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> How does facilitationof an improvedinteraction betweenthe head and trunkgain improvedpostural control in afunctional task?

> Ulnar nerveinvolvement andstroke

Spring/Summ

er 2011

www.acpin.net

JOURNAL AND NEWSLETTER OF THE ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS IN NEUROLOGYwww.acpin.net

Spring/Summer 2011

ISSN 1369-958X JOURNAL AND NEWSLETTER OF THE ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS IN NEUROLOGY

SYNAPSE Spring 2011 12/6/11 14:59 Page C4

ACPIN’S AIMS1. To promote and facilitate

collaborative interaction betweenACPIN members across all fields of practice including clinical,research and education.

2. To promote evidence informedpractice and continuing professional development of ACPIN members by assisting in the exchange and disseminationof knowledge and ideas within the area of neurology.

3. To provide encouragement andsupport for members to participatein good quality research (with adiversity of methodologies) andevaluation of practice at all levels.

4.To maintain and continue to develop a reciprocal communication process with theChartered Society of Physiotherapyon all issues related to neurology.

5. To foster and encourage collaborative working betweenACPIN, other professional groups,related organisations ie third sector, government departmentsand members of the public.

Syn’apseJOURNAL AND NEWSLETTER OF THE

ASSOCIATION OF CHARTERED

PHYSIOTHERAPISTS IN NEUROLOGY

Spring/Summer 2011

ISSN 1369-958X

CONTENTSFrom the Chair 2

EditorialA few words… from Margaret Mayston ACPIN President 3

Article 1How does facilitation of an improved interaction between the head and trunk gain improved postural control in a functional task? 4

Article 2Ulnar nerve involvement and stroke 12

Sharing good practiceDesign and implementation of an internal clinic referral form to improve interdisciplinary working in splinting and posture management for people with complex disabilities 14

Focus on…Community peer support for people with spinal cord injury 17

Articles in other journals 19

Brain over body ACPIN national conference 2011Abstracts and biographies of speakers 23Annual general meeting reports 26Delegate’s report 28

News 29

ReviewsCOURSE: Balance rehabilitation: translating research into clinical practice 32COURSE: Surrey and Borders neuro-oncology study day 32COURSE: Getting research into practice – Constraint Induced Movement

Therapy (CIMT) for arm recovery and function for stroke survivors 32

Websites of interest 34

Regional reports 35

Writing for Synapse 39

Regional representatives 40

SYNAPSE Spring 2011 12/6/11 14:57 Page 1

Current Executive Committee

PresidentMargaret [email protected]

Honorary chairSiobhan [email protected]

Honorary vice chairGita [email protected]

Honorary treasurerJo [email protected]

Honorary secretaryAnne [email protected]

Honorary research officerJulia [email protected]

Honorary membership officerSandy [email protected]

[email protected]

Honorary minutes secretaryEmma [email protected]

Honorary PROAdine [email protected]

CIG liaison representativeJakko [email protected]

Synapse coordinatorKate [email protected]

Diversity officerLorraine [email protected]

iCSP link and Move for HealthChampionChris [email protected]

Committee member 1Anita [email protected]

Committee member 2Lisa [email protected]

Welcome to the 2011 edition ofSynapse!

This is the thirtieth year of ACPIN andwe continue to go from strength tostrength! We have a record number ofmembers, over 2,200 and are leadingthe way as one of the largest specialinterest groups of the Chartered Societyof Physiotherapy.

I have just returned from the thirtiethannual conference in Northampton,where we had a fantastic turnout andfound ourselves having to turn peopleaway as we were sold out! Thefeedback was extremely positive and itwas great to catch up and meet withphysios from all corners of the UK,many having travelled many miles toget there. The lectures were superb andfor those of you who were unable tomake the conference there is anopportunity to download the contentfrom the website. Before I left I bookedfor next year which will be our two-day conference and we hope to havemany international speakers, so putthe date in your diary for 9th-10thMarch 2012! If there are any suggestionsfor the conference please email me andwe will try our best to oblige! Detailswill follow in the autumn edition ofSynapse.

All the details of the AGM aresummarised in full on pages 22-28.

Following the advertisements inFrontline and on interactive CSP, theAGM provided us with the opportunityof welcoming new committee membersonto the executive committee. We aredelighted to welcome Jane Petty andKate Busby onto the executivecommittee. Louise Dunthorne hasmade an extraordinary contribution toACPIN and Synapse over the last tenyears and will be greatly missed but weare delighted that Kate Busby has nowtaken on the role of Synapse adminis-trator. Joanne McCumisky has alsostepped down due to the arrival ofbaby Ava, very timely on the morningof the conference, though thankfully athome and not Northampton!

Chris Manning is busily arranging theneurology strand at the CSP congresswhich looks to be a very excitingprogramme so hopefully will see someof you in Liverpool in October.

Despite the continuing challenges inthe health service, ACPIN will continueto support our members in all areas ofpractice, research and education toensure the best possible patient carewell into the future.

Siobhan

FROM THE CHAIR

Syn’apse ● SPRING/SUMMER 2011

2

ACPIN apologise for the late publication of this edition of Synapse. This was due to unforseen production problems.


EDITO

RIA

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I have no wit, philosophy or history tooffer for this editorial, we are facingserious issues. I would like to makethree points for this editorial.

Firstly, it is hard to believe thatanother year has gone by. ACPIN has anew Chairperson, and the AGM is againupon us and as usual the ACPINcommittee has organised anotherexcellent study day at Northampton –Brain over Body – and continues toprovide high quality activities for itsmembers. The executive, all theregional representatives andcommittee members are saluted fortheir work and I would like to sincerelythank them for all that they do onbehalf of all of the membership.

Secondly, restructuring and re-branding seems to be going oneverywhere despite the difficult finan-cial climate and the CSP is noexception. It costs huge amounts ofmoney and is often led by a businessbrain who perhaps does not alwaysfully appreciate the nature of the groupwhich seeks the new structure.Changes taking place in the CSP relatingto the special interest groups presentyet another challenge for thecommittee and the membership whichwill certainly require your input. Lookat the CSP website and make sure youkeep up with all that they are doing tore-brand physiotherapy and restatewhat physiotherapy is. I am not surethat hands-on has much to do withtheir vision of physiotherapy at themoment. Siobhan will no doubt beasking for your views so be sure torespond and give your input to this. Itis one way in which we can allcontribute to ACPIN and the profession.

Thirdly and finally, I am veryconcerned about the effects of changesin the NHS. I do not work in the NHSbut have many interactions withpeople who do and hear many storiesof cuts, long waiting lists and lack oftime to treat the clients referred to us.It feels like the profession is headingtowards becoming an assessment/advisory service, which will not besatisfactory for clients or professionals.Amidst the cuts, there are alsodemands for physiotherapists toprovide new services, such as we heardabout at the national conference inGlenn Nielsen’s excellent presentationof the Physiotherapy Management ofConversion Disorders. And yet how canthis be achieved in the face of lesstherapy time? Job cuts make jobprogression and professional develop-ment difficult and for the newgraduate a job becomes a dream and afar distant reality. More than ever weneed to be prepared to stand up andexplain what we do and why. Iencourage you in all that you do tomaximise your client outcomes and asyou find the best ways to explain whatwe do whether it be through research,clinical observation and interpretation,scholarly activity or a combination ofall of these. There could also be a needto be creative in the way we deliver ourservices.

In these troubled times of worldunrest and earthquake, perhaps wecan be reminded that we must try tomake the best of the momentsbetween each tick of the clock. Make itall count.

A few wordsMargaret Mayston AM FCSP PhD ACPIN President



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Performing a functional task requires not onlythe ability to move an upper limb but ‘complexactivity of the whole organism’ (Craik 1992)and thus relies on a body’s ability to maintainpostural control. Shumway-Cook & Woolacott(2007), define postural control as the ability tocontrol the body’s position in space to enableboth ‘stability’ and ‘orientation’.

Stability aims to maintain the body’s centreof mass within specific boundaries related toits base of support (Horak 2006) whereas orientation aims to maintain appropriate rela-tionships between body segments, and keepthe body orientated to the environment foreach task (Shumway-Cook & Woolacott 2007).

If both the postural orientation and posturalstability are successful in creating and main-taining postural control in sitting, the upperlimb can be freed for a functional activity(Gillen et al 2007).

Horak (2006) and Di Fabio & Emasithi (1997)argue strongly that postural control is signifi-cantly influenced by the position and control ofthe head and its alignment and interactionwith the trunk, especially in upper limb func-tional tasks (Saavedra et al 2009).

This study therefore aims to investigatewhether improving the interaction betweenthe head and the trunk helps improve posturalcontrol in a functional task in a patient fol-lowing an acute brain injury. A case studydesign was used to investigate this topic inrelation to the functional task of reaching.

LITERATURE REVIEWThe ability of a body to maintain postural controlrelies on sensory input from receptors throughoutthe body such as the vestibular system, the somato-sensory system and the visual system. The

information from these sensory receptors enablesthe body to detect its position with respect togravity, the support surface, visual surroundingsand internal references (Horak 2006). Each indi-vidual sense can help produce a specific frame ofreference for assisting postural control, but it is onlythrough the integration of these senses and theirrespective frames of reference that effective pos-tural control can be achieved (Day & Cole 2002).

When frames of reference are integrated it pro-duces a ‘body schema’, which can be defined as ‘acombined standard against which all subsequentchanges of posture are measured’ (Di Fabio &Emasithi 1997).

The development of a body schema suggests thatonce the ‘standard’ for postural control isachieved eg an upright posture in sitting, all sub-sequent body movement can be measured againstit. In terms of a functional task, an individual’sexpectation of the task and prior experienceprovide the basis for anticipatory postural adapta-tions in the body (Massion & Woolacott 1996; DiFabio & Emasithi 1997; Horak 2006; Shumway-Cook & Woolacott 2007). The sensory receptorsthen continue to provide feedback regarding thetask and can update the postural responsesaccordingly to ensure that postural stability ismaintained and the task is achieved effectively(Horak 2006).

Many of the sensory receptors used to maintainpostural control, are located in the head andtrunk, suggesting that these two areas play a sig-nificant role in creating and maintaining posturalcontrol during functional tasks (Massion &Woolacott 1996).

The head contains the vestibular system, whichcalculates head orientation with respect to gravity(Massion & Woolacott 1996). If vestibular input islost, there is a loss of anticipatory control of headposition. This loss causes a reduction in trunk andlimb postural control as well reducing the quality

How does facilitationof an improved interaction between thehead and trunk gain improved posturalcontrol in a functional task?Nathaniel Walker BSc (Hons) Physiotherapy Senior Physiotherapist, University Hospitals of Leicester


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of feedback sensory information required by thebody to monitor the functional task and correcterrors (Di Fabio & Emasithi 1997).

The visual system assists in postural control byorientating the body’s axis to the vertical and hori-zontal structure of the visual frame. (Massion &Woolacott 1996). This is important in the feedbackelement of postural control as it reports motion ofthe head and body with respect to the externalworld, and stimulates postural responses. Thevisual system also contributes to spatial orienta-tion of the head and trunk through proprioceptivefeedback provided by eye muscles when ‘looking’at a target (Di Fabio & Emasithi 1997).

In summary, visual and vestibular inputs appearto orientate head position. However, the positionof the head relative to the trunk is not fixed, there-fore their influence on postural control dependson head position relative to the trunk (Massion &Woolacott 1996). This evaluation is made by neckmuscle proprioceptors and links to the ability ofthe body to create postural stability based oninternal references.

Treleaven (2007) and Armstrong et al (2008) bothidentify that neck muscles contain much higherdensities of muscle spindles than in other areas ofthe body eg the thumb (Boyd Clark et al 2002) andthese are often localised amongst slow twitchmuscle fibres, suggesting a specific role in posturalactivities. Both Armstrong et al (2008) andTreleaven (2007) also highlight the important inte-gration between neck proprioceptors, the vestibularsystem and the visual system in accurately deter-mining the position of the head in space and headrelative to the body. This interaction is used as thebasis for a number of important reflexes influencinghead, eye and postural stability.

The somatosensory system helps maintain headand trunk postural stability in relation to supportsurfaces. Peterka (2002) argues that on a firm, levelsurface, up to 70% of information regarding pos-tural control is gained from the somatosensorysystem and through internal references and cuta-neous receptors (for instance around the pelviswhilst sitting) when the body is orientated vertically(Horak 2006, Shumway-Cook & Woolacott 2007).

In conclusion, accurate postural control, particu-larly of the head and trunk, is a ‘complex motorskill derived from the interaction of multiple sen-sorimotor processes’ (Horak & Macpherson 1996),which rely on intact sensory motor networks.However neurologically impaired individualsexhibit damage to these systems (Basford et al2003, Raine et al 2009). This leads to problems‘organising appropriate goal-orientated patternsof activity on a background of postural control’(Raine et al 2009).

HYPOTHESISAvailable evidence from the literature appears tosupport the view that head position (Di Fabio &Emasithi 1997, Armstrong et al 2008) and trunkposition (Gillen 2007, Ryerson 2008) and theirinteraction (Massion & Woolacott 1996) canimprove postural control in sitting. It is also sug-gested that improved postural control affects armfunction (Gillen 2007). However, little evidencecould be identified to link improved head andtrunk control to improvements in functional tasksin neurologically impaired adults. I feel this war-rants further investigation and therefore proposedthe following hypothesis for this study:

“Facilitation of an improved interactionbetween the head and trunk, improves postural control during functional tasks of the upper limb.”

CLINICAL CASE ANALYSIS: MR AMr A is a 52-year old male who was admitted tohospital with a right thalamic bleed with exten-sion into the ventricles and early hydrocephalus.

Mr A had a history of hypertension and hadexperienced previous myocardial infarcts and atransient ischaemic attack. In 2007 he had alsosuffered a subdural haemorrhage and skull frac-ture following a fall from scaffolding. This hadresulted in slight residual left sided weakness,preventing him from returning to work butallowing him to drive and mobilise independently.

Mr A initially presented to hospital on thisadmission following a dizzy spell and subsequentworsening of his left leg weakness. Following hisdiagnosis of a thalamic bleed, Mr A deteriorated,showing increased hydrocephalus and cerebraloedema resulting in an extra ventricular drainbeing inserted 23 days post bleed.

Once stable (50 days post event), Mr A wastransferred for assessment at the Brian InjuriesUnit. Initial physiotherapy assessment findingsguided the development of the problem list (SeeTable 1 overleaf) and patient centred short-termgoals and achievements (See Table 2 overleaf).

TREATMENT HYPOTHESESThe identification of short-term goals for Patient Aallowed treatment hypotheses to be generated.These hypotheses and their associated treatmentinterventions are described with reference to themain hypothesis.

HYPOTHESIS 1

By improving neck range of movement and developing neck strength, Mr A will improvemidline awareness and head stabilisation.



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Lying• Treatment began initially in supine lying to

provide a safe environment for Mr A to startexploring movement and reduce compensatorystrategies.

Head and neck• The central (trunk) key point was stabilised and

treatment focussed on head and neck mobilitywork.• Mobilisation and soft tissue release techniques

were used to gain improved length in neck andshoulder muscles, improving neck mobility.

• The head and neck were facilitated into pat-terns of flexion and rotation.

Progression• As Mr A gained improved head and neck control

and volitional movement, independent neck rota-tion was encouraged to both visual and auditorystimuli.

• As volitional head and neck movement developedfurther, combined neck and upper trunk flexionwere used to activate the abdominals to improveabdominal alignment and strength and decreaserib flaring.

• Finally, head, neck and trunk activity were incor-porated into the functional task of rolling to theleft which also involved the use of right armreaching, hip activity and inter-segmental trunkactivity.

1 Restricted eye movementswith no vertical and minimalhorizontal gaze (sunseteyes). (See Figure 1)

2 Limited active neck movement – minimal neckflexion or rotation.

3 Right side flexion of neck.

4 Low tone left upper limb with no active ROM in shoulder, elbow, wrist and hand.

5 Mild left gleno-humeral subluxation.

6 Posteriorly tilted pelvis in sitting with no active trunk extension.

7 ‘Falling’ to left in sitting withcompensatory fixation inright upper limb. (See Figure 2)

8 Low tone left lower limb with no active ROM in hip, knee, ankle or foot.

9 Decreased passive ROM in left ankle – plantargrade only onstretch.

10 Persistently low arousal levels – 11/15 Glasgow Coma Scale score.11 Aphasic with poor compensatory communication abilities.

Table 1 Problem list

Table 2 Short term goals and achievements

SHORT TERM (TWO WEEK)FUNCTIONAL GOALS

ACHIEVEMENTS AFTERTWO WEEKS

1 To independently maintain upright midlinehead position in sitting.

2 To be able to independently take adrink with the right upperlimb whilst maintainingindependent sitting balance.

3 To be able to sit independ-ently in midline on aplinth without right upperlimb support.

1 Able to maintain uprighthead position in supportedsitting > 1 minute and look to left and right independently.

2 Able to sit on plinth withminimal assistance of oneperson in midline, withoutright upper limb support.

3 Able to reach outside baseof support with rightupper limb and take adrink in sitting with minimal trunk support.

Head

Upper Limb

Trunk

Lower Limb

General

IMPAIRMENTS

ACTIVITIES

1 Dependent on two to move in bed ie rolling and lie to sit.2 Unable to sit independently – moderate assistance of one required and ‘falls’

to left side.3 Unable to stand.4 Dependent on two for all PADL’s and ADL’s.5 Limited ability to use right upper limb for tasks due to comprehension/arousal.

