Dietz V, Gollhofer A, Kleiber M

and Trippel M (1992) Regulation

of bipedal stance: dependency

on load receptors Experim Brain

Res (89) pp229-231.

Karnath HO (2007) Pusher

syndrome – a frequent but little-

known disturbance of body

orientation perception Journal of

Neurology (254) pp414-424.

Karnath HO and Broetz D (2003)

Understanding and treating

‘pusher syndrome’ Physical

Therapy (83) pp 1119-1125.

Karnath HO, Ferber S and

Dichgans J (2000) The origin of

contraversive pushing: evidence

for a second graviceptive system

in humans.’ Neurology, (55), pp

1298-1304.

Karnath HO, Ferber S and

Dichgans J (2000) The neural

representation of postural control

in humans Neurology 25 (97)

pp13931-13936.

Karnath HO, Johannsen L,

Broetz D, Ferber S and Dichgans J

(2002) Prognosis of contraversive

pushing Journal of Neurology

(249) pp1250-1253.

Karnath HO, Johannsen L,

Broetz D and Kuker W (2005)

Posterior thalamic hemorrhage

induces ‘pusher syndrome’

Neurology (64) pp1014-1019.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 18

ARTICLE 3

Paci M, Baccini M and Rinaldi L

(2009) Pusher behaviour: A

critical review of controversial

issues Disability and

Rehabilitation 31 (4) pp249-258.

Panturin E (2004) Pusher

syndrome [Letter to the Editor]

Physical Therapy (84) pp580-583.

Pederson PM, Wandel A,

Jorgenson HS, Nakayama H,

Raaschou HO and Olsen TS (1996)

Ipsilateral pushing in stroke:

Incidence, relation to

neuropsychological symptoms,

and impact upon rehabilitation.

The Copenhagen Stroke Study

Arch Phys Med Rehabil pp25-28.

Pérennou DA, Amblard B,

Leblond C and Pélissier J (1998)

Biased postural vertical in

humans with hemispheric

cerebral lesions Neurosci Lett (252)

pp75-78.

Saj A, Honore J, Coello Y and

Rousseux M (2005) The visual

vertical in the pusher syndrome:

Influence of hemispace and body

position Journal of Neurology

(252) pp885-891.

Trueland J (2009) Seeing is

believing [Online] Available at:

http://www.csp.org.uk/frontline/

article/seeing-believing

[Accessed 26/01/2012].

www.coventry.ac.uk

Postgraduate Opportunities for

Neurological Physiotherapists

Coventry University’s Faculty of Health and Life Sciences has a

range of modules designed to build and extend the professional

practice of neurological physiotherapists. For example:

• The Neural Control of Human Behaviour

• The Principles of Neurorehabilitation

• Injection Therapy

• Evidence Based Practice

• Developing Expertise in Working with Children and Young People

The modules can be taken as stand alone modules or incorporated into one

of our MSc Programmes. They would be suitable for those therapists wanting

to develop their knowledge and understanding of neurology and those wishing

to move into more specialist roles.

For more information please contact Julie Sellars (Course Tutor)

at j.sellars@coventry.ac.uk the Postgraduate Admission Unit

on 024 77 654321 or gradadmissions.uni@coventry.ac.uk

SYNAPSE Spring 2012 28/05/2012 11:22 Page 19

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SPRING/SUMMER 2012

Lecture

abstracts

Plasticity in

neurorehabilitation:

some unanswered

questions

John C Rothwell

Professor of Human Neurophysiology, UCL

Institute of Neurology, Queen Square,

London, UK

There is now reasonable evidence that at

least some of the recovery of function fol-

lowing damage to the CNS or even the

periphery, is due to reorganisation of neu-

ral connections in the brain. It is thought

that rehabilitation therapy harnesses

these processes, allowing the CNS to

achieve optimal output from a damaged

system. New brain stimulation protocols

such as transcranial magnetic stimulation

or transcranial direct current stimulation

are presently being tested to improve

recovery, usually with the rationale that

application of ‘plasticity modifying’ inter-

ventions before or during therapy will

enhance the overall response. Effectively

the reasoning is to try to improve or

speed natural processes of reorganisation.

However, although this type of model is

attractive and based on a steadily increas-

ing body of evidence, there are still a

number of questions that need to be

addressed in future investigations, for

example:

1 Is there any formal evidence that

behavioural learning is improved by

these interventions in clinical popula-

tions? Or could improved outcomes

actually be the result of completely dif-

ferent mechanisms?

2 How well will enhanced functions gen-

eralise to untrained movement? Will

brain stimulation therapy make newly

learned function more fixed and less

adaptable?

3 How well are gains within each session

of training consolidated for future use?

ACPIN

NATIONAL

CONFERENCE

& AGM 2012

Hilton Hotel Northampton

9th and 10th March 2012

THE ASSOCIATION

OF CHARTERED

PHYSIOTHERAPISTS

IN NEUROLOGY

www.acpin.net

SYNAPSE Spring 2012 28/05/2012 11:22 Page 20

THE BACKBONE OF NEUROLOGY

Are there ways in which this can be

improved?

4 Finally, if brain stimulation interventions

work by enhancing natural processes of

behavioural learning, will standard ther-

apy reach the same performance

plateau if applied for a sufficiently long

period of time?

John C Rothwell

After receiving a PhD from the University of London,

UK, in 1980, John Rothwell worked in London as a

Royal Society University Research Fellow in the

Neurology Department of Professor CD Marsden at

the Institute of Psychiatry until 1988, before moving

as a senior scientist to the Medical Research Council

Human Movement and Balance Unit at the Institute

of Neurology. In that period he developed his inter-

est in the pathophysiology of human movement dis-

orders, with particular attention to Parkinson’s

Disease, dystonia and myoclonus. The 1980s were

times of great expansion in the new technique of

transcranial magnetic stimulation, which he and oth-

ers developed for the study of the human cortical

motor system. He became acting director of the

MRC Unit in 1998 before being appointed to be head

of the Sobell Department of Motor Neuroscience

and Movement Disorders at UCL Institute of

Neurology in London and was elected a Fellow of

the Academy of Medical Sciences in 1994. He is cur-

rently Professor of Human Neurophysiology at UCL

Institute of Neurology. Current research projects

include using neurophysiological techniques to study

the mechanisms of neural plasticity that underpin

motor learning, and using this knowledge to devise

new therapeutic interventions for rehabilitation after

stroke.

Physiotherapy

management of

people with spinal

cord injuries:

the essentials

Lisa Harvey

Associate Professor, Rehabilitation Studies

Unit, Northern Clinical School, Sydney Medical

School, University of Sydney, Sydney, Australia

The primary aim of physiotherapy for

people with spinal cord injuries (SCI) is to

help individuals attain optimal levels of

independence with mobility and activities

of daily living. There are five steps

involved in planning and implementing

an appropriate physiotherapy programme

regardless of a patient’s stage of rehabili-

tation.

They are: assessing impairments,

activity limitations and participation

restrictions; setting goals; identifying key

problems amenable to physiotherapy;

administering treatments and measuring

outcomes. Often the most difficult step for

physiotherapists not familiar with SCI is

setting goals. This is difficult because it

requires an understanding of what

patients can be expected to achieve. This

of course varies, depending on a number

of factors, but most importantly depend-

ing on neurological status. Identifying key

problems amenable to physiotherapy can

also be a challenging step for physiother-

apists inexperienced in SCI. It requires an

understanding of the evidence base for

different therapeutic approaches. The best

evidence about appropriate treatments

comes from randomised controlled trials

and systematic reviews. We are still in the

early stages of building high-quality evi-

dence but there is reasonable evidence to

support the use of physiotherapy to treat

six key impairments.

These are: lack of

strength; lack of dexterity and skill; poor

respiratory function; limited cardiovascu-

lar fitness; restricted range of motion and

pain. There is also emerging evidence to

support new and novel therapeutic

approaches which include the use of

robotics. However, as we move forwards

it will be important to ascertain the cost-

effectiveness of new interventions before

advocating for their widespread rollout to

the public.

References

1 Harvey L (2008) Management of spinal cord

injuries: a guide for physiotherapists London:

Elsevier.

2 Harvey L, Lin CM, Glinsky J, De Wolf A (2009) The

effectiveness of physical interventions for people

with spinal cord injuries: a systematic review

Spinal Cord 47 pp184-195.

3 Harvey L, Wyndaele JJ (2011) Are we jumping too

early with locomotor training programs? Spinal

Cord 49 p947.

Lisa Harvey

Lisa has 25 years clinical and research experience in

the area of spinal cord injuries. She is currently

Associate Professor at Sydney School of Medicine,

University of Sydney and has a conjoint appointment

at the Moorong Spinal Unit, Royal Rehabilitation

Centre Sydney. She has over 70 publications on a

diverse range of topics including contracture and

hand management, gait along with exercise and

respiratory physiology. She primarily focuses on clini-

cal trials designed to determine the effectiveness of

different physiotherapy interventions for people

with spinal cord injury and other neurological condi-

tions. Lisa teaches widely both nationally and inter-

nationally, and is very involved in assisting with the

further development of physiotherapy services for

people with spinal cord injuries throughout the less-

resourced countries of Asia. She initiated and contin-

ues to manage a website of physiotherapy exercises

appropriate for people with neurological conditions

(www.physiotherapyexercises.com). In addition, she

has sole authored a comprehensive text book on

physiotherapy management of spinal cord injuries

and is currently coordinating a large international

initiative to develop freely available online learning

modules in spinal cord injuries for physiotherapy stu-

dents and junior clinicians. Lisa sits on the editorial

boards of Spinal Cord, Journal of Physiotherapy and

the Journal of Neurologic Physical Therapy and is

chairperson of the International Network of Spinal

Cord Injury Physiotherapists (www.scipt.org).

“Stop blubbing and

get to work”

neurophysiotherapy – a

consumer’s viewpoint

Melanie Reid

Journalist for The Times

A personal insight into the experience of

rehabilitation from a serious spinal injury;

the discovery that my injury was not com-

plete, as was first thought; and my subse-

quent fight to regain some function aided

by spinal physiotherapists. I will talk

about the importance of having a good

relationship with one’s physiotherapist;

about the huge impact the Locomat had

on my rehabilitation; about mental

resilience; and about my maddeningly

slow progress from Asia A to knocking on

the door of Asia D.

Melanie Reid

Melanie Reid, 54, was born in London and studied

English at Edinburgh University. An award-winning

journalist for more than 30 years, she held senior

editorial posts on the Scotsman, the Sunday Mail

and the Glasgow Herald and for the last five years

has been a columnist for The Times. In 2010 she fell

off her horse at a jump and broke her neck at C6

and fractured T12. Since then she has charted her

life in Spinal Column in The Times’ Saturday maga-

zine.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 21

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SPRING/SUMMER 2012

Washed up and worn

out? Implementing

evidence based practice in

the current financial climate

Michelle Price

Consultant therapist for stroke and neuroreha-

bilitation, Powys Teaching Health Board,

Brynheulog Rehabilitation Unit, Newtown

Hospital, Powys, Wales

Driving forward improvements in physio-

therapy services and implementing evi-

dence based practice is hard in the current

financial climate. Efforts to constantly

improve clinical services can leave physios

feeling washed up and worn out. This

presentation explores how the attributes

of neurophysiotherapists can help them

be instrumental in developing effective

and efficient services and gives some

practical tips on how to achieve small

changes that improve the quality of

patient care even in the most rural setting.

Michelle Price

Michelle graduated from Bath School of

Physiotherapy in 1992. She has specialised in neuro-

sciences since 1996. She moved to Wales in 1999.

She has worked in a wide variety of clinical roles

across south Wales in acute, rehabilitation and com-

munity settings. She completed an MSc in

Physiotherapy at Cardiff University in 2006. She

completed the Gateway to Lead Programme deliv-

ered by the National Leadership and Innovation

Agency for Healthcare (NLIAH) in 2008. She was the

programme manager for the All Wales Stroke

Service Improvement Collaborative (AWSSIC)

between 2008 and 2011 initially as part of the

Stroke Service Improvement Programme and then

as mini-collaboratives as part as 1000 Lives Plus.

This involved supporting the development and

implementation of care bundles for acute stroke,

early stroke rehabilitation and TIA services. She

started her role as Consultant Therapist for Stroke

and Neurorehabilitation in Powys in December

2010, becoming full time in April 2011.

The effect of

temperature on

neuromuscular

function

in health and

neurological disease

Jon Marsden

Professor of Rehabilitation, School of Health

Professions, Faculty of Health, Education and

Society Plymouth University UK

Changes in temperature have several

physiological effects in healthy partici-

pants with cooling and warming having

opposite effects. Cooling a limb leads to a

reduction in motor and sensory nerve

conduction velocity, maximal voluntary

strength and the rate of force generation.

These changes are in part mediated by

alterations in voltage-gated ion channel

dynamics and a reduction in Na+/K+

ATPase activity that are vital for regenera-

tive nerve and muscle action potentials.

Limb cooling may also increase muscle

stiffness and viscosity and reduce muscle

thixotropy. A comparison of tendon and H

reflexes further suggests that cooling can

affect muscle spindle activity resulting in

a decrease in stretch reflex size.

The effect of temperature on people

with neurological deficits varies depend-

ing on the underlying pathology. In the

presence of peripheral or central nerve

demyelination an increase in temperature

can cause conduction block. This may

underlie Uhthoff’s phenomema in people

with multiple sclerosis, where symptoms

worsen with an increase in core tempera-

ture as occurs with exercise.

Cooling has been used to manage vari-

ous symptoms in people with neurologi-

cal disease. Studies of the effects of

cooling on spasticity are variable but cool-

ing does consistently reduce tremor asso-

ciated with cerebellar disease, essential

tremor or dystonia. Localised warming

may enhance reductions in limb stiffness

with stretching and recent work in people

with hereditary spastic paraparesis sug-

gests that it can lead to increases in

strength, rate of force generation and

walking ability. In people with long term

neurological conditions, autonomic nerv-

ous system dysfunction and/or vascular

changes secondary to limb disuse may

affect the vascular response to a change

in temperature. This may further impact

on temperature-related changes to the

neuromuscular system.

Jon Marsden

Jon Marsden qualified as a physiotherapist in 1991;

he undertook clinical rotations at the United Bristol

Healthcare Trust and the National Hospital for

Neurology and Neurosurgery in London. From 1999

he worked as a postdoctoral scientist in the Sobell

Department for Motor Neuroscience and Movement

Disorders, UCL investigating the pathophysiology

and rehabilitation of walking and balance following

peripheral and central nervous system damage.

Since 2007 he has been Professor of Rehabilitation

at the School of Health Professions, University of

Plymouth.

Parkinson’s

physiotherapy audit

2011: preliminary results

Fiona Lindop

Specialist Physiotherapist, Derby Parkinson’s

Disease Service, Derbyshire Royal Infirmary,

Derby UK

The first physiotherapy audit of the NICE

Guidelines for Parkinson’s Disease was

carried out between July and November

2011 with the aim of evaluating whether

services are providing assessment and

interventions appropriate to the needs of

people with Parkinson’s, taking into

account both the NICE and NSF for Long

Term Conditions recommendations. The

audit also looked at whether physiothera-

pists were aware of the UK Quick refer-

ence Cards which provide standardised

guidance for physiotherapists working

with people with Parkinson’s. I will pres-

ent the preliminary findings and the

implications of these results.

Fiona Lindop

Fiona Lindop is a specialist physiotherapist in

Parkinson’s Disease and related conditions, working

as part of a multi-disciplinary team in Derby who

have been awarded ‘Centre of Excellence’ status

from the American National Parkinson Foundation.

Since qualifying in Aberdeen she has worked in

London, Hertfordshire, Yorkshire and Derbyshire. She

SYNAPSE Spring 2012 28/05/2012 11:22 Page 22

THE BACKBONE OF NEUROLOGY

has developed a physiotherapy-specific assessment

tool for Parkinson’s Disease (The Lindop Parkinson’s

Disease Assessment Scale- LPAS) and was a co-

writer of the physiotherapy section of the

Parkinson’s UK Guide for Professionals. Fiona is vice-

chair of the Association of Physiotherapists in

Parkinson’s Disease Europe (APPDE) and is currently

representing physiotherapy on the committee for

the national audit of the NICE guidelines for

Parkinson’s Disease.

Vestibular

rehabilitation:

the true backbone of

neurology

Anne Rodger

Clinical specialist, National Hospital for

Neurology and Neurosurgery, London, UK

Dizziness is very common (one in five vis-

its to GPs are for dizziness). This can com-

monly be caused by dysfunction within

the peripheral vestibular system, for

which physiotherapy has a huge role in

the assessment and successful treat-

ment.Neurologically impaired people

often present with vestibular dysfunction.

This could be viewed as being a central

disorder, but it could equally be of periph-

eral origin. Being able to assess appropri-

ately is as ever the key to treatment

success. A knowledge of vestibular reha-

bilitation is essential to any physiothera-

pist involved in treating people with

balance dysfunction.

Anne Rodger

Anne qualified as a physiotherapist in 1990 and has

since worked in Brighton, Addenbrookes, The Royal

Free and most recently at the National Hospital for

Neurology and Neurosurgery where she has been a

clinical specialist for the last 10 years. She com-

pleted an MSc in Neurorehabilitation at Brunel

University in 2003. At the NHNN, she treats a mix-

ture of vestibular and neurologically impaired

patients. She helped set up the Vestibular Special

Interest Group (ACPIVR) and was the chair from

2005 to 2011.

Information

technology:

how can we use it to

progress physiotherapy and

better communicate around

the world?

Lisa Harvey

Associate Professor, Rehabilitation Studies

Unit, Northern Clinical School, Sydney Medical

School, University of Sydney, Sydney, Australia

Information technology provides a rich

opportunity to progress and globalise

physiotherapy. For example, physiothera-

pists from around the world can now

communicate and share ideas through

social media forums; teachers can put

their educational material online for all to

see; clinicians can share exercise ideas

and treatment videos through sophisti-

cated internet-based software; patients

can access guidance and help from phys-

iotherapists in the comfort of their homes.

In addition, information technology is

helping to bridge the gap between phys-

iotherapists around the world. For exam-

ple, online learning packages are helping

to upskill physiotherapists from low

resource countries where access to high

quality physiotherapy-specific education

can sometimes be limited. While all these

uses of information technology are to be

welcomed they raise some interesting

issues. These include issues around

patient privacy, intellectual property, lia-

bility, funding and copyright. They also

include issues related to the potential

misuse of material and the blurring of

lines between physiotherapists’ profes-

sional and personal lives. We are yet to

work our way through the complexities

associated with advances in information

technology but regardless, the next ten

years will see information technology

change the face of physiotherapy across

the globe.

Lisa Harvey

Lisa has 25 years clinical and research experience in

the area of spinal cord injuries. She is currently

Associate Professor at Sydney School of Medicine,

University of Sydney and has a conjoint appointment

at the Moorong Spinal Unit, Royal Rehabilitation

Centre Sydney. She has over 70 publications on a

diverse range of topics including contracture and

hand management, gait along with exercise and

respiratory physiology. She primarily focuses on clini-

cal trials designed to determine the effectiveness of

different physiotherapy interventions for people

with spinal cord injury and other neurological condi-

tions. Lisa teaches widely both nationally and inter-

nationally, and is very involved in assisting with the

further development of physiotherapy services for

people with spinal cord injuries throughout the less-

resourced countries of Asia. She initiated and contin-

ues to manage a website of physiotherapy exercises

appropriate for people with neurological conditions

(www.physiotherapyexercises.com). In addition, she

has sole authored a comprehensive text book on

physiotherapy management of spinal cord injuries

and is currently coordinating a large international

initiative to develop freely available online learning

modules in spinal cord injuries for physiotherapy stu-

dents and junior clinicians. Lisa sits on the editorial

boards of Spinal Cord, Journal of Physiotherapy and

the Journal of Neurologic Physical Therapy and is

chairperson of the International Network of Spinal

Cord Injury Physiotherapists (www.scipt.org).

Stretch for the

treatment and

prevention of

contractures:

what does the evidence

say?

Lisa Harvey

, Owen Katalinic

and

Robert D Herbert

1 Associate Professor, Rehabilitation Studies Unit,

Northern Clinical School, Sydney Medical School, The

University of Sydney, Australia. 2 Physiotherapist,

Rehabilitation Studies Unit, Northern Clinical School,

Sydney Medical School, The University of Sydney,

Australia. 3 Associate Professor, Musculoskeletal

Division, The George Institute for Global Health, The

University of Sydney, Australia.

Stretch is widely used for the treatment

and prevention of contractures but little is

known about its effectiveness. A Cochrane

Systematic Review was undertaken.

1, 2

All randomised controlled trials of stretch

interventions (sustained passive stretch-

ing, positioning, splinting and serial cast-

ing) applied for the purpose of treating or

preventing contractures were considered

for inclusion. Two reviewers independ-

ently selected trials, extracted data, and

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SPRING/SUMMER 2012

assessed risk of bias. Pooled estimates

were obtained using a random-effects

model. 35 trials with 1,391 participants

met the inclusion criterion. 25 trials inves-

tigated the effect of stretch in people with

neurological conditions. In these people,

stretch increased joint range of motion by

3° (95% CI, 0 to 5) in the immediate term

(<24 hours after last stretch), by 1° (95%

CI, 0 to 3) in the short term (<1 week

after last stretch) and by 0° (95% CI, -2 to

2) in the long term (>–1 week after last

stretch) when compared with no treat-

ment or usual care. The results were simi-

lar for people with non-neurological

conditions. The results of this review do

not support the use of stretch interven-

tions administered for less than six

months for the treatment or prevention of

contractures. These results are challenging

for the physiotherapy profession because

they require the reappraisal of an inter-

vention which we have long believed to

be effective. Contractures are a complex

problem and can not be readily treated or

prevented by stretch alone. We are yet to

identify an effective treatment strategy

but it may involve a multi-pronged

approach including a package of modali-

ties such as electrical stimulation, motor

training, botulinum toxin and stretch.

References

1 Katalinic OM, Harvey LA, Herbert RD, Moseley AN,

Lannin NA, Schurr K (2010) Stretch for the treat-

ment and prevention of contractures The Cochrane

Database of Systematic Reviews Issue 9 Art No:

CD007455. DOI:

10.1002/14651858.CD007455.pub2.

2 Katalinic OM, Harvey LA, Herbert RD (2011)

Effectiveness of stretch for the treatment and pre-

vention of contractures in people with neurologi-

cal conditions: a systematic review Physical

Therapy 91 pp11-24.

Lisa Harvey

See previous.

Owen Katalinic

Physiotherapist, Rehabilitation Studies Unit,

Northern Clinical School, Sydney Medical School,

The University of Sydney, Australia

Owen is a physiotherapist working part-time as a

project officer on the freely accessible physiotherapy

exercise website: www.physiotherapyexercises.com.

The website contains exercises appropriate for peo-

ple with neurological disabilities and has recently

received funding from the NSW Department of

Ageing, Disability and Home Care to add 200 addi-

tional paediatric exercises.

Robert D Herbert

Associate Professor, Musculoskeletal Division,

The George Institute for Global Health, The

University of Sydney, Australia

Robert is a senior research fellow at The George

Institute, associate professor in the Faculty of

Medicine at the university, and senior honorary

research associate at the Prince of Wales Medical

Research Institute. Rob’s primary interest is in the

effectiveness of physiotherapy interventions, partic-

ularly stretch-based interventions for prevention and

treatment of contracture. He also conducts comple-

mentary research into the passive mechanical prop-

erties of human muscles and tendons.

What is the cause of

balance impairment

in patients with

cerebellar disease?

Lisa Bunn

Post-doctoral research fellow and physiother-

apy lecturer, School of Health Professions,

Faculty of Health, Education and Society,

Plymouth University, UK

Balance impairment is a common feature

of cerebellar disease. This affects a variety

of long term neurological conditions

involving cerebellar pathology but the

cause of balance impairment remains

unknown. In order to begin to understand

the effect of cerebellar pathology on bal-

ance this program of study explores sen-

sory processing for balance control in

persons with pure cerebellar lesions. SCA6

provides a good human model of pure

cerebellar disease; cerebellar atrophy is

principally caused by Purkinje cell death,

the condition can be genetically diag-

nosed with a blood sample and balance

impairment is commonly the presenting

symptom on initial diagnosis

Advantageously, a validated measure of

disease severity for those with SCA6 (the

scale for assessment and rating of ataxia)

is also available in order to explore

associations with measures of balance

impairment

Laboratory-based recordings of 3D

whole body motion as balance measures

were initially collected whilst subjects

were positioned in five different stance

widths (0 ,4, 8, 16 and 32cm between

medial calcanei). Once SCA6 measures

were compared against those of the

healthy control group, the extent of bal-

ance impairment and distribution of

whole body instability was better under-

stood for those with pure cerebellar dis-

ease. Laboratory driven means of

perturbing balance via manipulation of

isolated sensory afferent signals were

then used to explore sensory control

mechanisms of balance. Balance

responses to visual stimuli were particu-

larly elevated in magnitude compared to

healthy controls and response magni-

tudes correlated strongly with disease

severity scores

. A newly designed novel

home-based therapy was then trialled

and feasibility of use established.

Although underpowered (due to an initial

focus on feasibility), early outcome meas-

ures suggest potential for effectiveness of

the intervention in terms of impairment,

function and participation. A fully pow-

ered randomised controlled trial of the

therapy is now needed.

Guidelines for the management of

ataxia are currently lacking in the quantity

and scientific rigour of supporting evi-

dence base

. This program of study pro-

vides one significant contribution to future

development of guidelines concerning

management of balance impairment in

cerebellar ataxia.

References

1 Giunti & Wood (2007) The inherited ataxias ACNR

7 (5) pp18-21.

2 Schmitz-Hübsch et al (2006) Scale for the assess-

ment and rating of ataxia. Neurology66 (11)

pp1717-1720.

