Balance-Mechanisms Governing Equilibrium B y D r . A N N I E T H E R O N , M .B . C h b . M . M e d . S e n io r P h y s ic ia n o f t h e N e u r o g ic a l D e p a r t m e n t — G e n e r a l H o s p it a l, P r e t o r i a . A Lecture given to the N orthern Transvaal B ranch M em bers o f the S outh A fric a n S o c ie ty o f P hysiotherapy, in N ovem ber, J9 5 9 . Page 6 P H Y S I O T H E R A P Y June, 1960 OV E R t h e p a s t th r e e c e n tu r ie s o r m o r e N e u r o lo g is ts h a v e d is p la y e d g r e a t in te r e s t in th e u n d e r ly in g n e r v o u s m e c h a n is m s c o n c e r n e d w ith t h e m a i n te n a n c e o f p o s t u r e a n d e q u ilib riu m . T h e f a c t t h a t a h u m a n c a n m a in ta in his e q u ilib riu m in s p ite o f c o n t i n u o u s u n r e la te d m o v e m e n ts o f h is e y es, h e a d , t r u n k a n d e x tre m itie s , is s o m e th in g t h a t is u s u a lly a c c e p te d w ith o u t th in k in g . B u t a c tu a lly th is p h e n o m e n o n d e p e n d s o n a v e ry e l a b o r a te sy s te m o f re fle x e s in itia te d b y a m a s s o f s tim u li o r ig in a tin g in a lm o s t e v e ry p a r t o f t h e b o d y , e.g . th e ey es, e a rs , m u sc le s a n d j o i n t s . T h e s e im p u lse s a r e in te g r a te d a n d in te r p r e te d b y th e c e n tr a l n e r v o u s sy s te m w h ic h in it s t u r n se n d s o u t m e ssa g e s t o all t h e d if fe r e n t sk e le ta l m u sc le s in o r d e r t h a t t h e a p p r o p r i a t e m o v e m e n ts a r e c a r r ie d o u t a n d e q u ilib riu m is m a in ta in e d . I t w ill b e n e c e s s a ry to d is c u s s in m o r e d e ta il th e d iffe re n t c o m p o n e n t s o f t h is s y s te m :— 1 . V e s tib u la r A p p a r a tu s . E a c h in n e r e a r c o n t a i n s a d e lic a te o r g a n o f b a la n c e c a lle d t h e l a b y r i n th o r v e s tib u le m . I t c o n s is ts o f th r e e s e m i- c ir c u la r c a n a ls , e a c h ly in g in a d if fe r e n t p la n e a n d c o m m u n ic a tin g w ith tw o f u r t h e r sp a c e s, t h e s a c c u lu s a n d u tr ic u lu s . T h is w h o le s y s te m is c o n ta in e d in a b o n y l a b y r i n th w h ic h is lin e d w ith m e m b r a n e . T h e s p a c e s a r e a ll fille d w ith flu id , th e e n d o ly m p h , w h ic h b y its m o v e m e n t a n d g r a v ity p r e s s u re s tim u la te s g r o u p s o f n e rv e e n d in g s s itu a te d in th e m e n b r a n o u s lin in g . I n t h is w a y e v e ry p o s t u r a l c h a n g e o r m o v e m e n t o f t h e h e a d is r e c o r d e d a n d th e im p u ls e s a r e c a r r ie d a lo n g th e v isti- b u la r n e r v e t o n u c le i s itu a te d in t h e b r a in s te m . T h e y a re re la y e d f r o m h e r e t o d if fe r e n t p a r t s o f th e n e r v o u s sy s te m o f w h ic h t h e f o llo w in g a r e th e m o s t i m p o r t a n t : — (a ) The Cerebellum. T h is f o r m s th e m a i n c e n tr e o f e q u ilib r iu m r e g u la tio n . (b ) The Spinal Cord. H e r e v e s tib u la r s tim u li h a v e a d ir e c t in flu e n c e o n t h e a n t e r i o r h o r n c e lls a n d t h e r e f o r e o n c o n t r a c t i o n o f s k e le ta l m u sc le s. (c) F urther V estibular Im pulses a r e c o n d u c te d u p w a r d s in t h e b r a in s te m t o c e n tr e s g o v e r n in g ey e m o v e m e n ts . T h is c o n n e c tio n e x p la in s n y s ta g m u s o r th e in v o lu n ta r y j e r k y e y e m o v e m e n ts s o o f te n o b s e rv e d in d is tu r b a n c e s o f t h e v e s tib u la r a p p a r a t u s . (d ) A n o th e r im portant connection is b e tw e e n th e v e s tib u la r n u c le i a n d t h e v ita l c e n tr e s c o n c e r n e d w ith b r e a th in g , b l o o d p r e s s u r e c o n t r o l , p u ls e - r a te a n d v o m itin