physiotherapy for stroke rehabilitation: a need for evidence-based handling techniques: literature...

Physiotherapy July 2000/vol 86/no 7

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Introduction

The EC Manual Handling OperationsRegulations (MHOR) were introducedprimarily in response to the high incidenceof occupational injuries caused by faultylifting practices, and subsequent loss ofindustrial working days (HSE, 1992a).

Within the health sector, injuries tonursing personnel caused by incorrectpatient handling have been the subject ofboth ergonomic and occupational healthresearch (Stubbs et al, 1983; Seccombe andBall, 1992; Arad and Ryan, 1986). Nursinghas subsequently been highlighted as avulnerable profession, predisposed to a highincidence of low back pain (LBP), largelydue to the nature of patient handling tasks.As a protective strategy and in response tothe MHOR, the Royal College of Nursingissued prescriptive manual handling guide-

lines for nurses, with an aim of workingtowards a ‘no lift’ policy (RCN, 1996a,b).

Physiotherapy involves extensive hand-ling of patients (Hignett, 1995) and it issurprising that both manual handlingtechniques and prevalence of LBP havebeen poorly researched within this field,particularly when compared to the manypublished studies investigating handling bynurses.

A specialism within physiotherapy whichcan be considered most vulnerable is that ofneurological rehabilitation, in whichtherapists are required to offer extensivephysical support to patients duringtreatment (Davies, 1995). Working postureanalyses have categorised neurologicalphysiotherapy as high risk for musculo-skeletal disorders (Jackson and Liles, 1994).Nonetheless, from experience, the authorknows that particular transfers recently‘condemned’ by the RCN are still being used by neurological physiotherapists as amethod of rehabilitation.

The treatment technique practised byphysiotherapists depends largely upon whichtheory they espouse (Davidson and Waters,2000). Treatment techniques are notadequately researched in the UnitedKingdom, and as a result the manualhandling practices of neurological physio-therapists have not been placed underscrutiny.

Many issues within neurological physio-therapy practice regarding manual handlingand its possible consequences need to bedefined. Before considering various areasfor future research it is necessary to reviewthe literature about many aspects ofneurological handling.

Historical Perspective There have been many philosophies ofneurological rehabilitation which have beenoutdated through continual developments

Physiotherapy for StrokeRehabilitation: A need for evidence-basedhandling techniques Literature review

Summary This paper seeks to identify, through reviewing theliterature, a focus for future research on manual handling practicesin neurological physiotherapy. The lack of evidence to supportneurological rehabilitation in general places some treatmentmodalities in question. One of these is the use of the ‘pivot’assisted transfer.

The introduction of the EC Manual Handling OperationsRegulations (1992) prompted the scrutiny of lifting and handlingmethods within the health sector. Some manoeuvres, such as thepivot transfer, were then condemned by various professionalbodies who considered it to be physically dangerous to thehandler.

However, anecdotal evidence still suggests that the pivot transferis widely used by neurological physiotherapists practising theBobath technique. Neither the effectiveness nor outcome of thismethod of neurological handling has been adequately researchedin light of these regulations.

Similarly, there is little research on the incidence ofmusculoskeletal disorders among neurological physiotherapists asa result of their handling methods. This literature review indicatesan immediate need for further investigation of these subjects.

Key WordsManual handling, back pain, physiotherapy, stroke rehabilitation.

by Victoria Sparkes

Sparkes, V (2000).‘Physiotherapy for strokerehabilitation: A need forevidence-based handlingtechniques: Literaturereview’, Physiotherapy, 86,7, 348-356.


349Professional articles

Author and Address forCorrespondence

Victoria Sparkes MScMCSP PGCert is alecturer in theDepartment ofPhysiotherapy, Universityof Hertfordshire, HatfieldCampus, College Lane,Hatfield, Herts AL10 9AB

This article was receivedon February 17, 2000,and accepted on March 7,2000.

within neurophysiology. Contemporaryconcepts use the theory of neuroplasticity toexplain changes in brain functioning andsubsequent recovery of motor control(Lowrie, 1998). The two models describedmost frequently within physiotherapy arerehabilitation through facilitation (Bobath)(Davies, 1985, 1990, 1995) and the motor re-learning model (MRM) (Carr andShepherd, 1982, 1989, 1998).