3 Bunn L (2010) Sensory mechanisms of balance

control in pure cerebellar disease Doctoral thesis,

UCL (University College London)

http://discovery.ucl.ac.uk/1306178/

4 Marsden J, Harris C (2011) Cerebellar ataxia:

pathophysiology and rehabilitation Clinical

Rehabilitation 25 (3) pp195-216.

Lisa Bunn

Lisa Bunn worked as a physiotherapist at Stoke

Mandeville Hospital and North Bristol NHS Trust prior

to embarking on a career as a researcher and lec-

turer. In 2006 she undertook a PhD with University

College London investigating balance impairment in

persons with cerebellar ataxia. PhD work, based in

the Institute of Neurology and the Specialist Ataxia

Centre, focussed in on patients with pure types of

cerebellar disease. One aim was to establish a base-

line from which effects of additional extra-cerebellar

SYNAPSE Spring 2012 28/05/2012 11:22 Page 24

THE BACKBONE OF NEUROLOGY

pathologies can later be compared against. PhD

work led directly onto the development of a novel

therapy targeting ocular control of balance and a

feasibility study evaluating home-based delivery of

this study was conducted in 2010. Post-doctoral

research has continued to focus on neuro-rehabilita-

tion; specifically on improving an understanding of

patho-physiological mechanisms with the aim to

target future therapies. Now employed at Plymouth

University, Lisa is working on projects consistent

with this aim. Lisa is currently working a split role

between post-doctoral research, undergraduate and

post-graduate lecturing duties within the School of

Health Professions at Plymouth University.

Taking the patient to

the next level: high

intensity exercise in

neurological rehabilitation

Bernhard Haas

Associate Professor in Physiotherapy and

Deputy Head of the School of Health

Professions at Plymouth University, UK

The health related benefits of exercise in

the general population are well docu-

mented. Individuals following neurologi-

cal insult are severely tested to achieve

recommended quantities of activity and

exercise and their lack of exercise

increases the risk for cardiovascular dis-

ease further. This presentation challenges

rehabilitation professionals to support

their patients to overcome barriers to

exercise participation. The evidence for

incorporating cardiovascular and strength-

ening exercises into neurological rehabili-

tation is now firmly established. Exercise

training therefore should be the backbone

of neurological rehabilitation. High inten-

sity exercise trials have recently shown

promise in improving fitness, strength as

well as function still further and have the

potential to raise the rehabilitation out-

comes of patients in a numbers of condi-

tions. The intensity aspect of the

frequency, intensity, type and time (FITT)

exercise prescription principles therefore

should receive a stronger focus in treat-

ment planning.

Bernhard Haas

At Plymouth Bernhard has specific responsibility for

all matters relating to learning and teaching of the

seven health professions in the School (dietetics,

occupational therapy, operating department practice,

optometry, paramedicine, physiotherapy and podia-

try). Bernhard qualified as a physiotherapist in 1984

in West Berlin. He moved to the UK in 1984, working

in hospitals and trusts in Oxford and

Buckinghamshire. It was at the National Spinal

Injuries Centre at Stoke Mandeville where he devel-

oped his expertise in rehabilitation and patient man-

agement. He left full time work in the NHS in 1992

to take up his first teaching post at the University of

Brighton. Bernhard joined Plymouth in 2003 in order

to design the new physiotherapy programme and

taking it to its initial approval and validation. His

research interests are in the area of neurological

rehabilitation, specifically related to activity, exercise

and function in conditions such as Parkinson’s

Disease and spinal cord injury.

Workshop

sessions

OPTION 1

What is going on down

under in spinal cord injuries:

clinical driven research and

research driven practice

Lisa Harvey

Associate Professor, Rehabilitation Studies

Unit, Northern Clinical School, Sydney Medical

School, University of Sydney, Sydney, Australia

The primary aim of this workshop is to

provide an informal opportunity for dele-

gates to discuss barriers and opportunities

for driving and practicing evidence-based

practice in the clinic. While the focus will

be on spinal cord injuries, the broad prin-

ciples will be equally relevant to all areas

of neurology. The presenter will provide

some short examples of the model used

in Australia to bridge the gap between

researchers and clinicians. There will also

be an opportunity to discuss recent

advances in physiotherapy management

of people with spinal cord injuries and the

current push away from teaching com-

pensatory strategies and push towards

focusing on the potential for recovery

below the level of the lesion. The expec-

tations of the media, neuroscientists and

consumers for people with spinal cord

injury to recover and walk following

spinal cord injury and influence of these

expectations on the way physiotherapy is

being increasingly marketed and provided

around the world will also be discussed.

OPTION 2

How to write a case study

Gita Ramdharry

Senior Lecturer, Faculty of Health and Social

Care Sciences, St George’s University of

London/Kingston University

This session will outline case reports, their

contribution and what to write about.

Using examples and exercises, attendees

will be given the opportunity to start

thinking about and planning a report on a

case of interest.

OPTION 3

Independent practice – is it

for you?

Sally de la Fontaine

Milestones Clinic, Egham, Surrey

Is there a need for a support network? A

unique opportunity to discuss these ques-

tions with a panel of experienced neuro-

physiotherapists all of whom work, in

varying ways, within private practice.

OPTION 4

Company presentations

Bioness Inc

Bioness offers award winning wireless

functional electrical stimulation (FES) sys-

tems – the NESS H200 Hand Rehabilitation

System, the NESS L300 Foot Drop System

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SPRING/SUMMER 2012

and the highly innovative NESS L300 Plus

Thigh Simulation System. The devices

offer real therapy solutions both during

treatment sessions or for home use.

Bioness technologies can improve hand

function and walking and so independ-

ence and quality of life, as well as

improving ROM, muscle strength and local

circulation and reducing muscle tone.

With high technology that is easy to use,

the systems can be used at any stage dur-

ing the recovery process.

Saebo UK

Saebo UK are an orthotic

distributor and training

company specialising in

neurological rehabilitation. In addition to

our SaeboReach, SaeboFlex and

SaeboStretch we have now launched our

new Saebo Mobile Arm Support which we

are demonstrating at the ACPIN confer-

ence. To find out more about our Free

Assessment Sites, product range and

training please contact us at

[email protected]om

Cyclone Technologies

Cyclone Technologies is a

leading UK manufacturer

of custom wheelchairs,

providers of functional

electrical stimulation products, spinal

injury therapy equipment, The ReWalk

and more.

Speed

updates

What does ACPIN do?

UPDATE 1

Splinting guidelines

Jo Tuckey

Private Practitioner, co-chair of national ACPIN

2008 -2010, ACPIN representative for devel-

opment of splinting guidelines

ACPIN in conjunction with the College of

Occupational Therapists specialist section

neurological practice (COT SSNP) have

finalised a contract to produce neurologi-

cal splinting practice guidelines.

The work is being joint funded by ACPIN

and COT SSNP and being carried out at

Brunel University London under the direc-

tion of Dr Cherry Kilbride and Prof Lorraine

De Souza.

The need for splinting guidelines and

current practice was established by a joint

survey carried out in 2009/10. It was

completed by 420 therapists, one third

were physiotherapists and all responses

indicated a need for better guidelines. The

results of this survey are due for publica-

tion.

The work has commenced with the lit-

erature review; it is envisaged that the

guidelines will be completed by 2013.

There will be a call to be involved in a

Delphi Method later this year. Expressions

of interest should be sent to

[email protected]om.

This will be the first published joint

physiotherapy and OT guideline to be

undertaken.

UPDATE 2

International Neurological

Physical Therapy

Association (INPA)

Cherry Kilbride

Physiotherapy lecturer, Brunel University, UK,

co-Chair of national ACPIN 2008-2010, ACPIN

representative on INPA

INPA was formerly recognised at a sub-

group of the World Confederation for

Physical Therapy (WCPT) last year in

Amsterdam at the 16th World Physical

Therapy Congress.

INPA represents national groups of phys-

ical therapists with a special interest in

neurology and neuroscience. INPA is com-

mitted to promoting and facilitating excel-

lence in neurological physical therapy in

clinical practice, research and education.

For more information about the INPA,

please consult the Association web page

at: www.wcpt.org/INPA and join forum

discussion at the WCPT Neurology Forum

at: www.wcpt.org/smfforu

UPDATE 3

Intercollegiate Stroke

Working Party (ICSWP)

Royal College of Physicians London

Cherry Kilbride

See previous

The Stroke Programme at the RCP began

in 1996 and ACPIN has had a constant rep-

resentation since. The work of the Stroke

Programme is led by the Intercollegiate

Stroke Working Party, made up of repre-

sentatives from all the professional bodies

involved in stroke care including the vol-

untary sector and patient representation.

The purpose is to set evidence based stan-

dards, measure compliance in the organi-

sation and delivery of stroke care and

encourage service improvement. ACPIN

members will be familiar with the

Sentinel Stroke National Audit Programme

and the National Clinical Guideline for

Stroke. Nicola Hancock (past Chair of

ACPIN) is our representative on ICSWP.

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THE BACKBONE OF NEUROLOGY

UPDATE 4

Behind the scenes for

Parkinson’s

Bhanu Ramaswamy

Independent Physiotherapy Consultant

Fiona Lindop and I currently represent the

CSP, ACPIN and AGILE on several projects

relating to physiotherapy and Parkinson’s.

During this session, I will summarise the

work we have completed recently, and

are involved with at the moment, for and

with the Professional Networks that fur-

ther the profession and standards of clini-

cal practice for physiotherapists working

with people with this condition.

UPDATE 5

UK Stroke Forum (UKSF)

Fiona Jones

Reader in Rehabilitation, School of

Rehabilitation Science, Faculty of Health and

Social Care Sciences, St George’s University,

London, and Kingston University. Fiona

currently represents ACPIN on the UK Stroke

forum steering committee and scientific

committee

In December 2011, the UK Stroke forum

held another successful conference in

Glasgow. Against gloomy estimates of

reducing numbers, more delegates have

attended this conference year on year

since 2006 . ACPIN is represented on both

the UK Stroke Forum steering committee

and the Scientific Committee. We make

sure our voice is heard, working together

with colleagues from the special section

of neurologcial OTs and the Society for

Research In Rehabilitation. The aim is to

ensure that rehabilitation is fully repre-

sented as a topic within the programme,

and promote the role of ACPIN and phys-

iotherapy for people with stroke. This has

not always been easy! Fiona Jones will

present a short overview of her role on

the UK Stroke Forum committees, and

ideas for how ACPIN can gain greater

recognition and respect within these

groups.

WINNER ONE

Katherine Stone

Consultant Therapist in Neurology, PCH,

Cornwall.

Development of a new

clinical audit tool for

splinting in neurology

‘Splints and casts are external devices

designed to apply, distribute or remove

forces to or from the body in a con-

trolled manner to perform one or both

basic functions of control of body

motion and alteration or prevention in

shape of body tissue.’ ACPIN 1998

Aim: The aim of developing a new splint-

ing audit tool is to inform delivery of best

clinical care for adults who require splints

following acquired or progressive neuro-

logical dysfunction.

Objective: To evaluate the reliability and

validity of the new splinting audit tool in

clinical practice. The audit tool was devel-

oped from the standards in the National

Clinical Guidelines for Splinting Adults

with Neurological Dysfunction ACPIN

1998.

Method: A simple questionnaire identi-

fied five clinical areas that provided

splints for this population. Physiothera-

pists and occupational therapists in each

area were identified as raters to use the

audit tool. The audit tool grouped the

standards from the guidelines into twenty

five standards within six key topics. Each

set of clinical notes was double audited.

Results: One area was unable to complete

the audit resulting in four areas completing

the double audit on twenty sets of notes.

An interrater reliability analysis using the

Kappa statistic was performed to deter-

mine consistency among raters.

Measurement of the agreement between

the raters of the categorised variables was

found to have substantial agreement

(0.61-0.80) in three of the four areas and

almost perfect agreement in one area

(0.849) see Table of Aagreement.

Kappa Interpretation

<0 Poor agreement

0.00 – 0.20 Slight agreement

0.21 – 0.40 Fair agreement

0.41 – 0.60 Moderate agreement

0.61 – 0.80 Substantial agreement

0.81 – 1.00 Almost perfect agreement

Table of agreement (Landis & Koch 1977)

Posters

Winners’ presentation abstracts

Poster winners Jodi Afori

(left) and Katherine Stone

(right) with retiring Chair,

Siobhan MacAuley.

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SPRING/SUMMER 2012

Conclusion: This new audit tool has been

found to be both reliable and valid as a

measure of the standards of practice used

in neurological splinting. Further work to

ensure validity can be explored in a larger

study. The existing guidelines are to be

revised this year to allow for new evi-

dence to be incorporated into the recom-

mendations. The audit tool can be further

refined and evaluated to ensure it is still

valid as well as reliable.

Splinting Pathway

1 Clinical indication for splinting

• Goal & aims of splinting are identified

• Alternatives are considered

• Contraindications and cautions are

identified

• Clinical rationale to proceed is

documented

2 Consent

• Patient and carer are fully informed

with written/relevant information

• Verbal consent is documented

• Relevant health and social care

professionals are informed

3 Assessment

• Standardised assessment proforma

is used

• Aims are identified and agreed within

a management plan

• Outcomes are identified as appropri-

ate, valid and relevant

• Photograph record is taken (adhering

to Trust policy)

4 Application

• Splint materials follow specific

manufacturer’s guidelines

• Choice of splint material is

documented

• Splint regime is recorded

5 Monitoring

• Written information on splint use and

care is provided to patient and carer

• Method of monitoring is established

• Plan for re-assessment is documented

6 Evaluation

• Evaluation of the outcome is

documented

• Decision to re-apply or discontinue

use of splint is documented

Clinical Audit Tool for Splinting in Neurology

Management of neurological dysfunction with splinting: tool for audit of service provision.

Clinical Indication for splinting

1 Goal of splinting is identified Yes / No

2 Aim(s) of splinting are clearly identified Yes / No

3 Alternatives have been considered Yes / No

Contraindications and precautions

4 Cautions are identified and clinical rationale to proceed is documented Yes / No

Consent

5 MDT decision to splint is identified (Inpatient) Yes / No

Outpatient N/A

6 GP/other health care professionals involved in care informed (outpatient) Yes / No

Inpatient N/A

7 Family member/carer is involved in discussion for feasibility Yes / No

8 Patient is fully informed with written information Yes / No

9 Verbal consent is documented Yes / No

10 Written consent documented (non-removable splint) Yes / No

Removable splint N/A

Assessment

11 Standardised splinting assessment used Yes / No

12 Aim(s) are clearly agreed and identified within the management plan Yes / No

13 Outcome measure is appropriate and valid Yes / No

14 Outcome measure is relevant to the goal(s) Yes / No

15 Photograph record available (adhering to Trust protocol) Yes / No

Application

16 Splint materials are stored and used following specific manufacturers guidelines Yes / No

17 Choice of material is documented Yes / No

18 Position (lying/seated) during application is documented Yes / No

19 Splinting regime is recorded Yes / No

Monitoring

20 Written information on use and care of splint is provided to patient and carer Yes / No

21 Method of monitoring is established (skin integrity, pain, swelling etc) Yes / No

22 Protocol for emergency removal of splint is established (non-removable splint) Yes / No

23 Plan for re-assessment is documented Yes / No

24 Objective measure is documented at re-assessment Yes / No

25 Decision to re-apply or discontinue splint use is documented Yes / No

SYNAPSE Spring 2012 28/05/2012 11:22 Page 28

THE BACKBONE OF NEUROLOGY

WINNER TWO

Jodi Ofori

The effect of applied torque

and stretch duration on

range of movement,

passive stiffness and

spasticity in people with

multiple sclerosis.

AUTHORS

Ofori J

; Freeman J

; Bugman G

, GibbonsP

Zajicek J

, Hobart J

, Marsden J

1 School of Health Professions, Plymouth University

2 School of Computing and Mathematics, Plymouth

University

3 Peninsula College of Medicine and Dentistry,

Plymouth University

Purpose: To determine the effect of

stretch duration and applied torque on

peri- and post stretch changes in plan-

tarflexor passive stiffness, stretch reflex

excitability and ankle range of motion in

people with multiple sclerosis (pwMS).

Relevance: 80% of pwMS have an

increase in muscle stiffness caused by

changes in passive stiffness and/or spas-

ticity. Increases in stiffness are commonly

managed with stretching. However, the

current evidence base for stretching is

variable and there is a paucity of literature

regarding the stretch-related parameters

that effectively reduce stiffness.

Participants: Participants with clinically

defined MS (n=27; age 58 ± 10 yrs), with

a median EDSS 6.0 (range 4.5-7.0) who

self-reported leg stiffness.

Methods: The application of a constant

torque stretch using three different torque

values [high (0.42Nm/Kg), medium (0.30

Nm/Kg) and low (0.18 Nm/Kg)] over

either 30 minutes or 10 minutes was

investigated. For both stretch durations

participants were seen on three occasions

separated by a minimum of three days.

The order of the applied torque was

randomised. Ankle stiffness

(itorque/gposition) was measured

immediately before and after stretching

and at ten minute intervals post-stretch

over a 30 minute period. Slow (5o/sec-

ond {s}) and fast stretches (170o/s) of

the plantarflexors using a customised

motor were used to quantify the degree

of passive stiffness and stretch reflex

activity respectively. ROM was monitored

throughout the course of the experiment.

Analysis: The effect of applied torque on

passive stiffness, stretch reflex activity

and ROM, were compared using a

repeated measures analysis of variance

(ANOVA).For all statistical tests, the level

of significance was set at P<0.05.

Results: Constant torque stretches applied

for 10- 30 minutes significantly improved

ankle range of movement in pwMS; this

was more pronounced when higher forces

were applied (P<0.001).

Passive stiffness decreased with stretch-

ing although this was not affected by the

size of the applied torque

(P>0.05).Following a 30 minute stretch

passive stiffness decreased on average by

27% (±19%, P<0.05) and subsequently

increased by 7% in the 30 minutes post

stretch period. In contrast, 10 minutes of

stretching resulted in a 13% decrease in

passive stiffness (P<0.05) on average, this

returned to baseline levels within10 min-

utes post stretch.

There was no significant change in

stretch reflex excitability following a 30

minute stretch, regardless of the torque

applied (P>0.05). There was a significant

change in stretch-evoked stiffness follow-

ing a 10 minute stretch (P<0.05). Post hoc

tests revealed a 25% (±46%) decrease in

stretch-evoked stiffness immediately post

stretch (P<0.05). This then significantly

increased 10 minutes post stretch, such

that it was 31% (±60%) higher than

baseline levels.

Conclusions: Stretches using higher

torques led to significantly greater gains

in ROM. Longer duration stretches of 30

minutes achieved significantly greater

improvements in passive muscle stiffness

compared to 10 minutes with improve-

ments being maintained for up to 30 min-

utes post stretch.

The effect of constant torque stretches

on stretch-reflex evoked stiffness varied

with the length of stretch. Rebound

increases in spasticity after the end of a

stretch were seen, these were temporary

and the cause of this change and their

effects on function requires further inves-

tigation.

Implications: The torques applied in this

study were within the range that pwMS

could apply during manual stretches of

the ankle plantarflexors (Ofori et al,

2011). Thus, this study has implications

for the short term clinical management of

stiffness and contracture. We did not find

that stretching for a period greater than

ten minutes reduced spasticity. The

impact of the reduction in passive stiff-

ness and improvement in joint ROM on

functions such as walking ability need to

be assessed.

Keywords: stretching, multiple sclerosis,

spasticity, torque, stiffness

Funding acknowledgements: This study

was funded by an MS Society grant

(907/08)

Ethics: This study was conducted with the

approval of Devon and Torbay REC (REF

09/H0202/42)

SYNAPSE Spring 2012 28/05/2012 11:22 Page 29

Syn’apse

●

SPRING/SUMMER 2012

ACPIN AGM

2012

Minutes of the ACPIN AGM 2012

The meeting opened at 12.15pm

1 Welcome and introduction to

committee members

Committee members present: Adine

Adonis, Lorraine Azam, Sandy

Chambers, Jo Kileff, Siobhan

MacAuley, Chris Manning, Margaret

Mayston , Gita Ramdharry, Anne

Rodger, Jane Petty, Kate Busby, Lisa

Knight, Nicki Guck

2 Apologies

Emma Proctor, Jakko Brouwers

3 Minutes of AGM 2011

Accepted as an accurate account

Proposer: Chris Manning

Seconder: Adine Adonis

4 President’s address

Margaret Mayston

5 Chair’s address

Siobhan MacAuley

6 Treasurer’s report

Jo Kileff

Proposal to retain the current

accountant: Langers

Proposer: Helle Sampson

Seconder: by Chris Manning

7 Re-election of existing officers to

the Executive Committee

Honorary PRO

Adine Adonis

Proposer: Gita Ramdharry

Seconder: Kate Busby

Honorary research officer

Jane Petty

Proposer: Cherry Kilbride

Seconder: Andrea Stennett

Synapse editor

Lisa Knight

Proposer: Margaret Mayston

Seconder: Anne Rodger

iCSP officer

Chris Manning

Proposer: Jane Petty

Seconder: Anita Wade-Moulton

Membership secretary

Sandy Chambers

Proposer: Sue Edwards

Seconder: Kirsty Elliot

8 Election of new officers to the

Executive Committee

Committee member

Ralph Hammond

Proposer: S Paddison

Seconder: H Sampson

Committee member

Jennifer Barber

Proposer: Kirsty Elliot

Seconder: Claire Guy

10 Constitution

Amendment to the constitution as

published on notice boards and

distributed to regional reps.

Accepted by majority vote.

11 Affiliation agreement

Vote for acceptance of affiliation

agreement.

Accepted by majority vote.

12 AOB

None

The meeting closed at 1.00pm.

President’s address

Dr Margaret Mayston

The text of this address appears on page 3

of this edition of Synapse.

Chair’s address

Siobhan MacAuley

Our regional reps have all worked

together recently and produced A Guide

to Running an AGM so I hope we are com-

plying so far, and that I can follow their

instructions on the Chair’s address!

The instructions are to produce a report

of a description of the work over the past

year, “you may wish to mention particular

successes, frustrations, funding difficulties,

volunteer contributions or staff changes”,

“to thank those that have contributed”

and that the report should “be fairly

upbeat unless you are going to report the

folding of your organisation”. That makes

it all fairly easy and straightforward for

me!

In a year of lots of changes within the

healthcare system, particularly in England

but no doubt to follow in the other three

countries, ACPIN has remained buoyant

healthy and growing!

We have 2,600 members now and a

streamlined online membership system,

thanks to a mammoth task undertaken by

Sandy. So clearly upbeat as we are not in

any danger of folding!

We hosted an outstanding neurology

strand at CSP congress last year, and a big

thank you to Chris for that.

We have reached capacity for this con-

ference and unfortunately even had to

turn some delegates away, a sign that

ACPIN continues to provide its members

with superb continual professional devel-

opment. Thank you to Lorraine and Nicki

for organising the delegates and the

exhibitors.

We successfully facilitate links with a

number of other professional groups and

tomorrow morning you will get a full

account of the work and contribution from

Jo Tuckey, Cherry Kilbride, Bhanu

SYNAPSE Spring 2012 28/05/2012 11:22 Page 30

AGM 2012

Ramaswamy and Fiona Jones when they

present their speed updates.

Some of the frustrations have been the

work regarding the formation of the pro-

fessional networks with the CSP. We have

now become a ‘professional network’ and

sit within the neurology alliance with

ACPIVR. This was part of a streamlining

exercise within the CSP. As a result we

have also had some minor adjustments to

the constitution namely to do with the

membership criteria.

Funding difficulties … clearly not an

issue as Jo Kileff will report shortly.

Volunteer contributions … all ACPIN

committee members are volunteers and

manage to fit this in around work, family

and other demands – so thank you to all

the regions, committees and those that

work for ACPIN.

There are a few changes to the commit-

tee with Kate Busby stepping down after

a successful year as Synapse editor and

changes to the Chair and Vice Chair role.

ACPIN are always looking at ways to

improve and deliver our best to you, so

please fill in your delegate forms and let

us know how we can do that.

The thank-you’s are plentiful as I am

only the spokesperson for a tireless net-

work of people behind me. A big thank

you to our President, Margaret Mayston,

to all the exec and regional committee

members and local ACPIN groups. A thank

you to Lorraine Azam for all the delegate

arrangements and making your stay

enjoyable.

As I am finishing my role as chair and

stepping down from the executive com-

Income 2010 2011

£ £

Course Fees 34,526 13,150

Congress 324 0

Membership 53,146 60,608

Capitation 3,186 5,864

Synapse 60 0

Database 784 899

Bank Interest 50 59

TOTAL 92,076 80,580

Figure 1 Inc ome

Expenditure 2010 2011

£ £

Courses 26,202 12,198

Synapse 12,187 8,374

Travel 10,430 9,727

Administration 4,486 3,818

Capitation 7,393 11,710

Computer costs 2,103 6,275

UK Stroke Forum/

Stroke Guidelines 76 0

Accounts, bank,

sundry 1,445 1,472

TOTAL 64,322 53,574

Figure 2 Expenditure

Courses income

expend

£ £

March conf 13,150 12,198

Congress 0 0

Figure 3 C ourses

Reserves £

Reserves brought forward 120,398

Surplus/(deficit) 26,549

Reserves carried forward 146,947

Figure 4 Reserv es

mittee I would like to offer a personal

note of thanks to you all, for allowing me

the honour of being Chair, a thanks for all

of those people behind me on the com-

mittee, to those of you who gave your

unending support and those who were on

the end of the phone when I didn’t quite

know what to do!

Thank you and I wish ACPIN every sup-

port in the future, over to you Gita and

Jakko!

Treasurer’s Report

Jo Kileff

I will now present a summary of the

financial accounts for National ACPIN for

the year end 31st December 2011.

The total income (Figure 1) was

£80,580. This was a decrease on last

year’s income and was mainly due to a

decrease in income from the March con-

ference, which was intended to return

some monies to the membership. We can

see in the income figures that we have

had another substantial increase in our

membership and a resultant increase in

capitation. Bank interest remains low and

we need to continue the debate on where

to put the money whilst it is waiting to be

spent, which is proving reasonably diffi-

cult to do!