g . D i s t u r b a n c e s o f th e s e f u n c tio n s e.g . p a l l o r , v o m itin g , f a s t p u ls e a n d lo w b lo o d - p r e s s u r e a r e c le a rly s e e n in a t t a c k s o f v e s tib u la r d y s f u n c tio n e.g . m o t i o n sic k n e ss. 2 . T h e C e re b e llu m . T h is is t h e m a in i n te g r a tin g o r g a n in th e r e g u l a t i o n o f e q u ilib riu m . I t c o n s is ts o f th r e e c o m p o n e n t s ; tw o h e m is ­ p h e r e s a n d a c o n n e c tin g p ie c e c a lle d th e v e rm is. A l t h o u g h stim u li c a u s in g m o t o r a c tiv ity d o n o t o r ig in a te in th is p a r t o f t h e b r a in , it is o f t h e u t m o s t im p o r t a n c e in r e g u la tin g c o - o r d i n a t i o n o f m o v e m e n ts . T h e h e m is ­ p h e r e s in flu e n c e v o l u n t a r y m o v e m e n ts e .g . w a lk in g a n d u s e o f t h e a r m s . T h e v e rm is c o n t r o l s in v o lu n ta r y p o s tu r a l to n e , e s p e c ia lly in t h e t r u n k m u s c u la tu r e a n d p a t i e n t s w ith le s io n s o f th is a r e a s h o w p r o f o u n d lo s s o f e q u ilib r iu m e v e n in t h e s ittin g p o s itio n . I n o r d e r t o fu lfil a ll th e s e f u n c tio n s , t h e c e r e b e llu m h a s t o b e k e p t in f o rm e d a b o u t t h e p o s t u r e a n d m o v e m e n t o f e v e ry p a r t o f th e b o d y . I m p u ls e s f r o m th e m u sc le s a n d j o i n t s , s o c a lle d p r o p r io c e p tiv e o r k in a e s th e tic im p u ls e s , re a c h it v ia th e lo n g s e n s o r y tr a c k s o f th e s p in a l c o r d ; m e s sa g e s f r o m t h e ey es a n d e a r s a r r iv e v ia b r a in ­ s te m t r a c k s ; a d d i t i o n a l in f o r m a tio n is s e n t d o w n f r o m h ig h e r c e r e b r a l c e n tr e s . A ll th e s e stim u li a r e p o o le d in t h e c e r e b e llu m w h e r e th e y a r e c o n t i n u o u s l y s o r te d a n d c o - o r d in a te d . S u ita b le r e g u la tin g im p u ls e s a r e th e n s e n t o u t m a in ly t o t h e s p in a l c o r d a n d h ig h e r m o t o r c e n tre s. I n th is w a y t o n e a n d c o n t r a c t i o n o f e v e ry sk e le ta l m u sc le a r e m o d ifie d in s u c h a w a y t h a t e q u ilib riu m is m a in ta in e d a t a ll tim e s. D is tu r b a n c e s in E q u ilib riu m . T h e c lin ic a l a p p lic a tio n o f a ll th e s e a n a t o m i c a l a n d r p h y s io lo g ic a l fa c ts c a n b e s t b e illu s tr a te d b y c o n s i d e r i n g ' a few c lin ic a l d ise a s e s w h ic h p r e s e n t w ith d is tu r b a n c e s in e q u ilib riu m . T h e m a in c lin ic a l sig n o f c o n d itio n s f a llin g in to th is c a te g o r y is A ta x ia . A ta x ia is a c o n d i t i o n w h e r e in th e a b s e n c e o f a n y m u s c u la r w e a k n e s s , th e p a t i e n t f in d s it d iffic u lt o r e v e n im p o s s ib le t o s ta n d s till w ith h is fe e t to g e th e r , t o w a lk in a s tr a ig h t lin e a n d t o p e r fo r m c o ­ o r d in a te d m o v e m e n ts w ith his a r m s a n d h a n d s . A t a x i a h a s m a n y c a u s e s. C lin ic a lly th r e e m a i n ty p e s c a n be d i s t i n g u i s h e d :— (a ) Sen so ry A ta x ia . I n th e s e c a s e s th e le s io n is s itu a te d s o m e w h e re in t h e se n s o ry t r a c k s c o n d u c tin g p r o p r io c e p tiv e im p u ls e s f r o m th e t r u n k a n d e x tre m itie s to th e c e r e b e llu m a n d o t h e r h ig h e r c e n tr e s . D e p r iv e d o f t h i s s o u r c e o f in f o r m a t i o n th e c e re b e llu m is n o w u n a b l e t o f u n c tio n n o r m a lly . T h e p a t i e n t ’s d is a b ility c o n s is ts o f th e fo llo w in g : w ith ey es c lo s e d h e is u n a b ie to d e te r m in e th e p o sitio n a n d r a n g e o f m o v e m e n t o f h is lim b