60 F I S I O T E R A P I E SEPTEMBER 1979 OPENING ADDRESS AT T H E 13th NATIONAL COUNCIL MEETING O F T H E S .A . SOCIETY OF P H YS IO TH ER A PY /O PEN IN G S R ED E BY DIE 13de NASIONALE RAADSVERGADERING VAN DIE S .A . FISIOTERAPIE VERENIGING A. J. B R IN K * M .D . (Pret.) F .R .C .P . (L ondon) F.A .C .C . (U.S.A.) D.Sc. (M d.) (Stell.) I t is a great ple asu re fo r m e to be he re on the occasion o f the th irte e n th N a tio n a l C ouncil M eeting of the S outh A fric a n Society o f P hy sioth erapy. L uckily I have no fears a b o u t the n u m b er thirteen and w illingly and eagerly jo in you today during y o u r d eliberatio n s. E k w a ard ee r h ie rd ie u itn o d ig in g terdee, veral as k ard io lo o g w a a r ek v ir b a ie jare bewus is van die rol w at fisio te ra p ie kan speel in die reh a b ilitasie van hartpasiente. Volgens d ie p ro g ram w at vandag voor- afgegaan het, lyk d it v ir my aso f m eeste van die aspekte rak e n d e d ie fisio terapeu t goed gedek is ge- du ren d e die verskillende W erkssim posia. T og is d a a r ’n aspek w at m iskien goed in m y k raa l pas en w at wel w aardevol v ir d ie fisio terap eu t kan wees, en d it is die rol w at die fisio terapeu t in die m ediese navorsings- w ereld in S u id -A frik a k a n speel. G R O W TH OF PH YSIO TH ERA PY T h e p h y sio th erap y p rofession has grow n in leaps an d b ounds o v e r the p a st 15 years. I was interested to learn recently fro m the S.A. M edical an d D e n tal C o u n ­ cil th a t 1 683 ph y sio th erap ists are registered w ith the C ouncil an d I believe th a t y o u r o rg an isa tio n (the S.A. Society of P hy sio th erap y ) represents som e 70% o f the registered p h y sio th erap ists in the country. D e sp ite a grow ing level o f p ro fessio n al expertise, there does seem, how ever, to b e an u rg e n t need f o r research in th e field o f ph y sio th erap y . P articu larly as it ap p ears as if m ost p h y sio therapy treatm ents o f today a re still largely em pirical. I t is interesting to n o te th a t the South A frican M edical R esearch C ouncil has n o t had a sig­ nificant n u m b e r o f a p p licatio n s fro m ph y sio th erap ists fo r research grants in the past. I believe th a t the ph y sio th erap ists can play a bigger role in the research activities o f S outh A frica, p a rtic u ­ larly in view o f th e fact th a t there a re now 5 u n iv ersi­ ties offering degree courses in p h y sio th erap y — w hich m eans th a t th e re is a grow ing nucleus o f p h y sio ­ th e ra p ists in academ ic en v iro nm en ts w ho could take the lead in an y research efforts in the field o f p h y sio ­ therapy. W ith these thou ghts in m in d I was in terested to n ote th a t an “In terest G ro u p fo r R esearch in P h y sio th e ra p y ” has recently been fo rm ed a t the U n iv ersity o f the W it- w atersran d — this is a very pro m isin g developm ent an d if carried th rou g h to its logical co nclusion will, I am sure, result in w o rth w hile research projects. W H AT IS TH E V A L U E OF RESEAR CH E N D E A V O U R FO R T H E PHYSIOTHERAPIST? R esearch activ ities b y p h y sio th erap ists will n o t only help to place p h y sio th erap y treatm en t along less em ­ p irica l lines an d p ro v id e d a ta on w hich im provem ents * D ean, F ac u lty o f M edicine, U n iv ersity o f Stellenbosch and Presiden t, M edical R esearch C ouncil, can be based, but also p ro v id e the p h y sio th erap ist w ith a n o p p o rtu n ity to ev aluate h e r treatm en t m ethods accurately. T h e stric t research disciplin e th a t has to be ad h ered to in o rd er to achieve results has v aluab le spin-offs in the clinical en viro nm ent. I t teaches one hum ility in th a t one know s th a t one does n o t have all the answ ers to every problem ; it encourages th e de­ velopm ent o f a logical and scientific ap p ro ach , whicfc together w ith u nd erstan d in g an d co m passion fo r th ^ p atien t, is essential f o r effective treatm ent. F u rth e r advantages to the ph y sio th erap y p ro fessio n o f research en deav ours m ay well pro v e to be a b e tter acceptance by th e m edical p rofession o f the “science” of physio-, therapy. I f th e do cto r accepts it as a science in its ow n rights, h e w ill be less