Rehabilitation through Facilitation: The Bobath concept uses techniques to helpstroke patients to regain normal movementin both their affected and unaffected sides.A core principle of the Bobath concept isthe alignment of body segments, throughmanual facilitation, with an emphasis onachieving functional symmetry (Davis,1996). The sessions are predominantlytherapist-led, with an emphasis uponsuppressing patient-generated incorrectmovements until a normal movementpattern is achieved (Lennon, 1996) -- aconcept negatively described by Sackley andLincoln (1996, page 92) as ‘enforcedimmobility’.

Unsupervised patient practice is stronglydiscouraged as the adoption of an incorrectpattern of movement is deemed detrimentalto rehabilitation (Davies, 1990), althoughtreatment is still considered to be a 24-hourprocess, with carers or healthcare workerssupplementing therapy sessions.

TransfersWithin the Bobath paradigm, the mostcommon initial functional goal for a patientis to achieve independent transfers, fromwheelchair to toilet, bed, chair or car, sinceweight-bearing through the affected limb is believed to ‘normalise’ tone (Sackley and Lincoln, 1996). Independent transfersare considered to be a large functionalmilestone within a patient’s rehabilitation,and Bobath therapists practise transfers with patients long before they are able toachieve independent sitting to standing.

Transfers are facilitated through a ‘pivot’assisted transfer, until the patient hasenough control to perform the movementindependently and correctly. The practice ofthe ‘pivot’ transfer has been stronglydiscouraged in the collaborative guide-lines devised by the National Back PainAssociation (NBPA) in conjunction with theRoyal College of Nursing (RCN), due to theexcessive biomechanical loading of thetherapist’s spine (NBPA and RCN, 1997).

Bobath tutors continue to run practicalpostgraduate courses teaching this transfer.Davies, an advocate of the Bobath concept,states that if a patient cannot bear weightsufficiently through his affected side, thetherapist should offer complete supportduring a transfer in order to ensure anormal movement pattern (Davies, 1990).Lynch and Grisogono (1991) and Johnstone(1995) both consider the transfer to be‘learned’ through repetition during therapysessions. The concept of repeatedly allowingpatients the complete physical support ofone therapist throughout their hospital stay has contentious manual handlingimplications, especially as neurologicalphysiotherapists often have large caseloadsof patients requiring similar physicalsupport.

In the Bobath literature, there is nomention of using mechanically assistedtransfers to facilitate a ‘normal movement’.Use of adaptive equipment is considered as alast resort, not part of the rehabilitativeprocess (Davis, 1996). Although there is norecent literature supporting the Bobathconcept and transfer methods, anecdotalevidence suggests that they are stillpractised, and pre-manual handling reg-ulation literature from the early 1990s is stillused to outline many of the principles oftreatment (Davies, 1985, 1990). Davies morerecently (1995) offered practical strategiesfor handling using the Bobath technique,although she did not apparently considerthe MHOR when she was suggesting suchmanoeuvres.

The Motor Re-learning Model The motor re-learning model of strokerehabilitation, developed by Carr andShepherd (1982), focuses on accessingexisting ‘motor programmes’, or pre-planned patterns of movement, to relearnmuscle activity functionally through ‘task-oriented’ goals. The emphasis is placedupon active patient participation, withguidance, instruction and various forms offeedback, until the correct movement isperformed to solve the motor problem. Theconcept is all-encompassing, with anemphasis upon analysing not only bio-mechanics, but behaviour (Ostrosky, 1990),and lends itself to functionally meaningfulenvironments in which re-learning takesplace (Carr and Shepherd, 1982).

Three main strategies underlying theMRM are: ‘[1] the elimination of unnec-essary muscle activity. ... [2] feedback of


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information about performance. ... [3]practice’ (Partridge, 1996, page 6). Initialtherapist guidance is later superseded bypatient-initiated active movements, whichencourage the patient’s volitional movementcontrol (Ostrosky, 1990).

Sit to StandWhen considering the transfer of a patient,Carr and Shepherd (1982) advise that thepatient must first achieve the more definedtasks of moving from sitting to standing, andstanding to sitting. They propose that thetherapist should provide minimal help, andpivot transfers are not practised as they arebelieved to constrain patient performance,while failing to replicate a normal activity(Carr and Shepherd, 1998). The authorsalso advocate recruiting more than onetherapist in the initial stages of helping apatient to stand.

Carr and Shepherd acknowledge therelatively slow uptake of their concept intopractice (Carr et al, 1994) and voice generalconcern over physiotherapists’ lack ofinitiative to embrace new theoreticalconcepts.