s . H e lite ra lly d o e s n o t k n o w w h e re h is fe e t a r e a n d w i t h o u t t h e u se o f h is e y e s h e is u n a b le t o o r i e n t a t e h im s e lf in sp a c e . H e is a b le t o s ta n d still w ith f e e t to g e th e r p r o v id e d h i s ey es a r e o p e n b u t a s s o o n a s h e c lo s e s th e m h e s t a r t s s w a y in g a n d m a y f a ll. H e w a lk s o n a b r o a d b a s e a n d h a s a h ig h s te p p a g e g a it e sp e c ia lly / in t h e d a r k w h e n v isu a l c o m p e n s a tio n is im p a ire d A W ith e y e s c lo s e d h is o u ts t r e t c h e d a r m s w a n d e r a n d fin g e r m o v e m e n ts la c k a c c u r a c y . O n n e u r o lo g ic a l e x a m in a tio n a lo s s o f p r o p rio c e p tiv e s e n s o r y m o d a litie s w ill b e f o u n d , m a in ly t h e se n se o f j o i n t p o s itio n a n d m o v e m e n t. V a r io u s d ise a s e s c a u s e s e n s o r y a t a x i a , e .g .: (i) P e r e p h e r a l n e u r itis , w h e r e t h e lo n g n e r v e s a re a f fe c te d , m a in ly th o s e t o t h e leg s. T h e c o n d u c t i o n o f s e n s o r y im p u ls e s t o t h e s p in a l c o r d is im p a ire d a n d s e n s o r y a t a x ia m a y r e s u lt. T h e c o n d itio n is f u r t h e r c o m p lic a te d b y m o t o r w e a k n e s s a n d m u s c u la r a t r o p h y d u e t o d a m a g e t o t h e m o t o r f ib re s in th e p e r ip h e r a l n e rv e s. G a i t d i s t u r b a n c e is, t h e r e fo r e , d u e t o tw o f a c t o r s : — s e n s o r y a ta x ia a n d m o t o r w e a k n e s s , o f w h ic h a n y o n e m a y p r e d o m i n a t e . T h e m a in c a u s e s o f p e r ip h e r a l n e u r i t is a r e v itim in d e fic ie n c ie s, a lc o h o lis m , d ia b e te s a n d v a r io u s h e a v y m e ta l p o is o n in g s . (ii) S p in a l c o r d le s io n s a ffe c tin g t h e lo n g s e n s o ry t r a c k s a r e th e r e b y in te r f e r in g w ith c o n d u c tio n o f p r o p r i o c e p t i v e im p u ls e s , s im ila r ly r e s u l t in s e n s o r y a ta x ia . I n th is c a te g o r y th e r e a r e tw o d is e a s e s o f i m p o rta n c e . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) June, I960 P H Y S I O T H E R A P Y Page 7 T a b e s D o r s a l i s : a sy p h ilitic in f la m m a tio n o f th e s e n s o r y s p in a l r o o t s a n d d o r s a l s e n s o r y t r a c k s o f t h e s p in a l c o r d . T h e ty p ic a l c lin ic a l c a s e s h o w s se v e re a t a x ia w ith h y p o t o n i a o f m u s c le s a n d v e ry p o o r c o - o r d i n a t i o n . O n c e th e d is e a s e m a n if e s ts its e lf it is p r o g re s s iv e in s p ite o f m e d ic a l t r e a t m e n t a n d t h e u l tim a te p r o g n o s is is th e r e f o r e p o o r . S u b a c u te c o m b in e d d e g e n e r a tio n o f t h e c o r d : th is d is e a s e is c a u s e d b y a V it. B . 12 d e fic ie n c y a n d is c o m m o n ly a s s o c ia te d w ith p e r n ic io u s a n a e m ia . A s in p e r ip h e r a l n e u r itis th e d is a b ility is d u e t o b o t h m u s c u la r w e a k n e s s a n d se n s o ry a t a x ia . T r e a t m e n t w ith V ita m in B . 12 a lw a y s a r re s ts t h e d is e a s e b u t c e r ta in ly d o e s n o t c u r e it, e s p e c ia lly in a d v a n c e d c a se s. (b ) Cerebellar A ta x ia . T h is ty p e o f a t a x i a b e c o m e s e v id e n t m o s tly in c h r o n ic b i l a te r a l le s io n s o f t h e c e r e b e llu m o r its c o n n e c tio n s . I t is se e n in its c la s s ic a l f o r m in h e r e d i t ­ a r y o r a c q u ir e d c e r e b e lla r d e g e n e r a tio n . T h e h e r e d ita r y a ta x ia s m o s tly s t a r t in c h ild h o o d a n d a r e slo w ly p ro g re s s iv e . T h e a c q u ir e d f o r m s a r e m a n if e s te d in la te m id d le life. B