likely to assum e th a t he know s the best p h y sio th erap y techniques an d to p re ­ scribe them exactly! H e m aintains, how ever, a respon­ sib ility w ith reg a rd to th e th e ra p y th a t he is p rescrib ­ ing. A t this p a rtic u la r ju n c tu re a few w ords ab o u t the M edical R esearch C ouncil, its p u rp o se an d policies m ay, I believe, be useful to y ou r p rofession, poised as it is a t the en trance to the scientific research w orld. TH E M ED IC A L R E SEAR CH CO UNC IL A N D ITS ROLE IN RESEAR CH IN SO UTH AFRICA T h e M edical R esearch C ouncil, established in 1969, is responsible fo r m edical research in S outh A frica in the areas o f m edicine an d related areas. Wetsopdragte D ie W et op die S uid -A frikaanse M ediese N avorsings- ra a d (W et nr. 19 van 1969) stip die oog m erke van die R aad d uid elik uit. Benewens al die an d er o p d ra g te^ m o et die R a a d m ediese navorsin g stim uleer op b i n n t f > sowel as buiteland se gebied, sam ew erking ten opsig&_ van nav orsin g bevorder, plaaslik e navorsingspogings k o o rd in eer, geko nsentreerd e inspan n ing bew erkstellig, en oorvleueling tot ’n m in im u m terugbring. Eic beleidsformulering ’n Belangrike beleidsbeginsel is d a t d a a r nie met builelandse navorsers kom peteer m oet w ord op gebiede van nav o rsin g w at elders net so goed as p la aslik gedoen kan w o rd nie. H ie rd ie beginsel im pliseer dus d at plaaslik e geleent- hede o p tim a a l b e n u t m oet w ord, soos bv. d ie navorsing o o r siektes w at un iek is aa n h ie rd ie land (byvoorbeeld porfirie, sekere k ard io m io p a tiee, tro p iese siektes, ens.), navorsin g w at gerig is om d ie inter-etn iese verskille na te sp eu r en te verklaar, asook die o p tim ale g eb ru ik van sekere p ro efd ie re soos p rim a te w at plaaslik nog redelik b e sk ik b aar is in teenstelling m et die toestand oorsee. H ie rd ie beleid im pliseer verder d a t vaardigheids- b e n u ttin g van p laaslik e navo rsers, sowel as die o p ti­ m ale g eb ru ik van b estaande fasiliteite in die RSA nougeset nagestreef m oet w ord 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. ) SEPTEMBER 1979 P H Y S I O T H E R A P Y 61 Student Research Grants P erh aps w h at is little realised a b o u t the M edical R esearch C ouncil is that aside fro m the very so p h isti­ cated research th a t it undertakes, it is a g rea t believer in the d evelop m ent o f research ex pertise in the young person w ho has just jo ined th e m edical en vironm ent. In this way w e pro v id e a R 200 b u rsary w h ich is speci­ fically design ed fo r studen t-u se an d can be used, fo r exam ple, by students on a research project w hich can then be presented a t a U n iv ersity academ ic day o r as p a rt o f th e activities o f .a larger scientific m eeting. P erhaps it should be the role of the p h y sio th erap ist in ed ucatio nal in stitu tio n s to encou rag e h e r student- phy sio therapiss w ho are u nd ergoing train in g to m ake use of this facility in th e ir u n d erg rad u a te days and thus establish a feel fo r m edical research. T h is is, o f course, a v ery m odest sta rt in m edical research, b u t these sm all steps, w e believe, a re essen­ tial to a successful research career. A t a m ore special­ ised level the M R C m akes a certain am o u n t o f m oney A vailable an nually fo r u n iv ersity research in the form p f sh o rt-term grants. T hese grants n o rm a lly cover a p e rio d o f 3 years an d the projects w hich we su p p o rt tend to be projects w hich will be ab le to be com pleted in the 3 year period. Short-Term Research Grants W e believe th a t this short term research link to the un iv ersity en v iro n m en t is o f co nsid erable value. T he ad vantages of s u p p o rtin g research a t the univ ersities is obvious in th a t it ensures th a t expensive facilities do n o t have to be re-created fo r the research en v iro n ­ m ent. W e have in effect, o v er the last co up le o f years, increased o u r su p p o rt o f u n iv ersity research to the extent th a t in 1976/77 we w ere spending R l,5 m illion on un iv ersity research and in 1977/78 n early R l,7 m illion. Even so, we find it difficult to s u p p o rt m o re than two o u t o f three o f the w o rth y applicatio ns. HOE