Figure 1 Sunset eyes. Sunset eyes with

no vertical gaze. Note head side flexion

to right and left sided gleno-humeral

subluxation.

Figure 2 Sitting. ‘Falling’ to left side and

fixing with right UL. Poor interaction of

left UL and LL in sitting posture.


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HYPOTHESIS 2

By developing increased trunk and head posturalcontrol in midline and improved awareness of leftside it will decrease fixation with right side.

Sitting• The treatment was progressed from work in

supine to sitting on the edge of a plinth in order to increase Mr A’s postural control through:• Increasing the patient’s arousal level, • Stimulating the vestibulospinal system and• Developing axial muscle strength (IBITA 2007).

Head• Mr A was encouraged to align himself visually to

vertical targets in midline to increase head pos-tural control (Massion and Woolacott 1996).

Trunk• In order to create better vertical orientation in

the trunk, the left hip was ‘packed’ with towels toincrease somatosensory input and improve thebase of support (Horak 2006).

• Work on de-weighting the upper trunk and assist-ing Mr A with anterior and posterior pelvic tiltinghelped increase inter-segmental trunk control.

Limbs• Mobilisation of the left and right foot increased

somatosensory afferent input and helped improvefoot-floor contact – thus providing Patient A withan improved distal frame of reference (Figure 3).

• Specific left upper limb activation improved theContact Hand Orientating Response (CHOR) tofacilitate head stabilisation (Jeka et al 1994),midline orientation (Raine et al 2009) and gleno-humeral and scapular stability (Figure 4).

Progression• As midline alignment was improving, the

patient’s postural control could then be progres-sively challenged by: • Graded removal of the right hand from contact

surfaces to reduce reliance on upper limb fixa-tion (Figure 5).

HYPOTHESIS 3

By developing effective postural control in the headand trunk it will improve orientation to a task andfree the upper limbs for functional use.

Sitting• As Mr A developed improvements in his head

and trunk postural control and reduced his rightUL fixation, treatment continued in sitting tochallenge this control further.

Trunk• The low toned left upper limb was de-weighted

and then weight transfer both laterally and ante-riorly/posteriorly was facilitated to allow PatientA to explore his base of support and developmore selective trunk control (Figure 6).

Figure 3 Foot Orientation Specificgastrocnemius lengthening to left andright leg improved foot-floor contactand leg orientation.

Figure 5 Midline Bilateral handplacement and cutaneous stimulationof trunk extensors, coupled with anincreased plinth height to gain anteriorpelvic tilt improved trunk and neckextension in midline. This createdbetter postural control.

Figure 4 Realignment Once effective CHOR wasachieved, forearm and upper arm were realigned.Realignment and activation of distal triceps helpedgain elbow extension and improve shoulder stabilityand position. Progression was made towards activeleft scapular depression to improve thoracic extension.



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• The base of support was decreased further byraising the plinth height, and this helpedencourage more anterior pelvic tilt, trunk exten-sion and symmetrical leg activity.

Progression• Visual targets of high motivational interest ie a

cup of juice, were used to increase the eye, headand trunk orientation to a task and this notice-ably improved participation (Ching-yi Wu et al2001) (Figure 7).

• Incorporating drinking as a task improved coor-dination of the head and right upper limb, whilstmaintaining postural control.

A 24-hour, holistic approach was utilisedthroughout this study to aid rehabilitation. ThisIncluded:• Pharmacological treatments and the use of a

light box were started to help improve Mr A’ssleep/wake cycle, thereby increasing arousallevels during the day and allowing better partici-pation in therapy.

• Combined work with both occupational thera-pists and speech therapists was initiated toprovide appropriate seating and to assessswallow and language abilities.

• Positioning guidelines for nursing staff andfamily members were produced with appro-priate education about handling andstimulation.

• Mr A had improved arousal levels when visitorswere present, so positioning awareness andappropriate functional activities were very rele-vant when they were present.

RESULTSThe use of outcome measures is essential in deter-mining the effectiveness of therapy interventions(CSP 2010). Outcome measures need to be rele-vant and meaningful to the individual beingtreated as well as being reliable and valid. From areview of the literature the following outcomemeasures were selected.

PhotographsPre and post treatment photographs illustratedchanges in postural orientation (See photographsin previous section and Appendix 1)

Postural Assessment Scale for Stroke (PASS)The PASS is an ordinal scale outcome measureapplicable to all stroke patients, even those withvery poor postural abilities (Mao et al 2002). Itcontains 12, four point items that produce a totalscore from 0 (poor postural control) to 36 (goodpostural control). The PASS was selected for thisstudy as it demonstrates an individual’s ability tomaintain or control changes in a variety of lying,sitting or standing postures (Benaim et al 1999). Itis reported as being one of the most valid, reliableand responsive clinical assessments of posturalcontrol for patients at different stages of recoveryfollowing neurological injury (Benaim et al 1999,Mao et al 2002).

Goal Attainment Scale (GAS)The GAS is an individualised outcome measurebased on a 5-point ordinal scale. The individuals’starting level is at –1 on the scale and theexpected outcome is normally set at 0. Scores of+1 and +2 show more favourable outcomeswhereas –2 demonstrates a worse than expectedoutcome. It has been shown to be a valid, reliableand responsive measure in settings including

Figure 6 Reaching Deweighting the low tone left UL improved trunk stability and left shoulder position. Reaching was facilitated to gain increased trunk extension. Objects of high motivational interest (cup) and use of wife helped with head and trunk orientation, active participation and improved weight transfer and stability over right hip.

Figure 7 Lateral weight transfer CHOR and improved head/trunk alignment improved the lateral weight transfer ability.


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brain injury (Raine et al 2009). Rockwood & Stolee(1997) suggested it is an important supplement toother outcome measures as these can be insensi-tive to change, especially in brain injury patients(Joyce et al 1994). See Table 3 for GAS.

DISCUSSIONThe results of this study support the hypothesisthat facilitation of an improved interactionbetween the head and trunk improves posturalcontrol during functional tasks of the upper limb.

It shows that specific facilitation of head andtrunk interaction may help improve the sensoryintegration of the vestibular, visual andsomatosensory systems in the central nervoussystem and create an improved ‘body schema’,thus generating more appropriate anticipatorypostural adjustments and postural control. Thismay have allowed the upper limbs to be freed toparticipate in more functional tasks. The improvedhead and trunk position may also optimise thequality of sensory feedback, allowing appropriatereinforcement or adjustment of postural control.

Mr A demonstrated improvements in theoutcome measures during the study.

Mr A showed a three-point improvement on thePASS, improving in his sitting and rolling abilities.This demonstrates a clear development in pos-tural activation and control of both head andtrunk. This is supported by the GAS increase to 0,which required increased postural stability andmidline orientation in order to stop fixing with hisright upper limb (see Table 4).

Mr A exhibited variable arousal levelsthroughout the study, which was assumed to be asa result of damage to thalamic and midbrain

structures (Schiff et al 2007). The reduced arousalpresented difficulties with attention and motiva-tion during treatment therefore activity andpositioning had to be varied repeatedly to main-tain attention, which limited the opportunities towork on specific tasks requiring careful repetition.

From a motivational perspective, Mr A hadbetter arousal levels and participated moreactively in tasks that were of high motivationalinterest such as reaching for a drink. However, notall treatment could be combined with highly moti-vational tasks, thus participation and arousalwere, at times, diminished.

Given the nature and severity of the presentingbrain injury, diminished arousal levels were notunexpected and treatment was likely to have onlylimited effect in the relatively short, two-weektreatment period. Whilst, as highlighted, changewas identified through the outcome measures,they were not as sensitive to some of the small butsignificant subjective improvements noted in thepatient. A broader application of the GoalAttainment Scale may have helped rectify this.

The study was also limited by the inclusion ofonly one patient, and its case study format, whichreduce its generalisation to a wider population.

CONCLUSIONThis study has changed my practice, demon-strating to me the potential importance of specifichead and trunk interaction in regaining posturalcontrol in functional tasks. It is impossiblehowever, to state that improving head and trunkinteraction was the sole reason behind theimprovements seen. Certainly within this study,there were multiple influencing factors, includingthe use of distal reference points and sensoryreceptors all of which may have contributed toimproving postural control. More high qualityresearch, using larger numbers of participants,needs to be performed to assess the relative con-tributions of the head and trunk to posturalcontrol.

As such, the hypothesis can neither be provednor disproved, however what is clear is that pos-tural control remains a ‘complex sensori-motorskill’ that will require ongoing investigation.

Table 3 GAS for Mr A

+2 Mr A to be able to maintain midline head position in independent sitting and reach to an object on a table in front with right UL independently in two weeks.

+1 Mr A to be able to maintain midline head position in independent sitting without right UL fixation in two weeks.

0 Mr A to be able to maintain head position in sitting withminimal support without fixing with right UL in twoweeks.

-1 Mr A to be able to maintain midline head position in supported sitting on plinth without right UL fixation in two weeks.

-2 Mr A to be unable to maintain midline head position insupported sitting with right UL fixation in two weeks.

Timescale

Beginning of Week 1

End of Week 1

End of Week 2

PASS score

3

4

6

GAS score

-1

-1

0

Table 4 Results of PASS and GAS for Mr A



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REFERENCES

Armstrong B, McNair P, Taylor D(2008) Head and Neck PositionSense Sports Med 38(2) pp101-117.

Basford JR, Chou L, Kaufman KR,Brey RH, Walker A, Malec JF,Moessner AM, Brown AW (2003)An assessment of gait andbalance deficits after traumaticbrain injury Archive of PhysicalMedicine and Rehabilitation 84pp343-349.

Benaim C, Perennou DA, Villy J,Rousseaux M, Pelissier JY (1999)Validation of a standardisedassessment of postural control instroke patients: the PosturalAssessment Scale for Stroke Stroke30 pp1862-1868.

Boyd Clark L, Briggs C et al (2002)Muscle spindle distribution,morphology and density in thelongis colli and multifidus

muscles of the cervical spineSpine 27(7) pp694-701 Cited in:Treleaven J (2007) Sensorimotordisturbances in neck disordersaffecting postural stability, headand eye movement controlmanual therapy 13 pp2-11.

Ching-yi Wu, May-keun Wong,Keh-chung Lin, Hsieh-chingChen (2001) Effects of task goaland personal preference onseated reaching kinematics afterstroke Stroke 32 pp70-76.

Craik RL (1992) Recovery Processes:maximising function Cited inShumway-Cook A, Woolacott MH (2007) Motor control:Translating research into clinicalpractice 3rd edition LippincottWilliams & Wilkins Philadelphia.

CSP (Chartered Society ofPhysiotherapy) (2010) Outcomemeasures www.csp.org.uk

Day BL, Cole J (2002) Vestibular-evoked postural responses in theabsence of somatosensoryinformation Brain 125 pp2081-2088.

Di Fabio RP, Emasithi A (1997)Ageing and the mechanismsunderlying head and posturalcontrol during voluntary motionPhysical Therapy 77 pp5.

Gillen G , Boiangiu C, Neuman M,Reinstein R, Schaap Y (2007) Trunkposture affects upper extremityfunction of adults Perceptual andMotor Skills 104 pp371-380.

Horak FB (2006) PosturalOrientation and equilibrium;What do we need to know aboutneural control of balance toprevent falls? Age and Ageing 35S2 ppii7-ii11.

Horak FB, Macpherson JM (1996)Postural orientation andequilibrium cited in: Rowell LB,Shepard JT eds Handbook ofPhysiology Section 12 Exerciseregulation and integration ofmultiple systems pp255-292Oxford University Press New York.

IBITA (2007) TheoreticalAssumptions and clinical practicewww.ibita.org

Jeka JJ, Lackner JR (1994)iFingertip contact influenceshuman postural controlExperimental Brain Research 100pp495-502. Cited in: Di Fabio RP,Emasithi A (1997) Aging and themechanisms underlying headand postural control duringvoluntary motion PhysicalTherapy 77 pp5.

1st day• Head control required due to poor neck extension and right side

flexion of neck.• Fixing with right UL and trunk orientated to right side.• Poor postural control, requiring maximal assistance on trunk and left

UL to maintain sitting balance.• Poorly interactive left UL and leg.

Week 2• Improved independent head control with better midline head

orientation.• More interactive right and left UL with no fixing.• Improved postural control with midline orientation of trunk and no

external assistance to maintain sitting balance (except left arm).• More symmetrical and interactive lower limbs.

APPENDIX 1: PHOTOGRAPH OUTCOME MEASURE


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Joyce BM, Rockwood K, Mate-Kole C (1994) Use of GoalAttainment Scaling in braininjury in a rehabilitation hospitalAmerican Journal of PhysicalMedicine and Rehabilitation 73pp10-14. Cited in: Raine S,Meadows L, Lynch-Ellerington M(2009) Bobath Concept: Theoryand Clinical practice inNeurological rehabilitationChapter 1 Wiley-BlackwellChichester.

Mao HF, Hseuh IP, Tang PF, SheuC, F Hsieh CL (2002) Analysis andcomparison of the psychometricproperties of three balancemeasures for stroke patientsStroke 33 pp1022-1027.

Massion J, Woolacott MH Postureand Equilibrium Cited in:Bronstein AM, Brandt T,Woolacott MH (1996) ClinicalDisorders of Balance, posture andgait Arnold London pp1-18.

Peterka RJ (2002) Sensorimotorintegration in human posturalcontrol Journal ofNeurophysiology 88 pp1097-1118.

Raine S, Meadows L, Lynch-Ellerington M (2009) BobathConcept: Theory and Clinicalpractice in Neurologicalrehabilitation Chapter 1 Wiley-Blackwell Chichester.

Rockwood K, Stolee P (1997) Useof goal attainment scaling inmeasuring clinically importantchange in cognitiverehabilitation patients Journal ofclinical epidemiology 50(5)pp581-588. Cited in: Raine S,Meadows L, Lynch-Ellerington M(2009) Bobath Concept: Theoryand Clinical practice inNeurological rehabilitationChapter 1 Wiley-BlackwellChichester.

Ryerson S, Nancy N, Brown DA,Wong RA, Hidler JM (2008)Altered trunk position sense andits relation to balance functionsin people post-stroke Journal ofNeurologic Physical Therapy 32pp14-20.

Saavedra S, Joshi A, Woolacott M,Van Donkelaar P (2009) Eye handcoordination in children withcerebral palsy Experimental BrainResearch 192 pp155-165.

Schiff ND, Giacino JT, Kalmar K,Victor JD, Baker K, Gerber M, Fritz B, Eisenberg B, O’Connor J,Kobylarz EJ, Farris S, Machado A,McCagg C, Plum F, Fins JJ, RezaiAR (2007) Behaviouralimprovements with thalamicstimulation after severetraumatic brain injury Nature448(2) pp1038.

Shumway-Cook A, Woolacott MH(2007) Motor control: Translatingresearch into clinical practice 3rdedition Lippincott Williams &Wilkins Philadelphia.

Treleaven J (2007) Sensorimotordisturbances in neck disordersaffecting postural stability, headand eye movement controlManual Therapy 13 pp2-11.



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In the last three months, I have assessed twomale stroke patients, approximately twomonths after stroke event, both in their fortiesand both presenting with mild non-dominanthemipaeresis. No abnormalities were seen onCT. On examination they both demonstrated aclinical manifestation of sensory-motor deficitindicating ulnar nerve involvement on thehemiplegic side.

THE PATIENTSPatient A had a stroke resulting in a mild left sidedweakness and sensory deficit. Muscle strength wasGrade 4 on the Oxford scale on the left side. Thereappeared to be some weakness and wasting ofmuscles supplied by the ulnar nerve in the left hand,with the beginnings of a characteristic posture ofthe hand, known as the ‘ulnar claw hand’. Hissensory deficit was greatest over the medial aspectof his left palm and the left fifth finger and medialaspect of the ring finger. He was spending manyhours a day on his computer and since the stroke hehad not been using his left hand on the keyboard,but holding it flexed on the computer table.

Patient B had a stroke which also resulted in amild left sided weakness. Muscle strength wasGrade 4 on the Oxford scale on the left side. He alsohad a sensory deficit over the area supplied by theulnar nerve. Like Patient A, he was also spendingmany hours a day on his computer and since thestroke he had not been using his left hand on thekeyboard, but holding it flexed on the computertable.

Neither patient had reported falling nor lying onthe left side for any considerable time, both ofwhich can lead to ulnar nerve compression.

Was this just a co-incidence? What was the likelycause? Is this a complication of stroke? Should webe looking for lower motor nerve (LMN) lesions aswell as upper motor nerve (UMN) lesions?