o t h ty p e s o f c e r e b e lla r a t a x i a c a r r y a p o o r p r o g n o s is . M o s t p a tie n ts u ltim a te ly b e c o m e b e d - rid d e n a n d t r e a t m e n t is p u r e ly p a llia tiv e . C e re b e lla r a t a x i a d iffe rs f r o m s e n s o r y a t a x ia in th e fo llo w in g r e s p e c ts : (i) N e u r o g ic a l e x a m in a tio n r e v e a ls n o s e n s o r y d e fic it, th e p a tie n ts a r e c o m p le te ly a w a r e o f th e p o s itio n a n d r a n g e o f m o v e m e n t o f th e i r lim b s . (ii) C lo s u re o f th e e y e s h a s little effe ct o n th e ir d is a b ility . T h e y s w a y a n d s o m e tim e s fa ll w h e th e r th e ir e y e s a r e o p e n o r c lo s e d . (iii) T h e s e p a t i e n t s o f te n h a v e a s p e e c h d is tu r b a n c e d u e t o p o o r c o - o r d i n a t i o n o f th e m u sc le s o f a r t i c u ­ la tio n . (iv) T h e in c o - o r d i n a t i o n o f a r m m o v e m e n ts is o f te n m o r e p r o n o u n c e d t h a n in se n so ry a ta x ia . O n a t t e m p t i n g sk ille d v o l u n t a r y m o v e m e n ts o f t h e a r m s th e y o f te n d e v e lo p a j e r k y t r e m o r , th e so -c a lle d in t e n t i o n t r e m o r . (v) T h e d i s t u r b a n c e in g a it a n d e q u ilib r iu m is th e o u t s t a n d i n g f e a tu r e . T h e g a it is b r o a d b a s e d ; re e lin g a n d s ta g g e rin g is m o r e p r o n o u n c e d t h a n in s e n s o r y a t a x i a w h e r e v isu a l c o m p e n s a tio n o c c u r s t o s o m e e x te n t. (c) Vestibular A ta x ia . T h is ty p e o f e q u ilib riu m d is tu r b a n c e is c a u s e d b y a le s io n a n y w h e r e in th e p e r ip h e r a l o r c e n tr a l v e s tib u la r a p p a r a t u s , i.e . in th e la b y r i n th its e lf in th e in n e r e a r ; a l o n g th e c o u r s e o f th e v e s tib u la r n e rv e ; o r in its c e n t r a l p a th w a y s in th e b r a in - s te m ; b e c a u s e t h e la b y r i n th is a b i- la te r a l o r g a n , a le s io n o n o n e sid e o n ly c a u s e s d i s t u r b a n c e o f e q u ilib riu m o n ly in th e a c u te p h a s e . V e ry s o o n t h e b a la n c e is r e s to r e d b y m e a n s o f c o m p e n s a t o r y c h a n g e s o n t h e o t h e r sid e . T h e r e f o r e th e s e p a tie n ts c h a r a c te r is tic a lly c o m p la in o f a c u t e a t t a c k s o f lo s s o f b a la n c e w h ic h te n d t o im p r o v e w ith in h o u r s o r d a y s . O n e x a m in a tio n d u r i n g a n a t t a c k th e y a r e o fte n u n a b l e t o sit, s ta n d o r w a lk . W h e n th e e r e c t p o s tu r e is a s s u m e d th e y te n d t o fa ll s h a r p ly t o th e sid e o f th e a ffe c te d e a r . F u r t h e r m o r e , th e y s h o w t h e c h a r a c t e r ­ istic je r k y ey e m o v e m e n ts , c a lle d n y s ta g m u s a n d , v ery o f te n c o m p la in o f d e a f n e s s a n d rin g in g n o ise s o n th e a ffe c te d sid e . T h e i r m a in c o m p la in t, h o w e v e r, is t h a t o f d iz z in e s s o r vertigo. T h is b r in g s u s t o o n e o f t h e m o s t c h a r a c te r is tic f e a tu re s o f v e s tib u la r le s io n s , i.e. v e rtig o . T h e te r m “ d iz z in e s s ” is v e ry c o m p r e h e n s iv e a n d v a g u e a n d th e r e f o r e m isle a d in g . I t c a n h a v e a h o s t o f m e a n in g s : lig h t-h e a d e d n e s s ; fe e lin g o f f a in tin g ; n a u s e a ; u n s te a d in e s s ; c o n f u s e d t h o u g h t s ; a n d la s tly a se n se o f a p p a r e n t m o v e m e n t o r tu r n in g . T h is la s t s e n s a tio n is tr u e v e rtig o . A fu ll d e f in itio n o f v e rtig o is a s fo llo w s : t h e p a tie n t b e c o m e s a w a r e o f a tu r n in g s e n s a tio n , e i th e r o f h im s e lf o r h is e n v ir o n m e n t. T h is h a llu c in a