W ORD AA N SO E K E V IR ’N M N R - T O E K E N N IN G H A NTEER? A ansoekvorm s v ir M N R -toekenning s is b esk ik b aar by d ie A d m in istratiew e H o o f van u inrigtin g . D ie sluitin gsdatu m v ir h ie rd ie aan so eke is gedurende M ei elke ja a r en d ie presiese d a tu m w o rd jaa rlik s bepaal. fc lig tin g in h ie rd ie v e rban d is ve rk ry g b aa r by die B jdm inistratiew e H o o f van u inrigting. P laaslik e na- ^ o rs in g s k o m ite e s aa n die o nd ersk eie u n iv ersite ite sif dan eers alle aan so ek e om finansiele steun aa n die M N R en m aak d ie n o oreenko m stig aanbev elings by die R aad o o r d ie m e rie te van elke aansoek. Nie- a m p telik e terag v o erin g van h ie rd ie k om itee n a die ind iv iduele navorsers o o r gebreke in h u lle aanso eke het in d ie verlede van g ro o t w a ard e geblyk te wees. H ie rd ie goedgekeurde aansoeke w o rd d an n a d ie M N R se T o ekenning sk om itee verwys. E lk e u n iv ersite it be- tro k k e by geneeskundige navorsin g benoem 'n verteen- w o o rd ig er op h ie rd ie kom itee w at dan jaa rlik s o o r die navorsin gsaansoek e besin. H ie rd ie k om itee is dus verteenw oordigend van die m ediese w etenskap in Suid- A frik a en spesiale sorg w o rd geneem d a t soveel as m oo n tlik van d ie verskillen de m ediese dissiplines in h ie rd ie kom itee verteenw o ordig word. T h e M R C ’s financial resources cannot, as I have said ea rlie r, su p p o rt every w o rth w hile a p p lican t, and if a research er has n o t received M R C su p p o rt, he o r she should n o t regard it as a lack o f confidence in the reserach p ro jec t as such, as o ften w e w o uld like to s u p p o rt the p ro je c t b u t cannot. M y advice, if th e re are phy sio therapists he re today who have ap p lied to the M R C fo r funds an d h ave n o t o b ta in e d any, is to try an d get the research p ro jec t off the g roun d w ithin y o u r ow n u niv ersity en viro n m en t, w ith oth e r su p ­ port perhaps, even if it be on a sm aller scale than you in itia lly a n ticip ate d , and th en ap ply ag ain w hen you h a v e p u t y o u r should er to the w heel and are ab le to show w h a t can be done w ith lim ited resources. T his can, I believe, tu rn the v o te in y o u r fav ou r. O ver an d ab ove th e financial s u p p o rt o f research, the M R C has o th e r specialised facilities to offer the researcher. SPECIALISED FACILITIES T h e M R C has gone to great lengths to establish these specialised facilities w hich will s u p p o rt the re ­ search er in his research endeavour. Institute for M edical Literature P erhaps one o f the m ost im p o rta n t o f these is the b ib lio g rap h ic retriev a l service offered by the In stitu te fo r M edical L iteratu re. T h is In s titu te is ab le to access the M E L L A R S D A T A BASE v ia in te rn a tio n a l tele­ co m m unications links to the m a in co m puter w hich is situated at the N atio n al L ib ra ry o f M edicine in W ashington, D.C. T his service offers the research er the o p p o rtu n ity to o b ta in a ra p id a n d efficient search of the lite ra tu re in his p a rtic u la r field. T h is can be o f p a rtic u la r valu e a t the sta rt o f a research project, in th a t o ne can have access to w h a t has been don e in a p a rtic u la r field b e fo re em b ark in g on y o u r p a rtic u lar project. T his lite ra tu re is av ailab le o n-line w ith in fo rm atio n dating back as fa r as 1966. T h e service has been a v a il­ ab le in the R ep u b lic since 1976 a n d there is a grow ing dem and f o r the services of th e In stitu te; thus fo r exam ple, in 1978, 373 b ib lio g ra p h ic searches were m ade du rin g th e year. O f in te re st to p hy sio therapists fro m the T ran svaal an d th e F re e S tate is th a t decen­ tralised term in a ls have been established at the U n i­ versity lib raries o f the W itw atersran d an d the U n i­ versity o f the O ran ge F re e S tate w h ere train e d lib ra ria n s a re ab le to assist you w ith y o u r lite ra tu re search. If y ou r research p ro jec t involves num bers in any w ay, num bers of patients, nu m b ers o f experim ents, in o rd er to show w h ether a p a rtic u la r treatm en t m eth od is b e tter than an o th er, then a second M R C facility is