Likely cause?The ulnar nerve provides sensory innervation tothe fifth finger and the medial half of the fourthfinger and corresponding part of the palmar anddorsal aspects. It innervates flexor carpi ulnaris,flexor digitorum profundus (medial half) and mostof the smaller muscles in the hand that help withfine movement. It is the largest unprotected nervein the human body and ulnar nerve compression isthe most common entrapment neuropathy aftercarpal tunnel syndrome. It usually occurs due tochronic compression/stretch of the ulnar nerve,which, at the elbow, occurs either at the ulnargroove formed by the medial epicondle of thehumerus and the olecranon process of the ulna orat the cubital tunnel. Bending the elbow stretchesthe ulnar nerve and puts pressure on it as it passesthrough the cubital tunnel, pressing it against thebone. Constant rubbing damages the myelin sheathor the nerve itself and disrupts conductivity.

Complication of stroke?Lampl Y et al 1995, in his paper, StrokesMimicking Peripheral Nerve Lesions, reported on‘seven patients with a clinical manifestation ofsensory-motor deficit, imitating peripheral nerveinvolvement due to lacunar brain infarcts verifiedby brain CT. Five of the patients had an ulnarnerve-like deficit and two had a median nerve-likedeficit. The infarcts were located in the thalamusand the corona radiate. No clinical or electrophys-iological evidence for peripheral nerveinvolvement was found.’

Looking for LMN lesions?Paolini M et al’s, 2010 study, Peripheral NerveConduction Abnormalities in Non-paretic Side ofIschaemic Stroke Patients, looked at whetherstandard nerve conduction studies showed signifi-cant differences in a group of post strokehemiplegic patients. A percentage of patientsshowed a slowing of ulnar and common peronealnerve conduction suggesting that there is an

Ulnar nerve involvementand strokeGill Alexander AHP Stroke Consultant for NHS Greater Glasgow and Clyde


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overall increased risk of neuropathies amongstroke patients, even on the non-paretic side.

A study by Kabayel L et al 2008, of 20 severestroke patients within the first month of the eventshowed, on nerve conduction studies, that seven ofthe 20 patients had median nerve entrapment at thewrist, five had ulnar nerve entrapment at the elbowand seven had peroneal entrapment at the fibularhead in the hemiparetic side, three patients hadmedian nerve entrapment at the wrist, one patienthad ulnar nerve entrapment at the elbow and nonehad peroneal entrapment in the non-paretic side.The results confirmed that in severe stroke patientsthe entrapment neuropathies may be commonlyseen, especially in the paretic extremities. Van Kuijket al 2007, concluded from their study of 27 severeischaemic stroke patients that, ‘Given this strongrelationship between the central and peripheralsystem, it is possible that UMN lesions lead to func-tional changes in the LMN as well. In UMN lesionsthe LMN may become functionally depressed orundergo transsynaptic degeneration through loss ofsynaptic input and lack of activation’.

In Qaisar et al’s 2008 study looking at, UlnarNerve; Occupational Causes of Compression Acrossthe Elbow, they found that out of the 267 cases ofulnar nerve compression at the elbow diagnosed,‘most of the cases had left sided involvement thatwas contralateral to the dominant side. This reflectsbad posture with sustained flexion at the elbowcausing over stretching of the ulnar nerve at theelbow.’ ‘Regarding occupation this study showedthat a large group was associated with occupationalcauses of ulnar nerve compression at the elbow …Electro-physiological evaluation showed prevalanceof occupational 121(45%) and traumatic 51 (21%)causes.’ ‘Out of 267 patients, 70 (26%) were clerks,46 (21%) were signal/telephone operators … and 50(20%) were computer operators.

INTERVENTIONQaisar et al 2008, concluded that, ‘management ofulnar nerve compression must include a compre-hensive rehabilitation programme that shouldfocus on postural correction and workstationergonomic modifications along with pharmacolog-ical and surgical advice.’

As well as routine stroke rehabilitation, advicewas given to both patients on how to prevent andreduce ulnar nerve compression at the elbow. Thisincluded advice on positioning of the elbow, partic-ularly when working at the computer, using apillow to prevent pressure and also to avoid toomuch elbow flexion especially when sleeping. Thepatients were encouraged to use their left handmore when using the computer keyboard ratherthan leaving it to rest on the computer table.

Unfortunately Patient A failed to attend after hisinitial appointment.

Patient B was reassessed at his second visit. Hissensory symptoms had disappeared and althoughhis left hand lacked the last refinements of finefinger movement, he was now using his left handon the computer keyboard and starting to play theguitar again. Hand strength now measured 5 onthe Oxford Scale.

IMPLICATIONS FOR PRACTICEEvidence from the research found suggests that:• patients with an UMN lesion have a predisposi-

tion to develop LMN lesions,• we should expect to see LMN lesions and• prevention is better than cure.Positioning (and regular changes in positionavoiding excessive flexion at the elbow), earlymobilisation, FES, constraint induced movementtherapy, electromechanical/ robotic devices, repeti-tive task training and muscle strengtheningexercises are all recommended treatments in SIGN118. Could it be that these treatments have moresuccess in outcome following stroke because theyalso, inadvertently, address the issue of LMN lesionsby preventing the synaptic degeneration caused byloss of synaptic input and lack of activation and bymaintaining body positions which prevent excessivestretch or pressure on peripheral nerves?

SUMMARYAs therapists we need to:• be aware that stroke patients have a predisposi-

tion to LMN lesions, • be proactive in the prevention of LMN lesions and• be knowledgeable in how to treat LMN lesions

when they occur.There is the need for more research into LMNlesions following stroke.

REFERENCES

Kabayel L, Balci K, Turgut N,Kabayel DD (2009) Developmentof entrapment neuropathies inacute stroke patients Acta NeurolScand 120(1) pp53-58.

Lampl Y, Gilad R, Eshel Y, Sarova-Pinhas I (1995) Strokes mimickingperipheral nerve lesions ClinicalNeurology and Neurosurgery97(3) pp203-207.

Paoloni M, Volpe B, Mangone M,Ioppolo F, Santilli V (2010)Peripheral nerve conductionabnormalities in nonparetic sideof ischemic stroke patients Jounalof Clinical Neurophysiology 27(1)pp48-51.

Qaisir S, Hanif S, (2008) Ulnarnerve; occupational causes ofcompression across elbowProfessional Medical Journal 15(1)pp37-40.

SIGN 118 (2010) Management ofpatients with stroke:rehabilitation, prevention andmanagement of complications,and discharge planningwww.sign.ac.uk

Van Kuijk A, Pasman J, HendricksH, Schelhaas J, Zwarts M, GeurtsA (2007) Supratentorial ischemicstroke: more than an uppermotor neuron disorder Journal ofClinical Neurophysiology 24(6)pp450-455.



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A patient in a vegetative or minimally con-scious state is considered to be in a lowawareness state as defined below:

Vegetative State (VS): A patient who demon-strates a sleep-awake pattern, responding tostimuli at a reflexive level and without meaningfulresponse to the environment (Jennett and Plum1972).

Minimally Conscious State (MCS): A person witha severe brain injury who show signs which arenot reflex in nature and do not occur consistentlyenough to be used to demonstrate awareness or tocommunicate (Giacino et al 2002).

Advances in medical sciences and technology haveresulted in increased survival for patients in LowAwareness States (Wild von et al 2007).

Management of this heterogeneous patientgroup is a complex process involving the multidis-ciplinary team, (Andrews 2005).

Increased muscle tone and development of con-tractures is a common secondary complication.Interventions to manage these include spasticitymanagement (RCP 2009), casting and splinting(Pohl et al 2002, Lannin et al 2007) and 24-hourposture management (Pope 2006). This articledescribes a good practice example implementedat a specialist unit providing long term care andrehabilitation for people in Low Awareness States.

At the unit there is a strong emphasis on teamworking with interdisciplinary training toencourage continuing professional development.This includes tracheostomy management con-ducted by registered nurses and posturemanagement conducted by physiotherapists,

Patients are admitted to the unit with a varietyof diagnoses including acquired brain injuries(including hypoxia and trauma) and end stagedegenerative diseases. Length of stay varies froma few months for intensive rehabilitation to manyyears (up to 34 years in the author’s experience)for long term care.

On admission patients’ posture and splintingrequirements are assessed by physiotherapistsand occupational therapists.

Posture management & wheelchairsPatients’ posture is assessed in sitting and lyingusing the Nuffield Orthopaedic Centre posturalassessment form. Suitable prescriptions arefinalised after discussions with the local wheel-chair services or special seating services. Bedpositioning equipment (rolls and wedges) are pro-vided by the unit and specialist sleep systemsprovided through the patients funding authority(Primary Care Trust).

SplintingSplints and casts are provided to assist manage-ment of muscle tone and maintain range ofmovement. Splints are made using thermoplasticor fibreglass material. Tolerance is built up gradu-ally and patients wearing time varies from a fewhours for splints to few days or a week for serialcasts.

WHAT WAS THE DRIVING FORCE TO INITIATE CHANGE IN PRACTICE?Step-by-step guidelines with photographic illus-trations formed part of each patient’s care plan onpositioning in bed and wheelchair and splinting.When nurses and HCA’s experienced problemsrelated to these areas, they reported it to the ther-

SHARING GOOD PRACTICE

Design and implementation of an internal clinic referral form to improveinterdisciplinary working in splinting andposture management for people with complexdisabilitiesPhysiotherapy Team, Holy Cross Hospital


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apists through informal verbal handover orthrough telephone calls. The referrals wererelated to problems in three areas:• positioning patients in bed and wheelchair,• mechanical adjustments to wheelchairs, special

seating systems and sleep systems and• issues related to splinting.

On receiving the referrals therapists arrangedappointments for patients to attend the assess-ment clinic along with the nurse or HCA who hadsubmitted the form. Repairs, reviews and demon-strations were carried out in the clinics held in thetherapy department or in the ward as required.The usual process of referral was telephone callsfrom the ward to the therapy office or informalverbal handovers between the nursing andtherapy teams.

The physiotherapy team decided to introduce asystem to formalise the referral process by intro-ducing a referral form to identify common issuesand to provide an audit trail.

HOW DID YOU GO ABOUT THE PROCESS OF CHANGINGPRACTICE?• A brainstorming session was organised within

the therapy team to list issues raised in the threeareas.

• Separate forms were developed for each area.• A series of consultation sessions were organised

with the nursing teams.• The forms were then used for internal referral

by the nursing teams over a three month period. • An audit of forms received was undertaken to

review the accuracy of completion prior tofurther consultation sessions.

• A collaborative decision was made to design acombined clinic referral form containing allinformation from the original three forms. Theform was designed with tick boxes relating to 40items for referral in the three areas.A sample of the clinic referral form is given as

Appendix 1 overleaf.

WHAT RESOURCES DID YOU NEED?This work was carried out within the protectedcontinuing professional development and servicedevelopment time for the physiotherapy depart-ment.

The forms were developed using informationfrom past referrals and with information from pos-tural assessment forms from the Oxford Centre forEnablement, Nuffield Orthopaedic Centre, Oxford.

Relevant literature related to posture manage-ment of people with complex disabilities wasreviewed in journal clubs during in-servicetraining.

WHAT DID YOU LEARN ABOUT THE PROCESS?Protected time for continuing professional devel-opment resulted in the team looking intoinnovative ideas for improving practice. Thenumber of forms completed was higher after thethree forms were simplified and condensed intoone.

The consultation process improved collaborationbetween nursing and therapy teams and accept-ance of change within the teams was achievedsmoothly.

HOW HAS IT CHANGED YOUR SERVICE?The nurses and HCA’s now have an accurate,auditable method of referring patients with prob-lems relating to splinting, wheelchairs andpositioning.

Implementation of this form has enhanced com-munication between the nursing and therapyteams thereby improved patient positioning andaccurate splinting.

The audit of these clinic referral forms showedpatterns of commonly occurring issues when posi-tioning patients in wheelchairs, bed and insplinting (eg the way the head rests when Allenkey banana joints were applied). The training pro-grammes at Holy Cross (HCA Developmentprogramme, Induction training etc) were reviewedand restructured addressing these issues.

ContactRasheed Ahamed Mohammed Meeran, MSc NeurorehabilitationPhysiotherapy Team Leader, Physiotherapy Department, Holy CrossHospital, Hindhead Road, Haslemere GU27 1NQ

REFERENCES

Andrews K (2005) Rehabilitationpractise following profoundbrain damage Neuro-psychological rehabilitation15(3/4) pp461-472.

von Wild K et al (2007) Guidelinesfor Quality Management ofApallic Syndrome / VegetativeState European Journal of Traumaand Emergency Surgery 33(3)pp268-292.

Giacino JT, Ashwal S, Childs N,Cranford R (2002) The minimallyconscious state: Definitions anddiagnostic criteria AmericanAcademy of Neurology 58 pp349-353.

Jennett B, Plum F (1972) Persistentvegetative state after braindamage: a syndrome looking fora name Lancet pp734-737.

Lannin NA, Cusick A, McCluskey A,Herbert R (2007) Effects ofsplinting on wrist contractureafter stroke. A Randomisedcontrolled trial Stroke 38 pp111-116.

Pope PM (2006) Severe andcomplex neurological disability:Management of the physicalcondition. 1st edition.Butterworth and Heinemann.

Pohl M, Ruckriem S, MeHrholz J,Ritschel C, Strik H (2002)Effectiveness of serial casting inpatients with severe cerebralspasticity: A comparison studyArchives of Physical Medicine andRehabilitation 83 pp784-790.

Royal College of Physicians (2009)Spasticity in adults:management using Botulinumtoxin National Guidelines.



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APPENDIX 1: REFFERRAL FORMS FOR CLINICS


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A spinal cord injury (SCI) can have devastatingconsequences on a person’s life. Whether sus-tained through accident, illness or disease, theimpact of partial or total paralysis, and facinglife as a wheelchair user can be overwhelming.Loss of mobility is often combined withbladder and bowel incontinence and loss ofsexual function, as well as a reduced ability toregulate heart rate, blood pressure, sweating,and temperature. As a result the rehabilitationprocess is long and arduous as the person triesto come to terms with the huge physical andpsychological impact.

England, Wales and Northern Ireland has ten spe-cialist NHS spinal cord injuries centres, each onededicated to the acute care and rehabilitation ofpatients with SCI. The multi-disciplinary teams ateach centre aim to maximise neurologicalrecovery, functional abilities and psychologicaladjustment, enabling each patient to return to thecommunity as independent and productive as pos-sible – and prepared to resume their life.

The highly specialized, experienced staff andappropriate facilities and equipment, provide eachpatient with the necessary tools to maximize theirrecovery. However, one important element of therehabilitation process is not provided by staffmembers and requires no specialist equipment.

The centres each have a dedicated Peer Adviser,someone who is available to share personal experi-ences of life with a SCI, as well as offer practicaladvice on a wide range of topics. This support, earlyon in a patient’s rehabilitation, has been shown tohave a significant impact on a newly injuredpersons ability to come to terms with their new situation and, in turn, maximize their potential.

The presence of peer support during the longand difficult rehabilitation process cannot beunderestimated. Knowing you’re not alone in

coming to terms with the impact of SCI and itsconsequences and being able to discuss fears andconcerns with someone that can emphathise isinvaluable. The opportunity to talk to someonewho has been there and done it and come throughthe other side can change a newly injured personsoutlook by demonstrating there is life after SCI.

In an ideal world, everyone that sustains a spinalinjury, whether through traumatic or non-trau-matic means, would be immediately transferred toa spinal centre to undergo rehabilitation andbenefit from peer support. Unfortunately, we don’tlive in an ideal world, and more and more patientsthat sustain a SCI are waiting for long periods tobe transferred to a specialist centre, never receivetreatment in a specialist centre at all. Delays intransfer or non-admittance can leave patientsincredibly isolated on wards, or in hospitals,where they may be the only person coming toterms with SCI.

The Spinal Injuries Association’s CommunityPeer Support (CPS) service has been developed tooffer support to patients with a SCI who are beingtreated in district general hospitals and rehabili-tation facilities. The service gives patients theopportunity to talk to someone who understandsthe impact of SCI and can offer personal experi-ences of the key issues facing the newly injured.Whether it is a listening ear, information on bowel

FOCUS ON…

Community peer supportfor people with spinal cord injuryJamie Rhind Spinal Injuries Association



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and bladder management, advice on sexual issuesor just someone to talk to about life with SCI, eachofficer is there to demonstrate that life needn’tstop because of paralysis.

The service is led by a team of Community PeerSupport Officers, all of whom have many yearsexperience of life with SCI. Currently covering theSouth, Greater London, Midlands, North West andWales, CPS Officers provide face to face supportfor the newly injured, their families and friends,and healthcare professionals (HCP).

Referrals to the service can come from any HCP

involved in the treatment of a spinal cord injuredpatient, as well as family or friends or the personthemselves. Each Officer is available from theacute phase of injury, right through the rehabilita-tion process and beyond, all with the sole aim ofmaximizing the quality of life for each newlyinjured person moving forward.

If you are involved in the treatment of patientswith SCI and would like more information on theservice, or to make a referral, please contact yourlocal SIA Community Peer Support Officer via telephone or email, their details are below.Alternatively you can contact SIA Head Office on 0845 678 6633.