tio n c a u s e s h im t o f a ll o r sta g g e r b e c a u s e h is s p a tia l o r i e n t a t io n is d i s tu r b e d . T r u e v e rtig o o c c u r s o n ly in v e s tib u la r a t a x i a a n d n o t in t h e c e r e b e lla r a n d se n s o ry ty p e s . A s a lr e a d y m e n tio n e d it is a lw a y s tr a n s i t o r y a n d n e v e r la s ts m o r e t h a n a fe w h o u r s . I t is o f te n a g g r a v a te d o r in itia te d b y s u d d e n h e a d m o v e m e n ts . A c la s sic a l e x a m p le o f a c u t e v e s tib u la r d is tu r b a n c e is t h e d ise a se o f M e n ie re . T h is c o n d i t i o n u s u a lly o c c u r s in m id d le -a g e d w o m e n a n d is c h a r a c te r is e d b y r e c u r r e n t a t t a c k s o f in te n se v e rtig o , a t a x ia le a d in g to c o m p le te p r o s t r a t i o n , n a u s e a , v o m itin g a n d f re q u e n tly d e a f n e s s a n d r in g in g in o n e e a r. T h e a t t a c k is o f a c u t e o n s e t, la s ts f o r o n ly a few m in u te s t o h a l f a n h o u r a n d is u s u a lly f o llo w e d b y a p e r io d o f lig h t­ h e a d e d n e s s o f g a it. B e tw e e n a t t a c k s t h e p a t i e n t is q u ite w e ll e x c e p t f o r s lig h t d e a fn e s s w h ic h b e c o m e s p ro g re s siv e ly w o rs e a f te r e a c h a t ta c k . M e n ie re s d is e a s e is t h o u g h t to b e d u e t o a n a c u te sw e llin g o f th e l a b y r i n th w ith a rise in t h e flu id p r e s s u re le a d in g t o a b n o r m a l s tim u la tio n o f th e v e s tib u la r n e rv e e n d in g s . V e ry m u c h t h e s a m e m e c h a n is m e x p la in s t h e v e s tib u la r a t a x ia s e e n d u r i n g a c u te e a r o r m a s tio d in fe c tio n s . L e s io n s o f th e v e s tib u la r n e rv e a n d its c e n tr a l p a th w a y s w ith in th e b r a in s te m a ls o c a u s e v e rtig o a n d a ta x ia b u t t o a le sse r e x te n t a n d s e ld o m le a d to th e d r a m a t i c a t t a c k s a s d e s c rib e d in M e n ie re s d ise a se . T h e s e a r e th e n th e th r e e m a in ty p e s o f a t a x i a — v e s tib u la r c e r e b e lla r a n d se n s o r y . O c c a s io n a lly a sim ila r c lin ic a l p ic tu r e c a n b e se e n in le s io n s o f th e f r o n t a l lo b e s o f th e b r a in a n d in su ffe re rs f ro m c h o r e a (S t. V itu s D a n c e ). I n c e r ta in f o r m s o f h y s te ria a t a x ia c a n b e c lo s e ly s tim u la te d . T H E U S E O F P H Y S I O T H E R A P Y I N A T A X IA . P h y s io th e r a p y is o f g r e a t v a lu e in m o s t o f th e c o n d itio n s m e n tio n e d . T h e m e th o d u se d w ill b e d e te r m in e d b y th e ty p e o f a t a x i a a n d its p ro g n o s is . A s a lr e a d y m e n tio n e d t h e c e r e b e llu m h a s th r e e m a in s o u r c e s o f i n f o r m a t i o n : th e l a b y r in th , t h e p r o p r io c e p tiv e s e n s o r y im p u lse s f ro m t h e m u sc le s a n d jo in ts a n d t h e ey es. I n t h e c o u r s e o f p h y s io th e r a p y tw o m a in p r in c ip le s sh o u ld be f o llo w e d :— 1. D a m a g e t o a n e rv e p a th w a y , i.e . n e rv e e n d in g s , a p e r i ­ p h e r a l n e rv e o r a t r a c t in th e s p in a l c o r d o r b r a in s te m , is n o t a lw a y s c o m p le te o r irre v e rs ib le . B y r e p e titiv e e x e rc is e s th e r e m a in in g n e r v o u s tiss u e c a n b e fu lly u tilise d a n d n e w p a th w a y s m a y e v e n d e v e lo p . I n a d d itio n d isu s e a t r o p h y o f m u sc le s is p r e v e n te d . 