Expenditure (Figure 2) for 2011 was

down by £10,748 compared to 2010. This

was mainly due to less conference

expenses, with it being a one day event

rather than a residential course which nat-

urally has more costs involved. The capita-

tion and computing costs have increased,

other expenses have stayed much the

same.

Courses (Figure 3), divides the course

income and expenditure up for the course

that ACPIN held this year. The March con-

ference was planned to run at a loss, with

low course fees in order to put some

money back into the membership.

Despite this we have managed to end up

breaking even. We had exhibitors for the

first time in 2011 and the costs accrued

from the exhibitors increased our income.

Congress expenses were organised by the

Outgoing Chair Siobhan MacAuley and the

incoming Chair, Gita Ramdharry at the 2010 ACPIN

conference and AGM.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 31

Syn’apse

●

SPRING/SUMMER 2012

greater complexities this presents. Using

researched examples he led us through

the importance of variability, reward and

skill transfer as the main contributory fac-

tors to facilitating plasticity and changes

in outcome. Surprising to many delegates

who have heard him before were his

thoughts that plasticity per se was not as

important as was once thought, but it is

important to put it into the context of

adaptation and motor skills acquisition.

This led on well to Associate Professor

Lisa Harvey’s presentation on the

‘Management of Spinal Cord Injuries’.

Using clear headings of assessment, goal

setting, analysis and evidence based prac-

tice she explored the finer details of the

skills a physiotherapist would build up

specialising in this field. Steeped in a gold

standard of the importance of RCTs, Lisa

led the delegates through asking ques-

tions of established practice such as pas-

sive movements, stretching and strength

training. With the emergence of more

robotic and stimulatory equipment there

was time to discuss this and their role in

current rehabilitation.

She discussed the importance of not

raising the expectations of patients for

their outcomes but to keep a realistic and

open mind.

Much of Lisa’s talk resonated with the

next speaker, Melanie Reid. Melanie sus-

tained a spinal cord injury in April 2010,

and since that time has continued to write

a regular column in The Times newspaper

charting her progress.

Hooked by a resonance in Siobhan’s

email acknowledging rehabilitation is like

‘pushing a pea uphill with your nose

sometimes’ she agreed to travel to

Northampton, via Birmingham airport and

give what was an illuminating insight into

her experience of spinal cord injury. It gen-

erated much discussion. Notable quotes

were: ‘the gap as a patient between per-

ception and reality’, ‘wanting to be in the

gym was her salvation’, how in the gym

there was often a combination of ‘deep

emotion and gallows humour’, her dislike

of the light use of the term ‘functional’,

feeling the lokomat was her ‘break-

through in recovery’ and most discussed

off line the ‘fine line between not giving

false hope but encouraging hope’.

The AGM was concise and informative

and contained a great title from Margaret

Mayston in her address, ‘Participate or

Perish’.

The four workshops for an hour and a

half each were a success and all well

attended.

Michelle Price, a consultant physiothera-

pist rounded off day one with an illumi-

nating and informative session talking

about stroke service changes in Powys

and how they have been working

towards meeting need in new and inno-

vative ways using outcome to shape serv-

ices. She referred often to the PDSA

model, Plan, Do, Study, Act.

The evening gala dinner was very well

attended and involved dancing into the

night with live music.

Saturday started with ‘Speed’ updates

from work that is represented via ACPIN.

These were the Splinting Guidelines due

in 2013 which have been jointly planned

by both physiotherapy and OT organisa-

tions. The work will be undertaken by

Brunel University, and clinical involve-

ment will be requested by a Delphi

Method; expression of interest should be

sent to [email protected]om. The other

updates were from the International

Neurological Physical Therapy Association

(INPA), the Intercollegiate Stroke Working

Party (ICSWP), Behind the Scenes for

Parkinson's and the UK Stroke Forum

(UKSF).

Fiona Lindop presented the Parkinson’s

physiotherapy audit which highlighted

the desire to improve standards of care

and equitable service for all. The full

results will soon be available and Fiona

highlighted the wealth of material avail-

able including the UK quick reference

cards.

Professor Jon Marsden gave an enlight-

ening talk on the effect of temperature on

neuromuscular function. He explained

how cooling can change neuromuscular

function but that this is altered with differ-

ing pathology. He also talked about how

temperature can alter tremor and the vari-

able results in relation to spasticity.

Ann Roger unpacked vestibular rehabili-

tation in a talk which must have opened

up this topic as an essential addition to a

therapist’s toolkit. Anyone working with

CSP and hence there were no costs

incurred.

The balance sheet (Figure 4) on the

31st December 2011 showed a profit of

£26,549 and we carry forward reserves of

£146,947 into 2012. We have explored

and continue to explore ways of feeding

this money back into the growing mem-

bership. We are still supporting the writ-

ing of splinting guidelines at a cost of

£10,000. We have increased capitation to

£5 per person despite no increase in capi-

tation from the CSP as a way of directly

influencing regions’ income. We are heav-

ily subsidising this conference again this

year and will continue to run our courses

at a very low rate. We are investigating

other ideas to allow regions to benefit.

Siobhan was concerned that she would

leave as chair having spent too much

money. However, no matter how hard we

try, we continue to make money! If only

we had the same success with our own

accounts! If anyone has any suggestions

of projects that ACPIN could get involved

in that would benefit all members, do

speak to one of the committee.

Copies of Accounts 2010

Full copies of the ACPIN accounts for 2011

are available on request.

Vote for accountants

Vote to retain the current accountants for

2012: Langers, 8-10 Gatley Road, Cheadle,

Cheshire, SK8 1PY.

Delegate report

Every place had been booked, speakers

and exhibitors ready and the ‘Backbone of

Neurology’ conference was eagerly antici-

pated. Looking at the programme the del-

egates should not be disappointed.

Professor John Rothwell led the way

with an engaging presentation on plastic-

ity in neurorehabilitation, discussing the

current thinking around the importance of

this topic amid other factors that might

affect outcome. He concentrated on the

changes that could take place in the brain

rather than the spinal cord due to the

SYNAPSE Spring 2012 28/05/2012 11:22 Page 32

THE BACKBONE OF NEUROLOGY

older people needs to be aware of the

importance of assessing for any impair-

ment in the peripheral vestibular system

affecting balance and dizziness. She went

through a comprehensive summary of

assessment which therapists can explore

further.

Lisa Harvey ended a busy weekend

with two sessions, firstly some indications

suggesting the lack of evidence for pas-

sive stretch to avoid contractures. It high-

lights the importance of clinical reasoning

and mature decision making when con-

sidering treatment modalities. Her second

session was to share a number of ways

we can use information technology to

better share practice and communicate

around the world. Lisa discussed web

based exercise resources, an e learning

package, professional forums and mobile

applications. (www.physiotherapy

exercises.com and www.scipt.org)

Dr Lisa Bun delivered a presentation

looking at the cause of balance impair-

ment in patients with cerebellar disease.

Summarising a detailed understanding of

her subject, Lisa then described a newly

designed home based therapy whose

early results suggest as a potential inter-

vention.

Finally, and still from the south west

team, Professor Bernhard Haas rounded

off a very successful conference which

pulled together many strands that had

been discussed over the two days. His

subject of identifying the most effective

exercise to take people to the next level

was supported with a comprehensive

combination of evidence. Among the evi-

dence suggested for effective exercise

was strength training, intensity, velocity,

psychological elements, motivation and

environment.

This was a highly successful two day

conference exploring the backbone of

neurology, with new ideas, comprehen-

sive exhibitors and a buzz around the del-

egates. The well attended dinner and live

music added to a relaxed networking

environment and once again thanks for a

huge effort by the executive committee.

This year also saw Gita Ramdharry take

over the chair from a busy and committed

two year term from Siobhan MacAuley

who will be very much missed by all.

WIN A FREE

PLACE TO

ACPIN AGM

2013!

Annual prize for the

two best articles or

case studies

supplemented

to Synapse in

2012 editions

Closing date for

supplementing articles is

August 6th 2012.

Winners will find out in

January 2013. This will be

rolled out annually.

Please email Lisa Knight, Synapse coordinator,

on lis[email protected]om for all

correspondence.

ALL LEVELS OF EXPERIENCE ARE ENCOURAGED TO ENTER!

SYNAPSE Spring 2012 28/05/2012 11:22 Page 33

Syn’apse

●

SPRING/SUMMER 2012

Case reports are defined as replicable,

detailed and credible descriptions of practice

where there is an integration of the best avail-

able research evidence with clinical

experience.

Case reports are a good way for physiotherapists

to start writing for publication. Preparing the

manuscript will develop skills in concise written

communication and critical thinking. It is also a

good way to learn about a topic. Any description,

any patient or patient management scheme that

has not featured previously in the literature is

worthy of describing in a case report. We are a

relatively young profession that often struggles to

verbalise what we do. This can be a great opportu-

nity to showcase our creativity and worth.

Case reports are low down in the hierarchy of

evidence, so what is their contribution? A compre-

hensive case report will provide new knowledge

through documentation of a novel occurrence. The

report will be of interest to other physiotherapists

and will be educational. The report may also form

preliminary work or evidence for larger studies.

Cases can be reported retrospectively or

prospectively. Retrospective cases are the most

common reports published. The intervention may

be well described and of high quality, but often the

best outcome measures will not have been used.

This will affect the credibility. Prospective reports

involve some forward planning of the intervention

and data collection. This can be done over mul-

tiple time points in a time series case description

e.g. three measurement points. It is possible that

ethical approval may be required. It is wise to

check with your local trust research and develop-

ment department first. You may find that guidance

varies from trust to trust.

Most case reports fall into three main categories:

1. Diagnostic or assessment reports: An assess-

ment or diagnostic method is described. This is

often a description of a rare or complex case.

2. Treatment or management reports: Detailed

descriptions of interventions and outcomes.

3. Educational report: A presentation of current

practice strategies with presentation of the lit-

erature.

Many case reports are between 1,500 and 2,000

words in length, but this will depend on the

journal. It's best to check with the author guide-

lines first. Many guidelines will also recommend a

structure but it is often as follows:

Title

This should be an accurate and concise descrip-

tion of the study. Some authors recommend four

elements to a study title: the intervention; the

outcome; the population under study and the

condition of interest.

Structured abstract

This should be a structured summary of about 200

words. Some journals will provide headings they

prefer to guide an abstract.

Introduction

In the introduction, there should be a clear state-

ment of the purpose of the report or study. The

background and contribution to the literature

should be highlighted.

Case report (methods and results)

This is the most salient part of the report. The

details of the methods and intervention are docu-

mented here, plus the primary aspect of the

patient's condition. Keep the results brief and suc-

cinct.

Discussion

This is the section where you make sense of the

findings. You will discuss how your outcome con-

tributes to the literature but be clear about your

limitations.

Conclusion

This is the overall conclusion statement but be

careful not to be too far reaching in your supposi-

tions and avoid using unsupported statements.

Acknowledgements

References

Tables

Figures and captions

Although case reports can make a contribution,

you must be aware of the limitations. The inter-

ventions described will usually occur in an

SHARING GOOD PRACTICE 1

Writing a case

report

Gita Ramdharry PhD

SYNAPSE Spring 2012 28/05/2012 11:22 Page 34

SHARING GOOD PRACTICE

uncontrolled environment. There can be other

confounding factors that may have influenced the

outcome in addition to the intervention you

describe. Because of the issues with generalis-

ability of case reports, you cannot conclude that

management will be effective for other patients.

When reading case reports, be aware that publi-

cation bias is prevalent with this type of report.

Cases may have been cherry picked to best illus-

trate a hypothesis or standpoint.

To get started the first step is to formulate your

idea for the report. You could talk it through with

a colleague to structure your thinking. Don't

forget to jot down their feedback afterwards. You

may also use a tool like a mind map. Then it's time

to jump in. I recommend that if you’re struggling

to get going, don’t aim for a perfect first draft.

Either sit with a pen and paper and just write or

type at your PC without going back to edit for five

to ten minutes just to start the process. Review

what you have written and underline the main

points emerging. You can then go back and write

again, bringing these points together so your ideas

are refined. I also recommend that you get

someone else to read it and give you constructive

feedback on the clarity and message.

Then you are ready to submit. You should have

decided where you will submit before you finish

the manuscript, to ensure it meets all of the

journal requirements. Many physiotherapy jour-

nals are case report friendly and our very own

Synapse is very keen to receive your work! Expect

criticism from the review process and don’t be put

off if it seems harsh at first. Use it to refine the

report. It will be a better paper for the inde-

pendent feedback and your revisions based on it.

Go on, jump in! I know there is some fascinating

practice out there. I'm looking forward to reading

it soon!

REFERENCES

Albrecht et al (2009) The role of

case reports in evidence based

practice, with suggestions for

improving their reporting Journal

of the American Academy of

Dermatology 60 pp412-418.

Green et al (2006) How to write a

case report for publication

Journal of Chiropractic Medicine 5

pp72-81.

McEwen (2004) Case reports:

Slices of real life to compliment

evidence Physical Therapy 84

pp126-127.

Neely et al (2008) Practical guide

to understanding the value of

case reports Otolaryngology -

Head and Neck Surgery 138

pp261-264.

Rothstein (2002) Case reports: still

a priority Physical Therapy 82

pp1062-1063.

In 2001, a functional training programme

(ARNI – Action for Rehabilitation from

Neurological Injury www.arni.uk.com) was

developed for people with stroke by a stroke

survivor called Tom Balchin.

A year-long feasibility study of this approach using

ARNI trained exercise instructors has been com-

pleted by Brunel University London in conjunction

with physiotherapists from the Hillingdon commu-

nity team and Hillingdon Hospital and staff from

the leisure services of the London Borough of

Hillingdon (LBH). The study was funded by LBH

from their National Stroke Strategy monies; this

was supplemented by an ACPIN research bursary

award.

The study evaluated the delivery of four twelve-

week stroke groups using a combination of

laboratory and functional based tests including

balance, gait, strength and quality of life measures

taken before and after the twelve week pro-

gramme and then three months later. Focus

groups were conducted to explore the experience

of participation.

Results indicate a significant improvement in

functional balance and in the overall score of the

quality of life measure. Gait speed also improved

sufficiently to reach the ‘minimal clinically impor-

tant difference’, although this change was not

statistically significant; changes were noted in

strength but they did not reach the level of signifi-

cance. Participants reported positive changes in

their ‘real life’ capacity including being able to

hoover again, having the confidence to join a gym,

SHARING GOOD PRACTICE 2

Functional

stroke training

evaluating a community

-based programme

SYNAPSE Spring 2012 28/05/2012 11:22 Page 35

The projects were mainly undertaken by Band 6

physiotherapists from the Portsmouth and

Southampton areas. Both projects had taken at

least a year to develop.

The first presentation was a project that reviewed

the outcome measures used by local physiotherapy

staff within neurology. The project collected infor-

mation on what outcome measures were actually

being used and whether there was a trend amongst

physiotherapists locally. Why certain outcome

measures, as opposed to others were used was also

evaluated. The outcome measures that were regu-

larly used by physiotherapy staff were evaluated to

see if they were the most appropriate, and in line

with best practice. Further development was

undertaken to try and collate a database of certain

outcome measures that could be easily accessed.

The second project looked at the format in which

exercise is prescribed (within neurorehabilitation).

Patient data was collected from focus groups and

local physiotherapy staff completed a questionnaire.

There were several results from this project. An

example is that patients’ preferences in exercise

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SPRING/SUMMER 2012

using the underground, going to the pub and one

person has even started to train as an ARNI

instructor!

Plans for the future include sourcing funding for

more classes to take ‘new comers’ once formal

rehabilitation has stopped and for a continuation

class for people to carry on with their exercises in

a group environment if they wish. Funding is also

being sought for a fully powered trial to continue

to explore the effectiveness of the ARNI approach.

The full results of this study are currently being

written up for publication.

For further information about the project please contact:

• Jackie O’Dowd (Jackie.o@dow[email protected]) (Community

Physiotherapy Team)

• Centre for Research in Rehabilitation [email protected] (Cherry

Kilbride and Meriel Norris)

• Centre for Sports Medicine and Human Performance

(amir.mohagheghi@brunel.ac.uk)

Wessex ACPIN held an evening lecture on

Tuesday 19th July 2011. This was entitled

‘Sharing Local Practice’ and highlighted proj-

ects that had been developed locally. The

evening was hosted by physiotherapy staff at the

Turner Centre, St James’s Hospital, Portsmouth.

The aim of the evening was to share good clin-

ical practice amongst colleagues and further

discuss issues about these clinical areas.

Alahna Barratt and Carl Adams.

left to right: Margaret Martins,

Laura Dyer and Emma Harris.

SHARING GOOD PRACTICE 3

Sharing ‘local’

practice

Wessex ACPIN

Jenny Barber

SYNAPSE Spring 2012 28/05/2012 11:22 Page 36

SHARING GOOD PRACTICE

prescription were primarily focused around the

content and delivery of their exercise programme.

Further recommendations were divided into the

production of exercise information, the content of

the exercise and the delivery of the exercise (see

Figure 1).

In summary, the evening was well attended by

members of Wessex ACPIN and it was agreed that

the discussion at the end of the evening was

extremely interesting and stimulating. I think it is

definitely something that could and should be

extended out to all regions in the future to ensure

that local research is better shared and acknowl-

edged. Further information about either of these

projects is available upon request.

Figure 1

Recommendations poster

Splinting is one of the important interventions

in the treatment or prevention of contractures.

The physiotherapists at Holy Cross Hospital, a spe-

cialist centre providing rehabilitation and long term

care for people with severe and complex disability,

developed a technique to incorporate aluminium

screw rivets (homecraft Rolyan) when fabricating

fibreglass splints. These screw rivets were used to

attach straps which were used instead of a crepe

bandage to hold the splints in position. When fabri-

cating the splint one part of the rivet was placed

between the Scotch Cast layers and a custom made

strap was attached to the splint by using the other

(screw) part of the rivet. Positioning of the screws

and the length of the straps are flexible depending

on the part of the body/limb that is being splinted eg

a figure of ‘8’ strap can be used when applying an

elbow splint. The use of straps for application/

securing of the splint has become popular with staff

as it has made the process easier especially in

patients with high muscle tone. A document with

step-by-step instructions on how to incorporate the

screw rivets and attach the strap will be made

available in the neurology section of the interactive

CSP. Please acknowledge source (Holy Cross

Hospital) when using or quoting this technique.

If you have any questions please contact:

Rasheed Meeran (r.meeran@holycross.org.uk ) Physiotherapy team

leader, Holy Cross Hospital, Haslemere, Surrey GU27 1NQ

SHARING GOOD PRACTICE 4

A novel technique

to attach Velcro straps

to fibreglass splints

SYNAPSE Spring 2012 28/05/2012 11:22 Page 37

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SPRING/SUMMER 2012

WEBSITES

www.scipt.org

The international Network of SCI

physiotherapists (SCIPT) is a not-for-

profit initiative of physiotherapists

worldwide. It is for physiotherapists

working in the area of spinal cord

injuries, although other physiothera-

pists are welcome to join. The website

contains presentations, documents

and videos. Registration is free.

www.physiotherapyexercises.com

This website has been promoted before

but in case some are not familiar re:

this website it will enable you to:

1. Search for exercises appropriate for

people with spinal cord injuries and

other neurological conditions.

2. Select exercises and compile them

into booklets for your clients.

If you register (this is free), you can:

1. Save your clients’ exercise booklet

2. Edit the text of exercises

3. Format exercise booklets in any way.

www.elearnSCI.org

An e-learning site for health profes-

sionals working in the area of spinal

cord injuries. Provides a series of

online modules for students and junior

clinicians. The learning content

includes, case studies, videos, self-

assessment and lectures. No fee!

www.rehabmeasures.org

The website was designed to help

clinicians and researchers identify

reliable and valid outcome measures

within all phases of rehabilitation. It

provides a list of instruments each with

evidence-based summaries, instruc-

tions for implementation including

length of tests, and a link to the

instrument in a pdf format. Although

the instruments currently in the

database only contain full reviews for

stroke and spinal cord injury, more

diagnoses will be added shortly.

www.neurosymptoms.org

An excellent website for patients with

functional symptoms/ conversion

disorder/ dissociative symptoms.

www.improvement.nhs.uk/stroke

You can access an eBulletin

produced by the Stroke Improvement

Programme and is available to anyone

working in healthcare, social care, or

the voluntary sector with an interest in

stroke. It contains up to date projects

and relevant information centred

around stroke care. You can email

infor@improvement.nhs.uk to opt in

or out at any time.

www.stroketraining.org

Contains core competency stroke

training and ten advanced modules on

the multidisciplinary management of

stroke.

www.ebrsr.com

A comprehensive and up to date

evidence-based review of stroke

rehabilitation.

www.appde.eu

This is the website for the Association

of Physiotherapists in Parkinson’s

Disease in Europe. There is a newsletter

tab, which provides you with up to

date news on PD in Europe.

www.parkinsons.org.uk

Don’t forget to use the cue cards avail-

able to assist in all staff’s clinical

practice with Parkinson’s Disease

patients. They can be downloaded

from this website.

www.1000livesplus.wales.nhs.uk/

programmes

You can access The Quality

Improvement Guide online from this

website. It provides simple but effec-

tive tools and strategies to equip staff

to drive change forwards and assists in

developing leadership skills and

highlighting the importance of utilising

teamwork. It is based on the ‘Model for

Improvement’ developed by associates

in Process Improvement

(www.apiweb.org) which has previ-

ously been used very successfully in the

UK and USA. The guide particularly

focuses on the health structure in

Wales but lot of the theory could be

utilized throughout the UK.

GUIDELINES

Mind The Gap; Enhancing therapy

provision in stroke rehabilitation

NHS Improvement (November 2011)

http://system.improvement.nhs.uk/Im

provementSystem/ViewDocument.aspx?

path=Stroke%2FNational%2Fwebsite

%2FMind%20the%20gap%2FMind_the

_Gap.pdf

DOH: Service for people with neuro-

logical conditions National Audit

Office

www.nao.org.uk/publications/1012/neu

rological_conditions.aspx

RESOURCES OF INTEREST

WEBSITES GUIDELINES PAPERS

This feature contains resources which may prove useful in clinical practice.

Please share any resources by contacting the editor via email.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 38

FOCUS ON…

The history of classification

In the 1940s, Dr. Ludwig Guttmann

founded paralympic sport as an exten-

sion of the rehabilitation process.

During the early years of the

paralympic movement, classification

was medically based. The organiza-

tional structure of medically based

classification systems reflected the

structure of a rehabilitation hospital,

with separate classes for people with

spinal cord injuries, amputations and

those with other neurological or

orthopaedic conditions.

Athletes received a class based on

their medical diagnosis, and competed

in that class for all sports offered. An

athlete with a complete L2 spinal cord

injury (resulting in lower limb paresis

but normal arm and trunk power)

would compete in a separate wheel-

chair race from a double above-knee

amputee because their medical

diagnosis was different. The fact that

the impairments resulting from their

medical condition caused about the

same activity limitation in wheelchair

propulsion was not considered in the

classification process because classifi-

cation was based on medical

diagnosis.

Sport drives classification

As the paralympic movement matured,

sport was no longer an extension of

rehabilitation and alone became

important. The focus on sport, rather

than rehabilitation, drove the devel-

opment of what commonly became

referred to as functional classification

systems.

In functional systems, the main

factors that determine a class are not

diagnosis and medical evaluation, but

how much the impairment of a person

impacts upon sports performance. For

example, in athletics, an athlete with a

complete L2 spinal cord injury now

competes in the same class as a double

above-knee amputee (class T54). This

is because these impairments have an

impact on wheelchair propulsion that

is approximately the same. Currently

most paralympic sports use systems of

classification that are described as

functional, a notable exception being

the classification system used by the

International Blind Sports Federation

(IBSA) which remains medically based.

In contrast to the medical classifica-

tion approach in which athletes

competed in the same class for all

sports, functional systems of classifica-

tion need to be sports-specific. This is

because any given impairment may

have a significant impact in one sport

and a relatively minor impact in

another. For example the impact that

bilateral below elbow amputation has

on swimming is relatively large

compared with the impact on distance

running. Basically, in functional classi-

fication systems, an athlete with such

impairment would compete in a class

that had relatively greater activity

limitation in swimming than they

would in athletics.

Leaving medical classification

The transition from medical to

functional classification systems began

in the 1980s. There was however a

considerable debate surrounding the

relative merits of the medical and

functional approaches that caused the

transition to be slow.

One feature of early functional

systems was that they comprised fewer

classes than the existing medical

systems. Event organizers favoured this

because the complexity of event

organization was significantly reduced.

In 1989, the bodies responsible for

organizing the Barcelona 1992

paralympic games – the predecessor to

the IPC (International Paralympic

Committee), the International Co-

ordination Committee of World Sports

Organizations for the Disabled (ICC),

and the Organizing Committee – signed

an agreement which stipulated that all

paralympic sports contested at the

Barcelona 1992 paralympic games were

to be conducted using sports-specific

functional classification systems. This

administrative decision greatly acceler-

ated the transition to functional

classification systems. At the time of

this decision many sports had not

begun to develop functional systems.

Given the short timeframe and the

absence of relevant scientific evidence,

the classification systems that were

developed needed to be based on

expert opinion. Within each of the

sports, senior paralympic classifiers

from a diverse range of backgrounds

(medical doctors, therapists, athletes

and coaches) led the development of

functional systems of classification.

Paralympic classification today

Since the widespread adoption of

functional systems of classification,

paralympic sport has continued to

mature rapidly. Currently there are

FOCUS ON… 1

Paralympic classification

Paralympics GB

SYNAPSE Spring 2012 28/05/2012 11:22 Page 39

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SPRING/SUMMER 2012

more than 15,000 registered competi-

tors with the international governing

bodies of the 25 paralympic sports, and

a much larger (but indeterminate)

number of athletes competing at local,

national, and regional level in their

home countries that are not registered

internationally. At the elite level,

successful paralympic athletes are

receiving increasing peer and commu-

nity recognition and many receive

commercial sponsorship and other

financial rewards.