Clinical Uptake of Neurological ConceptsThe clinical use of neurological conceptswithin the UK has not yet been established.Studies have, however, been performed inSweden (Nilsson and Nordholm, 1992),Australia (Carr et al, 1994), and the TrentRegion (Sackley and Lincoln, 1996).Collectively, they found that the Bobathconcept was the most commonly practisedtreatment technique and that theoreticalbases of treatment were not deemedimportant to treatment choice. All authorsreiterated the problem of a lack of publishedtheoretical evidence to support the Bobathconcept.

Evidence-based Practice The core of evidence-based practice is tointegrate expertise derived from practice,with research evidence when making clinicaldecisions, as successful practice cannotoccur with one of these factors in isolation(Sackett et al, 1996). Best practice for onepatient may not be appropriate for another,and it is clinical expertise which allowspractitioners to make these discriminations.Difficulties have been identified in clinicallyapplying evidence-based practice sincepatients rarely present with a one-dimen-sional problem (Greenhalgh, 1996), and thisis amplified in the case of stroke patients

who may present with a multitude of signsand symptoms.

Evidence-based treatments are most likelyto be clinically effective. Appropriately peer-reviewed research which shows the efficacyof a form of therapy may warrant its integ-ration into practice, and subsequentlyimprove clinical effectiveness. However therecorded outcomes of neurological physio-therapy interventions are not made knownwidely enough.

Stroke RehabilitationThere is a lack of published clinical evidenceto support the assumption that neurologicalphysiotherapy as a whole is effective in thetreatment of brain injured adults (Partridge,1996). Partridge elaborates by stating thatauthors of neurological physiotherapyliterature largely rely upon clinical evidenceas opposed to research findings upon whichto ground their theories. Riddoch et al(1995) state that the lack of publishedneurological case studies inhibits thedevelopment of a formal empirical evidencebase and consequent evidence of clinicaleffectiveness.

Riddoch et al (1995) and Ashburn et al(1993) reviewed trials investigating theefficacy of rehabilitation after stroke, andfound that most trials had inconclusiveresults, and no single treatment modality was found to be more effective than another. The former authors, in addition toPartridge (1996) and Sackley and Lincoln(1996) strongly suggest that literaturereviewers have had difficulty interpretingstudy results, as research comparing two or more treatment modalities has been found to use inappropriate method-ology.

Lennon (1996) offered another reason forinadequate comparison studies, byhighlighting that stroke patients are tooindividual to compare or standardise.Comparisons aside, to establish clinicaleffectiveness in a stand-alone model ofrehabilitation would require a control group to be excluded from physiotherapy.Ethically, this cannot be considered anacceptable option.

Bobath ReviewedClinical effectiveness within neurologicalphysiotherapy can therefore be stronglyquestioned. Within the Bobath techniquefor rehabilitation, the incongruity betweentheoretical underpinnings and practice isexplored. Lennon (1996) reviewed



the literature surrounding this and surmisedthe following problems:

� Failure of adherents of the Bobathconcept to update their theoreticalsupport, in response to recent advancesof motor control and motor learningmodels.

� Inability to holistically considerbiomechanical and psychosocialinfluences within neurologicalrehabilitation.

� Subjective and regionally variable oralcommunication of Bobath teachings.

� Absence of published literature byBobath tutors.

Edwards (1996) also identified the needfor evidence-based practice, yet believes thata lack of research should not prevent an‘assertion’ regarding treatment procedures.Perhaps this is the area where Bobathencounters its main criticism.

Carr and Shepherd (1982) believe that too much emphasis is placed upon onattempting to justify current techniques,rather than looking at how therapists canmake best clinical use of theoretical modelsarising from research. Best practice musttherefore be a reciprocal relationshipbetween clinical practice informingresearch, and scrutinised research informingtheory.

Expense or Quality?Current research into neurological re-habilitation is preoccupied with establish-ing the financial implications of therapy, this arising from the advent of NHS trusthospitals, primary care groups and localbudget control. Riddoch et al (1995)identified the need for increased evidencesurrounding the efficacy of physiotherapy instroke rehabilitation, but emphasised thechangeover from evaluating patients’improvement to calculating financial gain.

The core of rehabilitation is to improvepatients’ quality of life, but unfortunatelythere remains little interest in researchingquality of life gains as a direct result ofrehabilitation.

This need for rehabilitative justificationhas been more recently echoed at nationallevel as the NHS White Paper The New NHS:Modern, dependable (DoH, 1998) seeks toidentify ‘quality of care’ through clinicalgovernance.