South & MidlandsPeter Hutchings [email protected] 07593 538126

Greater London Simon Brierley [email protected] 07817 758144

North WestJamie Rhind [email protected] 07800 854605

WalesTony Stephenson [email protected] 07891 827149

above members of the Community Peer Support (CPS) team, from left toright: Peter Hutchings, Jamie Rhind and Simon Brierley.


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AMERICAN JOURNAL OF PHYSICALMEDICINE AND REHABILITATIONVolume 89:11

• Kim DY, Lim JY, Kang EK, You DS, OhMK, Oh BM, Paik NJ Effect of tran-scranial direct current stimulationon motor recovery in patientswith subacute stroke pp879-886.

•Stoykov ME, Stinear JW Active-pas-sive bilateral therapy as a prim-ing mechanism for individuals inthe subacute phase of post-strokerecovery: a feasibility studypp873-878.

Volume 90:1

• Hung JW, Chen PC, Yu MY, Hsieh YWLong-term effect of an anteriorankle-foot orthosis on functionalwalking ability of chronic strokepatients pp8-16.

ARCHIVES PHYSICAL MEDICINE ANDREHABILITATIONVolume 91:10

• Arango-Lasprilla JC, Ketchum JM,Cifu D, Hammond F, Castillo C,Nicholls E, Watanabe T, Lequerica A,Deng X Predictors of extendedrehabilitation length of stay aftertraumatic brain injury pp1495-1504.

• Askim T, Indredavik B, Håberg AInternally and externally pacedfinger movements differ in reor-ganization after acute ischemicstroke pp1529-1536.

• Fulk GD, Reynolds C, Mondal S,Deutsch JE Predicting home andcommunity walking activity inpeople with stroke pp1582-1586.

• Hurkmans HL, van den Berg-EmonsRJ, Stam HJ Energy expenditure inadults with cerebral palsy playingwii sports pp1577-1581.

• Langan J, Doyle ST, Hurvitz EA,Brown SH Influence of task oninterlimb coordination in adultswith cerebral palsy pp1571-1576.

• Rietberg MB, van Wegen EE,Uitdehaag BM, de Vet HC, Kwakkel GHow reproducible is home-based24-hour ambulatory monitoringof motor activity in patients withmultiple sclerosis? pp1537-1541.

• Sady MD, Sander AM, Clark AN,Sherer M, Nakase-Richardson R,Malec JF Relationship of preinjurycaregiver and family functioningto community integration inadults with traumatic braininjury pp1542-1550.

• Siu PM, Tam BT, Chow DH, Guo J,Huang Y, Zheng Y, Wong SHImmediate effects of two differ-ent whole-body vibration fre-quencies on muscle peak torqueand stiffness pp1608-1615.

• Tang WK, Lu JY, Chen YK, Mok VC,Ungvari GS, Wong KS Is fatigueassociated with short-termhealth-related quality of life instroke? pp1511-1515.

Volume 91:11

• Altman IM, Swick S, Parrot D, MalecJF Effectiveness of community-based rehabilitation after trau-matic brain injury for 489program completers comparedwith those precipitously dis-charged pp1697-1704.

• Horn SD, Deutscher D, Smout RJ,DeJong G, Putman K Black-WhiteDifferences in PatientCharacteristics, Treatments, andOutcomes in Inpatient StrokeRehabilitation pp1712-1721.

• Krause JS Risk for subsequentinjuries after spinal cord injury: a10-year longitudinal analysispp1741-1746.

• Jan Y, Jones MA, Rabadi MH,Foreman RD, Hiessen A Effect ofwheelchair tilt-in-space andrecline angles on skin perfusionover the ischial tuberosity in peo-ple with spinal cord injurypp1758-1764.

• Menon DK, Schwab K, Wright DW,Maas AI The Demographics andClinical Assessment WorkingGroup of the International andInteragency Initiative towardCommon Data Elements forResearch on Traumatic BrainInjury and Psychological HealthPosition statement: definition oftraumatic brain injury pp1637-1640.

• Thurmond VA, Hicks R, Gleason T,Miller AC, Szuflita N, Orman J, Schwab K Advancing integratedresearch in psychological healthand traumatic brain injury: com-mon data elements pp1633-1636.

• Treger J, Aidinof L, Lutsky L,Kalichman L Mean flow velocity inthe middle cerebral artery isassociated with rehabilitationsuccess in ischemic stroke patientspp1737-1740.

• Wilde EA, Whiteneck GG, Bogner J,Bushnik T, Cifu DX, Dikmen S, FrenchL, Giacino JT, Hart T, Malec JF, MillisSR, Novack TA, Sherer M, Tulsky DS,Vanderploeg RD, von Steinbuechel NRecommendations for the use ofcommon outcome measures intraumatic brain injury researchpp1650-1660.e17.

Volume 91:12

• American Congress of RehabilitationMedicine Brain Injury-Interdisciplinary Special InterestGroup, Disorders of ConsciousnessTask Force, Seel RT, Sherer M, Whyte J,Katz DI, Giacino JT, Rosenbaum AM,Hammond FM, Kalmar K, Pape TL,Zafonte R, Biester RC, Kaelin D, KeanJ, Zasler N Assessment scales for

disorders of consciousness: evi-dence-based recommendationsfor clinical practice and researchpp1795-1813.

• van den Berg-Emons RJ, BussmannJB, Stam HJ Accelerometry-basedactivity spectrum in persons withchronic physical conditions origi-nal research article pp1856-1861.

• Chen CC, Hong WH, Wang CM, ChenCK, Wu KPK, Kang CF, Tang SFKinematic features of rear-footmotion using anterior and poste-rior ankle-foot orthoses in strokepatients with hemiplegic gaitpp1862-1868.

• Combs SA, Dugan EL, Passmore M,Riesner C, Whipker D, Yingling E,Curtis AB Balance, balance confi-dence, and health-related qualityof life in persons with chronicstroke after body weight–sup-ported treadmill training pp1914-1919.

• Groothuis JT, Rongen GA, Geurts AC,Smits P, Hopman MT Effect of differ-ent sympathetic stimuli–auto-nomic dysreflexia and head-uptilt–on leg vascular resistance inspinal cord injury pp1930-1935.

• Motl RW, Dlugonski D, Suh Y,Weikert M, Fernhall B, Goldman MAccelerometry and its associationwith objective markers of walk-ing limitations in ambulatoryadults with multiple sclerosispp1942-1947.

• Nardone A, Marco Godi M, Artuso A,Schieppati M Balance rehabilita-tion by moving platform andexercises in patients with neu-ropathy or vestibular deficitpp1869-1877.

• Simmons-Mackie N, Raymer A,Armstrong E, Audrey Holland A,Cherney LR Communication partnertraining in aphasia: a systematicreview pp1814-1837.

ARTICLES IN OTHER JOURNALS



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• Skandsen T, Finnanger TG,Andersson S, Lydersen S, Brunner JF,Vik A Cognitive impairment threemonths after moderate andsevere traumatic brain injury: aprospective follow-up study orig-inal research article pp1904-1913.

Volume 92:1

• Fattal C, Fabbro M, Gelis A, Bauchet LMetastatic paraplegia and vitalprognosis: perspectives and limi-tations for rehabilitation care.Part 1 review article pp125-133.

• Fattal C, Fabbro M, Rouays-Mabit H,Verollet C, Bauchet L Metastaticparaplegia and functional out-comes: perspectives and limita-tions for rehabilitation care. Part2 review article pp134-145.

• Fong KN, Lo PC, Yu YS, Cheuk CK,Tsang TH, Po AS, Chan CC Effects ofsensory cueing on voluntary armuse for patients with chronicstroke: a preliminary study pp15-23.

• Jensen MP, Moore MR, Bockow TB,Ehde DM, Engel JM Psychosocialfactors and adjustment to chronicpain in persons with physical dis-abilities: a systematic reviewpp146-160.

• Mendonca GV, Pereira FD, Fernhall BEffects of combined aerobic andresistance exercise training inadults with and without downsyndrome pp37-45.

Seo NJ, Fischer HW, Bogey RA, RymerWZ, Kamper DG Use of visual forcefeedback to improve digit forcedirection during pinch grip inpersons with stroke: a pilot studypp24-30.

Volume 92:2

• Al-Rahamneh HQ, Eston RGPrediction of peak oxygen con-sumption from the ratings of per-ceived exertion during a gradedexercise test and ramp exercisetest in able-bodied participantsand paraplegic persons pp277-283.

• Britto RR, Rezende NR, Marinho KC,Torres JL, Parreira VF, Teixeira-SalmelaLF Inspiratory muscular training inchronic stroke survivors: a ran-domized controlled trial pp184-190.

• Dudley-Javoroski S, Littmann AE,Chang SH, McHenry CL, Shields RKEnhancing muscle force andfemur compressive loads via feed-back-controlled stimulation ofparalyzed quadriceps in humanspp242-249.

• Latif LA, Amadera JED, Pimentel D,Pimentel T, Fregni F Sample size cal-culation in physical medicine andrehabilitation: a systematicreview of reporting, characteris-tics, and results in randomizedcontrolled trials pp306-315.

• van Leeuwen CM, Post MW,Hoekstra T, van der Woude LH, de Groot S, Snoek GJ, Mulder DG,Lindeman E Trajectories in thecourse of life satisfaction afterspinal cord injury: identificationand predictors pp207-213.

• Lewis SJ, Barugh AJ, Greig CA,Saunders DH, Fitzsimons C, Dinan-Young S, Young A, Mead GE Isfatigue after stroke associatedwith physical deconditioning? across-sectional study in ambula-tory stroke survivors pp295-298.

• Roorda LD, Houwink A, Smits W,Molenaar IW, Geurts AC Measuringupper limb capacity in poststrokepatients: development, fit of themonotone homogeneity model,unidimensionality, fit of the dou-ble monotonicity model, differen-tial item functioning, internalconsistency, and feasibility of theStroke Upper Limb Capacity Scale,SULCS pp214-227.

• van Swigchem R, Weerdesteyn V,van Duijnhoven HJ, den Boer J,Beems T, Geurts AC Near-normalgait pattern with peroneal elec-trical stimulation as a neuropros-thesis in the chronic phase ofstroke: a case report pp320-324.

• Tamplin J, Brazzale DJ, Pretto JJ,Ruehland WR, Buttifant M, Brown DJ,Berlowitz DJ Assessment of breath-ing patterns and respiratory mus-cle recruitment during singing andspeech in quadriplegia. Originalresearch article pp250-256.

CLINICAL REHABILITATIONVolume 24:10

• Fliess-Douer O, Vanlandewijck YC,Manor GL, Van Der Woude LH A sys-tematic review of wheelchairskills tests for manual wheelchairusers with a spinal cord injury:towards a standardized outcomemeasure pp867-886.

Volume 24:11

• Outermans JC, van Peppen RPS,Wittink H, Takken T, Kwakkel GEffects of a high-intensity task-oriented training on gait per-formance early after stroke: apilot study pp979-987.

Volume 24:12

• Turner-Stokes L, Williams H,Howley D, Jackson D Can theNorthwick Park Dependency Scalebe translated to a Barthel Index?pp1112-1120.

Volume 25:1

• Fil A, Armutlu K, Atay AO, Kerimoglu U, Elibol B The effect ofelectrical stimulation in combina-tion with Bobath techniques inthe prevention of shoulder sub-luxation in acute stroke patientspp51-59.

• Han SH, Kim T, Jang SH, Kim MJ,Park S, Yoon SI, Choi B, Lee MY, Lee KHThe effect of an arm sling onenergy consumption while walk-ing in hemiplegic patients: a ran-domized comparison pp36-42.

• Sabapathy NM, Minahan CL, Turner GT, Broadley SA Comparingendurance- and resistance-exer-cise training in people with mul-tiple sclerosis: a randomized pilotstudy pp14-24.

• Yasar E, Vural D, Safaz I, Balaban B,Yilmaz B, Goktepe AS, Alaca R Whichtreatment approach is better forhemiplegic shoulder pain instroke patients: intra-articularsteroid or suprascapular nerveblock? A randomized controlledtrial pp60-68.

Volume 25:2

• Hesse S, Welz A, Werner C, Quentin B, Wissel J Comparison ofan intermittent high intensity vscontinuous low intensity physio-therapy service over twelvemonths in community dwellingpeople with stroke: a randomizedtrial pp146-156.

• Kim JS, Oh DW, Kim SY, Choi JDVisual and kinesthetic locomotorimagery training integrated withauditory step rhythm for walkingperformance of patients withchronic stroke pp134-145.

Volume 25:3

• Marsden J, Harris C Cerebellarataxia: pathophysiology andrehabilitation pp195-216.

GAIT AND POSTUREVolume 33:1

• Shaw JA, Huffman JL, Frank JS, Jog MS, Adkin AL The effects of skillfocused instructions on walkingperformance depend on move-ment constraints in Parkinson'sDisease pp119-123.

Volume 33:2

• Chisholm AE, Perry SD, McIlroy WEInter-limb centre of pressure symmetry during gait amongstroke survivors pp238-243.

• Paulis WD, Horemans HLD, Brouwer BS, Stam HJ Excellent test-retest and inter-rater reliability for Tardieu Scale meas-urements with inertial sensors inelbow flexors of stroke patientspp185-189.

Volume 33:3

• Bernhardt KA, Oh TH, Kaufman KRGait patterns of patients withinclusion body myositis pp442-446.

• Lohnes CA, Earhart GM The impactof attentional, auditory, andcombined cues on walking duringsingle and cognitive dual tasks inParkinson’s Disease pp478-483.

• Panzera R, Salomonczyk D,Pirogovosky E, Simmons R, Goldstein J, Corey-Bloom J, Gilbert PE


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Postural deficits in Huntington'sdisease when performing motorskills involved in daily livingpp457-461.

PHYSIOTHERAPY THEORY ANDPRACTISEVolume 26:7

• Freund JE, Stetts DM Use of trunkstabilization and locomotor training in an adult with cerebel-lar ataxia: a single system designpp447–458.

• Leahy TE Impact of a limited trialof walking training using bodyweight support and a treadmillon the gait characteristics of anindividual with chronic, incom-plete spinal cord injury pp483–489.

Volume 26:8

Carvalho C, Sunnerhagen KS, Willén CWalking speed and distance indifferent environments of subjectsin the later stage post-strokepp519–527.

Volume 27:1

• Fusco C, Zaina F, Atanasio S,Romano M, Negrini A, Negrini SPhysical exercises in the treatmentof adolescent idiopathic scoliosis:an updated systematic reviewpp80-114.

• Maruyama T, Grivas TB, Kaspiris AEffectiveness and outcomes ofbrace treatment: a systematicreview pp26-42.

Volume 27:2

• Kolber MJ, Vega F, Widmayer K,Cheng MS The reliability and mini-mal detectable change of shoul-der mobility measurements usinga digital inclinometer pp176-184.

• Timmerman H, de Groot JF,Hulzebos HJ, de Knikker R, Kerkkamp HE, van Meeteren NLFeasibility and preliminary effectiveness of preoperativetherapeutic exercise in patientswith cancer: a pragmatic studypp117-124.

PHYSICAL THERAPY Volume 90:11

• Finlayson M, Plow M, Cho C Use ofphysical therapy services amongmiddle-aged and older adultswith multiple sclerosis pp1607-1618.

• Kruse RL, LeMaster JW, Madsen RWFall and balance outcomes afteran intervention to promote legstrength, balance and walking inpeople with diabetic peripheralneuropathy: ‘feet first’ random-ized controlled trial pp1568-1579.

• Moreau NG, Simpson KN, Teefey SA,Damiano DL Muscle architecturepredicts maximum strength andis related to activity levels in cere-bral palsy pp1619-1630.

Volume 91:1

Combs SA, Diehl MD, Staples WH, Conn L, Davis K, Lewis N, Schaneman KBoxing training for patients withParkinson’s Disease: a case seriespp132-142.

• Field-Fote EC, Roach KE Influenceof a locomotor training approachon walking speed and distance inpeople with chronic spinal cordinjury: a randomized clinical trialpp91:48-60.

• Huang SL, Hsieh CL, Wu RM, Tai CH,Lin CH, Lu WS Minimal detectablechange of the timed ‘up and go’test and the dynamic gait indexin people with Parkinson’sDisease pp114-121.

• Katalinic OM, Harvey LA, Herbert RDEffectiveness of stretch for thetreatment and prevention of con-tractures in people with neuro-logical conditions: a systematicreview pp91:11-24.

• Lam T, Pauhl K, Krassioukov A, Eng JJUsing robot-applied resistance toaugment body-weight–sup-ported treadmill training in anindividual with incomplete spinalcord injury pp143-151.

• Leddy AL, Crowner BE, Earhart GMFunctional gait assessment andbalance evaluation system test:reliability, validity, sensitivity,and specificity for identifyingindividuals with Parkinson’sDisease who fall pp102-113.

Volume 91:2

van Langeveld SA, Post MW, vanAsbeck FW, Gregory M, Halvorsen A,Rijken H, Leenders J, Postma K,Lindeman E Comparing content oftherapy for people with a spinalcord injury in postacute inpatientrehabilitation in Australia,Norway, and the Netherlandspp210-224.