o f value. Institute for Biostatistics T h e In stitu te fo r B iostatistics, situated a t the M R C site, M edicina, was established by th e M R C in 1974 to ren d e r a co nsu ltation service to M R C sponsored research an d o th e r w o rth w hile research projects in respect o f the pla n n in g o f the research w o rk as well as the statistical analysis o f the results. In o th e r w ords, the In s titu te fo r B iostatistics is ab le to h elp you in the plan n in g of y o u r exp erim en t so th a t m axim um results can be o b ta in e d fro m m in im u m effort. T h is facility also p rovid es the o p p o rtu n ity f o r m aking y o u r d a ta c o m p atib le w ith co m puter analysis, w hich can save a g rea t deal o f tedious m athem atical analysis. T h e In s titu te fo r B iostatistics has a T ransvaal b ran ch situ ated a t the U n iv ersity o f th e W itw atersran d w hich is also av ailab le fo r co nsultation. T h e In s titu te has grow n trem endou sly o v er the first 5 years since its establishm ent an d has presently a staff o f o v er 20 train e d statistician s an d epidem iologists together w ith su p p o rtin g clerical staff. T hey have p a rtic u la r experience in the design o f clinical trials, f o r exam ple, w h ich w ould have p a rtic u la r relev ance to 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. ) 62 F I S I O T E R A P I E SEPTEMBER 1979 research th a t p h y sio th erap ists m ay well be interested in. C O M M U N IC A T IO N I N T H E R E S E A R C H E N V IR O N M E N T A n im p o rta n t p a r t o f any research u n d ertak in g is the o p p o rtu n ity to discuss its value w ith o n e ’s peers. T h e M R C has a n u m b e r o f schem es to encourage c o m m u nication am ongst m em bers o f sp eciality groups an d in this way fo ster co -o p cration an d en sure th a t th e re is n o t a d u p licatio n o f effort. F o r exam ple, the M R C w ill s u p p o rt atte n d an ce a t local conferences and assist scientists in this way to co m m un icate w ith one an other. T h e M R C also p rovid es the o p p o rtu n ity fo r scien­ tists to ap p ly fo r funds to spend a p e rio d o f tim e at an o th er research establish m ent w ith in the co un try w here a p a rtic u la r expertise is available. F o r exam ple, one m igh t wish to spend 3 m onths at a p a rtic u la r u n i­ versity w o rk in g on a research p ro jec t w ith p h y sio ­ th erapists o f standin g and this sort o f v isit could well be sponsored by th e M edical R esearch C ouncil. T h e M R C also m akes bursaries av ailab le f o r over­ seas stu d y in a p a rtic u la r techniqu e o r area w here S outh A frica does n o t have the necessary facilities. T h e qu e stio n o f th e av ailab ility o f sim ilar facilities T H E NEUROSURGEON J. C. D E V IL L IE R S * M .D ., T h e n e u ro su rg eo n is concerned p red o m in an tly with th e m anagem ent o f ch ro n ic pain. H is dealings with acute p a in a r e sim ilar to those o f m ost o th e r surgeons in th a t h e atte m p ts to rem ove the cause o f the trouble, as in ac u te disc p ro lap se w ith back and leg pain. A cute p a in seems to serve a purpose. I t causes av oidan ce o f the in ju rin g ag ent and induces rest. Some recu rren t attacks o f ac u te p a in , how ever, m ay lead to a ch ro n ic d isab ility e.g. b a ckache w ith o r w ith o u t sciatica. Som e recu rren t acute attacks o f p a in , such as in trigem inal n e u ra lg ia, serve no p u rp o se and can driv e th e sufferer to suicide. \ P atie n ts w ith persisten t pain can b e divided into two categories: (a) T h o se w ith lo ng-standing p a in o f co ntinuo u s o r recu rrin g n a tu re due to a lesion w hich is n o t life-th reate n in g b u t in w hich the p a in m ay th rea ten th e p a tie n t’s social integrity, (b) T h o se w ith severe p a in o f prolonged d u ra tio n d ue to life-th reaten in g lesions. W h atev er o ne believes ab o u t ac u te p a in does not ho ld fo r ch ro n ic pain. C h ro n ic u n relieved p a in is a disease in itself. T h e p a tie n t does n o t ad ap t to it; on th e c o n tra ry th e sufferer seems to becom e sensitized. L ack o f sleep, in a b ility to co ncen trate an d irrita b ility a re com m on associated features. T h e p a in becom es the focal p o in