It is well recognized that the classifi-

cation an athlete is assigned has a

significant impact on the degree of

success they are likely to achieve.

Unfortunately however, paralympic

classification and classification

research have not matured as rapidly

as other areas of paralympic sport and

current paralympic classification

systems are still too often based on the

judgement of a small number of

experienced classifiers, rather than

empirical evidence. As a consequence,

the validity of the methods used in

functional classification systems can be

strengthened. In 2003, the IPC devel-

oped a classification strategy with the

overall objective to support and co-

ordinate the ongoing development of

accurate, reliable, consistent and

credible sport focused classification

systems and their implementation. The

IPC Classification Code is a direct result

of recommendations made in this

strategy.

The IPC recognizes the need for

systems of classification that are

evidence-based and mandates the

development of such systems.

Future outlook

The IPC continues to be committed to

the development of evidence-based

classification systems, so that athletes

who enhance their competitive

performance through effective training

will not be moved to a class with

athletes who have less activity limita-

tion (as they would in a performance

classification system), but will be

rewarded by becoming more competi-

tive within the class they were

allocated.

“What inspired you to be involved in

wheelchair sport?”

Before my injury I was very sporty and

especially into team sports, jumpers for

goal posts and all of that. I liked the

social aspects, and the trust and

friendships that built up. When I was

in hospital in June 2005 I missed it and

did not realise how important sport

was to me. During rehab I got involved

in table tennis and swimming but they

didn’t have that ‘edge’ and I was not

strong enough to be involved in

basketball. Then one day I was asked if

I was interested in watching a GB

wheelchair rugby game. I was not

strong enough to push the distance so

my Dad pushed me down to the Stoke

Mandeville Stadium. Here were a

bunch of guys doing their best to get

people out of their chairs while I was

struggling to stay in it. Watching them I

could not believe they were as injured

as me but gradually I discovered that

some of their injuries were higher than

mine. Two days after my discharge in

October 2005 I went to my first training

session.

Everything was new to me, the

lifestyle, the sport; it was not like

returning to football, but everyone was

so friendly and welcoming, and they

really helped me to come to terms with

my injury. Now it is hard to believe I

am captain of this team.

“How has involvement in sport

changed your attitudes, or feelings

about yourself or others?”

I had always been motivated in

whatever I did and wanted to be good

at it so when I took up rugby, I set

small goals to achieve all along the

way and I knew to be good at it I

needed to work hard. I am keen to

FOCUS ON… 2

Steve Brown

Wheelchair rugby captain- GB Team

SYNAPSE Spring 2012 28/05/2012 11:22 Page 40

FOCUS ON…

support and help others who have the

drive and desire to want to succeed

and it is great to see people achieve

their potential.

“What would your advice be for

anyone newly injured?”

Look at the glass as half full. See how

others have achieved things and

believe in yourself. Also to keep things

in perspective! It should not have

taken me to lose two thirds of my body

to make the most of the other third.

“What is the feeling of the honour of

being able to captain the rugby team

at the London Paralympics?"

Representing your country in anything

is an absolute honour. I remember a

coach saying to me after I had been at

a Kent Crusaders training sessions “You

are the right shape, height and have

the motivation and if you put in the

work you could represent your country.

From then on, I knew if I worked hard

this was possible. With loads of

support from physios, coaches, nutri-

tionists I just worked to improve. I

remember the meeting I had when

they offered me the captaincy and as I

went in I thought I had done

something wrong. Seeing me nervous,

they assured me everything was fine

and told me they would like to offer

the captain’s role to me. I was lost for

words and then said yes.

“Do you have any top training tips?”

Do as you are asked. There is so much

support from strength coaches, condi-

tioning teams, nutritionists, physios

and they know what you need to do,

listen to them and work towards your

goal. One question I always ask myself

is, “Is this going to make my chair go

faster?” What I eat and when I go to

bed will make a difference. By not

following their guidance it is contra-

dictory to all I’ve strived for. For me

self-direction and self motivation is

key and in the team I cannot afford to

be the weak link.

During training today I looked around

the athletes and what they were

working for. It takes your breath away

seeing them working so hard towards

their own goals, keeping fit and

healthy. They work so hard for their

coaches and teammates, striving for

their best.

I began working for the MS Society six

years ago after 30 years service in the

NHS. My final job in the NHS was as

Clinical Lead for Neurology at the Royal

Hallamshire Hospital in Sheffield.

The original remit of my current job

was very much focused on supporting

the MS Society’s strategy to develop

new physiotherapy and occupational

therapy posts in the NHS and in Social

Services. In those days, the Society

invested significantly in pump priming

the development of new services. In

the last three years, the emphasis has

changed to influencing and overseeing

the sustainability and development of

high quality services.

We knew from a scoping exercise of

the Society’s membership, that people

affected by multiple sclerosis, valued

physiotherapy as much as the support

of the specialist nurses. However, it

also became obvious that it is much

more difficult to gain funding for MS

therapist posts.

It was – and still is - hard to get

recognition for the consultant or

specialist role for Allied Health

Professionals in the NHS and we also

know that many therapists do like to

keep their skills within other long term

neurological condition groups. One

way round this, was to support the

development of neurotherapist posts,

which later could develop a specialist

interest in MS. Their work could be

supported through the MS Society’s

information and education strategy,

and also through the MS Professional

Network. It also became evident that

we needed to collect information and

evidence on the impact of these posts,

to make sure they were sustainable in

the long term.

Working with the post holders and

with our service development officers, I

have supported professionals to deliver

high quality evidence based practice.

This work is now shaping our future

educational offer to professionals. I

have helped physiotherapists to

measure the impact of their posts

through MS-specific outcome measures,

satisfaction surveys and the cost effec-

tiveness of keeping people out of the

acute setting and supporting self-

management within the community.

Right now, we are developing a UK-

wide service development toolkit, to

FOCUS ON… 3

Jane Petty

Life as the national programme physiotherapy

lead for the MS Society

SYNAPSE Spring 2012 28/05/2012 11:22 Page 41

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SPRING/SUMMER 2012

help post holders to assess and

develop services. Several projects are

underway to help nurses and thera-

pists measure the cost of their service

and how they can demonstrate they

are making savings (using the MS

Society’s Cost calculator©). We are

working on adapting the economic

value of for example: a physiotherapist

in stroke care, to one specific for MS

and will be holding workshops for

allied health professionals on how to

use the tools developed in the future.

Another important aspect of my work

is to develop a position statement and

resource base for physiotherapy and

exercise. There have already been

several different projects around

exercise; providing advice for the

newly diagnosed and introducing them

to many different ways of exercising

including kick-boxing.

The current work around physio-

therapy and exercise is particularly

important. This is because in 2010 the

MS Society decided it could not

continue to pump prime posts and

would instead work to develop service

models through a partnership of

people with MS, our branch services,

the NHS and other providers. The aim

being, to develop pathways which

focus on exercise fitness and physio-

therapy.

This meant we had to develop

evidence based practice through our

research programme which will emerge

as service models to help the sustain-

ability and development of services

and make sure we continue to see high

quality services. I worked with the CSP

to produce the document, Physio

works for MS and to identify their

research priorities around MS.

In addition to this, the MS Society

research grant programme is currently

funding research into:

1 The effects of a practical exercise

programme on physical activity and

quality of life in people with MS

We know that exercise is beneficial to

people with MS – but there are still

many unanswered questions about

who will benefit most, how much

exercise is helpful and what types of

exercise are recommended. An

exercise programme designed specif-

ically for people with MS will be

tested in this three year study. 120

people with MS will be split into two

groups. They will either receive a

twelve week exercise programme or

their usual care. Researchers will

compare the following three things

in the two groups of people:

• physical activity levels

• disability levels

• quality of life

2 A pilot study into the effects of

Pilates on posture, pain, and quality

of life in wheelchair users with MS

This three month clinical trial of 30

people with MS who use wheelchairs

looked at the impact that Pilates has

on posture, pain and quality of life.

3 A three year clinical trial to deter-

mine if FES improves walking

performance in people with MS.

The following information is being

gathered:

• the perspectives of 10 to 15 people

with MS to assess how their

walking performance and feelings

of fatigue vary when using FES

• assessing the long term effects of

using FES compared with another

treatment for dropped foot, the

dynamic ankle foot orthosis

In 40 to 50 people with MS

researchers will assess:

• feelings of fatigue

• ability to engage in activities of

daily living

• levels of physical activity and

quality of life

4 A one year pilot study explore if

wearing textured insoles in shoes

can improve balance problems

experienced by people with MS.

This builds on earlier research

(already funded by the MS Society)

5 Using quality adjusted life years

in MS.

A quality-adjusted life year (QALY) is a

health economic tool used to

compare different treatments and

interventions – so that the NHS can

make decisions on which treatments

to fund. QALY’s are a generic

measurement however, and don’t

take the specifics of how MS can

impact on a person’s life into

account. This means that some treat-

ments and services

As well as working with clinicians and

researchers, I still meet many people

with MS in my role at the MS Society.

An issue that often arises is people

feeling that they need access to neuro-

physiotherapy on a regular basis, to

benefit from the service. It is part of my

role to get people to think differently

about how they could self manage

their MS through exercise and activity.

Although we have supported the

development of new posts, what also

became obvious was that we had a

network of branches throughout the

country that were supporting physio-

therapy, exercise groups and all sorts of

activity opportunities.

Many of these volunteer branches

also had significant funds and legacies

that were not being used for the

benefit of the wider MS population.

They were only attracting a small

percentage of the membership and

people with MS in their area.

I am currently work with the

branches and membership to change

people’s mindset, so that exercise and

activity rather than continued physio-

therapy is identified as the way to help

people with MS maintain their

independence.

I am also trying to address the issues

that people with MS have told us about

(through research from Leeds and

Oxford Brookes Universities). One point

made was that they felt the fitness

instructors didn’t understand the

symptoms of MS. Consequently, we

have jointly developed a Masters

module with REPS 4 accreditation (for

fitness instructors and physios) with

Oxford Brookes University. This covers

physical activity for people with a

neurological condition and we

currently offer 50% grants to undertake

the study. The study is an e-learning

resource with two weekends spent

working with people with a neurolog-

ical condition in a gym setting.

Work with our volunteer branches is

focusing on setting up exercise and

activity opportunities, ideally in

partnership with other providers. This

is so it can become part of a pathway

to activity. We have also organised

activity taster days where people with

MS can try out activities such as

archery, tai chi, climbing walls, boccia,

Pilates, yoga and canoeing. The main

principle being to demonstrate what

opportunities there are out there to

take part in activity, despite a

disability.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 42

FOCUS ON…

Another exercise initiative we are

supporting is a pilot of Yoodoo sports

with Leonard Cheshire. This aims to

encourage disabled people to use

leisure centres as a move on from the

‘Inclusive Fitness Initiative’ (IFI), using

a buddy system.

In Summary, the job I originally took

with the MS Society has developed into

a national programme, supporting

therapists across the four nations of

the UK. This involves more travel than I

had originally anticipated and I have

become something of a Billy no mates

in hotel rooms! However, every day is

different and I feel I am making a

difference, using and disseminating

the knowledge I have gained and am

still gaining!

I can be contacted on:

jpetty@mssociety.org.uk

From a discussion had within our

National ACPIN research workshop, it

seems that entering into postgraduate

research can be very daunting with no-

one knowing entirely what to expect,

or how it should feel to be a student

again! We have decided to follow two

PHD students on their epic journey

through the highs and lows that they

will inevitably experience! The want to

be able to share any useful advice they

have to give to others along the way to

assist with anybody who is thinking of

pursuing the research avenue

themselves.

PHD student 1

Ever felt like you are just tired of the

monotony of life and just wanted to do

something different?

Well, that was me! I found myself in

a job for a long time and thought I

liked what I was doing. There were

days when I felt that I wanted to do

something different. But what was that

something different? I never fully

thought about that. To cut a long story

short, I decided to go down the road of

academia. I applied for and was

awarded a PhD place at one of Britain’s

prestigious universities! This started my

period of change and I was thrilled!

With all the excitement I somehow did

not think too much about going from

being a clinician to a full time PhD

student. How hard could it be anyway?

The transition

I would like to think that I was a good

clinician and that I made a difference

in the lives of my patients – blowing

my own trumpet here! But making the

transition was not easy. I suddenly

went from a job where I was known,

celebrated (by a few), to a place where

no one knew my name, strengths or

weaknesses. It felt like I was starting a

new career and was at ground zero and

had to work my way up, wherever up

maybe in the academic world.

Also, I had to make the transition in

my mind from working in a big team to

working solo. Well, I paused and

thought about that! Did I have to work

solo? It was possible, because I had

everything I needed. I had a well kitted

out office that I shared with other PhD

students. I was assigned a desk that

had a panoramic view of the univer-

sity. I was in full view of people

passing, exquisite landscape, cars etc,

priceless, but also had the potential to

be very distracting. After much deliber-

ation (in my mind) I made the

conscious decision to enjoy the experi-

ence. So, I’ve decided to make friends

and to bring some people along with

me on my journey. Now we have a

little informal group of like-minded

PhD students. This I am beginning to

see the fruits thereof. You will hear

more about our group later.

Starting the journey

“I’m still adjusting”. Four months into

the program and I find myself still

making that statement. Oh dear! I’ve

been to the library and have read

books about people who have done

their PhD so I can learn from them and

help me to put things into perspective.

I am realising more and more that

the relationship with your supervisors

is crucial. I have two supervisors and

have met them a few times now. But

each time we meet my mind runs at a

million miles per hour. There is usually

more to read and more refining of my

research question. I am now officially

obsessed with finding this research

question. I thought I had it ‘nailed’.

I thought I knew exactly what my study

was about but I am now dubious. I was

so eager to move swiftly to do my

study, but I still have more reading to

do. I’ve read already over 200 articles

to choose the ones more relevant to my

study. However, I can’t tell you exactly

what I’ve read because they’ve all

rolled into one. I’ve been told by

people who have walked this way

before that it is best to go through this

process now rather than later. This is to

ensure that no one has done the study

that you want to do. I must admit (only

to you) that I now can see the logic

behind this, as I am now a little more

familiar with the key authors in my

field.

I guess you are wondering who my

supervisors are, but I can’t tell you

(smile) because this blog is anonymous

(tee hee hee!) anyway back to the blog.

I became very concerned so I spoke to

my little support group to see what

they think about my little frustration.

Rest assured they reported that they

were going through the same issue. In

FOCUS ON… 4

The life of a PhD student

SYNAPSE Spring 2012 28/05/2012 11:22 Page 43

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●

SPRING/SUMMER 2012

academia they call what we are going

through ‘the process’. Apparently we

all have to go through ‘the process’.

This is where your supervisors

challenge you about your study. They

call this finding ‘the research

question’ haahha. Well, I thought I

knew my research question but I’m

now four months in and am still

searching. Hopefully by the second

blog (if they allow me to write anymore

about this subject), I would have found

my research question. Otherwise I will

be in great trouble.

So, what’s good about doing a PhD

anyway?

I’m sure you’ve heard a lot of horror

stories like I have and you probably

think I am a bit crazy to still proceed.

But others have done it and so can I.

I think of this phase of my life as a

journey into the unknown, which is

scary but can be exciting at the same

time. I am able to do flexible working

as I am in control (most days) about my

start and end time. I get to choose my

flexible working conditions. You might

say that you get the same in the NHS

and that is true but you have to apply

for flexible working and make a very

good case for it. I on the other hand

just have flexible working and don’t

have to go through the drama of

applying for it. Also, for the first time

in a long while I get Christmas off. Yup,

did not have to apply for leave over the

Christmas period because the univer-

sity was officially closed anyway. Wow!

That was lovely.. I think the greatest

thing though is getting paid to do

something that I really enjoy.

So, ‘am still adjusting’. I must now

go and try to find my ‘research

question’!

PHD Student 2

After ten years working clinically in the

NHS I am now a full time student

again! It has taken five years to get

here but I am now where (I think) I

want to be. I have taken a circuitous

route to get to the starting point of my

PhD journey but have learnt a lot about

research processes along the way which

will no doubt be useful in the future.

In the first of this series I want to

explain my personal experiences of

getting to this point. I won’t be putting

any gloss on my experiences so I

suspect that some people may be put

off while reading this. My aim though

is to encourage others to join me on

this career route. It is not an easy one

but six months in, it has already been

very rewarding.

To go back to the beginning, I

completed an exceptionally good post

graduate diploma in neurological

rehabilitation in 2006 at the University

of Western Australia and discussed my

future plans with Barby Singer the

course leader. Having discussed my

career plans with her she advised me

on going straight to a PhD rather than

building from an MSc. This advice has

been corroborated by other researchers

that I have spoken with however this is

due to my particular career plans and

others will find the MSc route prior to

PhD a better option.

I had developed two main areas of

interest by this time. Neuroplasticity, in

particular the potential of transcranial

magnetic stimulation as a therapeutic

technique and spasticity, in particular

the very early treatment of it. Having

had many further discussions with

researchers and clinicians my chosen

plan was to investigate the changing

aspects of the upper motor neuron

syndrome over the first six months post

stroke With this in mind in May 2007 I

met with Dr Anand Pandyan at Keele

University regarding how to progress

this interest forward.

The challenge in deciding on a

specific research area rather than

joining a university through a PhD

studentship is that there is no

immediate funding. This is why it has

taken so long for me to begin the PhD.

For some, writing grant applications

is not a concern until after the PhD but

I have already written four full applica-

tions to different funding bodies. The

feedback is sometimes hard to take,

particularly when decisions appear

politically driven rather than due to

sound scientific rationale. Nevertheless

it was the biggest grant application

that finally came off in November 2009.

A National Institute of Health Research,

Research for Public Benefit Grant.

Different funding bodies require

different approaches to the research

methodology. The NIHR grant aims to

generate research that will translate in

to patient benefit. We therefore devel-

oped a double blind randomised

controlled trial investigating Botulinum

Toxin and electrical stimulation to the

forearm extensors as soon as signs of

abnormal muscle activity on EMG

presented. I will talk in more detail

about the trial in further entries but for

an overview look on the ISRCTN website

number: ISRCTN57435427.

The grant funding however, is only

available once a positive ethical

opinion has been given. This took a

very long time to come as the named

principal investigator Steve Sturman

(Consultant Neurologist) and I worked

for many hours in our spare time on

the protocol and ethics forms. Because

the trial uses a drug it requires further

approval by the MHRA and only certain

research ethic committees can hear it.

It was therefore to Manchester in

December 2010 that Anand and I

travelled to sit and argue our case to a

panel of 12 on an ethics committee.

They were very positive but advised on

a number of changes to patient infor-

mation and consent sheets before we

were given the all-important positive

ethical opinion in April 2011. Shortly

after this the MHRA agreement came

through and we were able to get the

grant funding. This allowed me to

begin my three year secondment from

the NHS as a full time PhD student in

July 2011.

I suppose my journey to the start has

been a back-packing expedition rather

than a relaxed business class flight but

I have seen more and encountered far

more challenges this way and

hopefully it has led to a more rounded

and fulfilling experience.

So, from being an experienced clini-

cian I now find myself at the lower end

of the pecking order as a PhD student.

Not quite student, not quite member

of the university staff and not a clinical

member of staff in the hospital. It

does feel a bit strange but I would not

change it. Whether this view changes

as I continue is yet to be discovered.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 44

REVIEWS

BOOKS

Physical management for

neurological conditions

Third edition

Edited by: Maria Stokes and Emma Stack

Churchill Livingstone

ISBN 978-0-7234-3560-0

Review by Elizabeth Hooks Senior

Physiotherapist, Poole Community Therapy Team

This physiotherapy orientated textbook

has been refined and includes four

new chapters. It is very easy to read,

using key points to help the reader

summarise and revise what they have

read. It comes across with a non-

prescriptive approach that strongly

encourages a multi-disciplinary and

patient-centred way of working. As an

overview the book is set out into three

main sections.

The first section of the book looks at

neurological and neuromuscular

conditions. Each chapter explores a

different condition; the chapters are

well set out, outlining the main points

regarding pathology, diagnosis, assess-

ment principles, management and the

physiotherapist’s role and treatments.

This allows the reader to gain a good

comprehensive coverage of the basics,

and allows them to be well enough

informed to manage patients with

these conditions. Experienced clini-

cians may find some of the information

a little basic in some areas. However, it

is a very good aide-memoire for those

areas in which clinicians may not find

themselves working on a regular basis.

The second section moves into

describing physiotherapeutic

approaches, starting with the guiding

principles and moving onto

summarising the most often used

techniques. Vestibular rehabilitation,

the management of pain, altered tone,

and also neuropsychology are

discussed in more detail.

The third section looks at core

rehabilitation skills that physiothera-

pists utilise on a daily basis, allowing

the reader to research or revise the

most essential facts in the areas of

exercise training, self management and

falls.

The book appears to be aimed at

undergraduates. However, it would be

a valuable addition to any department,

particularly those supporting rotational

staff. It will save time for clinicians

who want an overview of different

clinical groups, or treatment

techniques, without having to trawl

through a long literature search.

Finally, the book provides some

useful contact details and websites for

a variety of associations and support

groups, in a well set out appendix. In

addition, each chapter is well refer-

enced and where appropriate gives

details of additional resources. The

publishers also offer a feature called

‘pageburst™’, which allows you to

access the textbook online or through

an iPhone. I have tested this feature,

but in practice found it failed to load.

COURSES

Step into research

Wessex ACPIN

An evening lecture was hosted by the

Royal Hampshire County Hospital. This

took place on Wednesday 21st

September 2011 and was called ‘Step

into Research’. The aim of the evening

was to ‘re-visit’ research as a topic for

Wessex ACPIN members. Also to support

band 5 and 6 physiotherapy staff

thinking about research/undertaking

research and review what research was

happening locally. We tried to format

the evening in a slightly different way,

so that people attending would be

able to `mingle’ with presenters at the

start of the evening initially and then

enjoy the lecture during the middle

part of the evening. Time was also

available at the end for further inter-

action with colleagues and guest

speakers. We wanted to try this

approach to meet the different needs/

level of support/questions from the

people attending, rather than a ‘tradi-

tional’ single lecture format.

We also tried to keep the structure of

the evening very informal and relaxed.

This was done purposefully, so that

members were not discouraged from

thinking that research was ‘only for

senior level physiotherapists’. We had

representatives from the University of

Southampton, South Coast DeNDRon,

South Central Stroke Association and

Wessex members who had undertaken

MSc research volunteered to talk in

small groups/answer questions.

The main speaker during the evening

was Dr Jane Burridge, a research

physiotherapist from the University of

Southampton. Dr Burridge talked about

the two ends of the research process

and explored clinically driven research

that leads to effective changes in

practice. Wessex ACPIN members were

also able to learn about what research,

in relation to neurological therapy, is

taking place at the University of

Southampton. This includes pioneering

robotic equipment for upper limb

therapy and hand activity.

Wessex ACPIN also supports entry into

research and continued professional

development with a bi-annual bursary

scheme that is available.

REVIEWS ARTICLES BOOKS COURSES EQUIPMENT

Reviews of research articles, books, courses and equipment 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.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 45

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●

SPRING/SUMMER 2012

Physio wins The Royal

Society of Medicine’s

Gordon Holmes Prize

for Clinical Neuroscience

Lisa Bunn has won The Royal Society

of Medicine’s Gordon Holmes Prize

for Clinical Neuroscience for 2012,

which is open to all trainees in neu-

rosciences including neurology, neu-

rosurgery, neurophysiology,

neuropathology or neuroradiology.

As well as the prestige of winning, a

financial prize of £300 is awarded.

“I was initially shortlisted based on

submission of an abstract of my work

in January 2012 (along with four oth-

ers)”. The programme for the night is

available on: www.rsm.ac.uk/

academ/cnc05.php Each shortlisted

individual had ten minutes to pres-

ent a very concise but informative

account of their work and answer

five minutes worth of questions.

The prize was awarded to the

project because it was an ‘excellent

example of translational neuro-

science’ and the feedback was that

the talk was clear and well-paced.

Presentations took place during an

evening event at the Royal Society of

Medicine on March 1st 2012.

Lisa lectured at our ACPIN conference

this year presenting on her area of

research, ‘What is the cause of balance

impairment in patients with cerebellar

disease’. She is the first physiotherapist

to have received this award, with her

major competitors being neurologists

and neuroscientists. Lisa should be

congratulated on this break through

and we wish her all the best with her

ongoing drive in research to better

neurorehabilitation in the future.

Interactive CSP update

Chris Manning iCSP link moderator

for neurology.

There are 10,140 registered users on

the neurology network. The mem-

bership is growing by approximately

1,000 each year. This and the grow-

ing ACPIN membership demonstrate

the high profile neurology has in our

profession.

Many of the posted items, discus-

sions, documents and websites,

relate to topics covered in the ACPIN

national conference, ‘The Backbone

of Neurology’. Use the discussion

forum to carry on debates you may

have had at the conference. Keep in

touch!

Other news

An update of other ACPIN news can

be found in the section on this years

conference, the session named,

Speed updates- What does ACPIN Do?

on page 26 of this edition of Synapse.

ACPIN constitution revised

REVISED CONSTITUTION

March 2012 (Revised from previous constitution dated November 2008,

November 2004 and 17th July 1996)

1 TITLE

1.1 This Clinical Interest Group shall be known as the ‘Association of

Chartered Physiotherapists in Neurology’, herein referred to as

ACPIN, or ‘The Group’.

2 TERMS OF REFERENCE

2.1 To promote and facilitate collaborative interaction between ACPIN

members across all fields of practice including clinical, research and

education.

2.2

To promote evidence informed practice and continuing professional

development of ACPIN members by assisting in the exchange and

dissemination of knowledge and ideas within the area of neurology.

2.3 To provide encouragement and support for members to participate

in good quality research (with a diversity of methodologies) and

evaluation of practice at all levels.

2.4 To maintain and continue to develop a reciprocal communication

process with the Chartered Society of Physiotherapy on all issues

related to neurology.