• Lau RWK, Teo T, Yu F, Chung RCK,Pang MYC Effects of whole-bodyvibration on sensorimotor per-formance in people withParkinson’s Disease: a systematicreview pp198-209.

• Taraldsen K, Askim T, Sletvold O,Einarsen EK, Bjåstad KG, IndredavikB, Helbostad JL Evaluation of abody-worn sensor system tomeasure physical activity in olderpeople with impaired functionpp277-285.



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Main lecture abstracts pages 23-25AGM reports pages 26-27Delegate report page 28

Above left ACPIN President MargaretMayson addresses the conferenceright a farewell to Louise Dunthorne fromGita Ramdharry as she steps down asSynapse editor.

ACPIN NATIONAL CONFERENCE & AGM 2011SATURDAY 19 MARCH 2011

HILTON HOTEL NORTHAMPTON


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From motivation to movement

Prof Jon MarsdenProfessorship and Chair in RehabilitationSchool of Health Professions, University of Plymouth

GOAL DIRECTED BEHAVIOURS as opposed tohabitual behaviours are driven by reinforcement

expectancies, that is, the prediction that an actionwill have a certain positive outcome or utility. Thesepredictions are built up through associative (classicalor instrumental) learning and factors such as theprobability of success, required effort and temporaldifference between an action and the outcome canaffect the motivation of the individual as reflected inthe maintenance of a behaviour. Goal directed behav-iour further requires cognitive processes, forexample, to inhibit inappropriate habits, applycontext specific rules and evaluate the success of anaction.

Recent research has highlighted the role of circuitslinking the prefrontal cortex and the basal ganglia inmediating goal directed behaviour and the impor-tance of dopamine in learning associations betweenstimuli or actions and predicted outcomes.Disruption to prefrontal-basal ganglia circuits canresult in apathy, a reduction in self generated, voli-tional behaviour that can be dissociated fromsymptoms of depression. Apathy is commonly seenfollowing head injury and movement disorders suchas Parkinson’s Disease and progressive supranuclearpalsy and it significantly impacts on functionalrecovery and rehabilitation. This presentation willexplore the neural basis of learnt goal directed behav-iour; the causes of apathy and current evidencebased interventions.

Prof Jon Marsden qualified as a physiotherapist in 1991; heundertook clinical rotations at the United Bristol HealthcareTrust and the National Hospital for Neurology andNeurosurgery in London. From 1999 he worked as a post-doctoral scientist in the Sobell Department for MotorNeuroscience and Movement Disorders, UCL, investigatingthe pathophysiology and rehabilitation of walking andbalance following peripheral and central nervous systemdamage. Since 2007 he has been Professor of Rehabilitationat the School of Health Professions, University of Plymouth.

Underlying mechanismsof functional disordersand how they might fit intomodern theories of howthe brain works

Dr Mark EdwardsNIHR Clinician ScientistInstitute of Neurology, National Hospital forNeurology and Neurosurgery

PERHAPS THE FACT that we have so many wordsthat are used to describe patients with functional

disorders (hysteria, conversion, somatisation, psy-chogenic, non-organic, medically unexplained) sayssomething about how little we know about these disor-ders. There is a general idea that psychologicaldisturbance triggers unconscious manifestation ofphysical symptoms, but whether this is the case andhow this might happen in terms of neurobiology is notunderstood. In this talk I will show how these symp-toms are different from typical neurological symptoms,and discuss emerging theories of how these disordersmight fit in to modern theories of how the brain works.With this understanding we may begin to be able tounderstand how best to treat patients with these dis-abling and perplexing symptoms.

Dr Mark Edwards is a National Institute of Health ClinicianScientist in the Sobell Department at the UCL Institute ofNeurology and an Honorary Consultant Neurologist at theNational Hospital for Neurology and Neurosurgery. He has aclinical and research interest in movement disorders andheads a research team in the Sobell department that useselectophysiological techniques to explore the pathophysi-ology of movement disorders. He has a particular researchinterest in functional/psychogenic movement disorders andis developing a clinical service for such patients at theNational Hospital for Neurology and Neurosurgery.



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Physiotherapy approachto the management offunctional disorders

Glenn NielsenPhysiotherapistNational Hospital for Neurology and Neurosurgery

FUNCTIONAL DISORDERS are relatively commonand notoriously difficult to treat. Patients experi-

encing medically unexplained symptoms tend tohave high health care utilisation, ongoing investiga-tions, consultations from multiple professionals andare often frustrated by contradicting information anda lack of palatable answers. Evidence for the treat-ment of conversion syndrome is scarce; howeverthere seems to be a consensus amongst experts thata combined physical and psychological approach in aMDT is effective. This talk will discuss treatmentstrategies for some common functional neurologicalsymptoms and address complicating factors such asacceptance of diagnosis, the presence of maintainingfactors, chronic presentation, patient dissatisfactionand lack of progress. Developing skills in managingfunctional symptoms is important for all therapistsas symptoms can mimic disease from many bodysystems and can be present in confirmed organicdisease. An informed therapist can maximise poten-tial progress by addressing maintaining factors,avoid reinforcing unhelpful behaviours and minimisenegative client-therapist interactions. Additionallyearly rehabilitation could potentially minimise dis-ability and be cost effective.

Glenn Nielsen is a band 7 physiotherapist employed at theNational Hospital for Neurology and Neurosurgery. Hisexperience in functional disorders includes overseeing thephysiotherapy service on the MDT rehabilitation programmefor conversion syndrome, attending clinics for suitability ofadmission into the programme and assessment of patientsadmitted for investigations of complex neurological presen-tations. Glenn trained and started his career in Australia in alarge teaching hospital before joining the National in 2007.

The dog ate my trainers– compliance with homeexercises given to peoplewith multiple sclerosis byphysiotherapists

Wendy HendriePostgraduate Research Physiotherapist

THIS LECTURE REPORTS on a qualitative studywhich explored the experiences of 24 people with

multiple sclerosis (MS) concerning their adherenceto home exercise regimes prescribed by physiothera-pists. Themes related to compliance andnon-compliance emerged from the data. Issues arosewith performing the home exercise programme andthe approach of the physiotherapist. Of the partici-pants, 79% had not performed their exercises formore than two days. Lack of support by the physio-therapist was the most mentioned factor associatedwith decreased compliance. The findings have impli-cations for physiotherapists who are attempting toencourage a self-management approach to exercisein people with MS.

Wendy Hendrie qualified from The London Hospital in 1980and did rotational posts at the Gloucester Royal Hospital. In1986 she became Superintendent at Kelling Hospital inNorfolk and worked on a Younger Disabled Unit. After mar-rying she worked for the MS charity, Action and Research inMultiple Sclerosis (ARMS). In 1989 she and her GP husbandbuilt a 24 bedded, young disabled unit specialising in MS.She ran the home for 20 years providing permanent care,respite and day care to people with MS and other complexneurodisabilities. During this time she also continued towork for ARMS. She completed a masters degree in 2000and has almost completed her PhD looking at the use ofstanding frames in severe MS. She is passionate about allaspects of the management of people with complex neu-rodisabilities, especially postural care, the promotion ofself-management and education for formal and informalcarers in the community. She lectures widely to MS patientgroups, care staff and health professionals and recentlywrote. Are You Sitting Comfortably? an advice leaflet on goodposture for the MS Trust.


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Normal mechanisms of fatigue and the experience of fatigue inneuromuscular conditions

Dr Gita RamdharrySenior LecturerSt George’s and Kingston University’s School ofRehabilitation Sciences

IN THE HEALTHY INDIVIDUAL fatigue related toactivity and exertion is a normal experience

involving peripheral mechanisms and central influ-ences on continued activity. These mechanisms willbe outlined with reference to research in healthy populations.

Fatigue experienced by people with neuromusculardiseases has only recently been explored in terms ofits prevalence and possible causes. Evidence for pos-sible causes will be outlined, but also the impact offatigue will be discussed with some suggestions ofinterventions to support people with this problem.

Dr Gita Ramdharry qualified as a physiotherapist from UELin 1995 and developed a love of neurology while working as ajunior physiotherapist at King’s College Hospital. She specialised through rotational positions as a senior 2 at St George’s Hospital then a senior 1 at the National Hospitalfor Neurology and Neurosurgery. In 2004 she embarked on aresearch position at the UCL Institute of Neurology com-pleting a PhD in 2008 on compensatory walking patterns inpeople with Charcot-Marie-Tooth disease.

Gita is currently a senior lecturer at St George’s andKingston University’s School of Rehabilitation Sciences. In2009 she was awarded an NIHR Clinical Lectureship whichallows her to work three days a week at the MRC Centre forNeuromuscular Disease, UCL. In this role she is pursuingstudies into training and rehabilitation of people with neuro-muscular diseases.

Remembering personhood: supportingactive participation afterstroke

Dr Fiona JonesReader in RehabilitationSt George’s University of London and KingstonUniversity

THIS SESSION aims to present a synthesis ofcurrent evidence and theory to help us support

active participation for people after stroke. Key theoryand research on behaviour change, social models ofdisability and personhood will be used to encourageparticipants to reflect on their current practice inrehabilitation. A summary of skills and actionsrequired by both the person with stroke and physio-therapist will be presented, and ideas for futureresearch.

Dr Fiona Jones is a Reader in Rehabilitation and the founderof Bridges stroke self-management (previously ‘SteppingOut’). She has developed training programmes for clinicianson self-management and masters level modules on life afterstroke and is currently programme leader for the faculty’sMSc in Rehabilitation.

She originally trained as a physiotherapist and has workedin all areas of neurorehabilitation. She became interested inself-management after completing her MSc and working in anew community stroke rehabilitation team. She completedher PhD in 2005 and has published several articles on self-management and self-efficacy and is currently editor of thejournal Physiotherapy Research International. She is a co-applicant on a number of research projects in stroke andcurrently supervises six PhD students.

She is involved in a number of committees including theUK stroke forum and pan-London stroke groups. In 2009she received the UK Stroke Association’s ‘Excellence inStroke Care’ award and in 2010 she was made a Fellow of theChartered Society of Physiotherapy.



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AGM minutesOpened at 12.15pm

1. PresentMargaret Mayston, Siobhan MacAuley,Gita Ramdharry, Anne Roger, SandyChambers, Emma Procter, ChrisManning, Adine Adonis, Lorraine Azam,Jacko Brouwers, Lisa Knight, JuliaWilliamson, Nicki Guck, Kate Busby,Louise Dunthorne

2. ApologiesJane PettyJane McCumisky

3. Minutes of AGM 2010Accepted as an accurate account:Proposed: Adine AdonisSeconded: Chris Manning

4. Presidents addressMargaret Mayston

5. Chairs addressSiobhan Macauley

6. Treasurers addressJo KileffThe decision to retain the currentaccountant for 2011/2012 was made,majority vote

7. Re-election of current executive committee membersTreasurer: Jo Kileffproposed: Lisa Knightseconded: Gita Ramdharry

Research Officer: Julia Williamsonproposed: Sandy Chambersseconded: Jacko Brouwers

Secretary: Anne Rogersproposed: Margaret Maystonseconded: Lorraine Azam

Minutes Secretary: Emma Procterproposed: Louise Rogersonseconded: Jacko Brouwers

Diversity Officer: Lorraine Azamproposed: Adine Adonisseconded: Anne Rogers

8. Election of new members to executive committeeCommittee member: Kate Busby voted inby a majorityCommittee member: Jane Petty voted inby a majority

9. AOBScotland’s regional representative raisedan issue regarding the logistical andfinancial difficulties of the mandatoryattendance of regional representatives toconference. This is especially difficult forScotland at present as their committee isstruggling for members. This issue willbe taken further at the next Executive andNational ACPIN meetings

Meeting closed at 12.45.

Chair’s addressSiobhan MacAuley

Welcome to the AGM of 2011!2011 is the 30th birthday of ACPIN, one

of the largest and most successful clinicalinterest groups of the CSP, and as Chair Iam delighted to be able to inform you of allthe successes over the past year. Whilst Iam the one delivering the address, there isa large team of executive/regional repmembers behind me doing the work.

MembershipOur membership has gone from strengthto strength and we now have over 2100members. Our membership database hasbeen updated and modernised, a mam-moth task started by Mary Cramp and JoTuckey and completed this year by SandyChambers. Interest in ACPIN regions hasgrown so much that Wales have recentlyestablished a new subgroup.

Splinting guidelinesI feel that this has been a topic during all mytime on the committee! At long lastprogress has been made. Brunel Universityin conjunction with Cherry Kilbride, JoTuckey and the neuro OT clinical interestgroup have received funding from ACPINand the work has started!

CongressACPIN provided the neurology strand at theCSP congress. This was very successful andwell attended. There were two days of inter-esting and high calibre speakers and a veryinteractive and thought provoking debateon the Bobath concept. So thank you toChris Manning and we are already lookingforward to congress 2011.

CSPACPIN also liaised with the CSP on manyissues:• Baroness Gardener raised a motion at

the House of Lords on the “Role of theAHP’s in long term conditions”. We pro-vided quite a lot of information for use inthe motion. The Hansard report can befound on the website.

• We provided a speaker for the recenthealth and well-being conference inBirmingham NEC and also providedcomments for many frontline articlesrelating to neurological conditions overthe year.

• We are also working closely with the CSPon the formation of the new alliancegroups, which will be streamlining theprevious clinical interest groups. This isin the early stages but we will be askingfor membership feedback at variousstages so keep an eye on ICSP andplease do respond to ensure that ourmembership is heard.

FinanciallyI think we are the only organisation beatingthe fiscal trend and making a profit-despiteour best attempts to spend money. Thanksto Jo Kileff for her treasury skills and furtherdetails will be in the treasurers report.

Facilitating linksOne of the key roles and successes ofACPIN is making the voice of neurologyphysios heard and we are grateful to FionaJones, Cherry Kilbride, Adrian Capp, BhanuRamaswamy for maintaining those linkswith other organisations, and all our mem-bers in their daily work.

Thank you and congratulations to LorraineAzam who despite having a baby only sixmonths ago organised all the delegatesarrangements for this conference, and to allthe committee members for their role in

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making today a success.Joanne Mc Cumisky is stepping down

from the committee and we thank her forthe last five years work. She can’t be with ustoday, but she has a great excuse and I amdelighted to tell you that Ava KateMcCumisky arrived safe and sound thismorning at 6.15!

And that brings me lastly to Synapse!Synapse continues to develop and progress,the quality and content of article improvingwith every issue. Louise Dunthorne hasmanaged incredibly to coordinate and editSynapse on top of all her other commit-ments. She quietly and tirelessly works awayand even when we miss our set deadlines,the real deadline, the final deadline and “I’msending this off to the printers tomorrow”deadline, she never flaps but just nicelyreminds us and cajoles the article from us!However all good things must come to anend and after many years Louise is steppingdown, so it is with a heavy heart I want towish her a very big thank you from us all forall her hard work on Synapse and the execu-tive committee over the past decade.

So here’s to the next 30 years of ACPINand many happy returns!

Treasurer’s reportJo Kileff

I will now present a summary of the finan-cial accounts for National ACPIN for theyear end 31st December 2010.

IncomeThe total income (Figure 1) was £96,283.This was an increase on last year’s incomeand was mainly due to an increase inincome from the March conference, whichwas very well attended. It was also due to asubstantial increase in our membershipwhich has also led to an increase in capita-tion. Bank interest remains low and we havesourced a higher interest savings account toput the monies in whilst waiting to be spent!

ExpenditureExpenditure (Figure 2) for 2010 was up by£6,005 compared to 2009. This happenedfor a variety of reasons. Conference was sub-sidised to reinvest some money into themembership, our Synapse costs increasedand we have invested in more research bur-saries. Other expenses have stayed muchthe same.

CoursesFigure 3 divides the course income andexpenditure up for the courses that ACPINheld this year. The March conference wasplanned to run at a loss, with low coursefees in order to put some money back intothe membership. A large turn out meantthat our income still exceeded our expendi-ture. Congress expenses were largely organ-ised by the CSP and hence there wereminimal costs incurred.

ReservesThe balance sheet (Figure 4) on the 31stDecember 2010 showed a profit of £24,723and we carry forward reserves of £120,398into 2011. We have explored ways of feedingthis money back into the membership. Weare supporting the writing of splintingguidelines at a cost of £10,000. We haveincreased capitation to £5 per persondespite no increase in capitation from theCSP as a way of directly influencing regions’income. We are heavily subsidising thiscourse and will continue to run our coursesat a very low rate. We are investigating otherideas to allow regions to benefit. If you haveany additional ideas, do speak to one of thecommittee.

