SEPTEMBER 1975 F I S I O T E R A P I E 11 t h e "VIBRATOR” - THERAPEUTIC TOOL OR ACADEMIC TOY? g . E. B R IN K W O R T H , B .Sc. (Physio.) (Witwatersrand) M echanical v ib ra tio n o f skeletal muscle has been a subject of interest in the field o f neurophysiological research for some years. T h e reflex c o n tra c tio n o f muscle tissue when subject to m echanical v ib ra tio n o f certain frequencies was dem onstrated electro m y o g rap h ica lly by H agbarth and Fklund in 1966 (1). T h e term given to this response is the T O N IC V IB R A T O R Y R E F L E X a n d considerable research has been d one o ver th e last ten years investigating the nature of this reflex a nd its clinical a p p lic a tio n for both therapeutic and diagnostic p u rp o se s (2, 3). W hereas the physiological reports have been vast a nd interesting, the clinical use and specific p ractical a p p lic a tio n fo r physiotherapists has not so far been a d eq u a te ly investigated. T herefore it was felt th at p r e v i e w o f the lite ra tu re to d a te and a report on recent investigation in to som e aspects o f th e practical application of the T o n ic V ib ra to ry Reflex w ould be of some value to the physiotherapist. Subsequent to th e first ob se rv atio n s of the effects of vibration o n m uscle tissue, n u m e ro u s studies have been done using various frequencies o f v ib ra tio n and noting effects such as the chances in phasic a n d tonic reflex mechanisms (4), the n a tu re o f th e H -response a n d tendon reflexes (5) and the type o f ten sio n o r to n e built up in the muscle tissue (6 ,7 ). The effect o f v ib ra tio n has been com pared with th at of electrical stim u la tio n o f m uscle afferents (7) and factors which increase o r decrease the to n ic vibratory reflex have been investigated. S tudies have been conducted on decerebrate cats, o n h e althy h u m a n subjects and on patients with c en tral n ervous system lesions. In all, there is a wealth of basic research on the su bject w hich is now slowly being taken up by p h y sio th era p ists, b u t considering the wealth of m aterial which has been offered th e clinician, it is amazing to find a p p a re n tly only one in d ep e n d en t report submitted by a p h y sio th era p ist so far. T h is consisted of some case reports d one by S tillm an in A u s tra lia in 1970 (8). L et us co n sid er th e n the facts w hich emerge having sifted through th is m ate ria l a n d selected th a t which is of obvious practical clinical relevance. F R E Q U E N C Y O F S T IM U L U S M atthew s (1966) show ed th a t th e m uscle tension produced is directly p ro p o rtio n a l to the frequency o f stimulation (13). J /a rio u s frequencies o f v ib ra tio n have been used experi­ m en ta lly , how ever it seems th a t frequencies ranging from 50 to 500 H e rtz a re those w hich have been most used in hum an skeletal muscle. F o r clinical purposes Hagbarth and E klund in Sw eden used v ib ra to rs oscillating at 150 Hz (9), while Stillm an c o n d u c te d his clinical studies using 50 Hz (8). B oth a re u n d o u b te d ly effective a n d the type of vibrator com m ercially a v ailable in this c o u n try has a frequency of 100 Hz. It is in teresting to n ote th a t in recent studies at the U niversity o f th e W itw a te rsra n d the cylindrical battery- op erated v ib ra to r show ed a tre m e n d o u s range of frequencies with basically tw o c o m p o n e n ts o f 330 and 660 Hz em erging (10). T h is v ib ra to r h a s proved relatively less effective th a n o th e rs o f low er frequency. It has been suggested th at w ith hig h er frequencies th e re is a loss of effective energy and p ro b a b ly decreased a m p litu d e by the time the stimulus reaches th e m uscle tissue ( 12). B ishop (1975) c onsiders a frequency o f 200 Hz should be the u p p e r lim it o f a clinical v ib ra