2.5 To foster and encourage collaborative working between ACPIN, other

professional groups, related organisations ie third sector, govern-

ment departments and members of the public.

2.6

Any other objective not in conflict with 2.1 to 2.5 above which appears

to be appropriate to the needs and interests of the members of ACPIN.

3 ACPIN shall not take any action or express any view which in any way

affects or concerns the general policy of the Chartered Society of

Physiotherapy (CSP) without the express agreement of the Council of the

Chartered Society.

4 MEMBERSHIP

Membership shall be available upon completion of an application form

and payment of the appropriate subscription in the following terms:

4.1 Full members shall be registered Chartered Physiotherapists in good

standing with the CSP (This section includes CSP members who live

overseas).

4.2

Associate members shall have a professional interest in neurology and

thus, in the opinion of the Executive Committee are suitable to

become associate members of ACPIN. Associate members will not have

the right to hold any elected post within ACPIN. CSP Support workers

whose names appear on the register maintained by the Chartered

Society of Physiotherapy shall be eligible for associate membership.

4.3 Overseas members shall be qualified Physiotherapists who are

members of their country’s governing body.

4.4 Student members shall be Undergraduate Physiotherapists who are

student members of the Chartered Society of Physiotherapy.

4.5 Full and Associate members shall have the right to vote.

NEWS

SYNAPSE Spring 2012 28/05/2012 11:22 Page 46

NEWS

5 REGIONAL STRUCTURE

5.1 Application procedure

Applications for full, associate and student membership shall be

submitted in the first instance to the membership secretary. A new

member will be allocated to one Regional Group, according to the

location of his or her place of work or residence in accordance with

the map annexed hereto. A member who works or lives close to the

boundary of any region may elect to join an adjacent region.

5.2 Capitation

Regional Groups shall be entitled to receive a proportion of the

annual subscription paid by each member allocated at a level deter-

mined by the National Committee. It shall be open to the National

Committee to set different levels of local subscription allocations

among Regional Groups.

5.3 Regional constitutions

Each Regional Group shall adopt a written constitution in accor-

dance with guidelines at Appendix 1 of this constitution. A Regional

Group may not amend its own constitution without prior agreement

of the National Committee, signed by a resolution passed by a

majority of committee members present.

6 EXECUTIVE COMMITTEE

Shall comprise of:

6.1 Nine honorary officers, Chair, Vice Chair, Secretary, Treasurer,

Membership Secretary, Research Officer, Public Relations Officer,

Minute Secretary, Diversity Officer Post, or any others holding office

in accordance with Clause 7.2 below.

6.2 Not more than four full members elected at the Annual General

Meeting (AGM) who shall be entitled to serve as members of the

Executive Committee for such period as shall be permitted in the

case of an Honorary Officer.

6.3 The Executive Committee shall be empowered to co-opt four mem-

bers to serve in addition to those elected members, should the need

arise. The total number of coopted members shall never exceed one

third of the total membership of the committee. The Executive

Committee hereafter referred to as Executive shall be responsible for

the general management of the Group.

6.4 If any Executive Committee member fails to attend two-thirds of the

yearly total of meetings without good reason, where good reason is

decided at the discretion of the majority of the remaining Executive

members, their term of office shall be deemed to have lapsed. The

vacancy may be filled by the Executive Committee at its discretion.

7 THE HONORARY OFFICERS

7.1 Only full members shall be eligible for election as Honorary Officers.

Any candidate for election as an Honorary Officer must submit a

written nomination, countersigned by at least two other full mem-

bers to the Chair.

7.2 The Honorary Officers, whose numbers shall not exceed nine, shall

comprise Chair, Secretary, Treasurer, Membership Secretary, Research

Officer and Diversity Officer and such other officers that the Executive

consider expedient for the efficient management of the affairs of the

Group.

7.3 Honorary Officers shall be elected by ballot of enfranchised members

of the group at the AGM, save and except the Chair, who shall be

elected by a ballot of all Executive Committee Members at the first

Executive Committee Meeting to be held after the AGM in the year of

the Chair’s retirement.

7.4 Honorary Officers will hold office for two years, and may offer them-

selves for re-election for not more than three consecutive terms.

(Giving a maximum of six years service). A former Honorary Officer

may offer him or herself for first election not less than two years after

retirement from any earlier honorary office. An Honorary Officer may

transfer from one honorary office to another for the aggregate length

of continuous service. An Honorary Officer shall not exceed a period

of six years, as set out above. (See exception below for Chair).

7.5 The Chair Person must be on the Executive Committee for a mini-

mum of two years prior to becoming Chair for up to a maximum of

four years ie two terms with at least one year prior to taking the

Chair as Vice Chair.

7.6 In normal circumstances the Chair and Secretary shall not retire in

the same year as each other.

7.7 Retiring Honorary Officers shall leave office at the AGM and newly

elected replacements take office immediately, so that the Chair shall

hand over office at the first National Committee Meeting following

the AGM.

7.8 The Office of President shall be occupied by a person suitably quali-

fied and distinguished who has been invited by the Executive

Committee for a period not exceeding four years. The President shall

be entitled to attend all meetings of the Executive, but shall not

have voting rights.

7.9 Should any casual vacancy arise among the Honorary Office, except

Chair, that vacancy shall be filled by co-option of a suitably quali-

fied member of the Group, who shall hold office until the next AGM.

A casual vacancy for the Chair shall be filled by vote of the National

Committee as set out above. Any period of office served as a result of

the appointment following a casual vacancy shall not count towards

the maximum six year period of office for any member of the

Executive Committee.

7.10 Committee members will hold office for two years and may offer

themselves up for re-election for not more than two consecutive

terms for a maximum of four years. However, a Committee Member

who goes on to hold an Honorary Officer’s post can remain in this

Honorary post for up to six years, offering themselves up for re-elec-

tion at two yearly intervals during this period. Thus maximum serv-

ice on the Executive Committee can total ten years.

8 NATIONAL COMMITTEE

8.1

The National Committee shall consist of the Executive and

one

Representative elected from each Region. This may be the Regional

Chair or the Regional Representative and shall be full members of

the Regional Group whom they represent.

9 ANNUAL GENERAL MEETING (AGM)

9.1 The AGM shall be held in the month of March at a convenient time

and place, to be decided by the Executive, providing that no more

than 54 weeks shall elapse between AGM’s.

9.2 Notice of the date, time and place of the AGM shall be given to all

members by the Chair not less than 28 clear days in advance. Such

notice shall be accompanied by a provisional agenda.

9.3 The AGM shall receive reports from the Honorary Officers, consider

the accounts, and appoint an Auditor for the following year, hold

elections for office and transact such other business as notified to

the Secretary in writing not less than 14 days before the said AGM.

10 EXTRA-ORDINARY GENERAL MEETING (EGM)

10.1 An EGM may be called by the Secretary upon receipt of instructions

from the Executive or upon written representation from not less

than one third of the fullmembership.

10.2 Not less than 28 days clear notice of an EGM shall be given, specify-

SYNAPSE Spring 2012 28/05/2012 11:22 Page 47

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●

SPRING/SUMMER 2012

ing date, time and place, to all members of the Group. Such notice

shall also include an agenda which comprises a full and exhaustive

programme for the business which is to be considered at any such

meeting.

11 VOTING

11.1 All voting at Annual General Meetings or Extraordinary General

Meetings shall be by a show of hands. Voting at all Committee

Meetings shall be by a show of hands.

11.2 Any full or associate member may appoint another full or associate

member to act as his or her proxy at any Annual or Extraordinary

General Meeting by giving notice in writing to the Secretary. Such

notice specifying whether the said proxy is directed to vote in accor-

dance with the wishes of the members or given discretion in the

casting of any vote.

11.3 A National Annual General Meeting or Extraordinary Meeting shall

not be deemed quorate unless at least 50 full members, or one third

of the total full membership attends, whichever be the less.

11.4 Any other Committee Meeting shall require a quorum of not less

than one third of the membership of the Committee.

12 WINDING UP / DISSOLUTION

The Group may be wound up by a resolution passed at an Annual or

Extraordinary General Meeting supported by a simple majority of full

members casting votes. In the event of a motion to wind the Group up

being passed the CSP will be informed and entitled to recoup the balance

of the year’s capitation fees. The remaining assets of the Group shall be

handed over to the Members Benevolent Fund of the Chartered Society of

Physiotherapy.

13 AMENDMENT

This constitution may only be amended by a resolution passed by an

Annual or Extraordinary General Meeting of the group provided:

13.1 The proposed amendment has been notified to the Secretary in

writing and is supported by the signatures of not less than ten full

members.

13.2 At least 14 clear days notice has been given to each full member of

the proposed amendment.

13.3 The proposed amendment receives the support of at least two thirds

of the votes cast at the relevant meeting.

13.4 The amendments must be approved by the PPSD at the Chartered

Society of Physiotherapy

APPENDIX

When formulating a Constitution, Regional Groups shall have regard to the

provisions of the National Constitution, and in particular shall adopt the pro-

visions of Articles 1 to 5 thereof.

Regional Groups shall make provision for the election of a Regional

Committee not less than one month before each Annual General Meeting of

the National Group.

That Committee must include a Regional Representative who shall serve for

two years on the National Committee. It is envisaged that each Region will

also elect a Secretary and a Treasurer. The same time limits on service on a

Regional Committee shall apply as in the case of the National Committee and

Executive.

Not less than four meetings should be required to be held each year within

normal circumstances.

Amendment to the Constitution shall be at a Regional Annual General

Meeting or Extraordinary General Meeting, but shall only take effect when it

has been approved by Resolution of the National Executive and by the PPSD

at the CSP.

Winding up shall be by resolution of the members, save that if full member-

ships falls below 10 a Regional Group will be deemed to have been wound

up and its remaining members shall be allocated to other convenient

group(s).

Regional assets shall pass automatically to the National Group.

A copy of the Constitution of each Regional Group must be supplied to the

National Honorary Secretary.

The appropriate provisions of this Constitution may be adopted by Regional

Groups by the making of amendments to meet the specific needs of such

groups. It is envisaged that each Regional Group will adopt this Constitution

subject to such amendments.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 48

ARTICLES IN OTHER JOURNALS

ARCHIVES PHYSICAL

MEDICINE AND

REHABILITATION

Volume 92:10

• Bell KR, Brockway JA Hart T, Whyte J, Sherer M,

Fraser RT, Temkin NR and Dikmen SS Scheduled

telephone intervention for traumatic brain

injury: a multicenter randomized controlled

trial pp1552-1560.

• Herrmann SD, Snook EM, Kang M, Scott CB, Mack

MG, Dompier TP and Ragan BG Development and

validation of a movement and activity in

physical space score as a functional outcome

measure pp1652-1658.

• Hirsh AT, Braden AL, Craggs JG and Jensen MP

Psychometric properties of the community

integration questionnaire in a heterogeneous

sample of adults with physical disability

pp1602-1610.

• Huisinga JM, Filipi ML, Schmid KK and Stergiou N

Is there a relationship between fatigue ques-

tionnaires and gait mechanics in persons

with multiple sclerosis? pp1594-1601.

• Moreno CC, Mendes LA and Lindquist AR Effects

of treadmill inclination on the gait of indi-

viduals with chronic hemiparesis pp1675-1680.

• Norweg A, Ni P, Garshick E, O’Connor G, Wilke K

and Jette AM A multidimensional computer

adaptive test approach to dyspnea assess-

ment pp1561-1569.

• Selassie AW, Varma A and Saunders LL Current

trends in venous thromboembolism among

persons hospitalized with acute traumatic

spinal cord injury: does early access to reha-

bilitation matter? pp1534-1541.

• Severinsen K, Jakobsen JK, Overgaard K and

Andersen H Normalized muscle strength, aero-

bic capacity and walking performance in

chronic stroke: a population-based study on

the potential for endurance and resistance

training pp1663-1668.

• Waters DL, Hale LA, Robertson L, Hale BA and

Herbison P Evaluation of a peer-led falls pre-

vention program for older adults pp1581-1586.

Volume 92:10 (Supplement)

• Amtmann D, Cook KF, Johnson KL and Cella D

The PROMIS initiative: involvement of reha-

bilitation stakeholders in development and

examples of applications in rehabilitation

research ppS12-S19.

• Carlozzi NE, Tulsky DS and Kisala PA Traumatic

brain injury patient-reported outcome meas-

ure: identification of health-related quality-

of-life issues relevant to individuals with

traumatic brain injury ppS52-S60.

• Cella D, Nowinski C, Peterman A, Victorson D,

Miller D, Lai JS and Moy C The neurology qual-

ity-of-life measurement initiative ppS28-S36.

• Haley SM, Ni P, Lai J-S, Tian F, Coster WJ, Jette AM,

Straub D and Cella D Linking the activity meas-

ure for post acute care and the quality of life

outcomes in neurological disorders ppS37-S43.

•

Lai JS, Cella D, Choi S, Junghaenel DU, Christodoulou

C, Gershon R and Stone A How item banks and

their application can influence measurement

practice in rehabilitation medicine: a promise

fatigue item bank example ppS20-S27.

• Quatrano LA and Cruz TH Future of outcomes

measurement: impact on research in medical

rehabilitation and neurologic populations

ppS7-S11.

• Tulsky DS, Carlozzi NE and Cella D Advances in

outcomes measurement in rehabilitation

medicine: current initiatives from the

National Institutes of Health and the National

Institute on Disability and Rehabilitation

Research ppS1-S6.

• Tulsky DS, Kisala PA, Victorson D, Tate D,

Heinemann AW, Amtmann D and Cella D

Developing a contemporary patient-reported

outcomes measure for spinal cord injury

ppS44-S51.

Volume 92:11

• de Araújo RC, Lúcio Jr F, Rocha DN, Sono TS and

Pinotti M Effects of intensive arm training with

an electromechanical orthosis in chronic stroke

patients: a preliminary study pp1746-1753.

• Barclay-Goddard R, Lix LM, Tate R, Weinberg L

and Mayo NE Health-related quality of life

after stroke: does response shift occur in self-

perceived physical function? pp1762-1769.

• Conroy SS, Whitall J, Dipietro L, Jones-Lush LM,

Zhan M, Finley MA, Wittenberg GF, Krebs HI and

Bever CT Effect of gravity on robot-assisted

motor training after chronic stroke: a ran-

domized trial pp1754-1761.

• Fritz SL, Merlo-Rains AM, Rivers ED, Peters DM,

Goodman A, Watson ET, Carmichael BM and

McClenaghan BA An intensive intervention for

improving gait, balance and mobility in indi-

viduals with chronic incomplete spinal cord

injury: a pilot study of activity tolerance and

benefits pp1776-1784.

• Gadidi V, Katz-Leurer M, Carmeli E and Bornstein

NM Long-term outcome poststroke: predictors

of activity limitation and participation

restriction pp1802-1808.

• González-Fernández M, Davis C, Molitoris JJ,

Newhart M, Leigh R and Hillis AE Formal educa-

tion, socioeconomic status and the severity of

aphasia after stroke pp1809-1813.

• Hastings J, Robins H, Griffiths Y and Hamilton C

The differences in self-esteem, function and

participation between adults with low cervi-

cal motor tetraplegia who use power or

manual wheelchairs pp1785-1788.

• Jensen MP, Alschuler KN, Smith AE, Verrall AM,

Goetz MC and Molton IR Pain and fatigue in

persons with postpolio syndrome: independ-

ent effects on functioning pp1796-1801.

• Kasser SL, Jacobs JV, Foley JT, Cardinal BJ and

Maddalozzo GF A Prospective evaluation of

balance, gait and strength to predict falling

in women with multiple sclerosis pp1840-

1846.

• Krause JS and Saunders LL Health, secondary

conditions and life expectancy after spinal

cord injury pp1770-1775.

• Marchetti GF, Whitney SL, Redfern MS and

Furman JM Factors associated with balance

confidence in older adults with health condi-

tions affecting the balance and vestibular

system pp1884-1891.

• Meeus M, van Eupen I, van Baarle E, De Boeck V,

Luyckx A, Kos D and Nijs J Symptom fluctuations

and daily physical activity in patients with

chronic fatigue syndrome: a case-control

study pp1820-1826.

ARTICLES IN OTHER JOURNALS

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SPRING/SUMMER 2012

• de Niet M, Latour H, Hendricks H, Geurts AC and

Weerdesteyn V Short-latency stretch reflexes

do not contribute to premature calf muscle

activity during the stance phase of gait in

spastic patients pp1833-1839.

• Page SJ, Murray C, Hermann V and Levine P

Retention of motor changes in chronic stroke

survivors who were administered mental

practice pp1741-1745.

Volume 92:12

• Denkinger MD, Lindemann U, Nicolai S, Igl W,

Jamour M and Nikolaus T Assessing physical

activity in inpatient rehabilitation: validity,

practicality and sensitivity to change in the

physical activity in inpatient rehabilitation

assessment pp2012-2017.

• Fisher SR, Galloway RV, Kuo YF, Graham JE,

Ottenbacher KJ, Ostir GV and Goodwin JS Pilot

study examining the association between

ambulatory activity and falls among hospi-

talized older adults pp2090-2092.

• Hakkennes SJ, Brock K and Hill KD Selection for

inpatient rehabilitation after acute stroke: a

systematic review of the literature pp2057-2070.

• Hase K, Suzuki E, Matsumoto M, Fujiwara T and

Liu M Effects of therapeutic gait training using

a prosthesis and a treadmill for ambulatory

patients with hemiparesis pp1961-1966.

• Oh-Park M, Wang C and Verghese J Stair nego-

tiation time in community-dwelling older

adults: normative values and association

with functional decline pp2006-2011.

• Sosnoff JJ, Boes MK, Sandroff BM, Socie MJ, Pula

JH and Motl RW Walking and thinking in

persons with multiple sclerosis who vary in

disability pp2028-2033.

• Wu CH, Liou TH, Hsiao PL, Lin YC and Chang KH

Contribution of ischemic stroke to hip fracture

risk and the influence of gender difference

pp1987-1991.

Volume 93:1

• Bird M-L, Hill KD and Fell JW A randomized

controlled study investigating static and

dynamic balance in older adults after train-

ing with pilates pp43-49.

• van Bloemendaal M, Kokkeler AM and van de

Port IG The Shuttle Walk Test: A new approach

to functional walking capacity measurements

for patients after stroke? pp163-166.

• Cherry BJ, Zettel-Watson L, Chang JC, Shimizu R,

Rutledge DN and Jones CJ Positive associations

between physical and cognitive performance

measures in fibromyalgia pp62-71.

• Clark E, Hill KD and Punt TD Responsiveness of

two scales to evaluate lateropulsion or Pusher

Syndrome recovery after stroke pp149-155.

• Eicher V, Murphy MP, Murphy TF and Malec JF

Progress assessed with the Mayo-Portland

Adaptability Inventory in 604 participants in

four types of post–inpatient rehabilitation

brain injury programs pp100-107.

• Goedert KM, Chen P, Botticello A, Masmela JR,

Adler U and Barrett AM Psychometric evaluation

of neglect assessment reveals motor-

exploratory predictor of functional disability

in acute-stage spatial neglect pp137-142.

• Hitzig SL, E. Escobar MR, Noreau L and Craven BC

Validation of the reintegration to Normal

Living Index for community-dwelling persons

with chronic spinal cord injury pp108-114.

• van Leeuwen CM, Post MW, Westers P, van der

Woude LH, de Groot S, Sluis T, Slootman H and

Lindeman E Relationships between activities,

participation, personal factors, mental

health and life satisfaction in persons with

spinal cord injury pp82-89.

• Lewek MD, Osborn AJ and Wutzke CJ The influ-

ence of mechanically and physiologically

imposed stiff-knee gait patterns on the

energy cost of walking pp123-128.

• Kong KH, Lee J and Chua KS Occurrence and

temporal evolution of upper limb spasticity in

stroke patients admitted to a rehabilitation

unit pp143-148.

• van Vliet PM, Wimperis A, Creak J, Taylor A and

Vandereijk C Feedback device for improvement

of coordination of reach-to-grasp after

stroke 167-171.

• Yogev-Seligmann G, Giladi N, Brozgol M and

Hausdorff JM A training program to improve

gait while dual tasking in patients with

Parkinson’s Disease: a pilot study pp176-181.

• Yue Y, Song W, Huo S and Wang M Study on the

occurrence and neural bases of hemispatial

neglect with different reference frames

pp156-162.

• Zimbelman J, Daly JJ, Roenigk KL, Butler K,

Burdsall R and Holcomb JP Capability of two

gait measures for detecting response to gait

training in stroke survivors: gait assessment

and intervention tool and the Tinetti Gait

Scale pp129-136.

Volume 93:1 (Supplement)

• Hilari K, Needle JJ and Harrison KL What are the

important factors in health-related quality of

life for people with aphasia? A systematic

review ppS86-S95.

• Meinzer M, Rodriguez AD and Gonzalez Rothi LJ

First decade of research on constrained-

induced treatment approaches for aphasia

rehabilitation ppS35-S45.

• O’Halloran R, Grohn B and Worrall L

Environmental factors that influence commu-

nication for patients with a communication

disability in acute hospital stroke units: a

qualitative metasynthesis ppS77-S85.

• van de Sandt-Koenderman ME, van der Meulen

I and Ribbers GM Aphasia rehabilitation: more

than treating the language disorder ppS1-S3.

• Saur D and Hartwigsen G Neurobiology of lan-

guage recovery after stroke: lessons from

neuroimaging studies ppS15-S25.

• Smits M, Visch-Brink EG, van de Sandt-

Koenderman ME and van der Lugt A Advanced

magnetic resonance neuroimaging of lan-

guage function recovery after aphasic stroke:

a technical review ppS4-S14.

•Tompkins CA Rehabilitation for cognitive-

communication disorders in right hemisphere

brain damage ppS61-S69.

Volume 93:2

• Barclay-Goddard R, King J, Dubouloz CJ and

Schwartz CE Building on transformative learn-

ing and response shift theory to investigate

health-related quality of life changes over

time in individuals with chronic health con-

ditions and disability pp214-220.

• Brogårdh C, Flansbjer UB and Lexell J No specific

effect of whole-body vibration training in

chronic stroke: a double-blind randomized

controlled study pp253-258.

• Cicerone KD Facts, theories, values: shaping

the course of neurorehabilitation The 60th

John Stanley Coulter Memorial Lecture pp188-191.

• Connell LA and Tyson SF Clinical reality of

measuring upper-limb ability in neurologic

conditions: a systematic review pp221-228.

• Doeltgen SH and Huckabee ML Swallowing

neurorehabilitation: from the research labo-

ratory to routine clinical application pp207-213.

• Hoffman JM, Dikmen S, Temkin N and Bell KR

Development of posttraumatic stress disorder

after mild traumatic brain injury pp287-292.

• Krause JS, Terza JV, Erten M, Focht KL, Dismuke CE

Prediction of postinjury employment and per-

centage of time worked after spinal cord

injury pp373-375.

• Lin MR, Yu WY and Wang SC Examination of

assumptions in using time tradeoff and stan-

dard gamble utilities in individuals with

spinal cord injury pp245-252.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 50

ARTICLES IN OTHER JOURNALS

• Montero-Odasso M, Muir SW and Speechley M

Dual-task complexity affects gait in people

with mild cognitive impairment: the inter-

play between gait variability, dual tasking

and risk of falls pp293-299.

• Page SJ, Levin L, Hermann V, Dunning K and

Levine P Longer versus shorter daily durations

of electrical stimulation during task-

specific practice in moderately impaired

stroke pp200-206.

• Saunders LL and Krause JS Behavioral factors

related to fatigue among persons with spinal

cord injury pp313-318.

• Velthuis MJ, Peeters PH, Gijsen BC, van den Berg

JP, Koppejan-Rensenbrink RA, Vlaeyen JW and

May AM Role of fear of movement in cancer

survivors participating in a rehabilitation

program: a longitudinal cohort study

pp332-338.

• Wijesuriya N, Tran Y, Middleton J and Craig A

Impact of fatigue on the health-related qual-

ity of life in persons with spinal cord injury

pp319-324.

Volume 93:3

• Benito-Penalva J, Edwards DJ, Opisso E, Cortes

M, Lopez-Blazquez R, Murillo N, Costa U, Tormos

JM, Vidal-Samsó J, Valls-Solé J, European

Multicenter Study about Human Spinal Cord Injury

Study Group Gait training in human spinal

cord injury using electromechanical systems:

effect of device type and patient

Characteristics pp404-412.

• Carroll SL, Greig CA, Lewis SJ, McMurdo ME,

Sniehotta FF, Johnston M, Johnston DW, Scopes J

and Mead GE The use of pedometers in stroke

survivors: are they feasible and how well do

they detect steps? pp466-470.

• Chiu HT, Wang YH, Jeng JS, Chen BB and Pan SL

Effect of functional status on survival in

patients with stroke: is independent ambula-

tion a key determinant? pp527-531.

• Chuang LL, Wu CY and Lin KC Reliability, valid-

ity and responsiveness of myotonometric

measurement of muscle tone, elasticity and

stiffness in patients with stroke pp532-540.

Motl RW and Fernhall B Accurate prediction of

cardiorespiratory fitness using cycle ergome-

try in minimally disabled persons with relaps-

ing-remitting multiple sclerosis pp490-495.

• Pershouse KJ, Barker RN, Kendall MB, Buettner

PG, Kuipers P, Schuurs SB and Amsters DI

Investigating changes in quality of life and

function along the lifespan for people with

spinal cord injury pp413-419.

CLINICAL REHABILITATION

Volume 25:10

• Brady MC, Clark AM, Dickson S, Paton G and

Barbour RS Dysarthria following stroke – the

patient’s perspective on management and

rehabilitation pp935-952.

• Brock K, Haase G, Rothacher G and Cotton S Does

physiotherapy based on the Bobath concept,

in conjunction with a task practice, achieve

greater improvement in walking ability in

people with stroke compared to physiother-

apy focused on structured task practice alone?

A pilot randomized controlled trial pp903-912.