Copies of Accounts 2010Full copies of the ACPIN accounts for 2010are available on request

Vote for AccountantsVote to retain the current accountants for 2011:

Langers8 – 10 Gatley RoadCheadleCheshireSK8 1PY

INCOME 2010 2009£ £

Course fees 34,526 17,430

Congress 324 2,129

Membership 53,146 42,510

Capitation 7,393 5,554

Synapse 60 200

Database 784 883

Bank Interest 50 59

Total 96,283 68,765

Figure 1 Income

Courses 2010 Income Expenditure£ £

Marchconference 34,850 26,202

Congress 324 628

Figure 3 Courses

Reserves £

Reserves brought forward 95,675

Surplus/deficit 24,723

Reserves carried forward 120,398

Figure 4 Reserves

EXPENDITURE 2010 2009£ £

Courses 26,830 20,825

Synapse 12,187 6,854

Travel 10,430 10,036

Administration 3,858 3,554

Capitation 7,393 5,168

Research bursary 2,288 1,000

Computer costs 2,103 1,980

UK Stroke Forum/Stroke guidelines 76 681

Accounts, bank,sundry 2,188 1,542

Total 67,353 51,640

Figure 2 Expenditure



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Delegate report

Nic HillsSenior Physiotherapist, Ipswich Hospital NHS Trust

THE NATIONAL ACPIN CONFERENCE AND AGMseems to be an annual event in my diary, ACPIN

always puts on a packed, thought provoking pro-gramme covering a variety of ‘hot’ topics for neuro-physiotherapists. This year’s conference entitled BrainOver Body certainly lived up to expectation.

The conference kicked off with Professor JonMarsden’s lecture entitled From motivation to move-ment. He explored the difference between goal directedbehaviour and habits, and discussed physiology of goaldirected behaviour from a motor, cognitive and affec-tive perspective. Finally, he examined apathy, perhapsan overlooked symptom of neurological disease and areal cause of lack of compliance with therapy. As ever,Professor Marsden was a pleasure to listen to, his sim-ple explanations and sense of humour make applica-tion of complex physiology easy to relate within aclinical context.

Professor Marsden was followed by Dr MarkEdwards who discussed functional neurological disor-ders. Illustrated by exceptional video clips of caseexamples, he presented research data on functionalpatient’s behaviour, decision making and movementtraits (eg over-reliance on visual system for movement,demonstration of excellent balance when appearing to‘fall’ over). Explaining that these patients demonstratemany traits similar to schizophrenics, helped under-standing that functional patients are not malingeringand that input from physiotherapists could break thecycle of abnormal movement patterns.

Next were lectures from Glen Neilson, who dis-cussed his work as a senior physiotherapist onHughling Jackson’s ward at the National, he explainedthe role of the physiotherapist in the management offunctional disorders and handy tips for treatment and

assessment for this client group. Wendy Hendrie, lec-tured on reasons for lack compliance with exercises forMS patients. Dr Gita Ramdharry explored the differ-ences between central and peripheral fatigue in neuro-muscular conditions. This led to discussion ontailoring treatment approaches based on the fatiguemechanism.

The conference was concluded by Dr Fiona Jones, herlecture entitled Remembering Personhood: Supportingactive participation after stroke explained that perhapstherapists perceive that disability is a loss and tragedyand our approach to rehabilitation is limited by this.Alluding that rehabilitation is often dominated by pro-fessional values and beliefs, she discussed the impor-tance of listening to the stroke survivor’s story andworking towards their personal goals. She stated thatphysiotherapist’s management of emotional difficul-ties post stroke is an increasingly important part of ourrole. Finally, she asked us to reflect on our understand-ing of disability and rehabilitation approaches.

Threading through all lectures were themes of moti-vation, goal setting and adherence to therapy. How canwe use our expertise to gain active participation inrehabilitation enabling our client group to get the mostbenefit out of our increasingly pressured time?

Thank you ACPIN, see you again next year.

Above Wendy Hendrie delivering her talk on compliance with home exercises with MS patients.


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The UK Forum for Stroke Training (UKFST)

The UK Forum for Stroke Training(UKFST) launched successfully at theUKSF Conference in December. UKFSTis a new UK-wide initiative,designed to improve the quality ofstroke care for all. The aim of the ini-tiative is to support the developmentof quality, benchmarked stroke-spe-cific training and education as wellas developing a coordinatedapproach to workforce development.

Endorsement of training and edu-cation carries great benefits and isencouraged by the Department ofHealth. Endorsed courses and eventsfeature on UKFST’s database ofstroke-specific training, searchableby potential attendees. Organisationscan apply to endorse all training andeducation – from postgraduatecourses to conferences. All applica-tions are submitted through ourwebsite where you can also find awealth of publicly available informa-tion about the project. Reviews areconducted through assessmentagainst the Stroke-Specific EducationFramework (SSEF) which makes rec-ommendations about knowledgeand skills required by staff across thestroke care pathway from aware-ness-raising to return to work.

The UKFST is now welcoming thesubmission of conferences and sym-posia for endorsement. Specially tai-lored guidance notes are availableon the website. By endorsing yourevent you will ensure it is featuredon the UKFST e-bulletin and theUKFST database, further raisingawareness and boosting attendance.

To find out how the training oreducation provided by your organi-sation can benefit from endorse-ment, visit www.ukstrokeforum.organd until 7 March take advantage ofa special discount period when youapply for endorsement.

CSP Congress 2011

Chris ManningACPIN executive

CSP Congress will be held on Friday 7thand Saturday 6th October 2011 at theBT Convention Centre Liverpool.

Congress has four themes:• Cardiorespiratory• Musculoskeletal• Neurology• Public health, management and

clinical leadershipThe strapline for congress is

‘Physiotherapy works … for you, forus, for all’ and each session will belinked to these three areas.

For you How can you improve yourphysiotherapist patient interaction,treatment and assessment skills, effi-ciency, and maintain your CPD activity?

For us How will the professiondevelop and survive the recession?How can physiotherapy protect itsposition as a vital element of health-care? How can you improve yourservice design and delivery?

For all How can we continue to strivefor excellence in care levels, benefitsociety by preventing ill-health, keep-ing people fit for work, and providevalue for money healthcare?

The keynote speaker for the neurologytheme will be Professor Mark RogersPT, from the University of Maryland.He will be talking on Balance strate-gies and training. Mark is the recipi-ent of several large grants for researchin this area. Other topics include;telemedicine in MS clinics, serviceuser involvement to build capacity inneurological services, David Butler onmotor imagery for neuropathic painand Professor John Rothwell with anupdate on neuroplasticity. The pro-gramme will have been finalised bythe time you read this and up to dateinformation can be seen atwww.cspcongress.co.uk

Comments from last year that

demonstrated how delegates foundCongress useful are:• “I have improved understanding of

current NHS picture and changes.”• “It gave me ideas for improved,

more effective communication withpatients to improve assessment.”

• “Greater knowledge of informationavailable and how to access it.”

• “I will look into research trials instroke patients.”

• “May help with commissioning ofneuro services.”

• “Encourage more of my patients toself manage and importance ofexercise.”

• “I feel confident to liaise withresearchers to make changes to ourpractice.”The strength of Congress is the

variety of topics covered that youdon’t acquire from disease specificconferences. It is a chance to gainknowledge from different areas andmake links.

We don't all have time to trawl the

literature every day, so when some-one summarises the evidence on atopic, you don't just get the snapshot of that one study and you havethe opportunity to ask questions.

The breakout sessions provideopportunity to catch up with oldfriends, find out what is happeningin other practice areas and visit theexhibitor’s stands to see and try thelatest technology.

Liverpool is a wonderful location.The Convention Centre is close to theCity Centre and the Albert Docks withits shops, galleries and hotels. Cheaprail fares are available if booked inadvance.

If you haven’t been before or ifyou haven’t been for a while comeand see what is new. These are chal-lenging times for the profession andour strength is in the diversity offields and sectors in which we work.Congress is your opportunity to makethis work for you.

NEWS

Interactive CSP update

Chris Manning, iCSP link moderator for neurology.

The neurology network has 9251 registered users out of 32198 for the whole ofiCSP. There are currently 1912 discussions on the network so search the net-work to check if there is already a discussion on a topic and remember onlyuse the email members option if an urgent reply is needed.

The discussion of the Very Early Mobilization after Stroke (AVERT) trial hasstimulated debate about the pragmatics of this approach.

The assessment and demonstration of competency at various levels isbecoming of increasing importance and there are several posts relating tothis. For example Bournemouth and Christchurch Hospitals have publishedtheir splinting guidelines and competencies in the document section and thereare also competencies for injection of Botulinum toxin for spasticity producedby Lancashire Teaching Hospitals. There are several discussions seeking infor-mation about competencies in stroke and competencies for assistant practi-tioners.

Have a look at the Skills for Health website (www.skillsforhealth.org.uk) where there are national occupational standards for Stroke, Long termConditions Neurology Care and the Stroke Core Competencies website(www.strokecorecompetencies.org) for Stroke Training and awarenessResources (STARS).



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Fiona Jones PhD MSc FCSPReader in RehabilitationSt Georg’s University of London &Kingston University

Bridges stroke self-management isbased in the Faculty of Health andSocial Care at St George’s University ofLondon. Although the programmehad been running since 2008 asStepping Out, we felt a name changeand the publication of the 4th ver-sion of our stroke workbook was agood excuse to celebrate. In April2010 we held our first Bridges sympo-sium attended by over 150 stroke sur-vivors, carers, professionals,commissioners and academics. Thisevent helped to launch our newname, finally saying good-bye toStepping Out, and introducing ournew stroke workbook.

Bridges training has evolved con-siderably since 2008 and now consistsof a two-stage workshop for profes-sionals working through the strokepathway to learn the skills required tosupport self-management.Participants learn how to use struc-tured one-to-one sessions to supportan individual to set goals, recordprogress, and plan activities. Ourstroke workbook is used to facilitate apersonal record of goals, progress andself-management strategies. It is nowour belief that a self-managementprogramme such as Bridges can beembedded into stroke rehabilitation,and the principles of self-manage-ment can be introduced throughoutthe stroke pathway.

Since receiving an ACPIN grant in2004 to help develop the first strokeworkbook, we have come a long way.Bridges/Stepping Out workshops havenow been delivered to 44 stroketeams across the UK, and we havetrained in the region of 600 healthand social care professionals. We havealso carried out a detailed analysis ofcase reflections which participantscarry out as part of their training. Thishas helped us to respond and adaptthe workbook and training, andunderstand some of the barriers (andsuccesses!) of implementing a self-management programme. The resultsof this work are currently being pre-

pared for publication but preliminaryfindings were reported at the UKStroke Forum in 20091. Bridges hasalso been named as a case study onself-management in the recent Lifeafter Stroke Commissioning Guide(2010) and was selected as one of theNational Stroke Improvement Plan’spriority projects in 2009.

As with any complex interventionsuch as a self-management pro-gramme we are carrying out a stagedapproach to research. A proof of con-cept study with ten single case stud-ies was completed and published in2009, demonstrating that an individ-ualised stroke self-managementprogramme such as Bridges canchange self-efficacy2. The researchhas now been extended to a pilotrandomised controlled trial whichhas just been completed. The trialled by Dr Sheila Lennon and fundedby the Northern Ireland Chest Heartand Stroke Association, aimed toexplore the feasibility of using theBridges programme to enhance selfmanagement skills for stroke sur-vivors in conjunction with ongoingrehabilitation delivered by a com-munity stroke team. The objectivesalso included exploring the accept-ability of Bridges to all stakeholders(patients, carers and professionals).In addition, sensitivity of outcomemeasures were tested by comparingthe differential outcomes betweenthe Bridges group and the controlgroups to identify the effect of theBridges programme on self-efficacy,quality of life and mood in peopleliving at home after stroke.

The results of the pilot RCT inBelfast suggest that when comparingthe differential outcomes betweenthe Bridges and the control groupthere are positive trends in favour ofthe Bridges group. The interventionpositively impacts self-efficacy asintended during the interventionperiod, but has also resulted in whatseems to be a protective effect onparticipant’s quality of life during thefollow-up period. These positivetrends are supported by the findingsthat suggest the intervention wasfound to be feasible to implementand acceptable to stakeholders

involved. Feedback from patientswas supportive of the impact thatBridges has with regard to individualbehaviour change and the way theymanage their progress and profes-sionals felt the programme provideda structure for their practice tobecome more patient centred.

A great deal has been learned fromthis pilot RCT, but we also know thatBridges was provided in addition tousual rehabilitation which is a limi-tation. Our next question is to inves-tigate the feasibility of embeddingthe Bridges programme in to usualpractice, so that a dosage responsecan be discounted.

I am glad to say that Bridges is nolonger just a one woman show.There are three other trainers sup-porting delivery of the workshopswho have helped to develop thecontent and direction of the training,and we have graduate physiothera-pists providing administrative andresearch support. Our multiprofes-sional advisory group which hasbeen in existence since 2008 nowincludes more stroke survivors andcarers which help to oversee the pro-gramme and contribute to its devel-opment. Eileen and David who arestroke survivors on our advisorygroup are also on a research groupand helped to prepare a grant appli-cation for the next stage of research.We continue to have a number ofgoals, hopefully not unrealistic. Wewant the Bridges programme to beaccredited by the UK Stroke Forum forTraining, an application is alreadyunderway, and we want to developfurther support for carers as well ascontinuing our research programme-we still have lots to do!

For more information about Bridgesgo to www.bridges-stroke.org.uk

1. Jones F andLennon S (2009) A newstroke self-managementprogramme: preliminary analysis oftraining for practitionersInternational Journal of Stroke 4(s2)pp23.

2. Jones F, Mandy A and Partridge C(2009) Changing self-efficacy inindividuals following first stroke:preliminary study of a novel self-management intervention ClinicalRehabilitation 23(6) pp522-533.

UK Stroke Forum

December arrives and not only isChristmas shopping on the agendabut also the UK stroke forum,Glasgow was the venue for the 4thouting of this increasingly prestigiousevent. Unfortunately it was lookingvery festive as the country was alsoblanketed with snow which madetravelling up North somewhat chal-lenging. Despite this, attendanceremained high and there were fewcasualties due to the weather. One ofthe casualties was the courier trans-porting the ACPIN literature for ourstand- apologies again for this, aswe were not as well represented aswe could have been.

As usual the UK stroke forum hada huge range of topics and I foundthe biggest challenge choosingbetween clashing sessions. TheTuesday training day included ses-sions on pyschogenic stroke-likesymptoms, vascular cognitive impair-ment, environmental enrichmentand a fascinating session on whetherhead position in acute stroke affectedcerebral blood flow, which was fol-lowed by an interesting discussionbetween the speakers about howearly patients should get up.

The conference started fully on theWednesday and as expected therewas an extensive program on med-ical management of stroke , whichmay put some physiotherapists off ,however the sessions I attendedwhich included how BP should bemanaged after an acute stroke, canBP predict a stroke and what shouldbe monitored after an acute stroke Ifound extremely accessible and use-ful. It will certainly improve myunderstanding of acute stroke man-agement. There are without a doubtsessions that have too greater amedical bias to be relevant to thera-pists but there is always somethingelse going on. For Example, theBritish Orthoptist Society put togethera fascinating session on eye move-ment disorders following stroke, howit affects people and most impor-tantly how it can be managed.

ACPIN organised and chaired manysessions, often jointly with the col-lege of OTs specialist section in neu-rological practice and out thanksmust go out to Dr Fiona Jones for tak-

Bridges stroke self-management –goals achieved and things to do


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ing the lead on that on behalf ofACPIN. There was a session on goalsetting, its effectiveness and how toeffectively implement it in the clinicalsetting. The session on innovation onstroke rehabilitation showed us whatthe future may bring in terms ofrobot assisted therapy and the use oftechnology in supporting self man-agement. I found the session onintensity and motivation one of themost useful covering why a patientmay be de-motivated and what wecan do to we change it.

For me the Princess MargaretMemorial Lecture was arguably themost important, Robert McCrum, astroke survivor, spoke of his experi-ence of having a stroke, rehabilita-tion and getting back to life. I think itwas important that we rememberwhy we do this and what we mustimprove.

The final night included the dinnerand caleidh which I have to say theSassenachs (English) entered intowith a great deal of spirit if not a lotof skill but coped well with helpfrom the locals. Although one coulddescribe the Scottish country dancingas carnage – a great deal of fun washad by all.

On the final day there was animpressive program that included,psychological adjustments poststroke, improving the patient journeyafter acute stroke and whether stemcells could be used in stroke recovery.Sadly the snow was falling fast andthere was a sense of people driftingaway with worried looks at theweather as delegates started to wan-der if they would make it home. Themost tortuous route home I subse-quently heard about was Glasgow toSheffield via Bristol!

As always the greatest asset of theUK stroke forum is its multi discipli-nary nature- it gives you the oppor-tunity to dip into areas out of yourown expertise and the opportunityto network with other professionalwithin the same speciality and to sellour profession. The sessions are forthe most part applicable to day today practice and are not purely theo-retical. I thoroughly recommend it toanyone with an interest in stroke. Itis well worth the trip and of courseas an ACPIN member you receive asignificant discount.

Visit the ACPIN websiteto 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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COURSES

Balance rehabilitation: translating research into clinical practice

ACPIN London Study Day6th November 2010Course presenter: Anne Shumway-Cook,Professor Emeritus, Department of RehabilitationMedicine, University of Washington, Seattle, WA

Review by Ulrike Hammerbeck, ACPIN Londoncommittee member.

The study day was fully subscribed andattended by ACPIN members fromLondon and much further afield as wellas multi-disciplinary non-members.