Lifting and Moving RegulationsThe MHOR (1992) were applied to allworking environments from January 1, 1993,and replaced all pre-existing health andsafety regulations specific to handling. Theirobjective was to reduce the high incidenceof injury resulting from manual handlingwhich then accounted for more than aquarter of total occupational accidents(HSE, 1992).

Within the regulations, the duties of theemployer are to ‘reduce the risk so far as isreasonably practicable’ (HSE, 1992, page 8),and emphasis is placed upon the eliminationof all manual lifting and moving whereverpossible. However, this particular rule can beopen to a variety of interpretation, since itsdescription is somewhat imprecise (Tracey,1997).

Employees’ duties are similarly includedwithin the regulations. Emphasis is placedupon adhering to ‘the systems of work laiddown by their employers’ (HSE, 1992a, page 37). The regulations therefore openlyplace the greatest responsibility upon theemployers, and within the healthcare settingthis means the individual trusts within whichpractitioners are employed, since the NHSExecutive no longer has the authority toendorse such policies (White, 1997). Theimplication of this is that there is scope forregional variation in interpretation of theregulations, and therefore no definitivenational framework by which moving andlifting practices may be shaped.

In response to the MHOR, manyinstitutions have formulated lifting policiesto protect themselves in the event oflitigation following injury. This is a trustdisclaimer, rather than a protectiveapproach to staff, and many trusts areadopting a strict ‘no lift’ policy, whereby allhospital staff must use a hoist or transfer aidto move patients (Hodges, 1997). Althoughrestrictive within a rehabilitation setting, ‘no lift’ policies do fall in line with theguidelines issued by the RCN (1996a,b)which reflect the MHOR (HSE, 1992a).

Since the issues surrounding manualhandling within nursing have been wellresearched, it seems appropriate to use this as a model for comparison with that of physiotherapy.

Nursing PolicyThe consequences of incorrect patientlifting to the nursing profession have been well documented (Stubbs et al, 1983;Seccombe and Ball, 1992; Hollingdale,


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1997), and many of these studies focus uponthe incidence of LBP within nursing. Otherstudies have examined the economic costs oflost working days through sickness absence(Davies and Teasdale, 1994). Nurses are wellrepresented by an active governingprofessional body, the RCN, respondingrapidly to practice issues requiring nationalframeworks or guidance (Hodges, 1997). Inan effort to reduce the incidence of LBP innurses, the RCN published specific weightrestriction recommendations, advising that when transferring patients weighingmore than eight stones, nurses should usemechanical hoists (Tracey, 1997). The RCNclearly states that manual lifting should beeliminated in all circumstances except life-threatening situations (RCN, 1996a,b).

Physiotherapy PolicyThe Chartered Society of Physiotherapy(CSP) offered guidelines (CSP, 1993a,b) inresponse to the MHOR (HSE, 1992a),stating that before applying a manoeuvre,therapists should calculate the risks to thepatient, other healthcare workers, andthemselves. Similarly, lifting tasks delegatedto others must be assessed for risk beforethey are carried out. The guidelines arevague, and can be interpreted subjectively --what is deemed wholly appropriate by onetherapist may be considered high risk byanother. However, for the CSP to offerprescriptive advice might have negativerepercussions among therapists inneurological rehabilitation, and impactupon professional autonomy. The lack ofpublished concern regarding guidancesignifies a general acceptance of these non-specific guidelines.

Risk AssessmentThe CSP has proffered risk assessment as away of enabling physiotherapists to continueto practise lifting and moving, but this maynot be permissible within the regulations oftheir individual trusts, owing to the popularimplementation of the ‘no lift’ strategy.Little has been published about effectivenessof risk assessment in physiotherapy, but whatis accepted is that risk assessments should bea continuous process, incorporated into thedaily physiotherapeutic assessment ofpatients. To assess the risks of lifting andhandling procedures is now a legalrequirement (Carlowe, 1998). How this canensure the safety of physiotherapistspractising therapeutic transfers is not clear,due to the relative subjectivity of the

procedure. Similarly, whether riskassessment is adequately translated into riskmanagement is also questionable (Hignett,1994a). Hignett also believes that within ahealthcare setting, the concept of a generictask assessment is not viable, due to both thediverse nature of different professionals’remit, and the unpredictability of theanimate load being manipulated.