• Gharib NMM, El-Maksoud GM and Rezk-Allah SS

Efficacy of gait trainer as an adjunct to tradi-

tional physical therapy on walking perform-

ance in hemiparetic cerebral palsied children:

a randomized controlled trial pp924-934.

• Ma HI, Hwang WJ, Fang JJ, Kuo JK, Wang CY,

Leong IF and Wang TY Effects of virtual reality

training on functional reaching movements

in people with Parkinson’s disease: a ran-

domized controlled pilot trial pp892-902.

Volume 25:11

• Forghany S, Tyson S, Nester C, Preece S and

Jones R Foot posture after stroke: frequency,

nature and clinical significance pp1050-1055.

• Hedman LD and Sullivan JE An initial explo-

ration of the perceptual threshold test using

electrical stimulation to measure arm sensa-

tion following stroke pp1042-1049.

• Khan CM, Oesch PR, Gamper UN, Kool JP and

Beer S Potential effectiveness of three differ-

ent treatment approaches to improve mini-

mal to moderate arm and hand function

after stroke – a pilot randomized clinical trial

pp1032-1041.

• Lau RWK, Liao LR, Yu F, Teo T, Chung RCK and

Pang MYC The effects of whole body vibration

therapy on bone mineral density and leg

muscle strength in older adults: a systematic

review and meta-analysis pp975-988.

• Morioka S, Fujita H, Hiyamizu M, Maeoka H and

Matsuo A Effects of plantar perception training

on standing posture balance in the old old

and the very old living in nursing facilities: a

randomized controlled trial pp1011-1020.

de Sèze MP, Bonhomme C, Daviet JC, Burguete E,

Machat H, Rousseaux M and Mazaux JM Effect of

early compensation of distal motor deficiency

by the Chignon ankle-foot orthosis on gait in

hemiplegic patients: a randomized pilot

study pp989-998.

Volume 25:12

• Carda S, Invernizzi M, Baricich A and Cisari C

Casting, taping or stretching after botulinum

toxin type A for spastic equinus foot: a single-

blind randomized trial on adult stroke

patients pp1119-1127.

• Cauraugh JH, Naik SK, Lodha N, Coombes SA and

Summers JJ Long-term rehabilitation for

chronic stroke arm movements: a randomized

controlled trial pp1086-1096.

• Novak I Effective home programme interven-

tion for adults: a systematic review pp1066-1085.

• Steenbeek D, Gorter JW, Ketelaar M, Galama K

and Lindeman E Responsiveness of Goal

Attainment Scaling in comparison to two

standardized measures in outcome evaluation

of children with cerebral palsy pp1128-1139.

Volume 26:1

• Connell LA and Tyson SF Measures of sensation

in neurological conditions: a systematic

review pp68-80.

• Hiyamizu M, Morioka S, Shomoto K and

TShimada T Effects of dual task balance train-

ing on dual task performance in elderly peo-

ple: a randomized controlled trial pp58-67.

• Ward CD Is patient-centred care a good thing?

pp3-9.

Volume 26:2

• Dalton C, Farrell R, De Souza A, Wujanto E,

McKenna-Slade A, Thompson S, Liu C and

Greenwood R Patient inclusion in goal setting

during early inpatient rehabilitation after

acquired brain injury pp165-173.

• Liao W, Wu C, Hsieh Y, Lin K and Chang W Effects

of robot-assisted upper limb rehabilitation on

daily function and real-world arm activity in

patients with chronic stroke: a randomized

controlled trial pp111-120.

• Muller F, Cugy E, Ducerf C, Delleci C, Guehl D,

Joseph P, Burbaud P and Dehail P Safety and

self-reported efficacy of botulinum toxin for

adult spasticity in current clinical practice: a

prospective observational study pp174-179.

• Taylor-Piliae RE and Coull BM Community-

based Yang-style Tai Chi is safe and feasible in

chronic stroke: a pilot study pp121-131.

Volume 26:3

• Hesse S, Mach H, Fröhlich S, Behrend S, Werner C

and Melzer I An early botulinum toxin A treat-

ment in subacute stroke patients may prevent

a disabling finger flexor stiffness six months

later: a randomized controlled trial pp237-245.

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• Kang H, Kim Y, Chung Y and Hwang S Effects of

treadmill training with optic flow on balance

and gait in individuals following stroke: ran-

domized controlled trials pp246-255.

• Peurala SH, Kantanen MP, Sjögren T, Paltamaa J,

Karhula M and Heinonen A Effectiveness of con-

straint-induced movement therapy on activ-

ity and participation after stroke: a

systematic review and meta-analysis of ran-

domized controlled trials pp209-223.

• Turner-Stokes L, Bill A and Dredge R A cost

analysis of specialist inpatient neurorehabili-

tation services in the UK pp256-263.

• Turner-Stokes L, Sutch S and Dredge R

Healthcare tariffs for specialist inpatient neu-

rorehabilitation services: rationale and

development of a UK casemix and costing

methodology pp264-279.

• Turner-Stokes L, Sutch S, Dredge R and Eagar K

International casemix and funding models:

lessons for rehabilitation pp195-208.

Volume 26:4

• Cobley CS, Thomas SA, Lincoln NB and Walker MF

The assessment of low mood in stroke

patients with aphasia: reliability and validity

of the ten-item hospital version of the Stroke

Aphasic Depression Questionnaire (SADQH-10)

pp372-381.

• Coupar F, Pollock A, Rowe P, Weir C and

Langhorne P Predictors of upper limb recovery

after stroke: a systematic review and meta-

analysis pp291-313.

Taylor WJ, Brown M, William L, McPherson KM,

Reed K, Dean SG and Weatherall M A pilot cluster

randomized controlled trial of structured

goal-setting following stroke pp327-338.

DISABILITY AND

REHABILITATION

Volume 33:10

• Jones F and Riazi A Self-efficacy and self-

management after stroke: a systematic

review pp797–810.

• Scherer MJ, Craddock G and Mackeogh T The

relationship of personal factors and subjec-

tive well-being to the use of assistive tech-

nology devices pp811–817.

• Turner BJ, Fleming J, Ownsworth T and Cornwell

P Perceived service and support needs during

transition from hospital to home following

acquired brain injury pp818–829.

Volume 33:11

• Hunt MR and Ells C Partners towards auton-

omy: risky choices and relational autonomy

in rehabilitation care pp961–967.

Volume 33:12

• Hartley SE, Goodwin PC and Goldbart J

Experiences of attendance at a neuromuscu-

lar centre: perceptions of adults with neuro-

muscular disorders pp1022–1032.

• Kayes NM, McPherson KM, Schluter P, Taylor D,

Leete M and Kolt GS Exploring the facilitators

and barriers to engagement in physical activ-

ity for people with multiple sclerosis pp1043–

1053.

• Nilsson C, Bartfai A and Löfgren M Holistic group

rehabilitation – a short cut to adaptation to

the new life after mild acquired brain injury

pp969–978.

Volume 33:13-14

• Comans TA, Currin ML, Brauer SG and Haines TP

Factors associated with quality of life and

caregiver strain amongst frail older adults

referred to a community rehabilitation service:

implications for service delivery pp1215–1221.

• Darrigrand B, Dutheil S, Michelet V, Rereau S,

Rousseaux M and Mazaux JM Communication

impairment and activity limitation in stroke

patients with severe aphasia pp1169–1178.

• Doig E, Fleming J, Cornwell P and Kuipers P

Comparing the experience of outpatient ther-

apy in home and day hospital settings after

traumatic brain injury: patient, significant

other and therapist perspectives pp1203–1214.

• Eccles FJR and Simpson J A review of the

demographic, clinical and psychosocial corre-

lates of perceived control in three chronic

motor illnesses pp1065–1088.

• Geyh S, Peter C, Müller R, Bickenbach JE,

Kostanjsek N, Üstün BT, Stucki G and Cieza A The

personal factors of the international classifi-

cation of functioning, disability and health in

the literature – a systematic review and con-

tent analysis pp1089–1102.

• Hirsche RC, Williams B, Jones A and Manns P

Chronic disease self-management for individ-

uals with stroke, multiple sclerosis and spinal

cord injury pp1136–1146.

• McColl MA, Shortt S, Gignac M and Lam M

Disentangling the effects of disability and

age on health service utilisation pp1253–1261.

• Muenchberger H, Sunderland N, Kendall and

Quinn EH A long way to Tipperary? Young peo-

ple with complex health conditions living in

residential aged care: a metaphorical map

for understanding the call for change pp1190–

1202.

• Pellerin C, Rochette A and Racine E Social par-

ticipation of relatives post-stroke: the role of

rehabilitation and related ethical issues

pp1055–1064.

• Perry KN, Nicholas MK and Middleton J

Multidisciplinary cognitive behavioural pain

management programmes for people with a

spinal cord injury: design and implementa-

tion pp1272–1280.

• Van Rijssen HJ, Schellart AJM, Anema JR and Van

Der Beek AJ Determinants of physicians’ com-

munication behaviour in disability assess-

ments pp1157–1168.

Volume 33:15-16

Dogan A, Mengüllüoglu M and Özgirgin N

Evaluation of the effect of ankle-foot orthosis

use on balance and mobility in hemiparetic

stroke patients pp1433–1439.

• Duncan RP and Earhart GM Measuring partici-

pation in individuals with Parkinson’s

Disease: relationships with disease severity,

quality of life and mobility pp1440–1446.

• Eccles FJR, Murray C and Simpson J Perceptions

of cause and control in people with

Parkinson’s Disease pp1409–1420.

• Hall E, Verheyden G and Ashburn A Effect of a

yoga programme on an individual with

Parkinson’s Disease: a single-subject design

pp1483–1489.

• Khan F and Pallant JF Use of the International

Classification of Functioning, Disability and

Health to identify preliminary comprehensive

and brief core sets for Guillain Barre syn-

drome pp1306–1313.

• Kostanjsek N, Rubinelli S, Escorpizo R, Cieza A,

Kennedy C, Selb M, Stucki G and Üstün TB

Assessing the impact of health conditions

using the ICF pp1475–1482.

• Lindsay S Discrimination and other barriers

to employment for teens and young adults

with disabilities pp1340–1350.

• Mahmoudi H, Haghighi AB, Petramfar P,

Jahanshahi S, Salehi Z and Fregni F Transcranial

direct current stimulation: electrode montage

in stroke pp1383–1388.

Volume 33:17-18

• Bart O, Agam T, Weiss PL and Kizony R Using

video-capture virtual reality for children with

acquired brain injury pp1579–1586.

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ARTICLES IN OTHER JOURNALS

• Chung, EY, Packer TL and Yau M A framework

for evaluating community-based rehabilita-

tion programmes in Chinese communities

pp1668–1682.

• Findley PA, Banerjea R and Sambamoorthi U

Excess mortality associated with mental illness

and substance use disorders among veteran

clinic users with spinal cord injury pp1608–1615.

• Gaskill A, Foley FW, Kolzet J and Picone MA

Suicidal thinking in multiple sclerosis pp1528–

1536.

• Graven C, Brock K, Hill K and Joubert L Are reha-

bilitation and/or care co-ordination inter-

ventions delivered in the community effective

in reducing depression, facilitating participa-

tion and improving quality of life after

stroke? pp1501–1520.

• Jones JA and Curtin M Reformulating mas-

culinity: Traumatic brain injury and the gen-

dered nature of care and domestic roles

pp1568–1578.

• Nijs J, Aelbrecht S, Meeus M, Van Oosterwijck J,

Zinzen E and Clarys P Tired of being inactive: a

systematic literature review of physical activ-

ity, physiological exercise capacity and muscle

strength in patients with chronic fatigue syn-

drome pp1493–1500.

• Pooyania S, Mohr S and Gray S Alien hand syn-

drome: a case report and description to reha-

bilitation pp1715–1718.

• Szilasiova J, Krokavcova M, Gdovinova Z,

Rosenberger J and Van Dijk JP Quality of life in

patients with multiple sclerosis in Eastern

Slovakia pp1587–1593.

Volume 33:19-20

• Collett J, Dawes H, Cavey A, Meaney A, Sackley C,

Wade D, Howells K Hydration and independ-

ence in activities of daily living in people with

multiple sclerosis: a pilot investigation

pp1822–1825.

• Gauld S, Smith S and Kendall MB Using partici-

patory action research in community-based

rehabilitation for people with acquired brain

injury: from service provision to partnership

with Aboriginal communities pp1901–1911.

• Gebruers N, Truijen S, Engelborghs S and De

Deyn PP Incidence of upper limb oedema in

patients with acute hemiparetic stroke

pp1791–1796.

• Kierkegaard M, Harms-Ringdahl K, Holmqvist

LW and Tollbäck A Functioning and disability in

adults with myotonic dystrophy type 1

pp1826–1836.

Kuys SS, Brauer SG and Ada L Test-retest reliabil-

ity of the GAITRite system in people with

stroke undergoing rehabilitation pp1848–

1853.

• Pearl G, Sage K and Young A Involvement in

volunteering: an exploration of the personal

experience of people with aphasia pp1805–

1821.

• Perry L and Middleton S An investigation of

family carers’ needs following stroke sur-

vivors’ discharge from acute hospital care in

Australia pp1890–1900.

• Tsai SF, Yin JH, Tung TH and Shimada T Falls effi-

cacy among stroke survivors living in the

community pp1785–1790.

Volume 33:21-22

• Danielsson A, Willén C and Sunnerhagen KS Is

walking endurance associated with activity

and participation late after stroke? pp2053–

2057.

• Fayed N, Cieza A and Bickenbach JE Linking

health and health-related information to the

ICF: a systematic review of the literature from

2001 to 2008 pp1941–1951.

• Hansen T, Kjaersgaard A and Faber J Measuring

elderly dysphagic patients’ performance in

eating – a review pp1931–1940.

• Kim JH and Park EY Rasch analysis of the

Center for Epidemiologic Studies Depression

scale used for the assessment of community-

residing patients with stroke pp2075–2083.

• Kwok T, Pan JH, Lo R and Song X The influence

of participation on health-related quality of

life in stroke patients pp1990–1996.

• Lehman LA, Woodbury M, Shechtman O, Wang

YC, Pomeranz J, Gray DB and Velozo CA

Development of an item bank for a comput-

erised adaptive test of upper-extremity func-

tion pp2092–2104.

• Martins EF, De Sousa PHC, De Araujo Barbosa PHF,

De Menezes LT and Costa AS A Brazilian experi-

ence to describe functioning and disability

profiles provided by combined use of ICD and

ICF in chronic stroke patients at home-care

pp2064–2074.

• Melchior H and Velema J A comparison of the

Screening Activity Limitation and Safety

Awareness (SALSA) scale to objective hand

function assessments pp2044–2052.

• Miller A, Clemson L and Lannin N Measurement

properties of a modified Reintegration to

Normal Living Index in a community-

dwelling adult rehabilitation population

pp1968–1978.

• Papadimitriou C and Stone DA Addressing exis-

tential disruption in traumatic spinal cord

injury: a new approach to human temporal-

ity in inpatient rehabilitation pp2121–2133.

• Welfringer A, Leifert-Fiebach G, Babinsky R and

Brandt T Visuomotor imagery as a new tool in

the rehabilitation of neglect: a randomised

controlled study of feasibility and efficacy

pp2033–2043.

Volume 33:23-24

• Arnadottir SA, Gunnarsdottir ED, Stenlund H and

Lundin-olsson L Participation frequency and

perceived participation restrictions at older

age: applying the International Classification

of Functioning, Disability and Health (ICF)

framework pp2208–2216.

• Beesley K, White JH, Alston MK, Sweetapple AL

and Pollack M Art after stroke: the qualitative

experience of community dwelling stroke sur-

vivors in a group art programme pp2346–2355.

• Kamada K, Shimodozono M, Hamada H and

Kawahira K Effects of five minutes of neck-

muscle vibration immediately before occupa-

tional therapy on unilateral spatial neglect

pp2322–2328.

• Lohmann S, Strobl R, Mueller M, Huber EO and

Grill E Psychosocial factors associated with the

effects of physiotherapy in the acute hospital

pp2311–2321.

• McClure JA, Salter K, Meyer M, Foley N, Kruger H

and Teasell R Predicting length of stay in

patients admitted to stroke rehabilitation

with high levels of functional independence

pp2356–2361.

• Ng SSM Contribution of subjective balance

confidence on functional mobility in subjects

with chronic stroke pp2291–2298.

• Njelesani J, Couto S and Cameron D Disability

and rehabilitation in Tanzania: a review of

the literature pp2196–2207.

• Reinhardt JD, Miller J, Stucki G, Catherine Sykes C

and Gray DB Measuring impact of environ-

mental factors on human functioning and

disability: a review of various scientific

approaches pp2151–2165.

• Smith C, Olson K, Hale LA, Baxter D and

Schneiders AG How does fatigue influence

community-based exercise participation in

people with multiple sclerosis? pp2362–2371.

• van Velzen JM, van Bennekom CAM, van

Dormolen M, Sluiter JK and Frings-Dresen MHW

Factors influencing return to work experi-

enced by people with acquired brain injury: a

qualitative research study pp2237–2246.

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Xiong T, Bunning K, Horton S, Hartley S Assessing

and comparing the outcome measures for the

rehabilitation of adults with communication

disorders in randomised controlled trials: an

International Classification of Functioning,

Disability and Health approach pp2272–2290.

Volume 33:25-26

• Bergmark L, Westgren N and Asaba E Returning

to work after spinal cord injury: exploring

young adults’ early expectations and experi-

ence pp2553–2558.

• Davenport TE, Stevens SR, Baroni K, Van Ness JM

and Snell CR Reliability and validity of Short

Form 36 Version 2 to measure health percep-

tions in a sub-group of individuals with

fatigue pp2596–2604.

• Den Oudsten BL, Lucas-Carrasco R, Green AM,

The Whoqol-Dis Group Perceptions of persons

with Parkinson’s Disease, family and profes-

sionals on quality of life: an international

focus group study pp2490–2508.

• Garrett R, Immink MA and Hillier S Becoming

connected: the lived experience of yoga par-

ticipation after stroke pp2404–2415.

• Kitsos G, Harris D, Pollack M and Hubbard IJ

Assessments in Australian stroke rehabilita-

tion units: a systematic review of the post-

stroke validity of the most frequently used

pp2620–2632.

• Kiyota Y, Hase K, Nagashima H, Obara T and Liu

M Adaptation process for standing postural

control in individuals with hemiparesis

pp2567–2573.

Koskinen S, Hokkinen EM, Wilson L, Sarajuuri J,

Von Steinbüchel N and Truelle JL Comparison of

subjective and objective assessments of out-

come after traumatic brain injury using the

International Classification of Functioning,

Disability and Health (ICF) pp2464–2478.

• Liddle J, Fleming J, Mckenna K, Turpin M,

Whitelaw P and Allen S Driving and driving ces-

sation after traumatic brain injury: processes

and key times of need pp2574–2586.

• Offenbächer M, Sauer S, Hieblinger R, Hufford

DJ, Walach H and Kohls N Spirituality and the

International Classification of Functioning,

Disability and Health: content comparison of

questionnaires measuring mindfulness based

on the International Classification of

Functioning pp2434–2445.

Volume 34:1

• Buchanan RJ and Huang C Caregiver percep-

tions of accomplishment from assisting peo-

ple with multiple sclerosis pp53–61.

• Cikajlo I, Rudolf M, Goljar N, Burger H and

Matjacic Z Telerehabilitation using virtual real-

ity task can improve balance in patients with

stroke pp13–18.

• Hu GC, Hsieh SF, Chen YM, Hu YN, Kang CL, Chien

KL The prognostic roles of initial glucose level

and functional outcomes in patients with

ischemic stroke: difference between diabetic

and nondiabetic patients pp34–39.

• Juengst S, Skidmore E, Pramuka M, McCue M and

Becker J Factors contributing to impaired self-

awareness of cognitive functioning in an HIV

positive and at-risk population pp19–25.

• van Leeuwen CMC, Post MWM, van Asbeck FWA,

Bongers-Janssen HMH, van der Woude LHV, de

Groot S and Lindeman E Life satisfaction in peo-

ple with spinal cord injury during the first

five years after discharge from inpatient

rehabilitation pp76-83.

• Ploughman M, Austin MW, Murdoch M, Kearney

A, Fisk JD, Godwin M and Stefanelli M Factors

influencing healthy aging with multiple scle-

rosis: a qualitative study pp26–33.

Volume 34:2

• GlässeA, Coenen M, Kollerits B and Cieza A

Validation of the extended ICF core set for

stroke from the patient perspective using

focus groups pp157–166.

• Omu O and Reynolds F Health professionals’

perceptions of cultural influences on stroke

experiences and rehabilitation in Kuwait

pp119–127.

Phadke CP , Ismail F and Boulias C Assessing the

neurophysiological effects of botulinum toxin

treatment for adults with focal limb spastic-

ity: a systematic review pp91–100.

• Sahin N, Ugurlu H and Albayrak I The efficacy of

electrical stimulation in reducing the post-

stroke spasticity: a randomized controlled

study pp151–156.

Volume 34:3

• Høyer E, Jahnsen R, Stanghelle JK and Strand LI

Body weight supported treadmill training ver-

sus traditional training in patients dependent

on walking assistance after stroke: a random-

ized controlled trial pp210–219.

• Morris K, Hacker V and Lincoln NB The validity

of the Addenbrooke’s Cognitive Examination-

Revised (ACE-R) in acute stroke pp189–195.

• O’Brien MR, Whitehead B, Jack BA and Mitchell

JD The need for support services for family

carers of people with motor neurone disease

(MND): views of current and former family

caregivers a qualitative study pp247–256.

• Stergiou-Kita M, Rappolt S and Dawson D

Towards developing a guideline for voca-

tional evaluation following traumatic brain

injury: the qualitative synthesis of clients’

perspectives pp179–188.

• Tousignant M, Corriveau H, Roy PM, Desrosiers J,

Dubuc N, Hébert R, Tremblay-Boudreault V and

Beaudoin AJ The effect of supervised Tai Chi

intervention compared to a physiotherapy

program on fall-related clinical outcomes: a

randomized clinical trial pp196–201.

Volume 34:4

• Johansson GM and Häger CK Measurement

properties of the Motor Evaluation Scale for

Upper Extremity in stroke patients (MESUPES)

pp288–294.

• Morris R and Morris P Participants’ experi-

ences of hospital-based peer support groups

for stroke patients and carers pp347–354.

Ng L and Khan F Use of the international classi-

fication of functioning, disability and health

to describe patient-reported disability: A

comparison of motor neurone disease,

Guillain-Barré syndrome and multiple sclero-

sis in an Australian cohort pp295–303.

• Thomas A, Saroyan A and Lajoie SP Creation of

an evidence-based practice reference model

in falls prevention: findings from occupa-

tional therapy pp311–328.

Volume 34:5

• Finger ME, Escorpizo R, Glässel A, Gmünder HP,

Lückenkemper M, Chan C, Fritz J, Studer U, Ekholm

J, Kostanjsek N, Stucki G, Cieza A ICF Core Set for

vocational rehabilitation: results of an inter-

national consensus conference pp429-438.

• Hsieh MY, Ponsford J, Wong D and McKay A

Exploring variables associated with change in

cognitive behaviour therapy (CBT) for anxiety

following traumatic brain injury pp408–415.

• Rundquist PJ, Dumit M, Hartley J, Schultz K and

Finley MA Three-dimensional shoulder complex

kinematics in individuals with upper extremity

impairment from chronic stroke pp402–407.

• Singh R, Venkateshwara G, Kirkland J, Batterley J

and Bruce S Clinical pathways in head injury:

improving the quality of care with early

rehabilitation pp439–442.

Volume 34:6

• Cattaneo D, Ferrarin M, Jonsdottir J, Montesano

A and Bove M The virtual time to contact in the

evaluation of balance disorders and predic-

tion of falls in people with multiple sclerosis

pp470–477.

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ARTICLES IN OTHER JOURNALS

• Kersten P, White PJ and Tennant A The consulta-

tion and relational empathy measure: an

investigation of its scaling structure pp503–509.

• Post MWM, van der Zee CH, Hennink J, Schafrat

CG, Visser-Meily JMA and van Berlekom SB

Validity of the Utrecht Scale for Evaluation of

Rehabilitation-Participation pp478–485.

• Van de Velde D, Bracke P, Van Hove G,

Josephsson S, Devisch I and Vanderstraeten G The

illusion and the paradox of being

autonomous, experiences from persons with

spinal cord injury in their transition period

from hospital to home pp491–502.

Volume 34:7

• Baert I, Feys H, Daly D, Troosters T and

Vanlandewijck Y Are patients one year post-

stroke active enough to improve their physi-

cal health? pp574–580.

• Ghahari S and Packer T Effectiveness of online

and face-to-face fatigue self-management

programmes for adults with neurological

conditions pp564–573.

• Guilcher SJT, Craven BC, McColl MA, Lemieux-

Charles L, Casciaro T and Jaglal SB Application of

the Andersen’s health care utilization frame-

work to secondary complications of spinal

cord injury: a scoping review pp531–541.

• Reed MC, Wood V, Harrington R and Paterson J

Developing stroke rehabilitation and commu-

nity services: a meta-synthesis of qualitative

literature pp553–563.

Volume 34:8

• Crosby GA, Munshi S, Karat AS, Worthington E

and Lincoln NB Fatigue after stroke: frequency

and effect on daily life pp633–637.

• Kirkevold M, Christensen D, Andersen G,

Johansen SP and Harder I Fatigue after stroke:

manifestations and strategies pp665–670.

• Mason RR, Cochrane DJ, Denny GJ, Firth EC,

Stannard SR Is eight weeks of side-alternating

whole-body vibration a safe and acceptable

modality to improve functional performance

in multiple sclerosis? pp647–654.

• Phang SH, Ginis KAM, Routhier F, Lemay V The

role of self-efficacy in the wheelchair skills-

physical activity relationship among manual

wheelchair users with spinal cord injury

pp625–632.

Volume 34:9

• Frank AO, De Souza LH, Frank JL, Neophytou C

The pain experiences of powered wheelchair

users pp770–778.