to r (11). S IT E O F A P P L IC A T IO N O F S T IM U L U S In la b o ra to ry p re p a ra tio n s w here the vibratory stimulus could be a p p lie d directly to m uscle tissue, the effect of the stim ulus w as the sam e fo r a n y fibre o r group of fibres. H ow ever, in the clinical situ a tio n th e effectiveness o f th e stim u lu s will n a tu ra lly vary w ith th e site o f a p p lic a tio n , th e c o n d itio n o f stre tc h a n d th e initial to n e o f th e m uscle. T h e accessibility o f th e m uscle is a lso a n im p o rta n t c o n sid era tio n . All skeletal m uscle will re sp o n d to v ib ra tio n b u t all skeletal m uscles a re n a tu ra lly n o t selectively accessible. M o s t w orkers have fo u n d th a t th e m uscle te n d o n is th e m ost effective site o f stim u la tio n , w ith S tillm an re p o rtin g th a t in th e case o f g a stro cn e m iu s, a p o in t pro x im a l to th e m u sc u lo -te n d o n o u s ju n c tio n p ro d u c es th e m ost effective re sp o n se (8 ). T h u s w hile th e m uscle te n d o n c a n be ta k e n generally as the m o st su itab le site o f a p p lic a tio n in th e clinical situ a tio n , it is suggested th a t th e th e ra p ist ap p ly th e v ib ra to ry stim ulus first over th e m uscle te n d o n , th en h a v in g a llow ed a re a so n ­ a ble tim e fo r a re sp o n se to tak e p lace (tw o m inutes), a n d failing to get a response, to th e n re p ea t the stim u lu s o ver th e m u sc u lo -te n d o n o u s ju n c tio n a n d o ver m uscle fibres p roxim al to this p o in t (12). T IM E O F A P P L IC A T IO N O F S T IM U L U S T h e ten d e n cy is to w ith d ra w th e stim ulus if a d ra m a tic re sp o n se is n o t im m ediately perceptible. A lth o u g h th is is n o t advisable, B ishop (1975) does p o in t o u t th a t a fte r tw o m inutes th e stim u lu s sh o u ld b e w ith d ra w n d u e to th e h e at o f frictio n o n the skin. I t m ust be b o rn e in m in d , how ever, th a t a stim u lu s freq u e n c y o f 100-200 H z w as being referred to in th is in stance a n d th a t low er frequencies m ig h t well n o t have this effect so so o n , as b o rn e o u t by M a rsd e n et al (1969) w h o used a frequency o f 100 H z a n d re p o rte d n o ill-effects w hen th is w as a p p lie d fo r p eriods o f u p to tw en ty m inutes (7). W hile e le ctro m y o g rap h ica lly , a response to v ib ra tio n c an be picked up on im m e d ia te onset o f stim ulus, this is n o t alw ays im m ediately perceptible u sing o th er m eth o d s o f re co rd in g such as degree o f jo in t m o v em e n t o r th e response o f a p re ssu re tran sd u ce r. H ow ever, “ p la te a u te n s io n ” w as re ac h ed in ga stro cn e m iu s stu d ies w ith in 30 to 60 seconds (7) a n d responses in q u a d ric ep s fem oris using jo in t m ovem ent as a n in d ic a tio n o f response, have b e en observed in perio d s o f up to tw o m inutes (12). A n o th e r in teresting p o in t sh o u ld b e n o ted in th e clinical situ a tio n a n d th a t is th e p h e n o m e n o n described as P ost- V ib ra to ry P o te n tia tio n . T h is m eans th a t “ a p revious p e rio d o f v ib ra tio n will p o te n tia te a re sp o n se to a su b seq u e n t p e rio d o f v ib ra tio n ” (M a rsd e n et al 1969). T h e interval betw een perio d s o f v ib ra tio n in w hich this to o k place was five seconds to th ree m inutes. P o te n tia tio n alw ays d isa p ­ p e are d a fte r a five m in u te interval. T h e re fo re th e th e ra p is t co u ld be advised to re p e a t v ib ra to ry stim u la tio n a fte r re st perio d s o f less th a n th ree m inutes. A M P L IT U D E O F S T IM U L U S M a tth e w s (1966) has show n how th e ten sio n o f th e to n ic v ib ra to ry reflex is in creased w ith increased a m p litu d e (up to 200 u) a t a c o n s ta n t frequency o f 300 H z. N o te th