2. T h e se c o n d p r in c ip le in th e t r e a t m e n t o f a t a x ia s h o u ld b e a c tiv e d e v e lo p m e n t o f a c c e s s o ry m e c h a n is m s . I n th is w a y lo s s o f o n e s o u r c e o f in f o r m a t i o n is c o m p e n s a te d f o r b y m o r e e fficien t f u n c tio n in g o f t h e o t h e r s o u r c e s , e.g . a p a t i e n t w ith se n s o ry a t a x i a s h o u l d b e t a u g h t t o u s e h is ey es m o r e efficien tly in o r d e r t o g a in th e in ­ f o r m a t i o n a b o u t p o s i t i o n a n d m o v e m e n t w h ic h is n o r m a lly su p p lie d b y p r o p r io c e p tiv e im p u ls e s f r o m th e lim b s . P ro g n o s is. I n o r d e r t o t r e a t a n y d ise a s e in te llig e n tly , a k n o w le d g e o f its n a t u r a l c o u r s e a n d e x p e c te d o u t c o m e o r p r o g n o s is is e s se n tia l. P h y s io th e r a p is ts a r e n o to r io u s l y p a tie n t a n d o p tim is tic a n d o f te n effe ct m ir a c u lo u s i m p r o v e m e n t in so c a lle d h o p e le s s c a s e s. T h is is a n a d m ir a b le a t t i t u d e a n d it is th e r e fo r e w ith t r e p i d a t io n t h a t I e v e n m e n tio n th e w o rd p r o g n o s is . i n g e n e ra l t h e b e s t r e s u lts c a n b e e x p e c te d in se n s o ry a t a x ia d u e t o p e r ip h e r a l n e u r itis a n d e a r ly c a s e s o f s u b ­ a c u t e c o m b in e d d e g e n e r a tio n o f t h e s p in a l c o r d . I n t h e ( C ontinued on Page 12). R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 12 P H Y S I O T H E R A P Y June, 1960 S O U T H E R N T R A N S V A A L B R A N C H R e c e n t L e c tu r e s M is s S a v in ’s le c tu r e o n G e r i a t r i c s w a s fo llo w e d u p b y a t o u r o f t h e O ld A g e d H o m e in S a n d r i n g h a m . I n c o n j u n c t i o n w i t h t h e G e n e r a l M e e tin g in M a r c h . M r . N e v ille C o h e n , a p a r a p le g ic , g a v e a t a l k a b o u t s o m e o f h is e x p e r ie n c e s sin c e h is in ju ry . A s th e s e in c lu d e d d r iv in g h is h a n d - c o n t r o l l e d c a r t o E n g la n d a n d b a c k a g a in , it p r o v e d q u i t e a n e y e - o p e n e r t o u s . I t w a s a ls o a g r e a t s tim u lu s t o t h e t h r e e p a r a p le g ic p a tie n ts w h o w e re in v ite d f r o m t h e w a r d s . I t w o u ld b e in te r e s tin g t o h e a r t h e im ­ p r e s s io n s o f o t h e r l o n g te r m p a t i e n t s r e g a r d in g h o s p ita l life. M is s W in t e r g a v e a s t i m u l a t i n g l e c tu r e o n a c o n tr o v e r s ia l s u b je c t viz. “ M a n i p u la ti o n s in t h e T r e a t m e n t o f D is c L e s i o n s ,” w h ic h le ft t h e a u d ie n c e w ith m u c h f o o d f o r t h o u g h t . F u t u r e L e c tu r e s O n M a y 1 7 th , M is s J e a n B la ir w ill t a l k a b o u t h e r t r ip t o t h e P h y s i o t h e r a p y C o n g r e s s in P a r is , a n d a ll o f u s w h o k n o w h e r a r e lo o k in g f o r w a r d t o th is . T h e N o r t h e r n T r a n s v a a l B r a n c h s e c r e ta r y , M is s S a v in , h a s e x te n d e d a v e ry f rie n d ly i n v i t a t i o n o n b e h a l f o f h e r c o m m itte e f o r o u r b r a n c h m e m b e r s t o a t t e n d a n y o f t h e S o c ie ty le c tu r e s h e ld in P r e t o r i a . U n f o r t u n a t e l y w e c a n n o t c i r c u la r iz e a ll m e m b e r s a b o u t e a c h le c tu r e , b u t d e ta ils m a y b e o b t a i n e d f r o m M is s S c h w a r tz . W e h a v e iss u e d a c i r c u l a r i n v i t a t i o n t o N o r t h e r n T r a n s ­ v a a l m e m b e r s a n d w e l o o k f o r w a r d t o s e e in g t h e m a t o u r le c tu r e s . M a r r i a g e s M is s D e ly s e D u n s d e n t o J o h n H a r t in B e n o n i. M is s V a le r y S c h w a r tz t o D r . R u d o l p h in J o h a n n e s b u r g . M is s J . P illin g , o n 5 / 1 2 / 5 9 t o M r. R e g V a n D y k . M is s E . E d e lin g h u y s , o n 2 / 4 / 5 9 t o D r . H a n s O p p e r m a n . B i r th s T o M r s . B. H . d e B r u in ( n e e K l o o s t e r ) o n M o n d a y , ' A p r il 1 8 th , a s o n , A n d r ie s W ille m J o h a n n e s . T o M r s . N . v a n H e e r d e n , o n T u e s d a y , M a r c h 1 7th, a d a u g h t e r , “ A l t a . ” T o M r s . R . M . J u b s o n , o n S a t u r d a y , A p r il 2 3 r d , a s o n . I N M E M O R I U M . M R S . B R O N W E N F O U R I E , M . C .S .P . T r a in e d : a t S t. T h o m a s ’ H o s p it a l, L o n d o n . J o i n e d : S .A .S .P ., N o r t h e r n T r a n s v a a l B r a n c h , 1952. 