• Morris R, Jones J, Wilcox J and Cole S Depression

and anxiety screening after stroke: adherence

to guidelines and future directions pp733–739.

• Randström KB, Asplund K and Svedlund M

Impact of environmental factors in home

rehabilitation – a qualitative study from the

perspective of older persons using the

International Classification of Functioning,

Disability and Health to describe facilitators

and barriers pp779–787.

• Tebbet M and Kennedy P The experience of

childbirth for women with spinal cord

injuries: an interpretative phenomenology

analysis study pp762–769.

• Turner-Stokes L, Scott H, Williams H and Siegert

R The Rehabilitation Complexity Scale –

extended version: detection of patients with

highly complex needs pp715–720.

• Yorkston KM, Bamer A, Johnson K and Amtmann

D Satisfaction with participation in multiple

sclerosis and spinal cord injury pp747–753.

PHYSICAL THERAPY

Volume 91:10

• Hunter AJ, Snodgrass SJ, Quain D, Parsons MW

and Levi CR HOBOE (Head-of-Bed Optimization

of Elevation) study: association of higher

angle with reduced cerebral blood flow

velocity in acute ischemic stroke pp1503-1512.

• Szturm T, Betker AL, Moussavi Z, Desai A and

Goodman V Effects of an interactive computer

game exercise regimen on balance impairment

in frail community-dwelling older adults: a

randomized controlled trial pp1449-1462.

• Van der Wees PJ, Moore AP, Powers CM, Stewart

A, Nijhuis-van der Sanden MWG and de Bie RA

Development of clinical guidelines in physical

therapy: perspective for international collab-

oration pp:1551-1563.

Volume 91:11

• Burnfield JM, Shu Y, Buster TW, Taylor AP and

Nelson CA Impact of elliptical trainer

ergonomic modifications on perceptions of

safety, comfort, workout and usability for

people with physical disabilities and chronic

conditions pp1604-1617.

• Patel AT Successful treatment of long-term,

poststroke, upper-limb spasticity with

onabotulinum toxin A pp1636-1641.

Volume 91:12

• Agree EM and Freedman VA A quality-of-life

scale for assistive technology: results of a pilot

study of aging and technology pp1780-1788.

• Allen DD and Wagner JM Assessing the gap

between current movement ability and pre-

ferred movement ability as a measure of dis-

ability pp1789-1803.

• Bean JF, Ölveczky DD, Kiely DK, LaRose SI and

Jette AM Performance-based versus patient-

reported physical function: what are the

underlying predictors? pp1804-1811.

Craik RL From 1994‘s ‘physical disability’ to 2011’s

‘advances in disability research’ pp1706-1707.

• DeJong G, Hsieh CH, Putman K, Smout RJ, Horn

SD and Tian W Physical therapy activities in

stroke, knee arthroplasty and traumatic brain

injury rehabilitation: their variation, similar-

ities and association with functional out-

comes pp1826-1837.

• Ellis T, Cavanaugh JT, Earhart GM, Ford MP,

Foreman KB, Fredman L, Boudreau JK and Dibble

LE Factors associated with exercise behavior in

people with Parkinson’s Disease pp1838-1848.

• Jette AM and Latham NK Disability research:

progress made, opportunities for even

greater gains pp1708-1711.

• Rimmer JH, Chenn MD and Hsieh K A concep-

tual model for identifying, preventing and

managing secondary conditions in people

with disabilities pp1728-1739.

• Robinson CA, Shumway-Cook A, Ciol MA and

Kartin D Participation in community walking

following stroke: subjective versus objective

measures and the impact of personal factors

pp1865-1876.

• Roush SE and Sharby N Disability reconsidered:

the paradox of physical therapy pp1715-1727.

• Sullivan KJ and Cen SY Model of disablement

and recovery: knowledge translation in reha-

bilitation research and practice pp1892-1904.

• Van Swearingen JM, Perera S, Brach JS, Wert D

and Stephanie A Studenski Impact of exercise

to improve gait efficiency on activity and

participation in older adults with mobility

limitations: a randomized controlled trial

pp1740-1751.

• Zanca JM, Natale A, LaBarbera J, Schroeder ST,

Gassaway J and Backus D Group physical ther-

apy during inpatient rehabilitation for acute

spinal cord injury: findings from the SCI rehab

study pp1877-1891.

Volume 92:1

• Khalil H, Quinn L, van Deursen R, Martin R,

Rosser A and Busse M Adherence to use of a

home-based exercise dvd in people with

Huntington Disease: participants’ perspec-

tives pp69-82.

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• van Kordelaar J, van Wegen EEH, Nijland RHM,

de Groot JH, Meskers CGM, Harlaar J and Kwakkel

G Assessing longitudinal change in coordina-

tion of the paretic upper limb using on-site

3-dimensional kinematic measurements

pp142-151.

• Yang XJ, Hill K, Moore K, Williams S, Dowson L,

Borschmann K, Simpson JA and Dharmage SC

Effectiveness of a targeted exercise interven-

tion in reversing older people’s mild balance

dysfunction: a randomized controlled trial

pp24-37.

Volume 92:2

• Deng H, Durfee WK, Nuckley DJ, Rheude BS,

Severson AE, Skluzacek KM, Spindler KK, Davey CS

and Carey JR Complex versus simple ankle

movement training in stroke using telereha-

bilitation: a randomized controlled trial

pp197-209.

• Fairbairn K, May K, Yang Y, Balasundar S, Hefford

C and Abbott JH Mapping Patient-Specific

Functional Scale (PSFS) items to the

International Classification of Functioning,

Disability and Health (ICF) pp310-317.

• Freburger JK, Shank KH, Knauer SR and

Montmeny RM Delivery of physical therapy in

the acute care setting: a population-based

study pp251-265.

• Newell A, Van Swearingen JM, Hile E and Brach

JS The Modified Gait Efficacy Scale: establish-

ing the psychometric properties in older

adults pp318-328.

•Opheim A, Jahnsen R, Olsson E and Stanghelle JK

Balance in relation to walking deterioration

in adults with spastic bilateral cerebral palsy

pp279-288.

• Russell D, Rosati RJ and Andreopoulos E

Continuity in the provider of home-based

physical therapy services and its implications

for outcomes of patients pp227-235.

Volume 92:3

• Holdsworth LK, Valerie S. Webster VS and Rafferty

D Defining, agreeing on and testing an inter-

national physical therapy core data set:

results of a feasibility study involving seven

countries pp378-387.

• Lee ACW and Harada N Telehealth as a means

of health care delivery for physical therapist

practice pp463-468.

• Matsuda PN, Shumway-Cook A, Ciol MA,

Bombardier CH,and Kartin DA Understanding

falls in multiple sclerosis: association of

mobility status, concerns about falling and

accumulated impairments pp407-415.

• Pardasaney PK, Latham NK, Jette AM, Wagenaar

RC, Ni P, Slavin MD and Bean JF Sensitivity to

change and responsiveness of four balance

measures for community-dwelling older

adults pp388-397.

• Prado-Medeiros CL, Silva MP, Lessi GC, Alves MZ,

Tannus A, Lindquist AR and Salvini TF Muscle

atrophy and functional deficits of knee

extensors and flexors in people with chronic

stroke pp429-439.

• van Swigchem R, van Duijnhoven HJR, den Boer

J, Geurts AC and Weerdesteyn V Effect of per-

oneal electrical stimulation versus an ankle-

foot orthosis on obstacle avoidance ability in

people with stroke-related foot drop pp398-

406.

PHYSIOTHERAPY RESEARCH

INTERNATIONAL

Volume 16:4

• Carmeli E, Peleg S, Bartur G, Elbo E and Vatine JJ

HandTutor™ enhanced hand rehabilitation

after stroke — a pilot study pp191-200.

• Hackman D What’s the point? Exploring

rehabilitation for people with 1° CNS tumours

using ethnography: patients’ perspectives

(pp201-217)

• Jandt SR, da Sil Caballero RM, Forgiarini Jr LA and

Dias AS Correlation between trunk control,

respiratory muscle strength and spirometry in

patients with stroke: An observational study

pp218–224.

Volume 17:1

• Gunn H and Freeman J Repeated falls: A key

outcome or an adverse event? pp1-3.

• Janssen J, Pas R, Aarts J, Janssen-Potten Y, Vles

H, Nabuurs C, van Lummel R, Stokroos R and

Kingma H Clinical observational gait analysis

to evaluate improvement of balance during

gait with vibrotactile biofeedback pp4–11.

• Ko M, Hughes L and Lewis H Walking speed

and peak plantar pressure distribution dur-

ing barefoot walking in persons with dia-

betes pp29–35.

• Thomson D and Hilton R An evaluation of stu-

dents’ perceptions of a college-based pro-

gramme that involves patients, carers and

service users in physiotherapy education

pp36–47.

STROKE

Volume 42: 10

• Bushnell C Depression and the risk of stroke

in women: an identification and treatment

paradox pp2718-2719.

• Chen YH, Kang JH and Lin HC Patients with

traumatic brain injury: population-based

study suggests increased risk of stroke pp2733-

2739.

• Fischer U and Rothwell PM Blood pressure

management in acute stroke: does the scan-

dinavian candesartan acute stroke trial

(scast) resolve all of the unanswered ques-

tions? pp2995-2998.

• Langagergaard V, Palnum KH, Mehnert F,

Ingeman A, Krogh BR, Bartels P and Johnsen SP

Socioeconomic differences in quality of care

and clinical outcome after stroke: a nation-

wide population-based study pp2896-2902.

Volume 42: 11

• Abstracts from the 2nd Canadian Stroke

Congress, 2011 ppe586-e629.

• Bally J, Mégevand P, Nguyen D, Landis T and

Granziera C Crossed ataxia: a case report and a

diffusion tensor imaging tractography study

ppe571-e573.

• Barclay-Goddard R, Stevenson T, Thalman L and

Poluha W Mental practice for treating upper

extremity deficits in individuals with hemi-

paresis after stroke ppe574-e575.

• Ingeman A, Andersen G, Hundborg HH,

Svendsen ML and Johnsen SP In-hospital med-

ical complications, length of stay and mortal-

ity among stroke unit patients pp3214-3218.

• Pendlebury ST, Wadling S, Silver LE, Mehta Z and

Rothwell PM Transient cognitive impairment

in TIA and minor stroke pp3116-3121.

• Ronne-Engström E, Enblad P and Lundström E

Outcome after spontaneous subarachnoid

hemorrhage measured with the EQ-5D

pp3284-3286.

• Veerbeek JM, Koolstra M, Ket JCF, van Wegen EEH

and Kwakkel G Effects of augmented exercise

therapy on outcome of gait and gait-related

activities in the first six months after stroke:

a meta-analysis pp3311-3315.

• Webster F, Saposnik G, Kapral MK, Fang J,

O’Callaghan C and Hachinski V Organized outpa-

tient care: stroke prevention clinic referrals

are associated with reduced mortality after

transient ischemic attack and ischemic stroke

pp3176-3182.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 56

ARTICLES IN OTHER JOURNALS

Volume 42: 12

• Cramer SC Improving outcomes after stroke by

leaps (locomotor experience applied post-

stroke) and bounds pp3659-3660.

• Howard G, Cushman M, Kissela BM, Kleindorfer

DO, McClure LA, Safford MM, Rhodes JD, Soliman

EZ, Moy CS, Judd SE and Howard VJ Traditional

risk factors as the underlying cause of racial

disparities in stroke: lessons from the half-

full (empty?) glass pp3369-3375.

• Morgenstern LB, Sánchez BN, Skolarus LE, Garcia

N, Risser JMH, Wing JJ, Smith MA, Zahuranec DB

and Lisabeth LD Fatalism, optimism, spiritual-

ity, depressive symptoms and stroke outcome:

a population-based analysis pp3518-3523.

• Rist PM, Lee IM, Kase CS, Gaziano JM and Kurth T

Physical activity and functional outcomes

from cerebral vascular events in men pp3352-

3356.

• Saposnik G, Raptis S, Kapral MK, Liu Y, Tu JV,

Mamdani M and Austin PC The iScore predicts

poor functional outcomes early after hospi-

talization for an acute ischemic stroke pp3421-

3428.

Volume 43: 1

• Barker-Collo S, Starkey N, Lawes CMM, Feigin, V

Senior H and Parag V Neuropsychological pro-

files of five-year ischemic stroke survivors by

oxfordshire stroke classification and hemi-

sphere of lesion pp50-55.

• Béjot Y, Aboa-Eboulé C, Hervieu M, Jacquin A,

Osseby GV, Rouaud O and Giroud M The deleteri-

ous effect of admission hyperglycemia on sur-

vival and functional outcome in patients with

intracerebral hemorrhage pp243-245.

• Bowen A, Knapp P, Gillespie D, Nicolson D and

Vail A A systematic review of nonpharmaco-

logical perceptual rehabilitation after stroke

and other adult-acquired nonprogressive

brain injury ppe3.

• Diederich K, Quennet V, Bauer H, Müller HD,

Wersching H, Schäbitz W, Minnerup J and

Sommer C Successful regeneration after exper-

imental stroke by granulocyte-colony stimu-

lating factor is not further enhanced by

constraint-induced movement therapy either

in concurrent or in sequential combination

therapy pp185-192.

• Di Lazzaro V, Profice P, Pilato F, Capone F, Ranieri

F, Florio L, Colosimo C, Pravatà E, Pasqualetti P and

Dileone M The level of cortical afferent inhibi-

tion in acute stroke correlates with long-term

functional recovery in humans pp250-25.

• Dong JY, Zhang YH, Tong J and Qin LQ Depression

and risk of stroke: a meta-analysis of

prospective studies pp32-37.

• Flint AC, Kamel H, Navi BB, Rao VA, Faigeles BS,

Conell C, Klingman JG, Sidney S, Hills NK, Sorel M,

Cullen SP and Johnston SC Statin use during

ischemic stroke hospitalization is strongly

associated with improved poststroke survival

pp147-154.

• Garg RK, Liebling SM, Maas MB, Nemeth AJ,

Russell EJ and Naidech AM Blood pressure

reduction, decreased diffusion on MRI and

outcomes after intracerebral hemorrhage

pp67-71.

• Grube MM, Dohle C, Djouchadar D, Rech P,

Bienek K, Dietz-Fricke U, Jöbges M, Kohler M,

Missala I, Schönherr B, Werner C, Zeytountchian H,

Wissel J and Heuschmann PU Evidence-based

quality indicators for stroke rehabilitation

pp142-146.

• Paciaroni M et al Systemic thrombolysis in

patients with acute ischemic stroke and inter-

nal carotid artery occlusion: the ICARO study

pp125-130.

• Parker C, Schwamm LH, Fonarow GC, Smith EE

and Reeves MJ Stroke quality metrics: system-

atic reviews of the relationships to patient-

centered outcomes and impact of public

reporting pp155-162.

• Qureshi AI Significance of lesions with

decreased diffusion on MRI in patients with

intracerebral hemorrhage pp6-7.

Winter J, Hunter SM, Sim J and Crome P Hands-on

therapy interventions for upper limb motor

dysfunction after stroke ppe1-e2.

Volume 43: 2

• Gauthier LV, Taub E, Mark VW, Barghi A and

Uswatte G Atrophy of spared gray matter tis-

sue predicts poorer motor recovery and reha-

bilitation response in chronic stroke

pp453-457.

• Goldstein LB and Rothwell PM Advances in

prevention and health services delivery 2010–

2011 pp298-299.

• Hofmeijer J and van Putten MJAM Ischemic

cerebral damage: an appraisal of synaptic

failure pp607-615.

• Kidwell CS and Heiss WD Advances in stroke:

imaging pp302-304.

• Laver K, George S, Thomas S, Deutsch JE and

Crotty M Virtual reality for stroke rehabilita-

tion ppe20-e21.

• Minnerup J and Schäbitz WR Improving out-

come after stroke: time to treat new targets

pp295-296.

• Nogueira PG, Ferreira R, Grant PE, Maier SE,

Koroshetz WJ, Gonzalez RG and Sheth KN

Restricted diffusion in spinal cord infarction

demonstrated by magnetic resonance line

scan diffusion imaging pp532-535.

• Pendlebury ST, Mari J, Bull L, Mehta Z and

Rothwell PM MoCA, ACE-R and MMSE versus the

National Institute of Neurological Disorders

and Stroke–Canadian Stroke Network vascular

cognitive impairment harmonization stan-

dards neuropsychological battery after TIA

and stroke pp464-469.

• Ruscher K, Kuric E and Wieloch T Levadopa

treatment improves functional recovery after

experimental stroke pp507-513.

• Smith WS and Schwab S Advances in stroke: crit-

ical care and emergency medicine pp308-309.

• Stecksén A, Asplund K, Appelros P, Glader EL,

Norrving B, Eriksson M and for the Riks-Stroke

Collaboration Thrombolytic therapy rates and

stroke severity: an analysis of data from the

Swedish Stroke Register (Riks-Stroke) 2007–2010

pp536-538.

• Tilson JK, Wu SS, Cen SY, Feng Q, Rose DR,

Behrman AL, Azen SP and Duncan PW

Characterizing and identifying risk for falls in

the leaps study: a randomized clinical trial of

interventions to improve walking poststroke

pp446-452.

• Wiedmann S, Norrving B, Nowe T, Abilleira S,

Asplund K, Dennis M, Hermanek P, Rudd A, Thijs V,

Wolfe CDA and Heuschmann PU Variations in

quality indicators of acute stroke care in six

European countries: the European

Implementation Score (EIS) collaboration

pp458-463.

Volume 43: 3

• Batcho CS, Tennant A and Thonnard JL ACTIVLIM-

stroke: a crosscultural rasch-built scale of

activity limitations in patients with stroke

pp815-823.

• Bernstein AM, Pan A, Rexrode KM, Stampfer M,

Hu FB, Mozaffarian D and Willett WC Dietary pro-

tein sources and the risk of stroke in men and

women pp43:637-644.

Daniels SK, Anderson JA and Willson PC Valid

items for screening dysphagia risk in patients

with stroke: a systematic review pp892-897.

• Dennis M, Mead G, Doubal F and Graham C

Determining the modified Rankin Score after

stroke by postal and telephone questionnaires

pp851-853.

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SPRING/SUMMER 2012

• Donahue MJ, Strother MK and Hendrikse J Novel

MRI approaches for assessing cerebral hemo-

dynamics in ischemic cerebrovascular disease

pp903-915.

• Howard G, Waller JL, Voeks JH, Howard VJ, Jauch

EC, Lees KR, Nichols FT, Rahlfs VW and Hess DC

Simple, assumption-free and clinically inter-

pretable approach for analysis of Modified

Rankin Outcomes pp664-669.

• Jette AM, Ni P, Rasch EK, Appelman J, Sandel ME,

Terdiman J and Chan L Evaluation of patient

and proxy responses on the activity measure

for postacute care pp824-829.

Legg LA, Quinn TJ, Mahmood F, Weir CJ, Tierney J,

Stott DJ, Smith LN and Langhorne P

Nonpharmacological interventions for care-

givers of stroke survivors ppe30-e31.

• Leira EC, Ludwig BR, Gurol ME, Torner JC and

Adams Jr HP The types of neurological deficits

might not justify withholding treatment in

patients with low total National Institutes of

Health Stroke Scale scores pp782-786.

• Lyden P Editorial on ‘A simple, assumption-

free and clinically interpretable approach for

analysis of modified Rankin Outcomes’ pp621-

622, published online before print February 16

2012.

• de Man-van Ginkel JM, Hafsteinsdóttir T,

Lindeman E, Burger H, Grobbee D and

Schuurmans M An efficient way to detect post-

stroke depression by subsequent administra-

tion of a nine-item and a two-item patient

health questionnaire pp854-856.

• Oh S, Bang OY, Chung CS, Lee KH, Chang WH and

Kim GM Topographic location of acute pontine

infarction is associated with the development

of progressive motor deficits pp708-713.

• Palnum KH, Mehnert F, Andersen G, Ingeman A,

Krog BR, Bartels PD and Johnsen SP Use of sec-

ondary medical prophylaxis and clinical out-

come among patients with ischemic stroke: a

nationwide follow-up study pp802-807.

• Rowat A, Graham C and Dennis M Dehydration

in hospital-admitted stroke patients: detec-

tion, frequency and association pp857-859.

• ScheppSK, Tirschwell DL, Miller RM and

Longstreth Jr WT Swallowing screens after

acute stroke: a systematic review pp869-871.

• Shi Q, Presutti R, Selchen D and Saposnik G

Delirium in acute stroke: a systematic review

and meta-analysis pp645-649.

• Tong DC Avoiding thrombolysis in patients

with mild stroke: is it SMART? pp625-626, pub-

lished online before print February 2 2012.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 58

REGIONAL REPORTS

East Anglia

Nicola Alexander

In East Anglia 2011 saw high mem-

bership numbers, well attended and

well received courses. Our strong

committee now represents the whole

of the region and with our new chair

Louise Dunthorne at the helm an

exciting 2012 course programme has

been planned.

At the time of writing the 2012

course programme is as follows:

• 29th June Connective tissue and

myofascial course at Addenbrookes

• 21st/22nd September Locomotion a

two day course, with Helen

Lindfield, Bobath Tutor at Ipswich

Hospital

Please keep an eye on the ACPIN

website for up to date East Anglia

ACPIN course information. In a cli-

mate where course funding can be

difficult, we will continue to keep

course costs low in 2012.

As ever, if you would like to

enquire about any of our courses, or

have any course ideas, please get in

touch. I look forward to seeing you at

our courses this year.

Kent

Nikki Guck

My apologies must first be said to the

committee for my bad time manage-

ment in not getting a report to print

in time of the last Synapse; this

should not be seen as a committee

failure but my time management.

This past six months has been

pretty static for the committee with a

very strong team who are always

willing to give up time for meetings

and organisational duties. We have

the largest ever number of ACPIN

members in Kent, this is hopefully as

a result of the team driving to deliver

education programmes that are

appropriate to the needs of neuro-

physiotherapists in the region. We

hope that in the future we continue

to grow year on year, especially in

the challenging financial climates of

the NHS and peoples personal cir-

cumstances. Because of this we will

continue with our study days and try

to use local clinicians and facilities to

keep the costs low.

We successfully ran in collabora-

tion with the MS Trust an oversub-

scribed MS study day on 20th

September 2011, which generated lots

of thought provoking discussions

between clinicians regarding

research and clinical interventions to

manage the patient holistically.

In December 2011 we enjoyed our

annual Christmas evening lecture with

food and mulled wine with a brilliant

lecture from a neurologist to explain/

discuss the pharmacological manage-

ment in neurological conditions.

The AGM was titled “Mind over

Matter”.

As this goes to print we are in the

process of designing a newsletter

which we will upload onto the ACPIN

website under the Kent region to

allow local staff to be aware of

upcoming events and/or allow net-

working within the region. We have

been running a raffle ticket alloca-

tion per person that attends our lec-

tures/study days and at the end of

the year are offering a free place to

the 1-2 day ACPIN national confer-

ence which will allow Kent ACPIN

members to use some of the money

that they have generated.

The Kent committee would like to

say a big thank you for your contin-

ued support and as usual if you have

any suggestions, ideas on courses or

any other queries please feel free to

hotmail.co.uk

London

Andrea Stennett

Happy New Year to you all! We’ve

spent the latter half of 2011 working

on the program for 2012. This year is

tipped to be a year of great excite-

ment with the Olympics, Paralympics

and the Queen’s Diamond Jubilee

celebrations! Likewise we have an

exciting program for you that is

geared towards enhancing your

knowledge and professional devel-

opment.

We started the year in February

with our AGM and study morning,

‘Exploring the neuroscientific basis of

neurophysiotherapy’ with Dr

Margaret Mayston. Thank you Dr

Mayston for an informative morning.

Other events include two study days

with Professor Janice Eng and

Professor Sandra Brauer on the 21st of

April and 30th of June respectively.

Our annual wine and cheese event

will be in September this year and

our final event will be a study morn-

ing showcasing the research of our

physiotherapy colleagues in

November 2012. Please keep checking

our website (www.acpin.net/

London.html) for any changes and

details about registration.

As a committee we are well aware

of the economic situation facing us at

this time and as such we have con-

tinued to keep the cost of our study

mornings and study days to a mini-

mum. We are able to do this because

our courses are usually well

attended. In return, this is our way

to show our appreciation to you for

your continued support.

Our committee bid farewell to one

of our long-standing members, Mrs.

Sandra Chambers. Sandy we wish

you all the best with your future

endeavors and thank you for all your

hard work and wise words of wis-

dom over the years to the London

Committee. Sandy will still be active

on the National ACPIN committee so

I‘m sure we will see her around.

I would like to take this opportu-

nity to inform you that from time to

time we will send out emails per-

taining to different issues for you to

give your thoughts and opinions. So,

watch out for these emails. It is

important to get your views and ideas

on topics that could have an impact

on you in your clinical practice.

The Department of Health has

recently published the Allied Health

Professionals Referral to Treatment

Revised Guide in December 2011. This

may be of interest to you especially if

you work in the community. You can

view it at www.dh.gov.uk/en/

Publicationsandstatistics/Publications

/PublicationsPolicyAndGuidance/

DH_131948.

If you have any ideas for future

courses, feedback or general com-

ments please email us at london

[email protected]om

Manchester ACPIN

Stuart McDarby

2011 was another successful year for

Manchester ACPIN, with a combina-

tion of bi-monthly lectures and a

Saturday morning course on

‘Management of the neurological

shoulder’. This was undoubtedly one

of the highlights of the year and

received positive feedback from our

members.

As with other years, we have

aimed to produce another interesting

and relevant programme for 2012 and

we will continue with a schedule of

evening lectures every other month

and a two day course in September.

The course in September is pre-

sented in conjunction with

Merseyside and Yorkshire ACPIN and

we are pleased to present the inter-

nationally renowned Anne

Shumway-Cook. Further information

will follow later in the year regarding

places but it might be worth pen-

cilling it into your diaries now!

As always we welcome any ideas

REGIONAL REPORTS

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SPRING/SUMMER 2012

on speakers, topics and possible

venues and we strive to ensure our

programme represents neurological

physiotherapy in the 21st century.