a t increased a m p litu d e will cause in creased re c ru itm e n t o f m o to r u n its a n d th a t in th e ra p e u tic situ a tio n s th is is som e­ tim es b u t n o t alw ays the desired effect. In fact, ju d ic ou s use o f a m p litu d e m ust be em ployed to a v o id th e p ro d u c tio n o f a to n ic v ib ra to ry response in m uscle tissue w here a re sp o n se is n o t re q u ire d . A goo d e xam ple h e re is th e p h e n o m e n o n observed w hen tre a tin g th e h a n d w here th e finger flexors re sp o n d w hen the m uscles of the th e n a r em inence a re being vib rated . T h is has p a rtic u la rly been observed w here a m p li­ tu d es o f m ore th a n 2 m illim etres a re used w ith a frequency o f 50 H z (12). T h e a m p litu d e s used clinically a re n o t alw ays specifically sta te d in th e lite ratu re, how ever it seem s wise to k eep below 2,5 m m s d u e to th e a b o v e effect a n d only to re s o rt to the larger am p litu d e s w hen a n increase o f frequency o f up to 200 H z does n o t p ro d u c e a response. F A C T O R S A F F E C T IN G T H E T O N IC V IB R A T O R Y R E S P O N S E In the n o rm al subject th e to n ic v ib ra to ry reflex c a n be increased o r decreased in in tensity in c e rta in circum stances. D ru g s such as valium , b a rb itu ra te s, C iba 28,882-B a a n d p ro c ia n e b lo ck will d ep ress the re sp o n se (4, 8) a n d n o rm al 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. ) 12 subjects c a n volu n ta rily depress th e response. V ib ra tio n o f th e a g o n ist will decrease th e re sp o n se to v ib ra tio n o f the a n ta g o n ist m uscle. T h is ties up re aso n a b ly w ith th e fact th a t v ib ra tio n o f a skeletal m uscle will n o t only result in a su sta in ed c o n tra c tio n o f th e m uscle v ib ra te d , b u t a lso in a sim u lta n eo u s re la x a tio n o f its prim e a n ta g o n ist (17). T h e p o sitio n o f th e h ead has also b een fo u n d to influence th e effect o f v ib ra tio n w ith flexors re sp o n d in g b e tte r in p ro n e a n d th e e x te n so rs in supine, th u s d e m o n s tra tin g a link-up w ith th e m echanism s o f th e to n ic la b y rin th in e reflex (1). T h e re is n o c o rre la tio n betw een th e stre n g th o f th e te n d o n je rk s in a ny ind iv id u a l a n d the stre n g th o f th e to n ic v ib rato ry response (15), how ever a Je n d rassik -lik e like re sp o n se is observed in w hich th e to n ic v ib rato ry response is increased w h en th e subject c o n tra c ts o th e r m uscle g ro u p s (4, 6). It has b een o b se rv ed to o th a t cold increases th is response. T he initial m uscle length h a s a n influence w hereby a g re ater re sp o n se is re co rd e d w hen a m uscle is v ib rated while in its o u te r ra n g e (11); this fact will h old as long as th e to n e o f the m uscle is th e sam e in b o th po sitio n s, b u t w ith increased tone, th e re will sim ilarly be a n increased re sp o n se to th e v ib rato ry stim ulus. O TH ER N E U R O P H Y S IO L O G IC A L F IN D IN G S H a v in g estab lish e d th e fact th a t th e to n ic v ib rato ry reflex is th e to n ic reflex c o n tra c tio n o f skeletal m uscle w hen subject to high frequency m echanical v ib ra tio n a n d th a t reflex in h ib itio n o f th e a n ta g o n ist tak e s place sim u lta n eo u sly (Y a m a n a k a 1964, H a g b a rth a n d E k lu n d 1966, M a tth e w s 1966 a n d D e G a il e t al 1966), it is in te restin g to c o n sid er som e o th e r effects w hich have b een o b se rv ed in nerve a n d m uscle tissue w hen v ib ra tio n is ta k in g place. M uscle Receptors It h a s b een gra p h ic ally show n ho w th e p rim a ry endings fro m th e m uscle spindle c a n be seen to d ischarge a t th e sam e frequency as th e v ib ra to ry stim u lu s w hereas th e se c o n d ary e n dings a