1 h a v e k n o w n B r o n n i e F o u r i e ( b o r n V a u g h a n ) f o r th e p a s t se v e n y e a r s . S h e h a d b e e n a w a y in A m e r ic a f o r f o u r y e a r s , w h e r e h e r h u s b a n d B r a n d F o u r i e , w a s o n t h e S o u th A f r ic a n a m b a s s a d o r i a l s ta ff. A s s o o n a s s h e r e t u r n e d to S o u t h A f r ic a s h e to o k u p h e r p r o f e s s io n a s P h y s io th e r a p is t, a n d I w a s in d e e d m o s t f o r t u n a t e t o o b t a i n h e r se rv ic e s in c h a r g e o f m y d e p a r t m e n t . B r o n n i e F o u r i e w a s a b o r n P h y s io th e r a p is t, f o r s h e h a d t h e o u t s t a n d i n g q u a litie s o f h u m a n ity , in t h a t sh e t r e a te d a ll p a t i e n t s , ric h a n d p o o r w h ite o r c o l o u r e d a c c o r d in g t o t h e i r n e e d s , a n d w ith t h e u t m o s t s y m p a th y a n d u n d e r ­ s t a n d in g . S h e w a s m o s t c a p a b l e , a n d e v e n t e m p e r e d a n d a b o v e a ll h a d a se n s e o f h u m o u r . S h e e n jo y e d h e r w o r k . S h e le f t S o u th A f r ic a w i t h h e r h u s b a n d o n h is a p p o i n t ­ m e n t a s S o u t h A f r ic a n r e p r e s e n ta tiv e t o t h e U n i t e d N a t i o n s , a n d h e r o n ly r e g re t o n le a v in g , w a s t h a t s h e w o u ld n o t be a b le t o c a r r y o n h e r w o r k a s P h y s io th e r a p is t. A f t e r a y e a r a t t h e U n i t e d N a t i o n s h e a d q u a r t e r s sh e r e tu r n e d t o S o u t h A f r i c a o n a s h o r t v isit t o h e r p a r e n t s , a n d it w a s t h e n s h e m e t h e r tr a g ic e n d in a m o t o r a c c id e n t. T h e S o c ie ty o f P h y s i o t h e r a p i s t s w a s d e p r iv e d o f o n e o f its a b le s t m e m b e r s . W e e x te n d o u r s in c e re s y m p a th y t o h e r h u s b a n d , h e r p a r e n t s a n d t h e r e s t o f t h e fa m ily , in t h e i r u n tim e ly a n d sa d b e r e a v e m e n t. H . D . E P S T E I N , Q U E S T I O N S F O R J O U R N A L Q U E S T I O N B O X . 1. W h e n is it s a fe to g iv e m o v e m e n ts o f n e a r b y j o i n t s f o llo w in g a S k in G r a f t ? 2 . Is it tr u e , t h a t c a s e s o f D i s s e m in a te d S c le ro sis a r e r a r e ly f o u n d in S o u th A f r ic a , a n d o n ly in p e o p le w h o . h a v e a lr e a d y d e v e lo p e d it o v e r s e a s ? 3. Is it r e a lly n e c e s s a ry t o r e m o v e c lo th in g , w h e n a p p ly in g S H O R T - W A V E D i a t h e r m y ? M a n y P h y s io th e r a p is ts in th is c o u n t r y d is r e g a r d th is p r e c a u t i o n , s t a ti n g t h a t th e y h a v e n e v e r b u r n t a p a t i e n t . 4. W h a t ty p e o f P h y s i o t h e r a p y h a s b e e n f o u n d t o b e m o s t e ffe c tiv e in t r e a t i n g h a n d in ju rie s . 