Once again we would encourage

ACPIN members in Lancashire and

Cheshire to contact us if they would

like information on our programme,

or just come along if you fancy it!

Our committee has remained con-

sistent in 2011 with six members. We

like to think of ourselves as a small

but friendly and approachable

bunch and we always welcome any

interest in members joining our

committee!

Here’s to an interesting and thought

provoking 2012 and we hope to see

you at some of our get togethers!

Merseyside

Anita Wade-Moulton

Membership stands at 59.

In September 2011 we hosted a lec-

ture on Devics Disease which was

very well received and enlightening

on the recent developments of this

condition from a physiotherapy per-

spective and its similar presentation

to MS. The Walton Neurology Centre

is researching with Oxford on the

diagnostics and treatment of this

condition so was good to hear from

the ‘horses mouth’ what is happen-

ing so close to home.

February 21st was the AGM and

lecture on ‘Respiratory management

of the neuromuscular patient’

It is always a good reminder what

many of our patients have experi-

enced before they enter the hectic

and demanding ‘Rehabilitation pro-

gram’!

See the ACPIN website for our

future programme.

In September 2012, on Friday 21st

and Saturday 22nd, Merseyside are

working with Yorkshire and

Manchester ACPIN to host a two day

course by the eminent American

physiotherapist, Dr Ann Shumway-

Cooke! Venue yet to be confirmed,

keep yourselves posted on the ACPIN

web site.

If you have any suggestions on

topics or suggested speakers/course

tutors that you would like to be on

our program please let us know. Also

if you would like the venue to be

nearer your base please contact one

of the committee. We are aware the

venues are often Liverpool based but

we are open to other suggestions if it

means offering a closer venue to

more of our distant members. We are

aiming to change some of the venues

in our next program of lectures and

courses.

Could I remind all Merseyside

members to help our committee (and

myself as regional representative) to

be part of ACPIN and have your say

when it comes to replying to emails

forwarded on from the National

Committee. We do need your feed-

back and input regarding issues and

practice so as to gain an accurate pic-

ture from all member’s views.

Whilst I am on my begging plat-

form could I also remind all MSc stu-

dents and those participating in

research or interested in doing case

studies we need articles for Synapse.

If you are unsure if your work quali-

fies or need some advice please con-

tact me and I will point you in the

right direction to someone who can

help you!

North Trent

Anna Wilkinson

North Trent had a quiet end to last

year. On the 31st January 2012, Jane

Barton, consultant neuropsychologist

gave us a talk on ‘Psychological care:

what is important and whose

responsibility is it?’. We have also

planned a joint talk by David Nichols,

a podiatrist on neurological rehabili-

tation and myself on the correction

of biomechanics. We are also plan-

ning day courses on vestibular reha-

bilitation and a facilitation and

handling day aimed at junior staff.

Keep an eye out for other lectures

to be planned for later on in the

year. If there are any topics our

members want to hear presented,

please let us know as we have some

spaces later on in the year.

We are also pleased to have four

potential new committee members

attending our next meeting and look

forward to welcoming them.

We look forward to seeing you at

our future lectures.

Northern Ireland ACPIN

Dr Jacqui Crosbie

For 2011/12 programme, the commit-

tee has again organised a mix of lec-

ture and practical evening events. In

the rest of 2012 session we plan to

again join with the local AGILE group

to run a session on a topic of mutual

interest to both of these groups.

We opened the year in October 2011

with an evening demonstration of

the Bioness upper and lower limb

FES stimulators. This gave members

an opportunity to try out the equip-

ment and to discuss clinical implica-

tions for patients, with

representatives of the company. In

November we had a presentation

from a local research group based in

Queen’s University Belfast. Jemma

Ennis (School of Psychology)

explained the purpose of her PhD

study which examined the use of FES

for upper limb movements in people

with stroke. She had also used tran-

scranial magnetic stimulation to

assess the patency of the partici-

pants’ corticospinal tract. It was

interesting to hear that it is thought

that FES can act as a primer for this

pathway when used 30-40 minutes

before active exercise is used by the

therapist, thus increasing the poten-

tial for reorganisation and improve-

ment in conductivity within the CNS.

In January 2012 the session high-

lighted the importance of nutrition

for recovery, with speaker, Glenda

Duncan, a dietician at the Regional

Acquired Brain Injury Unit in Belfast.

Feedback from some of our mem-

bers has indicated that the rotational

band 5 physiotherapists find the NI

ACPIN meetings useful for keeping in

touch with neurological rehabilita-

tion. The job situation in NI for newly

qualified physiotherapists remains

difficult and attending ACPIN meet-

ings is a good way for therapists who

are still seeking employment to

maintain clinical knowledge and to

network.

Our current chair Anne-Marie

O’Kane has been successful in gain-

ing a promotion. This is taking her to

the Northern Board so unfortunately

she has had to step down as NI ACPIN

Chair. The NI Committee will elect a

new Chair for the forthcoming year.

Oxford ACPIN

Claire Guy

From our committee to all Oxford

members, welcome to our report for

the Spring edition. Our evening lec-

tures remain the mainstay for Oxford

ACPIN with regular attendance over

20 and although the venue tends to

be Oxford, we will hope to be shar-

ing these more widely. Please let the

committee know your preference on

venue location.

We were able to support two suc-

cessful courses last year, Richard Sealy

and Martine Nadler presented

‘Neuroplasticity, learning and cogni-

tion’, sharing their knowledge and

using stimulating and fun delegate

participation, I would never have

thought I would learn to juggle on

and neuroplasticity course! The sec-

ond course was looking at pusher

behaviour which was very well

attended. Evening lectures are still

popular, the research evening was

once again a success with four local

speakers making short presentations

with discussion and the topics were

self blood pressure management fol-

lowing stroke or TIA, physiotherapists

experiences of activity pacing with

chronic pain patients, stroke patients

experiences of weekends and gait.

Another new topic was neuro lin-

guistic programming (NLP) exploring

our communication with patients.

The 2012 programme started with

Brid Spillane sharing her dissertation

topic, and the AGM had a local

Paralympian, Nikki Emerson speak-

ing, whose approach to life in a

short space of time post SCI is an

inspiration.

There may be changes on the

committee but it will remain strong

and representative. Please let us

know ideas for lectures, check front-

line and email fliers for dates of ses-

sions and you can always contact me

on Claire.guy@buckshealthcare.

nhs.uk.

SYNAPSE Spring 2012 28/05/2012 11:22 Page 60

REGIONAL REPORTS

Scotland ACPIN

Gillian Crighton

The AGM was held on 28th April in

Perth with a lecture on motor

imagery. Further courses organised

for 2012 include; ‘The neurological

hand’ in June in Dundee, ‘FES’ in

September in Glasgow and ‘Balance’

in October in Inverness. Look out for

flyers for more details!

If you are interested in joining the

Scottish ACPIN committee, please

contact myself or the chair Fiona

Genney (fiona.g[email protected]).

We meet four times a year in Perth.

Remember you can apply to us for

course funding; up to £250, as long

as you have been a member of ACPIN

for a year or more. Please apply by

email to Fiona, giving the full details

of the course. All we ask is that you

are prepared to share your learning

with other ACPIN members after the

course.

If you have any ideas for courses /

events or would like to share useful

websites please do not hesitate to

contact me at gilliancrighton

@nhs.net

South West ACPIN

Helen Madden

South West ACPIN continues to run

well attended evening lectures and

courses supported by our large

membership. Courses organised over

the last six months have included an

overview of evidence-based practice

with Huntingdon’s Disease, a study

day alongside the Multiple Sclerosis

Trust, and the Devon subgroup held

its first event on the latest findings

on human anatomy.

Courses planned so far for 2012

include a Parkinson’s Disease study

day with Bhanu Ramaswamy, an

evening lecture on orthotics, and our

AGM which will provide an opportu-

nity to look at different technology

now in use within physiotherapy

practice. Courses will continue to be

advertised on our regional page on

the ACPIN website, interactive CSP

and via email to our members.

Places for courses will only be con-

firmed once a completed application

form and payment has been received

by the course organiser.

Our CPD fund will also be reviewed

at the AGM in 2012 as to whether we

continue with this, or explore other

options in supporting our members

with CPD.

Changes within the committee

include that Wales have formed their

own region as from 2012 so we wish

them every success with this. Our

Devon subgroup now has a number

of people on the committee, so we

hope to be organising more events in

the Devon/Cornwall area.

Please get in touch with us if you

wish to find out more information

about being on the committee as we

always welcome new members, or

ideas/suggestions for future courses.

Surrey and Borders

Emma Jones

Surrey and Borders ACPIN has had a

successful 2011. This has included

having a healthy membership of over

100, and a varied programme

encompassing both evening lectures

and practical study days. This was

concluded in November with an

evening lecture on Intrathecal

Baclofen.

2012 has commenced with posi-

tively. This has included having a

well-attended AGM and an informa-

tive and interesting lecture from

Claire Ward, a clinical specialist phys-

iotherapist on ‘Using the ICF Model to

support patient-centred rehabilita-

tion’. This was an interactive and

thought provoking session and one

attracting a variety of our members.

Please see our regional page on

the ACPIN website for our pro-

gramme. Ongoing events will also be

forwarded to Surrey and Borders

ACPIN members by email and may be

advertised in frontline and on the

iCSP website, so keep your eyes

peeled!

Please do not hesitate to contact

me with any queries or suggestions

for future programmes on

emrob222000@yahoo.co.uk. We

look forward to seeing you all at

future events!

Sussex

Gemma Alder

Welcome to any new and existing

members. Thank you to all ACPIN

members that have continued to

support the running of Sussex ACPIN.

The committee will continue to pres-

ent a combination of study days and

evening lectures and endeavour to

have these at a number of different

locations throughout Sussex.

We have had an inspiring combi-

nation of study days and evening

lectures thus far including; an

informative evening lecture on

‘Neglect post brain injury, uncompli-

cating a complex neurological condi-

tion’; followed by a very active study

day with Bob Wood tilted ‘Dynamic

movement screening and functional

exercise’. We enjoyed an evening

lecture with Margret Hewett on her

PhD which focused on ‘The experi-

ence of TIA patients’. February

brought a proactive but warming

study day on ‘Aquatic physiotherapy

in neurological conditions’ with

Jacqueline Pattman. In March we

had our AGM which I was delighted

to present a study day on ‘Motor

relearning a problem solving

approach; theory and applications in

neurophysiotherapy for stroke’.

The Sussex committee are grateful

to all of the programme speakers for

educating and enlightening us.

We have a selection of other

events in the pipeline for the rest of

2012. These will include; ‘Vestibular

rehabilitation – the dizzy patient’; ‘A

neurorehabiltation Msc journey’ and

‘The assessment and treatment of

apraxia’. More information and con-

firmation of these courses will be

available on the website in the near

future.

As always your thoughts and ideas

are important to us they really aid us

shaping the course format for the

following year. Please feel free to

contact myself, or any of the commit-

tee members to share your ideas.

Visit the ACPIN website

to apply for or to renew

your membership,

find out what is

happening in your region,

download past

presentations from

ACPIN conferences and

much more!

www.acpin.net

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Wales ACPIN

Adele Griffiths

Wales has formed a new regional

ACPIN group under the title of Wales

ACPIN during 2011, after many years of

being affiliated with the South West

ACPIN branch. An informal commit-

tee met regularly in 2011 and ran sev-

eral events, with formal election of

officers at the AGM in February 2012.

There are currently 66 ACPIN mem-

bers in Wales and the numbers are

growing steadily.

The inaugural meeting of Wales

ACPIN was an evening lecture given

by Dr Monica Busse-Morris on

research developments in

Huntingdons Disease. A day course

focusing upon ‘Pushers’ received

good feedback and in December a

two day practical course in Mid Wales

gave participants an opportunity to

practice skills in upper limb rehabili-

tation. The AGM on February 4th in

Port Talbot was part of the Winter

training day with guest Dr Lori Quinn

speaking about motor control.

Wales ACPIN has a WIKISPACE:

walesacpin for sharing minutes,

information and for members to link

up. There are also plans to use

WebEx for sharing lectures with those

who are unable to attend; increasing

opportunity to view lectures and

reducing travel costs for members.

This initiative has received support

from the ACPIN Executive committee

for 2012 and if it is successful it may

be rolled out to other regions.

The main event planned for 2012 is

an exciting three day balance course

taught by Anne Schumway Cook and

Marjorie Woolacott co-hosted by

Cardiff University September 7-9th.

Wessex

Jenny Barber

The last six months have been very

eventful. We have had a mixture of

events, from an `ataxia’ study day, a

`research’ evening and also our

annual Christmas meal!

Dr Lisa Bunn, from the University of

Plymouth, led a study morning on

ataxia. This was very well attended

and a popular course. We also had

an evening that focused on research

which reflected what was happening

clinically within our profession. This

was led by Dr Jane Burridge, from

Southampton University. The evening

was supported by the local branch of

Dendron, the Stroke Association,

information from the MS Trust and

local colleagues involved in research

(ie experience of working at Masters

Level). This was a two part event that

allowed members to attend the sec-

ond part at the University of

Southampton campus and see PhD

projects, work with robotics and

neuro-technology equipment. Our

band 6 physiotherapist colleagues

from the Southampton and

Portsmouth area hosted a joint

evening event, where they `shared

local practice’ by outlining projects

that looked in detail at exercise pre-

scription and outcome measures.

Our committee has undergone

some changes also. We have a new

Chair, Nicola Perkins. Our Regional

Representative is now Jenny Barber

and Gina Turner is Regional

Secretary. We are fortunate to have a

large committee (about ten mem-

bers) and also have a large regional

membership (approximately one

hundred and five members). We

continue to have our bursary, to sup-

port members with external courses

and professional development.

Wessex ACPIN also has strong links

with a physiotherapy project in

Ghana. We are supporting this proj-

ect to develop physiotherapy services

in the area and enhance the learning

experience of our colleagues in

Ghana.

In January in Poole there was an

event on the commissioning process.

In February there was an evening

focused on ‘neurosurgery’ led by a

local consultant. Wessex ACPIN com-

mittee also met in February. We did

not have any regional events

planned for March, as our focus was

on the national ACPIN conference. In

April, we continued our events with

an evening ‘Psychology’ lecture, fol-

lowed by our AGM. In May, we have

a ‘Gait’ study day planned, led by

Anna Gould. We also will be hosting

an evening looking at the ‘pusher

syndrome’ later in the year. More

information about any of these

events can be obtained from email-

ing at wessexacpinsec

@hotmail.co.uk

West Midlands

Cameron Lindsay

The West Midlands region continues

to increase in numbers (201 members

in December 2011). In the last six

months we have welcomed Ulrike

Uta and Anna Billingham to the

regional committee team.

Obtaining study leave to attend a

day course during the week has

become almost impossible so in

December we tried a different for-

mat. Our Multiple Sclerosis study

event began at 3.00pm and finished

at 7.00pm. This allowed people to

take a shorter time off work but still

allow for an intensive study session.

Interdisciplinary colleagues from

both clinical and research areas pro-

vided very interesting and thought

provoking lectures on areas of

fatigue, bladder management, dis-

ease modifying drugs and ataxia.

Over 70 people attended the study

day so given the attendance and the

feedback this format is likely to be

employed again.

We continue to attempt to get a

series of discussion or debate

evenings up and running with one

or more people advocating for diver-

gent points of view. Our first two

topics are stretching and core stability

in neuro rehab. The debate is aimed

at getting people thinking and per-

haps identifying areas of research in

a friendly atmosphere however we

are struggling to find people willing

to advocate for a certain point of

view.

At our recent AGM we announced

a new initiative to present a bursary

to a member of the West Midlands

ACPIN region on a bi-annual basis.

We wish to express thanks to the

Wessex ACPIN committee who have

helped us develop the policy. A bur-

sary of £500 will now be awarded in

March and September.

We are aware that the committee

continues to be made up of people

local to Birmingham and would love

to hear from people elsewhere in the

region who would be willing to join

the committee. We would also like

to locate upcoming events in differ-

ent venues around the region so any

suggestions would be gratefully

received.

Yorkshire ACPIN

Kirstie Maclaren

Despite weddings and babies,

Yorkshire committee have continued

to try and offer a varied and interest-

ing programme of events for 2012.

Our AGM covered some of the latest

updates in MS, Parkinson’s, MND,

and brain injury as well as volun-

teering in Bangladesh. Future events

for 2012 include Master Classes with

Mary Lynch-Ellerington, Neglect,

Spasticity Management and hope-

fully rerunning the popular Ataxia

course. Dates and venues are still to

be confirmed so please keep watch-

ing the ACPIN website for details.

Flyers for the courses are also sent to

all Yorkshire members via Email so

please ensure you have an up to date

email registered by checking the

website. We also use iCSP and front-

line to ensure the details get to as

many people as possible.

We are continuing to look at using

venues from all around our area and

setting up links with venues we have

not used before such as Harrogate

and possibly Northallerton. If you

have a venue that you think would

be of use or know of a good speaker

or topic that we could use please

listen.

Membership continues to rise in

Yorkshire making us one of the

biggest and most active groups

which we hope to continue

throughout the year. We are always

on the lookout for more committee

members as it’s a brilliant way of

meeting other like minded physio-

therapists in the area and accessing

great CPD opportunities as well as

being very sociable! If you are inter-

ested in finding out more (without

being press ganged!) please email

me for a chat.

We try to be as interactive as possi-

ble so please feel free to email myself

at Yorkshireacpin@yahoo.co.uk, or

the committee, if you have any

questions, suggestions or even com-

plaints as we aim to provide a service

that’s tailored to the needs of phys-

iotherapists in our area.

Look forward to seeing more of

you over the coming few months!

SYNAPSE Spring 2012 28/05/2012 11:22 Page 62

WRITING FOR SYNAPSE

Synapse is the official peer-reviewed

journal of the Association of Chartered

Physiotherapists in Neurology (ACPIN).

Synapse aims to provide a forum for

publications that are interesting,

informative and encourage debate in

neurological physiotherapy and

associated areas.

Synapse is pleased to accept submitted

manuscripts from all grades and

experience of staff including students.

We particularly wish to encourage

‘novice’ writers considering publication

for the first time and ACPIN provides

support and guidance as required. All

submissions will be acknowledged

within two working weeks of receipt.

Examples of articles for submission:

Case Reports

Synapse is pleased to accept case reports

that provide information on interesting or

unusual patients which may encourage

other practitioners to reflect on their own

practice and clinical reasoning. It is recog-

nised that case studies are usually written

up retrospectively. The maximum length is

3,000 words and the following structure is

suggested:

Title – this should be concise and reflect

the key content of the case report.

Introduction – this sets the scene giving

background to the topic, and why you con-

sider this case to be important, for example

what is new or different about it? A brief

overview of the literature or the incorpora-

tion of a few references is useful so people

can situate the case study against what

already is known.

The patient – give a concise description of

the patient and condition that shows the

key physiotherapeutic, biomedical and psy-

chosocial features. Give the patient a name,

but not their own name. Photographs of the

patient will need to be accompanied by

explicit permission for them to be used. Only

relevant information to the patients’ prob-

lem should be included.

Intervention/method – Describe what

you did, how the patient progressed and

the 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 the

knowledge gained, linking back to the

aims/purpose, and to published research

findings. Consider insights for treatment

of similar patients, and potential for

application to other conditions.

Summary – List the main lessons to be

drawn from this example. Limitations

should be clearly stated, and suggestions

made for clinical practice.

References – the Harvard style of referenc-

ing should be followed (please see

Preparation of editorial material below).

Original research papers

These should not exceed 4,000 words and

papers should include the following

headings:

Abstract – (maximum of 300 words)

Introduction

Method – to include design, participants,

materials and procedure

Results

Discussion

Conclusion – including implications for

practice

References

Abstracts of thesis and dissertations

Abstracts from research (undergraduate and

postgraduate) projects, presentations or

posters will be welcomed. They should be

up to 500 words, and broadly follow the

conventional format: introduction, purpose,

method, result, discussion, conclusion.

Audit report

A report which contains examination of the

method, results, analysis, conclusions of

audit relating to neurology and physio-

therapy, using any method or design. This

could include a Service Development

Quality Assurance report of changes in

service delivery aimed at improving quality.

These should be up to 2,000 words.

Sharing good practice

This Synapse feature aims to spread the

word amongst ACPIN members about

innovative practice or service develop-

ments. The original format for this piece

started as a question and answer session,

covering the salient points of the topic,

along with a contact name of the author

for readers to pursue if they wish.

Questions were loosely framed around the

following aspects (this would be for an

audit)

• 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 away

from this format, and provide a fuller

picture of their topic eg Introducing a

management pack for stroke patients in

nursing homes (Dearlove H Autumn 2007),

An in-service development education pro-

gramme working across three different

hospitals (Fisher J Spring 2006), A therapy

led bed service at a community hospital

(Ramaswamy B Autumn 2008) and

Establishing an early supported discharge

team for stroke (Dunkerley A Spring 2008).

Product news

A short appraisal of up to 500 words, used

to bring new or redesigned equipment to

the notice of readers. This may include a

description of a mechanical or technical

device used in assessment, treatment

management or education to include

specifications and summary evaluation.

Please note, ACPIN and Synapse take no

responsibility for these products, it is not an

endorsement of the product.

Reviews

Course, book or journal reviews relevant to

neurophysiotherapy are always welcome.

Word count should be around 500. This

section should reflect the wealth of events

and lectures held by the ACPIN Regions

every year.

OTHER REGULAR FEATURES

Focus on…

This is a flexible space in Synapse that

features a range of topics and serves to offer

different perspectives on subjects.

Examples have been a stroke survivor’s

own account, an insight into physiotherapy

behind the Paralympics and the topics of

research, 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 professionals

about their views and influences on topics

of interest to neurophysiotherapists. We are

always keen to receive suggestions of indi-

viduals who would be suitable to feature.

PREPARATION OF EDITORIAL

MATERIAL

Copies should be produced in Microsoft

Word. Wherever possible diagrams and

tables should be produced in electronic

form, eg excel, and the software used

clearly 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 note

about each author that indicates their

contribution and a summary of any funds

supporting their work.

All articles should be well organised and

written in simple, clear, correct English.

The positions of tables and charts or photo-

graphs should be appropriately titled and

numbered consecutively in the text.

All photographs or line drawings should

be 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’s

Disease Mobility Assessment: a preliminary

study Physiotherapy (95) pp126-133.

If the article mentions an outcome

measure, appropriate information about it

should be included, describing measuring

properties and where it may be obtained.

Permissions and ethical certification;

either provide written permission from

patients, parents or guardians to publish

photographs of recognisable individuals, or

obscure facial features. For reports of

research involving people, written confir-

mation of informed consent is required.

SUBMISSION OF ARTICLES

An electronic and hard copy of each article

should be sent with a covering letter from

the principal author stating the type of

article being submitted, releasing copy-

right, confirming that appropriate

permissions have been obtained, or stating

what reprinting permissions are needed.

For further information please contact the

Synapse coordinator Kate Busby at:

[email protected]

The Editorial Board reserves the right to

edit all material submitted. Likewise,

the views expressed in this journal are

not necessarily those of the Editorial

Board, nor of ACPIN. Inclusion of any

advertising matter in this journal does

not necessarily imply endorsement of

the advertised product by ACPIN.

Whilst every care is taken to ensure

that the data published herein is accu-

rate, neither ACPIN nor the publisher

can accept responsibility for any omis-

sions or inaccuracies appearing or for

any consequences arising therefrom.

ACPIN and the publisher do not spon-

sor nor otherwise support any

substance, commodity, process,

equipment, organisation or service in

this publication.

WRITING FOR SYNAPSE

SYNAPSE Spring 2012 28/05/2012 11:22 Page 63

Syn’apse

●

SPRING/SUMMER 2012

EAST ANGLIA

Nic Hills

e Nichills82@gmail.com

KENT

Nikki Guck

e Nikki.guck@

bartsandthelondon.nhs.uk

LONDON

Andrea Stennet

e andstennett@yahoo.com

MANCHESTER

Stuart McDarby

e Stuart.McDarb[email protected]

MERSEYSIDE

Anita Wade-Moulton

e anita@burscough

neurophysio.co.uk

NORTHERN

Emma Fitzsimmons

e emma-fitzsimmons@

hotmail.co.uk

NORTHERN IRELAND

Jacqui Crosbie

e dr.jacqueline.crosbie@gmail.com

NORTH TRENT

Anna Wilkinson

e anna@morerehab.com

OXFORD

Claire Guy

e claire.guy@buckshosp.nhs.uk

SCOTLAND

Gillian Crighton

e gilliancrig[email protected]

SOUTH TRENT

Katy Coutts

e katy[email protected]

SOUTH WEST

Helen Madden

e [email protected]

SURREY & BORDERS

Emma Jones

e emrob222[email protected]

SUSSEX

Gemma Alder

e gemma.alder@wash.nhs.uk

WESSEX

Jennifer Barber

e Jennifer[email protected]

WEST MIDLANDS

Cameron Lindsay

e camlin3@hotmail.com

YORKSHIRE

Kirstie McLaren

e kirstie.mclar[email protected]

REGIONAL REPRESENTATIVES

MAY 2012

Syn’apse

Editor

Kate Busby (this issue)

Future issues: Lisa Knight

Editorial Advisory Committee

Members of ACPIN executive and

national committees as required.

Design

kwgraphicdesign

t 44 (0) 1395 263677

e kw@kwgraphicdesign.co.uk

Printers

Henry Ling Limited

The Dorset Press

Dorchester

Address for correspondence

Lisa Knight

Synapse Editor

e lisaknight@finchingfield.plus.com

SYNAPSE Spring 2012 28/05/2012 11:22 Page 64

SYNAPSE Spring 2012 28/05/2012 11:22 Page C3

JOURNAL AND NEWSLETTER OF THE

ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS IN NEUROLOGY

www.acpin.net

Spring/Summer 2012

ISSN 1369-958X

SYNAPSE Spring 2012 28/05/2012 11:21 Page C4