n d th e G o lgi te n d o n o rg a n s a re relatively u n ­ responsive (14). H ow ever, th e G olgi te n d o n o rg a n s, while h a v in g a h igh th re sh o ld to stre tc h have a low th re s h o ld to c o n tra c tio n a n d these fibres c o uld sta rt re sp o n d in g to som e degree a s th e te n s io n p la te a u is re ac h ed o r as a n overall re sp o n se ta k e s p lace in the muscle. The “ H ” Response and Tendon Jerks T h e H re sp o n se (also called th e H reflex) c an be considered th e electrical eq u iv a len t o f th e a n k le je rk (4). It is elicited by stim u la tin g th e afferent a xons w ith a n electric sh o c k (th u s by-passing th e spindles), a reflex m uscle c o n tra c tio n ensues. B o th th e H response a n d th e te n d o n je rk s w ere fo u n d to be depressed d u rin g v ib ratio n . T h is is th o u g h t to be d u e to p re -sy n ap tic in h ib itio n . T hese p hasic reflexes a re depressed d u rin g v ib ra tio n w h e th er th e sp in a l c o rd vis in ta c t o r n o t, w hereas th e to n ic v ib ra to ry reflex is a b se n t in dece reb ra te c ats a n d in p a tie n ts w ith cervical a n d th o ra c ic spinal c o rd lesions (4, 5, 13). T h is im plies th a t the to n ic v ib ra to ry reflex d e p en d s o n lo n g reflex p a th w ay s involving h igher centres, w hereas th e d epression o f th e p hasic reflexes d e p en d s on spinal c o rd c ircu its (5). A rcangel, J o h n s to n a n d B ishop (1970) fo u n d th a t a lth o u g h phasic reflexes were depressed d u rin g v ib ra tio n , th e A chilles’ te n d o n reflex w as au g m e n ted fo r som e 30 seconds a fte r v ib ra tio n o f th e tendo-achilles. T h is, to a degree, ties u p w ith M a rsd e n , M e a d o w s a n d H o d g s o n ’s o b se rv atio n s in 1969 o n p o st-v ib ra to ry p o te n tia ­ tio n a n d B row n, E n g b erg a n d M a tth e w s’ o b se rv atio n s o n th e in itial m uscle ten sio n a n d fu sim o to r activity w ith reference to relative sensitivity to m uscle v ib ra tio n (14). B ish o p describes th is as a g a m m a -g e n e rated a u g m e n ta tio n b ro u g h t a b o u t d u rin g v ib ra tio n a n d p e rsisting a fte rw a rd s w hile th e a lp h a m o to r n e u ro n s a re still su bject to p re sy n ap tic inh ib itio n . CLINICAL A PP L IC A T IO N S — IN SU M M A R Y T h e u se o f th e to n ic v ib ra to ry reflex in early diagnosis of n e u ro lo g ica l p a th o lo g y a n d in in v estigating th e physiological fu n c tio n in g o f h u m a n m uscle spindles h a s been p u t fo rw a rd by m an y w o rk e rs in th is field, H a g b a rth a n d E k lu n d (1966) a n d M a rsd e n e t al (1969) being tw o exam ples (7, 16). SEPTEMBER, 1975 H a m m o n d , M e rto n a n d S u tto n (1956) re m a rk e d th a t th e te n d o n je rk is p robably n o m ore th a n “ a n accid e n tal o v e rlo a d co n d itio n o f a nervous p a th w a y ” w ith M a rsd e n e t al subsequently stating in 1969 th a t “ th e physiological a n d p a th o lo g ica l functioning o f h u m a n m uscle spindles is m ore likely to be discovered by th e use o f tec hniques such as v ib ra tio n th a n by th e use o f th e te n d o n h a m m e r” . So m uch fo r the changing face o f d iagnosis a n d research, b u t w h a t o f th e th e ra p is t? I n su m m ary , th e item s o f p ractical a n d th e ra p e u tic use which em erge fro m th is w e alth of research a re p u t forw ard. M e chanical vib ratio n o f frequencies ra n g in g fro m 50 to 200 H z is best used in the th e ra p e u tic situ a tio n . V ib ra to rs o p e ra tin g a t 50 H z thus oscillating a t 100 H z a re readily com m ercially available in this c o u n try . T he a m p lititu d e o f v ib ra tio n is p ro b a b ly m ost effective fo r selective a m p lic a tio n o f sm all muscles w hen less th a n 2,5 m m . A m p litu d e m ay be increased w ith no re ported ill-effects, b e arin g in m ind th a t m o re m o to r units a n d thereby possibly o th e r m uscles will be affected. T h e tim e fo r vib ratio n over a ny one p o in t sh o u ld p ro b a b ly n o t exceed tw o m inutes if frequencies a p p ro a c h in g 200 H z a re used. W ith low er frequencies th e a p p lic a tio n c o uld bar re -a p p lie d a fte r rest periods o f less th a n th ree m in u te { ] F u r th e r investigation is required here to assess effects a h different frequencies. T he best site fo r a p p lic a tio n o f the stim u lu s in the clinical situ atio n a p p e a rs to be o v e r the m uscle te n d o n alth o u g h a response c a n be elicited o v e r the m u sc u lo -te n d o n o u s ju n ctio n o r over th e m uscle belly. T his v a ria tio n in o ptim al site o f s tim u la tio n c o u ld d e p e n d o n th e initial m uscle length o r the state o f c o n tra c tio n o r to n e o f the m uscle a t th e onset o f vibration. So fa r v ib ratio n therapy has been m ost re p o rte d in the tre a tm e n t o f p a tie n ts with u p p e r m o to r n e u ro n e lesions w ith som e reference to th e effect it m ight have o n w eak o r paresed m uscle tissue. (By virtue o f the fact th a t v ib ra tio n resu lts in c o n tra c tio n o f the fibres vibrated w ith in h ib itio n o f the a n ta g o n ist, it is re ported to reinforce w eak v o lu n ta ry efforts a n d to reduce spasticity w hen a p p lie d to the a n ta g o n ist o f th e spastic muscle.) H ow ever, fa r m o re clinical assessm ent is called for in th is field a n d th is c an only be d o n e w ith a m ore judicious a n d specific a p p lic a tio n o f th e v ib ra to ry stim ulus a n d an aw areness o f th e physiological d a ta c o n ce rn ed w ith the evolution o f this technique. R EFEREN CES 1. H a g b a rth , K .-E . and E klund, G .: “ N o rm a l v ariab ility o f to n ic vib ratio n reflexes in m a n .” E xp. N e u ro l 16:80-92. Sept. 1966. 2. H a g b a rth , K .-E . and E k lund, G .: “ T h e effects o f m uscle v ib ratio n in spasticity, rigidity a n d c ere b ellar" d iso rd e rs.” J. N eurol. N eurosurg. P sychiat. 31:207-213v, J u n e 1968. 3. Stockm eyer, S. A .: “A n In te rp re ta tio n o f R o o d in the tre a tm e n t o f neurom uscular d y sfu n c tio n .” A m e r J P hys. M ed. 46:900-956. 1967. 4. D e G a il, P., Lance, J. W. a nd N eilson, P. D .: “ D iffer­ e ntial effects o n tonic and phasic reflex m echanism s p ro d u c e d by vibration o f muscles in m a n .” J. N e u ro l. N u e ro su rg . Psychiat. 29: I-II. 1966. 5. A rcangel, C.S., Johnston, R . a n d B ishop, B .: “ T he A chilles T e n d o n Reflex a n d H -R e sp o n se d u rin g a n d a fte r te n d o n v ib ratio n .” Physical T h e ra p y 5 1 :8 889-901 1971. 6 . J o h n s to n , R . M ., Bishop, B. a n d Coffey, G . H . : “ M ech­ anical V ib ra tio n o f Skeletal M uscles.” Physical T h era p y 50:4 499-505. A pril 1970. 7. M a rsd e n , C. D ., Meadows, J. C. a n d H o d g so n , H . J. F . : “ O b serv a tio n s o f the Reflex R e sp o n se to M uscle V ib ra tio n in M a n and its V oluntary C o n tro l.” B ra in 92: 829-846. 1969. 8 . S tillm an, B. C .: “ V ibratory M o to r S tim u la tio n — a Pre lim in ary R e p o rt.” A ustralian J. P h y sio th e rap y X V I: 3 118-123. Sept. 1970. P H Y S I O T H E R A P Y 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. ) 9 E k lu n d , G .: “ Som e physical p ro p e rtie s o f m uscle v ib ra to rs u sed to elicit to n ic p ro p rio ce p tiv e reflexes in m a n .” A cta. Soc. M ed. U p p sa la . 76: 271-280. 1971. m Brinicw orth, K . E. a n d Schuster, D . G .: “ S tudies of Physical P ro p e rtie s o f V ib ra to rs .” U n p u b lish e d . 1974. 11 B ishop, B . : “ V ib ra to ry S tim u la tio n — P a rt I I I — Possible A p p lica tio n s o f V ib ra tio n in th e tre a tm e n t of M o to r D y sfu n c tio n s.” Physical T h e ra p y 55: 2 139-143. Feb. 1975. 12 B rin k w o rth , K . E .: “ F u rth e r Studies o n th e C linical A pp lica tio n o f th e T o n ic V ib ra to ry R eflex.” U n p u b ­ lished. 1975. 13 M atthew s, P. B. C . : “ T h e reflex e x citatio n o f th e soleus m uscle o f th e d e ce reb ra te c a t c au sed by v ib ra tio n ap p lie d to its te n d o n .” J. Physiol. 192: 773-800, 1967. 184: 450-472. 1966. <4 B row n, M . C ., E ngberg, I. a n d M a tth e w s, P. B. C . : “ T he relative sensitivity to v ib ra tio n o f m uscle re ce p to rs o f th e c a t.” J. Physiol. 192: 773-800. 1967. 15. H a g b a rth , K .-E . a n d E k lu n d , G .: “ T h e m uscle v ib ra to r __a useful to o l in neu ro lo g ica l th e ra p e u tic w o rk .” S cand. J. R e h a b . M ed. I : 26-34. 1969. 16. H a g b a rth , K .-E . a n d E k lu n d , G .: “ T o n ic V ib ra to ry Reflexes in Spasticity B ra in R esearch 2: 209-203. 1966. SEPTEMBER 1975 13 O P S O M M I N G D ie ontw ik k elin g v a n die tonies-vibrerende-refleks as ’n diagnostiese e n ’n terapeutiese h u lp m id d e l w o rd bespreek. D ie tonies-vibrerende-refleks w ord gedifinieer as die toniese re fleks-sam etrekking v a n skeletspier w a n n ee r d it o n d e rw o rp e is a a n hoS frikw ensie m eganiese v ibrasie m et refleksinhibisie v a n die a n ta g o n is. H ie rd ie refleks is in die la b o ra to riu m - situ asie v ir die laaste tie n ja a r o n d e rso e k e n die kliniese to e p a ssin g w o rd n o u voorgestel. D ie tyd v a n to ep a ssin g , v ibreringsw ydte en frikw ensie w a t as d ie geskikste vir kliniese g e b ru ik b e skou w ord, w ord bespreek. A n d e r a an v e rw a n te neurofisiologiese a sp e k te v a n die tonies- vibrerende-refleks w ord besk ry f te n o psigte v a n hulle v e rb a n d m et die kliniese situasie. D ie to nies-vibrerende- refleks w ord as ’n n u ttig e h u lpm iddel in fisieketerapeutiese w erk b e sk o u , m et b e so n d e re to e p a ssin g in die neurologiese veld. F isio te ra p e u te m o et die b asiese beginsels v a n hierdie teg n ie k v e rstaa n o m dit m et m ak sim a le voordeel in kliniese p ra k ty k toe te pas. F I S I O T E R A P I E PHYSIOTHERAPY IN T H E COMMUNITY M. J . R U N N A L L S * ♦Senior lec tu re r; H e a d , D e p a rtm e n t o f P h y sio th e rap y , U niversity o f S tellenbosch a n d T y g e rb e rg H o sp ita l, Tiervlei. T he p o p u la tio n e x p losion, to g e th e r w ith im p ro v e d m edical care, h a s led to a n in sid io u s increase in th e n u m b e rs o f geriatric, ch ro n ic ally ill a n d d isabled p a tie n ts. T h e n u m b e r of h o spital beds is ever in sh o rt supply. T h e p o p u la tio n explosion how ever, does n o t seem to have ra dically influenced the n u m b e r o f p ra c tisin g p h y sio th era p ists. A t th e tim e o f w riting a n d w ith c o m p u lso ry re g is tra tio n o f p h y sio th era p ists with th e S o u th A fric a n M edical a n d D e n tal C o uncil having ■*ieen recently p ro m u lg a te d , th e re a re 1 149 registered p ra c tis­ i n g p h y sio th era p ists in S o u th A frica. T h e re su lts o f w hich indicate th e essential a n d ju d ic io u s use o f p h y sio th era p y services, especially de ce n tra lised /d eh o sp ita lised p hysio­ therapy w ith in th e c o m m u n ity . T h e fo llow ing q u e stio n s m ust th e re fo re be p o s e d : (1) Is p h y sio th e ra p y o f any v a lu e in th e c o m m u n ity ? (2) I f so, in w h a t w ay m ay p h y sio th e ra p y services be efficiently a n d com prehensively utilised to th e benefit o f th e c o m m u n ity ? The p h y sio th e ra p ist to d a y m ay n o lo n g er b e re g ard e d as “ the k in d lady w h o m assages p a in a n d p araly sis a w a y ” . The a verage p h y sio th e ra p y tra in in g in S o u th A frica to d ay consists o f a fo u r y e a r B.Sc. degree in P h y sio th e rap y . “ T he trad itio n a l love o f h e a t m u st be su perseded by a m o re realistic a p p ro ac h to th e p a th o lo g ica l c h anges w h ich h a v e o ccurred in disability a n d w h ich a re irreversible. A n a cc ep ta n ce o f the fact th a t a gas o r e lectric fire c a n give as m u c h relief fro m pain as a ra d ia n t-h e a t lam p o r sh o rtw a v e d ia th e rm y m ac h in e m ust b ecom e a re a lity .” (P a tric k 1973) A rticle received M a rc h 1975. T h e official definition o f p h y sio th era p y in S outh A frica states th a t p h y sio th era p y is th e skilled use o f physiologically b ased m ovem ent tec h n iq u es su p p le m e n ted w h e re necessary by m assage, e le c tro th e ra p y a n d o th e r physical m eans fo r the pre v en tio n a n d tre a tm e n t o f injury a n d disease. It is used to assist th e processes o f re h a b ilita tio n a n d re s to ra tio n o f fu n c tio n in cluding th e achievem ent o f p ersonal independence. C learly th e a im o f p h y sio th era p y in th e co m m u n ity sh o u ld bias strongly to w a rd s a tea ch in g a n d advisory c apacity. T h e p a tie n ts , th e ir fam ilies a n d relatives, a n d th e p u b lic in general m u st b e e d u c a te d to a ccep t th eir re sponsibility in p a rta k in g o f th e re h a b ilita tio n a n d long te rm m an a g em e n t o f th e c h ronically disabled a n d diseased. I f th e p a tie n t is in c a p a b le o f a cc epting th e responsibility fo r th e c o n tin u a tio n o f h is/h e r o w n se lf-tre atm en t p ersonally, th is sh o u ld be a ssu m e d by th e fam ily a n d relatives o r b ecom e a p u blic responsibility. T h e ro le o f th e general p u blic in th is re g a rd is extrem ely im p o rta n t. W h a t then, is the ro le o f th e p h y sio th e ra p ist? T h ere a re m any a v enues o p e n to the p h y sio th era p ist w ith in th e c o m m u n ity . I t c a n only be o f benefit to discuss som e o f these avenues. F irstly , c o n sid er th e p ro b lem s involving g e ria tric p a tie n ts. T h e ten d en cy to d a y , is fo r th e o ld er p e rso n to g ra v itate to w a rd s in stitu tio n s w here n u rsin g facilities are availab le if re q u ire d . M an y o f th e e n cro a ch in g pro b lem s o f o ld age c o u ld be stav ed off by a d e q u a te e d u c a ­ tio n o f th e elderly as to th e im p o rta n c e o f m ovem ent a n d th e up rig h t, active a n d a le rte d p o stu re (T ucker, 1960). P a rtic i­ p a tio n in specially o rie n ta te d exercise classes w hich m ain ta in p o stu re , jo in t m o bility, vital cap a city , physical fitness a n d general m o rale sh o u ld be o rganised by p h y sio th era p ists fo r th e h e alth y b u t elderly in such in stitu tio n s. T h e elderly p a tie n t w h o has b e en hosp italise d fo r som e tim e, e.g. fo r th e tre a tm e n t o f th e fra c tu re o f th e n eck o f the fe m u r o r cere b ro -v ascu lar a ccident sh o u ld have th eir hom e en v iro n m en t e v a lu a te d before th e ir discharge. T h eir re h a b ilita tio n p ro g ra m m e sh o u ld e n su re th a t they will be a ble to c ope w ith th e o rd in a ry activities o f daily life such as ge tting in a n d o u t o f th e b a th , being a b le to get to the w ashline to h a n g o u t th e daily w ash a n d , if n eed, to m anage stairs. I t is a lso necessary to see th a t they c a n neg o tia te tra n s p o rt so as to e n su re c o n tin u e d c o n ta c t w ith th e c o m ­ m u n ity ; I do n o t m ea n th e local b u s o r tr a in service, b u t ra th e r th e use o f a taxi o r p riv a te c ar. U n less th e elderly are re h a b ilita te d to this ex te n t, a n d th e ir fears allayed by d e m o n s tra tin g th e ir m o b ility they will ten d to w ith d raw a lto g e th e r. 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. )