Anne Shumway-Cook presented avery inspiring study day about balancerehabilitation. She highlighted theprevalence of balance impairmentsand the consequence of these onactivity and participation levels ofindividuals. Balance was divided intodifferent types depending on thedemands placed on the system. Thetypes consist of steady-state balance,reactive balance, to a perturbation, orproactive balance during anticipatedmovement. The day was structured astheoretical lectures consistently inter-spersed by interactive workbooksessions, applying the theory to videosof two case studies presenting withbalance impairments.

The morning session was divided intothree sessions discussing the mainsystems interacting to achieve balance,namely the motor, sensory and cogni-tive system. The role of each systemwas analysed and the relevance ofeach system to varying requirements ofdifferent types of balance. The videosof the two case studies were consis-tently incorporated into an interactiveworkshop which increased participa-tion. Available evidence for improvingthe performance of the differentsystems was reviewed.

The afternoon focussed on balanceassessment and treatment. Availableoutcome measures were discussed andhow they assess the motor, sensoryand cognitive systems required forbalance as well as which type ofbalance was assessed by the specificoutcome measure. The importance ofaddressing the specific primary riskfactor for balance loss in the treatmentwas emphasised as well as providingsufficient intensity of training.Evidence for effectiveness of trainingwas reviewed and the assessment andtreatment session were again linked tothe case studies and workshopsessions.

The feedback for the study day wasoverwhelmingly positive andhighlighted the ability of the presenteras well as the excellent content andstructure of the course. The consensusof the comments was that this coursewould alter the clinical practice ofparticipants.

ACPIN London would like to thankAnne Shumway-Cook for a verysuccessful study day.

Surrey and Borders neuro-oncology study day

Review by Michelle Green

In October 2010 we held a neuro-oncology study day. Lectures coveredtopics including: symptom presenta-tion and treatment options, the role ofthe clinical nurse specialist and pallia-tive care, insight into a patient’sexperience, physiotherapy within ahospice setting and recommendationsfor future service development. DizHackman from the Royal MarsdenHospital also presented the findingsfrom her recent work into the purposeof physiotherapy for patients withprimary brain tumour.

This study day proved popular on a

national level and attracted physio-therapists from a range of clinicalbackgrounds: neurology, elderly care,community, oncology and palliativecare. This gave an excellent opportu-nity for networking and createdthought provoking discussionthroughout the lectures. It is recog-nised that oncology services haveimproved significantly over the yearsbut as always, there is always morethat can and needs to be done tofurther improve service provision!

The day highlighted how invaluabletherapeutic involvement withinoncology services is and how thededication of those working within thisspeciality contributes to this.

Getting research into practice –Constraint Induced MovementTherapy (CIMT) for arm recoveryand function for stroke survivors

8th-11th March 2011The University of UlsterCourse facilitator: Dr David Morris, AssociateProfessor, University of Alabama (Division ofPhysical Therapy) and Training Coordinator for theUAB CIMT Research Programme

Review by Ciaran Daly, senior physiotherapist,Erne Hospital, Enniskillen, Northern Ireland

Constraint-induced movement therapy(CIMT) is an innovative treatmentapproach aimed at improvingfunctional use of the affected armfollowing a stroke. Patients using CIMThave reported marked improvementsin the use of their stroke arm evenmany years after their stroke. Delegatesfrom across Europe came to UU toattend the internationally renownedtraining course normally only offered atthe University of Alabama by the CITherapy Research Group led byProfessor Taub who has been devel-

REVIEWS ARTICLES BOOKS COURSES EQUIPMENTReviews of research articles, books, courses and equipment in Synapse are offered by regional ACPIN groups or individuals in response to requestsfrom the ACPIN committee. In the spirit of an extension of the ERA (evaluating research articles) project they are offered as information for membersand as an opportunity for some members to hone their reviewing skills. Editing is kept to a minimum and the reviews reflect the opinions of theauthors only. We give the authors of the original book or paper the opportunity to respond. We hope these reviews will encourage members to readthe original article and not simply take the views of the reviewers at face value.


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oping this technique since the 1970s.Dr David Morris, an Associate

Professor in the University of Alabama(Division of Physical Therapy) andTraining Coordinator for the UAB CIMTResearch Programme was the key facil-itator of the course. Professor GertKwakkel from the VU University MedicalCentre in Amsterdam, and the RudolfMagnus Institute in Utrecht discussedthe evidence base underlying strokerehabilitation for arm recovery andfunction post stroke.

Course participants heard firsthandabout the experience of a strokesurvivor who had used CIMT. The thera-pists’ view on the practicalities ofdelivering CIMT was presented byHeather Glenn and Laura Wheatley-Smith, expert clinicians from theRegional Acquired Brian Injury Unit(RABIU) in Belfast. They have beeninvolved in the ongoing research trialbased at RABIU led by theNeurorehabilitation for Health hub atUU. In collaboration with Dr Morris,Katy Pedlow, a doctoral student super-vised by Dr Sheila Lennon from theHealth and Rehabilitation ResearchInstitute at UU, and Dr Colin Wilsonfrom RABIU are currently comparingCIMT to an equally intensive conven-tional upper limb therapy delivered as

part of routine clinical practice. Twentypatients have been recruited; theresults from this feasibility RCT shouldbe available in October 2011.

I had initially come across CIMT whilereading an article around three yearsago. I then attended a studyday/workshop in RABUI which wasorganised by Dr Sheila Lennon (UUJ). Ifound the concept of CIMT extremelyinteresting as treatment of neurologicaldeficits, particularly in the post acutephase, can become difficult. Aftercompleting the study day I carried outa small pilot study using the concept ofCIMT on a small number of patients (Icontacted Katie Pedlow from UUJ forsome guidance). The results werepositive but I was not confident as tohow accurately I was applying theconcept. I then attended the UUJ CIMTModule which took place from 8th-11thMarch 2011 at UU.

On completion of the module I feel alot more confident on the applicationof the CIMT concept to patients. I feelthat I have a greater appreciation ofthe detailed subjective questioning,application of treatment, the transferpackage and the outcome measuresused. The course lecturers and organ-isers were excellent in theirpresentation of CIMT. They were very

approachable and provided excellentknowledge of the research to indicatethat CIMT is a very effective upper limband lower limb treatment approach.Several studies were debated duringthe module eg Excite trial and thisprovided therapists with a goodevidence base to promote CIMT into ourclinical work. I appreciate the opportu-nity to have attended this module as Ifeel it will improve my skills as a thera-pist. I feel that the CIMT approach is avery effective treatment to integrateinto patient care and may lead toimproved outcomes. After carrying outa small pilot study prior to attendingthis module where the results werepositive I feel that on proper applica-tion of the CIMT approach afterexcellent tuition on this module futureresults will only benefit patient care.

The organisation of this module andthe selection of lecturers by SheilaLennon and her staff were excellent.The module also provided therapistsfrom Northern Ireland with a greatopportunity to share ideas and experi-ences from therapists from otherEuropean countries who alsoattended.



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www.your-turn.org.ukThis is a campaigning group to reducepressure ulcers in vulnerable people. Ithas been running for three years andalso aims to highlight risks for thegeneral public to identify. They provideleaflets and cards and could be anadjunct to your Trust's campaigns toreduce pressure ulcers.

www.evidence.nhs.ukThis website allows professionals toview very recent evidence which helpsus to keep delivering quality of care forour clients. They have very recentjournals or information about a widevariety of health conditions.

www.londonstrokedirectory.org.ukThis website is user friendly and can beused by both professionals and generalpublic. It serves as a guide to show thesupport available across London to helppatients/carers get on with their livespost stroke. For example you can put inyour post code and it will show you thetypes of stroke services for that area. Itprovides a wide range of information.For example: advice and advocacy,practical help, communication, strokeclubs and family/carer support.

www.neurosymptoms.orgWritten by a neurologist and aimed atpatients diagnosed with functionalneurological syndromes, this has a verygood explanation of what a functionalsyndrome is, and guides the userthrough symptoms, causes and treat-ment available. There is a section onphysiotherapy, fatigue and gradedexercise. There is also a collection ofpatient's personal experiences offunctional problems. The links sectionincludes other useful websites, patientvideos and information leaflets, usefulfor both patients and therapists.

www.wiihabilitation.co.ukThis site has been developed by aBritish physiotherapist and is useful fortherapists using the Nintendo Wii inany area of practice. Wiihabilitationgives an overview of conditions thatthe Nintendo Wii can be used with, anda review of specific games and whicharea they will work on ie balance,upper limb, general fitness etc. Thereare blogs covering games, research,news and general updates, the researchblog includes published articles andhas links to the website containing theabstract/full text where available.

www.neural.org.ukA helpful neurology website for gettingthe bigger picture

http://neuroscience.uth.tmc.eduNeuroscience Online is a website that afair few of us have used to furtherdevelop our understanding of neuroanatomy. The website is an interactiveresource enabling the user to exploreneuroanatomy at their own pace. Thewebsite incorporates diagrams andillustrative pictures that can be used tosupport the text. The diagrams areanimated at points to further explain,for example the sensory and motor tractpathways are traced. The website is freeto use and, certainly as a teaching aid,we have found it very useful.

www.mssociety.org.ukThis site offers:• Library services, book loans, article

requests.• Professional network – link to join-

gives access to further advice oncurrent research, service audit anddevelopment.

• Patient information.

www.southernstrokeforum.orgOn offer here are:• A range of stroke competencies

templates for a range of staff involved.• Educational videos accessible online,

covering all topics within stroke care-suitable to use with carers, care homesand staff.

• Links to all relevant stroke guidelines.

www.parkinsons.org.ukLook on this site for:• Details and contacts for local PD groups.• Ordering for leaflets including

exercises booklet and Parkinsons andyou booklet for patients.

• Fact sheets for additional informationeg lewy body dementia.

www.sign.ac.ukThe Scottish Intercollegiate GuidelinesNetwork (SIGN) develops evidence basedclinical practice guidelines for theNational Health Service (NHS) inScotland. SIGN guidelines are derivedfrom a systematic review of the scientificliterature and are designed as a vehiclefor accelerating the translation of newknowledge into action aiming to reducevariations in practice and improvingpatient outcomes.

Range of topics eg stroke – diagnosisand acute management through torehab and discharge planning, diabetes,heart disease, pain in cancer, early headinjury, bipolar disorders, DVT etc.

Easy to read with clear explanationand clinical guidance, ongoing processsof updating and review. Many aremultidisciplinary. Available in large text,in format for patient and carers and indifferent languages.

Can access on the web, download orrequest paper copies

www.physiotherapyexercises.comA useful resource for spinal injuries.

WEBSITES OF INTEREST

This new feature is aimed to be a useful resource for members by recommendingsome of the multitude of web-sites available to help in our practice. Thank you tothe regional representatives who have contributed suggestions this time. If youuse or know of any websites that you think may be of interest to others pleasesend them to Kate Busby at [email protected]


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East AngliaNic Hills

East Anglia ACPIN membership num-bers have remained very high andour 2010 course programme (a mix ofevening lectures and study days) waswell supported by the members.Much of our 2010/11 course pro-gramme has been subsidised by EastAnglia ACPIN meaning they have beenvery accessible for our members.

Our 2011 course programme is nowunderway, and kicked off with anEast Anglia ACPIN subsidisedParkinson’s Disease study day, led byEmma Stack (Parkinson’s Diseaseresearcher) in Newmarket. Otherforthcoming events include:• July 2011 Neuro-pilates study day

Ipswich Hospital• 15th October 2011 Pusher Syndrome

study day at Ipswich HospitalAn up to date course programme isavailable on the ACPIN website(www.acpin.net/ eastanglia), pleaseemail me if you are interested inattending any of our courses.

As ever we would like to runcourses that the members would liketo attend and we are always lookingfor ideas for future courses from themembership, so please contact me ifyou have any innovative ideas. Wehope to see you at our coursesthroughout the year.

KentNikki Guck

We have had another very successfulyear with our numbers remaininghigh and a strong committee whichhas been led by Cathy Kelly Jones. Wemust send our gratitude to Cathy forher commitment as this is her last yearstanding as our chair, but thankfullyfor us she is remaining on the com-mittee.

Our programme in 2010/11 contin-ued with two really success full studydays. The first was in June, a lower

limb study reviewing the evidenceand adjuncts to treatment, such asthe Wii Fit, outcome measures, andthe ever popular orthotics with abrilliant talk from Paul Charlton. Ourthanks must be sent to Paul and thelocal clinical specialist physiothera-pists in the region for offering theirsupport and services.

The second study day was hostedat Darent Valley Hospital inNovember, it looked at the use of theVibrosphere/G4CE plate. It was verywell attended and thoroughlyenjoyed by all and our thanks mustbe extended to Eva Leach for a reallyexciting course, well recommendedto other regions.

On the 22nd March we will hostour AGM at The Wisdom Hospice,Rochester, with a talk from Dr DavidOliver on End of life care in long termneurological conditions. Dr Oliver has recently presented at TheInternational Symposium forMND/ALS in Orlando USA, so the com-mittee are really excited that he hasagreed to assist in developing ourskills in this important area.

Future courses in the planning areinfections in the central nervous system and implications of neuro-physiotherapy in immunology, andan MS study in collaboration with the MS Trust.

As the region covers a large geo-graphical area, we as a committeeare always keen to hear from mem-bers that wish to join us. It is verysociable as well as being a good timeto network and discuss changes thatare occurring in the NHS and privatesectors. We are always also lookingfor members to send us ideas forfuture courses and evening lectures.Please do not hesitate to contacteither myself or anyone on the com-mittee on [email protected],we look forward to hearing fromyou.

LondonAndrea Stennett

We had a very successful 2010 withboth growth in membership andfinances. The latter has allowed usgreater flexibility in providing a rangeof high quality lectures by dynamicspeakers from the UK as well as over-seas.

We started 2011 with our annualgeneral meeting and study morningentitled Life after a Neurologicalevent: Evidence and PracticalApplications on the 12th February. Wereceived presentations from Dr FionaJones (Self Management: Bridges intothe Future) and Nicole Walmsley andAmy Williamson, Occupational thera-pists working at National HospitalNeurology and Neurosurgery(Vocational Rehabilitation). Wewould like to express our sinceregratitude to our speakers for such aninformative morning.

The committee as you know it hasundergone some changes. We saidfarewell to Christopher Manning whoserved as chair person for the pastfour years. Chris will however con-tinue to serve as a committee mem-ber. Thank you Chris for all your hardwork, laughter and of course dedica-tion over the years. We also saidfarewell to Kerry Hellier and wish herall the best with future endeavours.Helle Sampson was appointed as thenew committee chair, and Lesley Millas treasurer. Leanna Dennis andVictoria Conway were elected as newcommittee members. Trudy-AnnSinclair will continue in her role assecretary and I will continue to servein the capacity of your regional rep-resentative. Other committee mem-bers are Sandra Chambers, MeganCampbell, Bethanie Goodfellow,Ulrike Hammerbeck, Maria Garciaand Andrea Shipley.

Due to the successful study eventslast year, you will notice that thisyear we have greatly subsidised thecost of our study events without

compromising the quality. This deci-sion was taken by the committee torecognise your ongoing and invalu-able support.

On the 21st of May we hosted anextended study morning entitled TheCerebellum and motor control withexciting lectures from Amy Bastianfrom the United States of America.Amy has been doing amazing,groundbreaking research into reha-bilitation for ataxia – mostly cerebel-lar ataxia. She is specificallyinterested in motor control and howpatients with cerebellar ataxia learn.

We have an exciting programmelined up for the reminder of the year.Our annual wine and cheese eventand evening lecture will be on the9th June. This will be in the form of apanel discussion with therapists whohave volunteered abroad sharingtheir experiences. On September 17thwe will host a joint event withACPIVR which will take the form of afull study day entitled VestibularRehabilitation. On the 12th November2011 we have brought back by popu-lar demand a study morning show-casing neurophysiotherapy research.This is to give our members who areinvolved in research an opportunityto share their current work.

All our lectures this year will beheld at the Clinical NeuroscienceCentre at 33 Queen Square. If thereare any changes we will let youknow in advance.

Please keep checking frontline andthe ACPIN website(www.acpin.net/london) for anychanges to our schedule.

If you find that you have not beenreceiving our emails please let meknow. You can send your queriesdirectly to my email: [email protected] or to [email protected]

REGIONAL REPORTS



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MerseysideLaura Phillips

Merseyside ACPIN has enjoyedanother successful few months ofcourses and evening lectures includ-ing a vision and balance course withNikki Adams, the second time wehave ran this course due to its successand popularity. We also had verygood attendance at both the eveninglecture on cauda equina and bladderand bowel dysfunction as well as thegym ball workshop that ran alongside the AGM In February.

Since our last update we have nothad any changes to the committee.However I will be handing over therole of regional rep into the verycapable hands of Anita Wade-Moulton from April. As always wewould like to make an appeal to allour members to join the committee ifyou are interested. We would reallyvalue your input and contributions.Please contact us through our email([email protected]) ifyou would like further information.