t o f th e p a tie n t’s existence and he loses in te r­ est in everything else. H e has seen m any doctors, is disillu sioned , dish earten ed an d suspicious. D epression is a fre q u e n t fe a tu re o f this state, th e treatm en t o f w hich can n ev er b e stra ig h tfo rw a rd , sim ple o r rap id . * H elen and M o rris M au e rb erg er P ro fesso r o f N e u ro ­ surgery, U n iv ersity o f C ape T ow n an d G ro o te S chuur H o spital. t P a p e r read at P a in Sym posium , precedin g 13th N a tio n al C ouncil M eeting 2 3 - 2 7 A p ril 1979. in South A frica is an im p o rta n t one, as th e M R C m ust en courag e the full u tiliz a tio n o f its ow n scientific facilities b e fo re scientists go a b ro a d to o th e r establish­ ments. So in effect we only s u p p o rt overseas visits if it involves som ething w hich can n o t b e don e in South A frica and w hich has v alu e fo r the South A frican situ atio n . Scientists who o b ta in these overseas travel b u rsaries o r overseas study b u rsaries, have to enter into an un d ertak in g w ith the M edical R esearch Council to re tu rn to S outh A frica fo r a p e rio d o f tim e so that w h at they have learn ed can be tran sferre d to their colleagues in South A frica. T h e M R C also suppo rts th e u n d ertak in g o f inter­ n a tio n a l o r natio n al conferences. It does not, how ever, assist societies w ith th e ir m eetings; there are so m any in the co u n try th a t this w ould b e a v irtu a lly im pos­ sible task. H ow ever, if an a re a o f m edicine w arrants a scientific m eeting and the research can clearly profit by the visit o f overseas scientists to such a conference the M R C w ill su p p o rt the u n d ertak in g financially and offer the facilities o f its C onference D iv isio n foi th e o rg an isa tio n of such a n M R C conference. j f I hop e fro m w h at I have said th a t you will n t | b elieve that “research en d eav o u rs” w ill cu re all the prob lem s facing th e p hy sio therapist. B ut certainly ] believe th a t it will offer an en riched career and im ­ proved treatm en t fo r th e p a tie n t — an aim that everyone involved in health care shares! AND CHRONIC PAIN t F.R .C .S. (Eng. & E din.) T H E P A T IE N T , T H E P A IN A N D T H E P H Y S IC IA N I t has been a tra d itio n a l concept that surgeons should be concerned w ith the excision o f lesions w hich are held to be useless o r deleterious in th e ir effects. S im ilarly it ap p eared logical th a t nerves, tracts and “ centres” concerned w ith th e tran sm issio n o r in te r­ p reta tio n o f im pulses concerned w ith th e ap p re ciatio n o f p a in should be divided o r ab ated if such pain served no purpose. T h e h isto ry o f surgery fo r pain shows that this a ttitu d e has been follow ed by disaster. U sually, w hen all surgery has failed, som eo s''- m iracu lously discovers th a t the p a tie n t is an individuft ' w ith problem s, w o rth y o f co n sid eratio n by a psychiatrist." All o th e r “a b stra c t” aids are then invoked to absolve the surgeon fro m an y gu ilt feeling w hich he m ay have engend ered as a result o f having becom e p a rt o f the n a tu ra l h isto ry o f the p a tie n t’s disease. A ny surgeon who em barks on surgery fo r ch ronic pain, w ith o u t having spent tim e w ith his p a tien t is set on a disaster course. O th er p eo p le who will talk to the p atien t, no m a tter who they a re — psychiatrists, psychologists, social w orkers, a nu rsin g sister o r p a ra ­ m edical staff — can lea rn a b o u t the p a tie n t and his reaction s and should sh are th e ir views w ith the sur­ geon; th e re is th e re fo re everything to b e said fo r a team ap p ro ach . T h e surgeon m ust get to know his p a tie n t and get to know him well an d this know ledge can b e gained only by repeated con versation in depth. A n attem pt sh o u ld be m ad e to establish the follow ing points: W h a t sensation does the p a tie n t call “p a in ” ? H o w does he describe it in his ow n w ords w ith o u t any p ro v o ­ ca tio n on th e p a rt o f th e exam iner? W h at does this sensation, call it p a in if you m ust, do to him , w hat does it do f o r him and w hat does he do w ith it? One 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. )