CollaborationThere is a need for more effective coll-aboration in the handling of rehabilitationpatients. Although nurses are not nowexpected to ‘lift’ patients, the handling roleof physiotherapists is less easily defined.Within neurological rehabilitation, theseprecise guidelines could be deemedrestrictive to the rehabilitation process.Transfers outside therapy sessions used to bepractised with nurses, to improve ‘carry-over’from therapy sessions. The emphasiscurrently falls upon therapy, as patients nowpractise assisted transfers only duringtreatment sessions. If independence isconsequently achieved more slowly, then theperiod of assisted transfers is extended, thuspotentially increasing the physical demandsplaced on therapists.

Thus the burden of a heavy workload,instead of being spread over the caringprofessions responsible for rehabilita-tion, has now been confined to only oneprofessional group. The argument for thishas been that physiotherapists, with theirunderlying knowledge of biomechanics, areexpected to use this expertise to handlepatients correctly (Fenety and Kumar, 1992; Ellis, 1993; Hignett, 1995). Similarly, it should not be expected that otherprofessionals who do not possess thisknowledge should be required to carry outthe same task (Fletcher, 1997; CSP et al,1997). However, Hignett (1995) deducedthat it has been assumed that physio-therapists would use their ‘kinaesthetic’knowledge. This conflicts with physio-therapists’ professional commitment tominimise the use of mechanised equip-ment to help in rehabilitating patients. If physiotherapists do have extensiveknowledge of biomechanics and ergo-nomics, it seems contradictory that they arereluctant to employ this wisdom whenconsidering their own health and safety.

Back Pain Physiotherapists have been highlighted asbiomechanical experts, and as such, there



has been a lack of research illustrating theprevalence of LBP or focusing on theirlifting practices (Ellis, 1993; Fenety andKumar, 1992). Before the advent of themanual handling regulations (MHOR)certain studies undertaken show alarmingresults. Scholey and Hair (1989) comparedthe incidence of LBP between physio-therapists and non-medical personnel. Atotal of 96% of respondents blamed heavylifting, while 100% identified frequent lifting as their main risk factor for LBP. Thisis supported by Hignett (1994b) whodemonstrated that physiotherapists aresusceptible to LBP due to their physicalworkload and the repetitive nature of theirtasks. This evidence therefore invalidates the premise that specialist ergonomicknowledge reduces the incidence of LBP ina physically demanding occupation. Hignett(1994b) also highlighted the vulnerability ofnewly qualified physiotherapists comparedwith their more experienced colleagues.

Physical stress encountered by neuro-logical physiotherapists was identified in astudy conducted by Broom and Williams(1996). They interviewed 10 neurologicalphysiotherapists over a cross-section ofgrades within one health district to identifytheir causes of stress, which were workoverload, under-staffing and large patientnumbers. Manifestations of stress within this group included back pain and anxiety.One stressful issue identified was whenattempting to fit the varied nature ofphysiotherapy into standards and policies –this is especially relevant with the currentadoption of trust manual handlingprotocols. Although this study representsonly the population and health districtstudied, the climate of physiotherapy under-staffing caused by recruitment and retentionproblems throughout the UK is welldocumented (Chadda, 1999). Hignett(1994b, page 447) declared in her closingstatement: ‘The cost of treatment handlingmay be the loss of physiotherapists’, whichenforces a longer-term cause for concern.Nonetheless, the underlying perceivedbiomechanical knowledge inherent withinphysiotherapy has so far prevented researchinto the potential handling risks en-countered by physiotherapists.

Ergonomics: Practising what we preach?The practice of ergonomics has two mainobjectives: to improve quality of output,while reducing the incidence of occup-ational musculoskeletal disorders, by using

the principles of kinesiology, anatomy,physiology, anthropometry, psychology,engineering and physics (Kerk, 1998).Although physiotherapists teach patientsergonomically sound techniques, whetherthey are practised by therapists themselves is debatable. Fenety and Kumar (1992)conducted an ergonomic survey of a hospitalphysiotherapy department. They foundnumerous unsafe handling manoeuvres, inspite of the therapists having receivedextensive training. The highest riskmanoeuvres identified were pulling,pushing, lifting, twisting, working withpatients in kneeling, and frequent handling.These postures are adopted regularly withinneurological rehabilitation, particularlywhen using Bobath techniques.

A pilot study was conducted by Hignett(1995) to investigate the working posture ofphysiotherapists during a care of the elderlytreatment session. Her findings showed thatphysiotherapists work at a biomechanicaldisadvantage since patients cannot beanthropometrically fitted to their therapists– instead, therapists need to adapt topatients.

Hignett (1995) also recognised thedangerously misplaced theory that physio-therapists can counteract the effects of theiroccupation by being able to treat their ownLBP. This was reinforced by a study toexamine the vulnerability of inexperiencedphysiotherapists. Jackson and Liles (1994)assessed the working postures of twoseparate years of physiotherapy students,using the Ovako Working Posture AnalysisSystem. They found that within neurology‘the optimum positions for patients’management were achieved largely at theexpense of the therapists’ posture’ (page436), and identified prolonged poorworking posture as hazardous. From thisstudy, they recommended that attentionshould focus upon the physical effect ofpractice on physiotherapists.

Stroke PatientsNeurological patients themselves can beconsidered an added risk within neurology,as they tend to present with a plethora ofphysical, cognitive or behavioural problems.Garg et al (1991) studied patient transferringtasks. They identified that transfers involvinghuman bodies are not amenable to hand-ling, as the load is usually awkwardly shaped and difficult to hold, and patientsare often unpredictable, combative orcontracted. Their study involved collating


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both subjective and objective data surr-ounding transfers, and their recommend-ation was that totally dependent patients(who were not able to bear weight fully)should be transferred only by hoist. This recommendation is reinforced by outcomes of another transfer methods study by Ulin et al (1997), who recommend theuse of mechanical aids for all patients whoneed transfer help.

Studies directly considering functionalability of stroke patients have identified thereduction of balance, reaction time, andmuscle activation during functional tasks ascommom physical impairments encounteredby patients (Yaretzky et al, 1994; Dickstein etal, 1994; Lee et al, 1997). The inherentquestion as to whether stroke patientsthemselves are a direct risk to therapistsduring manual handling practices needs to

be further explored in light of theseestablished physical impairments.

ConclusionThe physical risks taken by neurologicalphysiotherapists have been made explicitwithin this paper but are not at presentadequately researched, particularly inconjunction with the MHOR (HSE, 1992a).Although LBP should not be accepted as anoccupational hazard (Ellis, 1993), alternativeoptions for neurology treatment have notbeen explored -- extensive (and ofteninappropriate) handling still dominatespractice within this area.

Discrepancies between policy and practicehave arisen and have been discussed. Fromthis, a number of factors need to beconsidered for future research. These arelisted in the table below.

Issues within neurological physiotherapy and manual handling practices promptingfuture research

� There is a lack of theoretical and clinical evidence supporting the Bobath technique as part ofstroke rehabilitation, yet it continues to dominate contemporary neurological rehabilitation(Riddoch et al, 1995; Lennon, 1996).

� Certain manoeuvres involved in practising the Bobath technique directly oppose what isdeemed safe by the MHOR, yet evidence suggests that physiotherapists still support andpractice this (Davies, 1995).

� There has been no published evidence suggesting that supportive handling equipment is aneffective rehabilitative tool for neurological physiotherapy, therefore alternatives to manualhandling have not been explored within this specialism.

� Professional remit and expectations of service provision within neurological rehabilitationapparently conflict with manual handling policies laid down by individual hospitals.

� The incidence of LBP in physiotherapists has been poorly researched, especially in light of theMHOR (1992).

These factors, although listed separately, all impact upon one another, and no single point can beaddressed without considering the remaining issues.

It was the purpose of this review to discuss in depth the issues which surround current handlingtechniques in neurological physiotherapy, and to outline areas requiring thorough investigation.It has become apparent that neurological physiotherapy and handling techniques have not beenadequately considered in light of the MHOR (HSE, 1992a).

In order to protect the future of physiotherapists employed within neurology, further researchis imperative. Equally pressing is the need to encourage physiotherapists as a profession toconsider recent legislation and to offer, alongside other professional bodies, practical anddefinitive solutions to conflicts arising between policy and practice.

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Key Messages

� The clinical use of manual handlingtechniques as a method of neurologicalrehabilitation conflict with the ManualHandling Operations Regulations(1992).

� Some studies have identified the physicalvulnerability of physiotherapists workingin rehabilitation, due to the extensivehandling performed repetitively everyday.

� A lack of research in this area has not yetlegitimised the use of mechanical aids asa treatment technique in neurologicalrehabilitation.

� Professional remit and expectations ofservice provision within neurologicalrehabilitation apparently conflict withmanual handling policies laid down byindividual trusts.

physiotherapy for stroke rehabilitation: a need for evidence-based handling techniques: literature...

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