Some of the details for the remain-der of the 2011 programme are to beconfirmed and we will send out fur-ther information closer to the time.Programme 2011• June 11th and 12th Workshop with

Clare Fraser (Bobath tutor). Venue,topic and price to be confirmed

• September (evening lecture)NeuromyelitisOptica (NMO) – Devic’sDisease at the Walton Centre forNeurology and Neurosurgery,Liverpool. Start time and date to beconfirmed. Free to ACPIN membersand £3.00 for non-members

• October course To be arrangedOur current membership stands at 52and we would like to thank allmembers of Merseyside ACPIN fortheir continued support.

Northern IrelandJacqui Crosbie

Hi to all our NI members. We havehad an exciting start to our pro-gramme this year, working jointlywith AGILE to present a successfullecture on vestibular rehabilitationand learning about early supporteddischarge in stroke. NI ACPIN isalways keen to investigate new

research happening in our localityand, as such, had the pleasure ofProfessor Richard Carson to supportour AGM with a lecture on his workin stroke and transcranial magneticstimulation.

The University of Ulster ran a verysuccessful course on CIMT in Marchand, in collaboration with NI ACPINwere able to provide a training dayon CIMT and also an evening lecturefrom Professor Gert Kwakkel onIntensity of Therapy. The variednature of our programme continuesinto the spring, with a workshop onmovement disorders and a final lec-ture on outcome measures in May.

The committee has had somemajor changes this season, withlong-standing members Maire Kerrand myself, both retiring, makingway for new, enthusiastic volun-teers! We are always happy for morecommittee members, which makesorganisation of the yearly pro-gramme and study days easier andthe content more varied.

NI ACPIN ran a lottery over the firsthalf of the programme, where atten-dees got a ticket for every eveninglecture. There was then a draw inJanuary for a free place to thenational ACPIN conference and thiswas won by one of our NI ACPINmembers. Your support at NI ACPINevents allows us to continue withthis kind of educational support andis, as always, greatly appreciated.

Enjoy the summer and we lookforward to seeing you at a NI ACPINevent soon!

North TrentAnna Wilkinson

We have already had two excitingevents this year. Dr Rebecca Palmerspoke to us about Cortex,Classification,Compensation andCommunication. It was very interest-ing to identify different traits in com-munication problems and look atstrategies around managing them inrelation to physiotherapy. We thenheld a technology day in conjunctionwith CSP network and local branchwhich was popular and introducedtechnologies currently being devel-oped, the research aspects and thenwent onto look at what is available

now. We had interesting talks frompeople who commission technologywhich hopefully got everyone think-ing about how we can move forwardin what is fastly becoming a big pri-ority in healthcare.

Over the next year we will be run-ning courses on:• neuroanatomy• legal and capacity issues• latest developments in Parkinsons

Disease and research• practical tutoring sessions• a joint podiatry evening course

looking at biomechanics and howthese can be corrected.

We also have a one day vestibularcourse planned in September.

Hopefully this is an exciting pro-gramme. If anyone has anythingthey would like to see in our region,as always, please let us know – wedo still have a couple of gaps in thisyear's programme.

We have space on the committeefor new members if anyone is inter-ested in joining us or wants a chatwhat it's all about, let us know.

We look forward to seeing you atour next events.

OxfordClaire Guy

From our committee to all Oxfordmembers, welcome to our report forthe Spring edition. Our evening lec-tures remain the mainstay for OxfordACPIN with regular attendance over20 and although the venue tends tobe Oxford, we will hope to be shar-ing these more widely. We appreci-ate the venue is not ideal as access isbecoming harder. Many of you donot live in Oxford and I hope you willbear with us and note new venueson the fliers. Please let the commit-tee know your preference on venuelocation.

Giles Yeates, principal clincal neu-ropsychologist, gave a very thoroughand stimulating talk on the psycho-logical aspects behind gait re-educa-tion. It was a very interactivediscussion into a minimally researchedarea. Professor Wade once again pro-vided a thought provoking talk andan evening lecture on apraxia with aphysiotherapist and occupationaltherapist had a bumper turnout.

The AGM once again welcomedStana Bojanic, always a popularspeaker.

We are planning two courses thisyear, Richard Sealy and MartineNadler will be presentingNeuroplasticity, learning and cogni-tion for therapists on 18th June andwe have yet to confirm a weekendday course exploring the pusher syn-drome. Evening courses planned willbe delivered by clinical psychologists,a speech and language therapist andJo Camp will speak on vibration ther-apy. A social will be held in July.

We hope to repeat the eveningresearch forum , with a range ofspeakers and topics in bite sizechunks to stimulate discussion andapplication to our neurological prac-tice. Please look out for details onfliers, frontline, and the Oxford sec-tion in the national ACPIN website orcall any of the committee.

Again thank you to all our mem-bers for your support, Oxford ACPIN isfor you; please feel able to suggesttopics and thank you for enteringinto healthy debate. Sophie has leftour committee but I am sure willcontinue to be an active local mem-ber.

ScotlandDorothy Bowman

Welcome to any new and existingmembers. Hopefully you will all havereceived your newsletters.

Since the last report we have had astudy day on Visual deficits inNeurology with Therese Jackson(Consultant OT). The day was wellattended and feedback was excel-lent. A study day on conversion dis-order is underway and hopefullythere will be a good turnout for thisfascinating topic. An Exercise inNeurology day is planned for Junewith a range of excellent speakers, itpromises to be a another really inter-esting and thought provoking day. Asa committee we would like to thanksall those who attend and supportthe courses and those that havehelped organise or been a speaker.

Several current committee mem-bers are stepping down and it isurgent that replacements are found.Please consider what you might be


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able to contribute to keep ACPINScotland from folding. If you wanttraining and study days to continuemore assistance is required. For thosecommittee members that are step-ping down thank you for all yourhard work and support for ACPINover the years.

Programme for 2011• Saturday June 4th 2011 Exercise in

Neurology. Currently confirmedtopics – Exercise Physiology, Stroke,PD, Neuromuscular Disesase, MS.Speakers: Mark Smith/John Dennis(Stroke), Dr Gita Ramdharry(Neuromuscular disease), BhanuRamaswamy (PD), PaulaCowan/Jane Lough (MS).Edinburgh Training and ConferenceVenue, St Marys Street, Edinburgh.

South TrentKaty Coutts

South Trent ACPIN has a healthymembership and the committee isnow stable after a few changes. I amnow the permanent regional repre-sentative and I look forward tomeeting more of you over the comingmonths.

Although we had a relatively quietAutumn/Winter period, things arepicking up and we are looking for-ward to the year ahead.

We have recently held an eveninglecture on The role of the psychologistin neurology. This was well attendedand gave us an insight into what wemay expect from a neuro patient interms of psychological presentationand when we might need to refer toa psychologist. He also gave us a briefoverview of his role once he hasbeen referred a patient and whattools he may use to assess them.

There are several events this yearto look forward to.• June Bobath Problem Solving

Workshop around gait (dates andprices to be confirmed)

• July Ultrasound Biofeedback GillCampbell, Physiotherapist at theAshbourne Physiotherapy Clinic

We have a couple of proposed eventsincluding evening lectures on move-ment science and one on vestibulardisorders. We also have Mary Lynch-Ellerington booked for February 2012

for an advanced Bobath workshop.As always, we are keen for our

members to contact us with ideas orfeedback so feel free to get in touch([email protected]).

South WestHelen Madden

South West ACPIN continues todevelop with a growing committeewith subgroups now formed inDevon and South Wales, so we hopeto be able to be running morecourses in more locations in 2011 andbeyond. Thank you to everyone whohas volunteered to join the commit-tee, and for all the committee fortheir continued hard work.

Courses held at the end of 2010and beginning of 2011 have includedfeedback on the National ACPIN con-ference on exercise and neurology,treatment of unexplained symptoms(back by popular demand!), neu-ropilates and ataxia which formedpart of our AGM in 2011. All thecourses have received positive feed-back and have been oversubscribedso thank you as ever for your contin-ued support. We also held our firstlecture in South Wales for some timeon Exercise and Huntingdon’sDisease. We hope to be running morecourses in South Wales as well asother locations across our region, somore of our members should hope-fully be able to access courses closerto where they live.

Courses will be continued to beadvertised on our regional page onthe ACPIN website, interactive CSPand via email to our members.Places for courses will only be con-firmed once a completed applicationform and payment has been receivedby the course organiser.

In 2011 we have launched a newinitiative for South West ACPIN mem-bers to potentially access coursefunding to enhance the individual’sphysiotherapy skills in managingneurological patients. Further detailsof this new initiative including thepolicy and application form areavailable on our regional page onthe ACPIN website. We will reviewthis at the end of 2011 but we hopeour members take advantage of thispotential source of funding to attend

courses and conferences.Please get in touch with us if you

wish to find out more informationabout being on the committee orideas/suggestions for future [email protected]

Surrey and BordersKate Busby

Hello to all members! We have had asuccessful 2010 with good attendanceat all events. After four years in term,Anna Lavelle (chair person), LouiseEverard (secretary) and myself will bestepping down from our roles. Wewill remain on the committee how-ever! In addition, I have now joinedthe executive committee as Synapseeditor. Emma Jones is becoming ournew regional representative andMichelle Green, our chair.

Our 2011 programme began inFebruary with our AGM and lectureon Mental Practice with MotorImagery in Rehabilitation by ThamarBovend’Eerdt. This was well receivedby all and created much discussion.

Future events• 18th-19th June Weekend course on

Gait and Postural control withNicky Penny. Woking CommunityHospital

• 24th September Day Gym Ballcourse with Janice Champion.Haslemere Community Hospital

• 23rd November Evening Lecture-Intrathecal Baclofen. Holy CrossHospital

Our courses will be advertised onicsp, in frontline and on the ACPINwebsite. Please do not hesitate tofeed back to us your ideas for futurelectures. If anyone is keen to join thecommittee or has any queries thenplease contact Emma Jones on:[email protected] you a lovely summer aheadand farewell!

Sussex Gemma Alder

A big thank you to all the speakersand everyone involved in supportingthe running of Sussex ACPIN to date.We were delighted to welcome anumber of new committee memberstowards the end of 2010.

We have had a mixture of studydays and evening lectures and our2010/2011 programme has been wellattended thus far. Here’s a quickrecap:

In September I was very excited topresent a study day on Understandingand treating Pusher Behaviour. Thiswas well received and attracted nonACPIN members as well as therapistsout of the Sussex area.

In October Diana Drawbridge andClare Hall our committee memberspresented an evening feedback ses-sion on the highlights from Fit for life– Neurology and Exercise from 2010snational conference. This was a greatopportunity for local members thatdidn’t manage to attend conferencethis year.

In November we were thrilled tohave Professor Anne Ashburn and DrEmma Stack from SouthamptonUniversity to present an interactiveworkshop on Falls and instability inpeople with Parkinson’s Disease andstroke. This also included discussionsabout their current research.

For our AGM in March 2011 we wel-comed Nicky Penny and Lesley Barnesto present an interactive and freshlook on the Assessment and treatmentof the upper quadrant and the role ofmusculoskeletal techniques. This alsoincluded patient demonstrations.

Our plans for the summer monthsahead include an evening lecture onthe Assessment and treatment ofneglect and a two day study week-end on Dynamic movement screeningand functional exercise with BobWood MCSP.

In order to keep up to date withthis year’s programme, venues andspeakers we will be providingupdated information on the ACPINWebsite and iCSP.

As always your thoughts and ideasare important to us. Please feel freeto contact myself or any of the com-mittee members to share your [email protected]



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Wessex ACPINHayden Kirk

2011 appears to be a key year forchange for Wessex ACPIN due to be anumber of key committee membersstepping down, chair, secretary andregional representative. It will there-fore require new committee mem-bers to take up these roles so pleaselet us know if you are interested. Inthe meantime the committee willcontinue to work hard to deliver anexciting regional events programmeat reduced rates for its members.

Also, if during these times of aus-terity you are finding CPD budgetsrestricted, may we remind you tolook on the website for the Wessexfunding application form. This can beused to assist individuals in thefunding of courses, conferences etc.Please refer to our websitewww.acpin.net/wessex for the formand funding policy.

Membership is up to 97 which isfantastic and it was great to see somany of you at our first event of theyear on CIMT, by Alison Burns, ClinicalSpecialist Physiotherapist. Thank youeveryone who completed the on-line survey for future course formatsand topics. This was very helpful andwe will try to deliver those topics thatmost of you requested. I hope youare able continue to support forth-coming events and please do chivvyalong any non members or MDT col-leagues.

West MidlandsKatherine Harrison

West Midlands ACPIN is looking for-ward to a successful year in 2011.Membership in the region remainsgood with a healthy sized commit-tee, although new committee mem-bers are always welcome. The mainrole of the committee is to organiseevents for West Midlands ACPINmembers but we have also started adiscussion group within the commit-tee. So far two interesting topics havebeen discussed; Hope in rehabilita-tion and Sensory assessment andrehabilitation both sessions led by aresearcher at Birmingham University.By discussing these topics we aim toidentify and promote emergingresearch in neurological physiother-apy.

Last year our Christmas eveninglecture was on the subject of TMS.There was a very enthusiastic studentattendance at the lecture and againit was interesting to find out aboutlocal research. The lecture gave agood grounding for the assessmentof neglect and also how local hospi-tals can get involved in this innova-tive area.

In January Paulette van Vliet gavea morning lecture to 40 people onthe subject Putting feedback intopractice. At a credit crunch bustingprice of £5 this course was oversub-scribed. Feedback from the coursewas very positive with participants

saying it gave a different way oflooking at treatment of neurologicalpatients with lots of practical sugges-tions. Ideas like group practice werethought to be especially useful inclinical areas where staffing levelshave been reduced. Other areas dis-cussed at the lecture were repetition,communication and the importanceof ADL practice in treatment.

So what will the rest of 2011 bring?Next on the agenda is our AGM andevening lecture on the BirminghamUniversity cognitive screening tool. Atthe time of writing this is likely to beheld at the end of March. After thiswe hope to do an evening lecture onthe cerebellum in May or June. Anevening lecture on CIMT will follow.Nearer the end of the year we hopeto do a study day on MS and possiblyconclude the year with the Christmaslecture on Saebo Flex. Wow … lots tolook forward to! Please check emailsand ACPIN website for details nearerthe time.

As always West Midlands ACPINwelcomes any suggestions or ques-tions you may have. Please do nothesitate to contact me via email:[email protected]


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

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

Examples of articles for submission:

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

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

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

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

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

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

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

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

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

Abstract – (maximum of 300 words)

Introduction

Method – to include design, participants,materials and procedure

Results

Discussion

Conclusion – including implications forpractice

References

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

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

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

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

Product newsA short appraisal of up to 500 words, usedto bring new or redesigned equipment tothe notice of readers. This may include adescription of a mechanical or technicaldevice used in assessment, treatmentmanagement or education to include specifications and summary evaluation.Please note, ACPIN and Synapse take noresponsibility for these products, it is not anendorsement of the product.

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

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

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

PREPARATION OF EDITORIALMATERIAL

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

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

correspondence• Professional and academic qualifications

for all authors and their current positions

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

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

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

All abbreviations must be explained.

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

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

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

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

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

The Editorial Board reserves the right toedit all material submitted. Likewise,the views expressed in this journal arenot necessarily those of the EditorialBoard, nor of ACPIN. Inclusion of anyadvertising matter in this journal doesnot necessarily imply endorsement ofthe advertised product by ACPIN.

Whilst every care is taken to ensurethat the data published herein is accu-rate, neither ACPIN nor the publishercan accept responsibility for any omis-sions or inaccuracies appearing or forany consequences arising therefrom.

ACPIN and the publisher do not spon-sor nor otherwise support any substance, commodity, process, equipment, organisation or service inthis publication.

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40

EAST ANGLIA

Nic Hillse [email protected]

KENT

Nikki Gucke Nikki.guck@

bartsandthelondon.nhs.uk

LONDON

Andrea Stennete [email protected]

MANCHESTER

Stuart McDarbye [email protected]

MERSEYSIDE

Laura Phillipse [email protected]

NORTHERN

Catherine Birkette [email protected] [email protected]

NORTHERN IRELAND

Jacqui Crosbiee [email protected]

NORTH TRENT

Anna Wilkinsone [email protected]

OXFORD

Claire Guye [email protected]

SCOTLAND

Dorothy Bowmane [email protected]

SOUTH TRENT

Katy Couttse [email protected]

SOUTH WEST

Helen Maddene [email protected]

SURREY & BORDERS

Emma Jonese [email protected]

SUSSEX

Gemma Aldere [email protected]

WESSEX

Hayden Kirke [email protected]

WEST MIDLANDS

Katherine Harrisone katherine.harrison@

warwickshire.nhs.uk

YORKSHIRE

Kirstie McLarene [email protected]

REGIONAL REPRESENTATIVESJUNE 2011

Syn’apse

EditorLouise Dunthorne (this issue)Future issues: Kate Busby

Editorial Advisory CommitteeMembers of ACPIN executive andnational committees as required.

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

Printers Henry Ling LimitedThe Dorset PressDorchester

Address for correspondenceKate BusbySynapse Editore [email protected]


> How does facilitationof an improvedinteraction betweenthe head and trunkgain improvedpostural control in afunctional task?

> Ulnar nerveinvolvement andstroke

Spring/Summ

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