5. S h o u ld t h e g r a d in g o f m u s c le p o w e r b e s ta n d a r d is e d t h r o u g h o u t S o u t h A f ric a . T h e s e q u e s t io n s w ill b e a n s w e re d b y S p e c ia lis ts in e a c h field b u t in t h e m e a n tim e m e m b e r s a r e in v ite d t o s e n d in th e ir o w n id e a s a n d s u g g e s tio n s f o r d is c u s s io n . B O O K REVIEW P r a c t i c a l E le c tr o th e r a p y f o r P h y s io th e r a p is ts B y B renda Savage. P ublished b y : F a b e r & F a b e r , 2 4 R u s s e l S q u a r e , L o n d o n , W .C . I. P rice 3 0 / - net. T h is b o o k g iv e s a s h o r t i n t r o d u c to r y c h a p t e r o n s o m e p h y s ic a l a n d m e c h a n ic a l p r in c ip le s o f v a r i o u s c u r r e n t f o r m s a n d p ie c e s o f e le c tr ic a l a p p a r a t u s . I n th is c h a p t e r it a ls o d e a ls w ith t h e r o le p la y e d b y th e s k in in t h e a p p l i c a ­ t i o n o f d if fe r e n t e le c tr ic a l t r e a tm e n ts . I t d e a ls f u r t h e r w ith t h e p h y s io lo g ic a l e ffe c ts o n t h e b o d y p r o d u c e d b y d if fe r e n t f o r m s o f e le c tr ic a l a n d r a d i a t i o n t r e a t m e n t s . I t a ls o d e s c rib e s in d e ta il t h e te c h n i q u e o f s o m e b a s ic f o r m s o f t r e a t m e n t s b y E le c tr o th e r a p y , i.e . t h e a p p l i c a ­ t i o n s o f D i r e c t C u r r e n t , c e r t a i n i o n is a tio n t r e a t m e n t s as H i s t a m i n e a n d R e n o ti n io n i s a t i o n , t h e d i s t r i b u t i o n o f e le c tr ic a l fie ld s in H ig h F r e q u e n c y c u r r e n t tr e a tm e n ts , t h e a p p l i c a t i o n o f S .W .D . c o ils , a n d t h e te c h n i q u e o f g iv in g G e n e r a l a n d L o c a l U .V .R . A n d fin a lly a n d m a in ly it d e a ls w ith a v a s t n u m b e r o f c o n d i t i o n s t h a t c a n b e tr e a t e d b y m e a n s o f E le c tr o th e r a p y . I n th is p a r t o f t h e b o o k d if fe r e n t f o r m s o f t r e a t m e n t a r e d is c u s s e d , s o m e o f t h e m o r e sp e c ia lis e d o n e s b e in g d e s c rib e d in d e ta il. T h e b o o k is illu s t r a t e d b y a g r e a t n u m b e r o f v e ry c le a r a n d v a lu a b le d ia g r a m s . T h is b o o k is a m u s t in a n y P h y s i o t h e r a p y lib ra ry . I t is o n e o f v e ry fe w b o o k s a t t e m p t i n g t o g iv e a d e ta ile d a c c o u n t o n t e c h n iq u e s a n d p o s s ib ilitie s in E le c tr o th e r a p y , s o m e th in g s a d ly l a c k in g u p t o n o w a s c o n t r a s t e d w ith th e / v a s t n u m b e r o f b o o k s b e in g w r i t te n a n d p u b lis h e d o n t h e ' e le c tr ic a l a n d m e c h a n ic a l p a r t o f E le c t r o t h e r a p y a p p a r a t u s . W e a r e s u r e t h a t e v e ry p h y s i o t h e r a p i s t a n d p h y s io ­ th e r a p y s t u d e n t w ill be v e ry g r a te f u l in d e e d t o b e a b le t o a c q u i r e a b o o k t h a t d e a ls w ith t h e p r a c tic a l a p p lic a tio n o f t r e a t m e n t s b y E le c tr o th e r a p y . B A L A N C E ( C ontinued fr o m P age 7). a b o v e m e n tio n e d c a s e s v ita m in th e r a p y c o m b in e d w ith in te n s iv e p h y s io th e r a p y w ill le a d t o a c u r e in m o s t o f th e m . T h e re s u lts in ta b e s d o r s a lis a r e u n f o r t u n a t e l y less e n c o u r a g ­ in g , b e c a u s e d a m a g e t o t h e n e r v o u s sy s te m is u s u a lly ir re v e r s ib le . N e v e r th e le s s g r a d u a t e d e x e rc ise s w ith sp e c ia l a t t e n t i o n t o t h e d e v e lo p m e n t o f o t h e r s e n s o ry m e c h a n is m s , e s p e c ia lly t h e e y e s ig h t, v e ry o f te n h a v e v e ry g r a tify in g r e su lts . I b e lie v e s p e c ia l p h y s io t h e r a p e u t i c m e th o d s h a v e b e e n d e v is e d in t h e t r e a t m e n t o f v e s t ib u l a r d i s tu r b a n c e s . O f th e s e I h a v e n o e x p e rie n c e . T h e u l t i m a t e o u tc o m e in c e r e b e lla r a t a x i a is t h a t o f a b e d - r id d e n p a t i e n t , b u t p h y s i o t h e r a p y c a n p o s t p o n e th is c o n s id e r a b ly a n d g iv e t h e p a t i e n t m a n y y e a r s o f u s e fu l life . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )