CYSTIC FIBROSJ MANAGEMENT ■ by E L Tannenbaum, BSc Phys U C T L MDavids BSc Phys Wits; BA Hons U O FS; Dip Ed Phys Pretoria INTRODUCTION Chest physiotherapy (CPT) form s an integral part of the treatm ent regi­ m en for Cystic Fibrosis (CF). It is aim ed at prom oting mucus and m u­ cociliary clearance. The mucus secre­ tions in CF are thick and sticky be­ cause of the basic defect which affects chloride and water secretion. Recur­ rent respiratory infections cause an increase in the am ount and density of the secretions. This leads to airway obstruction w ith subsequent infec­ tion and destruction of the airway walls and further im pairm ent of m u ­ co cilia ry clea ra n ce. C h est p h y sio ­ therapy is an attem pt to alleviate this process and im prove the quality of life for these patients. O ver the past 10 - 1 5 years a num ­ ber of alternatives to the original pos­ tural drainage (PD) with percussion, have been proposed. The traditional CPT is both time consum ing and un­ com fortable. Its value is questionable in the m ilder cases of CF. Com pliance with the regimen is generally poor and when the patients reach adoles­ cen ce it becom es an even g reater problem . The newer m ethods take less time and can be perform ed by the older child without assistance. This article presents the different m odalities available at present. A l­ though a great many studies have been performed using and com par­ ing the various m odalities, no one method has been proved to be the method of choice. Since CF is an hereditary condition with sym ptom s frequently present­ ing from birth, the C PT has to be age appropriate. Most of the techniques .......... * ________* . discussed are suitable only for the older child and adolescent but it is particularly these age groups that present with com pliance problems. CHEST PHYSIOTHERAPY MODALITIES Postural Drainage Postural drainage (PD) is the con­ ventional physiotherapy treatm ent for CF patients . PD is defined as po­ sitioning the patient to allow gravity to assist the drainage of secretions from specific areas of the lungs. Per­ cussion, shaking and vibration (m an­ ual and m echanical) are performed on the patient in the required posi­ tion. Patient com pliance with PD is poor because it is time consum ing, uncom fortable and som etim es pain- ful . Cystic Fibrosis sputum is thick and tenacious, and the likelihood of it draining through the bronchi is probably minimal. PD in the head- down position increases gastro-oeso- phageal reflux, and diaphragm atic work is increased in order to push the abdom inal contents against gravity on inspiration, thus further com pro­ mising respiratory function . PD po- , sitions recom m ended are alternate side lying and sitting only. These po­ sitions are applicable to children of less than five to six years of age, or until one of the breathing techniques has been affectively mastered. Dur­ ing respiratory infection exacerba­ tions, PD is the treatm ent of choice. A recent study by Lannefors and W ollm ers compared PD, Positive Ex­ piratory Pressure (PEP) and exercise. Interestingly, the PD position to clear the right middle lobe actually cleared the left dependent lung. This indi­ cates that gravity has little or no in­ fluence on mucus m obilisation and other m echanisms are involved. The e f f e c t s of PD in c o r p o r a tin g the Forced Expiration Technique (FET) was conducted by W ebber et a f ’. The results show ed significant im prove­ m ent in large airw ays function and they concluded that the addition of the FET im proves clearance of bron­ chial secretions in PD. Active cycle of breathing techniques The active cycle of breathing tech­ niques (ACBT) is the m ost frequently utilised and recognised m ethod in n the U K . The technique incorporates breathing control and relaxation, tho­ racic expansion exercises and forced expiration. The characteristics of FET can be described as a num ber of huffs from mid to low lung volum es, fol­ lowed by a period of relaxed, control- o led diap hragm atic breathing . The latter is necessary to allow the air­ ways to return to their resting calibre as they narrow follow ing any forced expiratory m anoeuvre. The FET can be explained using the concept of the equal pressure point (EPP)9, which is the point where the pressure within the airways in equal to the pleural pressure. D ow nstream of the EPP, to- w a rd s th e m o u th , th e d y n a m ic squeezing of airw ays allow s secre­ tions to be m obilised and cleared 10. As lung volum e decreases the EPP's move peripherally and a huff to low lung volum e clears secretions from the peripheral airw ay s11. Secretions m obilised to the upper airw ays is cleared by a huff from high lung vol­ ume! T h e A C B T w a s d e s c r ib e d by Louise Lannefors at a recent CF Sy m ­ posium 4. ACBT should be perform ed daily, even with m inim al chest sym p­ toms. The technique is repeated until the huff becom es dry sounding and non-productive, or a rest interval is needed. Recom m ended positions for treatm ent are sitting and/or alter­ nate side lying. The cycle consists of the following: • Relaxation and breathing control 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. ) (approxim ately one m inute). • Thoracic expansion exercises (4 or 5 deep breaths, em phasising insp i­ ration, with passive expiration - encou rages airflow through the c o l la t e r a l v e n t i la t o r y s y s te m : pores of K ohn and canals of L am ­ b e rt, in c r e a s in g a irflo w in the sm aller bronchi helping to m obi- 12lise secretions .) • FET (huffs from m id to low lung volum e, and breathing control). M obilised secretions are then ex­ pectorated. Pryor and W ebber11 evaluated the FET with PD in com parison to PD and percussion in 24 CF patients. The results show ed that sputum cleared in less time, and FEV increased after FET. U sing the A CBT in PD position, 13Pryor et al m easured oxygen satu­ ration, and concluded that there was no evidence of hypoxaem ia during the procedure. A C BT offers the p a­ tient a m eans of clearing secretions without the assistance of another p er­ son or a m echanical device . Positive Expiratory Pressure The rationale for the use of p osi­ tive expiratory pressure (PEP) is that it is a m ethod w hich will open up and recruit the obstructed lung periph- 15ery . PEP increases the airw ay trans­ m ural pressure in the lung - centrally and peripherally, which results in di­ lation of the bronchial tree; This p ro ­ motes inflow of air behind obstruc­ tions through the bronchial route or c o lla te r a l c h a n n e ls , re a c h in g o b ­ structed or collapsed lung periph­ ery15'16 The treatm ent m odality used is the PEP m ask. It consists of a face m ask and a one-w ay valve to which expi­ ratory resistors are attached. The re­ sistance is m easu red usin g a m a­ nom eter to enable the individual to m aintain a PEP of 10 to 20cm H 2O during m id expiration. The sm allest diam eter resistor which the patient can use com fortably for two m inutes w hile sim u ltan eo u sly m ain tain in g the correct PEP level is the suitable one. Treatm ent is perform ed in the 17sitting position . The m ask m ust be airtight over the nose and m outh. The patient inspires slowly and deeply th ro u g h the m a sk . E x p ir a tio n is slightly activated but not forced. This cycle is continued for 10-15 respira­ tions, the patient then rem oves the m ask and does FET to expectorate m obilised secretions11. Since som e patients found the m ask claustropho­ bic, a m outhpiece PEP device was designed and used by teenagers at the Red Cross C hildren's H ospital18. F alk et a/16 com pared the tech­ niques of A: PD and percussion, B: PD and PEP m ask, C: PEP in sitting position and D: FET in sitting posi­ tion. Sputum production was great­ est in B and C, and skin oxygen ten­ sion was increased follow ing treat­ m ent C. Falk concluded that PEP should be incorporated into physio­ therapy regimens. In a sim ilar study, Tyrell et a l19 showed that the PEP m ask alone did not clear the chest adequately and PEP should be used in conjunction with FET. The effect of PEP breathing in CF was conducted 90 by van der Schans et al . They stud­ ied mucus transport in the lung using a ra d io a ctiv e a e ro so l tracer tech ­ nique. Three m ethods were evalu­ ated, nam ely: coughing, PEP with pressure of 5cm and 15cm H 2O. The results showed that PEP temporarily increases lung volum e, but it did not im prove m ucus transport. The PEP m ask is a useful adjunct m ethod of chest physiotherapy which should be used in conjunction with other tech­ niques21. 4. Flutter VRP1 Legend: I . M o u th p ie c e . 2 . Circular cone. 3 . High density stainless s le e l ball. 4 . Perforated protective cover The flutter is a small, sim ple hand ­ held device which generates a con­ trolled oscillating positive pressure w h o s e fr e q u e n c y c a n be m o d u ­ lated .T h e oscillating pulsed during expiration increase airw ay patency and expiratory flow. The vibratory effect enhances m ucus clearance. As the patient exhales, the ball is displaced and then rolls back into place. The fluctuations in pressure result in oscillations of positive expi- 22ratory pressure and airflow . The bronchi are dilated up to the periph­ eral bronchioles. This positive expi­ ratory pressure vibrates the airway walls to loosen m ucus, decreases the collapsibility of the airw ays and ac­ celerates airflow . The frequency of o s c illa tio n s ca n b e r e g u la te d by changing the inclination o f the device slightly up or dow n from the hori­ zontal position. Use of the flutter In a sitting position, the patient m ust relax and take a few norm al breaths. The patient then takes a deep breath, inserts the device into the m o u th and clo se s the lip s firm ly around it. K eeping the cheeks flat, the p atient breathes out norm ally and deeply through the flutter. This cycle is repeated 10-15 tim es and m obilised secretions are then expectorated. The only contraindication for use of the flu tte r is a p n eu m o th o rax . H ow ever, hyperventilation could re­ sult in dizziness and should this oc­ cu r, fr e q u e n t s h o rt in te rru p tio n s every 5 -1 0 cycles m ust be encour­ aged22. A few studies have investigated the efficacy of the Flutter. K onstan et 23al evaluated the am ount of sputum ex p e cto ra te d co m p a rin g the tech­ niques of the Flutter, vigorous volun­ tary coughing and PD w ith percus­ sion. The results show ed that subjects using the flutter expectorated three tim es the am ount o f sputum com ­ pared to the other techniques. No lung function tests w ere recorded but a later study by Casaulta evaluated lu n g fu n c tio n . It c o m p a re d PEP- m ask versus the flutter. A fter use of the flutter; VC, F E V i, and M EF50 in­ creased significantly com pared to the PEP mask. The advantage of the flutter is that 22 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. ) it is a relatively inexpensive device - which is also small, easily transport­ able, and allow s for in d ep en d en t physiotherapy. Autogenic Drainage Autogenic drainage (AD) was de­ vised in 1967 by Jean C hevaillier in Belgium 24. C hevaillier observed that mucus clearance was enhanced dur­ ing forced expiratory m anoeuvres, p la y in g , b r e a th in g a c tiv itie s and laughing. Chevaillier described A D by the principle of reaching the great­ est possible airflow in different re­ g io n s o f b r o n c h i b y c o n t r o ll e d breathing, put into practice by three 26phase breathing exercise . At the beginning of AD, inspira­ tion is perform ed slowly through the nose to provide optim al hum idifica- tion. Expiration is done through the open glottis and open m outh, w ith­ out pursed lips. • Phase 1 : peripheral loosening of mucus This pase begins w ith a directed in creased in sp iratio n follow ed by deep expiration. Sim ultaneously, the mid tidal volum e is low ered in the range of norm al expiratory reserve volum e (ERV). Com pression of the peripheral alveolar ducts m obilises secretions from the peripheral lung regions26. • Phase 2 : collection of m ucus in large airw ays This second phase is achieved by d eep ening in sp iration and exp ira­ tion. M id tidal volum e is changed gradually from ERV into the insp ira­ tory reserve volum e (IRV). The veloc­ ity of flow m ust be co n tro lled to avoid high flow peaks which result in spasm of the collapsible segm ents at the equal pressure point26. • Phase 3 : transport of m ucus from the large airways to the m outh In the third phase, the patient in ­ cre a s e s re s p ir a to r y flo w s ta rtin g from a level at about the m iddle of the inspiratory reserve capacity. M ucus is expectorated by a sm all burst of coughing or huffing. T h e G e rm a n p h y s io th e r a p is ts have sim plified the Belgian method of AD, as they observed that respira­ tion in the ERV range seldom oc­ curred because patients were uncom ­ fortable breathing at low m id tidal 25volume . T h e p a tie n t b e g in s by varying the m id tidal volum e and adapts the process to the individual need w ithout excessive force. After every inspiration, the patient holds his breath for 2-3 seconds, followed by a passive but fast expiration to norm al expiratory level, follow ed by further active expiration to low ERV. A D is a difficult technique for the physiotherapist to learn and equally so in teaching the patient, therefore A D should be learned under the su­ pervision of a trained physiothera­ pist from one of the lim ited num ber of centres in Europe. The patient is initially guided by tactile and audi­ tory assistance of the physiothera­ pist, and gradually takes over and uses his/her proprioceptive sensa­ tion s for d etectin g m ov in g secre­ tions. A D requires considerable pa­ tient cooperation and m odification where indicated. Schoni registered flow volum e curves of CF patients during AD. T h is s tu d y sh o w e d th a t d u r in g forced expiration, com pression oc­ curs at low lung volum es, whereas, during A D, higher flow occurs m o­ m entarily with the sam e low lung volumes without bronchial collapse. The techniques of A D and A CBT w ere com pared in a study by M iller 27et al . A significant difference was that A D im proved FEF m ore often than ACBT and mucus clearance was greater on the A D treatm ent days. They concluded that AD is as effec­ tive as ACBT. Exercise Physical activity plays an im por­ tant role in daily life. Different forms of physical activity such as exercise, games and sport prom ote well being - physically, m entally and socially. Exercise therapy can range from 10 m inutes to vigorous sessions of hour- long activities including swimming, jo g g in g , g y m n a stic s, c y c lin g and 28skipping . The m ini-tram poline has b e e n in c lu d e d in p h y s io th e r a p y treatm ent of CF patients to avoid mo- 2 9notony in training . R esearch has not defined w hich physical activities are optim al for m obilising secretions. H o w e v e r, the c h o ic e o f e x e r c is e should be determ ined by the patient ^4n relation to the severity of their lung < disease, their environm ent and m oti- an vation . Physical activities selected for e n jo y m e n t g en era te in creased m otivation and enthusiasm , and en­ courage com pliance. Patients w ith m ild or m oderate lung disease may not find their exercise capacity se­ v e re ly lim ite d , in c o m p a ris o n to those with severe lung disease who m a y e x p e r ie n c e d i f f i c u l t y w ith physical exercise and require regular supervision31. S o m e p a tie n ts w ill p a r tic ip a te in s p o r tin g a c tiv itie s while others w ill be satisfied to climb stairs with m inim al breathlessness. M any first referral patients are un­ aw are of the im p o rta n ce o f exer- cise •. The physiotherapist should in­ troduce exercise to all CF patients, especially at an early age. It is im por­ tant to encourage children to partici­ pate in physical activities at hom e and at school. The patient and the physiotherapist should be aw are of dangers such as the possibility of in­ fectiv e e x a c e rb a tio n s, e x e rcise in­ duced asthm a, inju ry, exercise in­ duced arterial oxygen desaturation and the risk of salt depletion after 3 3strenuous exercise in h ot w eather . A recent study of Lannefors and W ollm er5 show ed that m ucociliary clearance of radiolabelled particles by physical exercise, PEP and PD and percussion was not statistically d if­ ferent. Exercise, was how ever, asso­ c ia te d w ith the lo w est clearan ce. C em y conducted a study on bron­ chial drainage and exercise for in- h o sp ital treatm en t o f C F patients. T h e study show ed sig n ifican t im ­ proved spirom etry. O renstein et a/34 showed no im provem ent in FE V 1 af­ ter exercise, but FE V 1 in their control chest physiotherapy groups had sig- 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. ) nificantly deteriorated. Salh et al studied the role of exercise and con­ v en tion al physiotherapy in aiding sputum expectoration. The results indicated no im proved am ounts of sputum expectoration with exercise, and concluded that exercise should not be considered as a replacem ent, b u t ra th e r an a d ju n ct to p h y sio ­ therapy. CONCLUSION T h e r e a r e n u m e r o u s p h y s i o ­ therapy m odalities available for CF patients. In addition to conventional PD se v e ra l new te ch n iq u e s h ave been developed during the past 10- 15 years. The physiotherapy m od al­ ity m ust be effective, less tim e-con­ suming, appealing to the patient and a llo w fo r g r e a te r in d e p e n d e n c e . Physiotherapists should be flexible in their approach to the treatm ent of CF patients. Parts of one m odality can be a p p lied and in teg rated in other m ethods and a com bination can be beneficial. The question of which m odality to use or which one is m ore effective often arises. A m o­ dality w hich su its the in d iv id u al needs of the patient and at which he/she is com petent is optim al. P a­ tients should be involved in this de­ cision m aking w hich will enhance c o m p lia n c e w ith in -h o s p ita l and hom e physiotherapy. Physiotherapy sh o u ld in te r fe r e m in im a lly w ith daily living. REFERENCES 1. D a v id s L M . In v e s tig a tio n in to c o m p lia n c e w ith p h y s io th e r a p y re g im e n in c y s tic f i­ b ro s is . S o u th A fr ic a n J o u r n a l o f P h y s io th e ra p y 1 9 9 0 ;4 6 :7 -1 0 . 2. R e rs m a n JJ, R iv in g to n -L a w B, C o re y M cl al. 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E ffe c t o f p o s itiv e e x p ir a to ry p re s s u r e b re a th in g in p a tie n ts w ith c y s tic fib ro sis. T h o r a x 1 9 9 1 ;4 6 :2 5 2 -2 5 6 . 2 1 . S te e n H J, R e d m o n d AOI1, O 'N e il D et al. E v a lu a tio n o f th e P E P M a s k in C y s tic Fi­ b ro sis. A c ta P a c d ia tr S c a n d 1 9 9 1 ;8 0 :5 1 -5 6 . 22 . F lu tte r V R P 1: In fo rm a tio n lea flet fo r th e p a tie n t. L e a flet a c c o m p a n ie s F lu tte r V R P i in b o x . M a n u f a c t u r e r : V a r i o r a u S A , A u b o n n e S w itz e r la n d . 23. K o n sta n M W , S te rn RC , D o e r s h u k C F . E f­ fic a c y o f th e F lu tte r fo r a irw a y m u c u s c le a r ­ a n c e in p a tie n ts w ith c y s tic fib ro s is . J P ac­ d ia tr 1 9 9 4 ;1 2 4 :6 8 9 -6 9 3 . 2 4 . C a s u a lt a C . E f fic a c y o f c h e s t p h y s i o ­ th e ra p y (P E P -m a s k v e rs u s F lu tte r) in p a ­ tie n ts w ith c y s tic fib ro sis (C F ). P o s te r p r e s - e n ta tio n a t th e 1 9 9 3 E R S (E u ro p e a n R e s p i­ ra to ry S o c ie ty ), Italy. E u r R e s p J 6 (S u p p l 17, S e p t 1 9 9 3 ): 2 2 0 s (A b s tra c t P 0 4 5 9 ) . 25. D av id A . A u to g e n ic d r a i n a g e - th e G e rm a n a p p r o a c h . In: P ry o r J A , ed . R es p ir a to r y C are L o n d o n : C h u r c h ill L iv in g s to n e 1 9 9 1 :6 5 -7 8 . 2 6 . S c h o n i MI L A u to g e n ic d r a in a g e : a m o d e rn a p p r o a c h to p h y s io th e r a p y in c y s tic fib ro ­ sis. IK S o c M e d l9 8 9 ;8 2 (S u p p l l6 ):3 2 -3 7 . 27. M ille r S, H all D. C h e s t p h y s io th e r a p y in c y s tic fib ro s is (C F ). A c o m p a r a tiv e s tu d y o f a u to g e n ic d r a in a g e (A D ) a n d a c tiv e c y c le b r e a t h in g t e c h n i q u e s (A C B T ) (fo r m e r ly F E T ). C o n g r e s s a b s tr a c t s , S e v e n th A n n u a l N o rth A m e r ic a n c y s t ic fib ro s is c o n fe r e n c e , T e x a s . O c t 1 9 9 3 , P a e d P u lm ( S u p p l 9) 1 9 9 3 ;1 6 :2 6 7 -2 6 8 . 28 . S t a g h e lle J K . P h y s ic a l E x e r c is e fo r p a tie n ts w ith c y s tic fib ro s is : A re v ie w . Int / S p o rts M e d 1 9 8 8 ;9 (S u p p l):6 -1 8 . 2 9 . S t a n g h e le JK , H je ltn e s N , B a n g s ta n d HJ et a l. E ffe c ts o f D a ily S h o r t B o u ts o f T r a m p o ­ lin e E x e rc is e d u r in g 8 w e e k s o n th e P u lm o ­ n a ry F u n c tio n a n d th e M a x im a l O x y g e n U p ta k e o f C h ild r e n w ith C y s tic F ib ro s is . h it I S p o r ts M e d 1 9 8 8 ;9 (S u p p l):3 2 -3 6 . 3 0 . D o d d M E . E x e r c i s e in C y s t i c F ib r o s is A d u lts . In P r y o r JA , ed . R e s p ir a to r y C are. L o n d o n : C h u r c h ill L iv in g s to n e 1 9 9 1 :2 7 -4 9 . 31 . S t a n g h e lle JK , M ic h a ls e n H , S k y b e r g D. F iv e Y e a r F o llo w - u p o f P u lm o n a ry F u n c ­ tio n an d P e a k O x y g e n U p ta k e in 16 Y ea r- O ld B o y s w ith C y s tic F ib ro s is , w ith s p e c ia l re g a rd to th e I n f lu e n c e o f R e g u la r P h y s ic a l E x e rc is e , h i t / S p o r ts M e d 1 9 8 8 ;9 (S u p p l):1 9 - 24. 32 . M o rto n S , G ilb e r t J, L ittle w o o d JM . Tine C u r r e n t P h y s ic a l T h e r a p y R e g im e n s o f 1 08 C o n s e c u t iv e P a tie n ts A t te n d in g a re g io n a l C y s tic F ib ro s is U n it. S c a n d / G a s tr o e n te r o l 19 8 8 ;2 3 (S u p p l 14 3 ): 1 10 -1 1 3 . 3 3 . C e r n y FJ- R e la t i v e e f f e c t s o f b r o n c h ia l d r a in a g e a n d e x e r c is e fo r in -h o s p ita l c a r e o f p a tie n ts w ith c y s t ic fib ro s is . P h y s T h e r 1 9 8 9 ;6 9 :6 3 3 -6 3 9 . 3 4 . O r e n s te in D M , F r a n k lin B A , D o e rs h u k C F et a l. E x e rc is e c o n d itio n in g a n d c a r d io p u l­ m o n a r y fit n e s s in c y s t i c fi b r o s i s . C h est 1 9 8 1 ;8 0 :3 9 2 -3 9 8 . 3 5 . S a lh W , B ilto n D , D o d d M e t a l. E ffe c t o f e x e r c is e a n d p h y s io th e r a p y in a id in g s p u ­ tu m e x p e c t o r a t io n in a d u lts w ith c y s tic fi­ b ro s is . T h o r a x 1 9 8 9 ;4 4 :1 0 0 6 -1 0 0 8 . ^SMITH A N D NEPHEW ^ EDUCATIO NAL TRUST S m ith an d N e p h e w a n n u a lly d o n a te a T ra v e l B u rsa ry to m e m b e rs of th e S A S P in recog nition of th e long as s o c ia tio n of th e C o m p a n y w ith th e p h y s io th e ra p y p ro fessio n . C rite ria for th e a w a rd of this a n n u a l b u rs a ry a re: • T h e N a tio n a l E x e c u tiv e C o m m itte e selects th e s u ita b le c a n d id a te or c a n d id a te s . • T h e b u rs a ry is a w a r d e d to a p h ysio th e ra p is t w h o is p re se n tin g a p a p e r at a local or o v e r­ s e a s c o n g re s s. • F o llo w in g pu b licatio n of th e p a p e r in th e p ro ­ c e e d in g s of th e C o n g re s s a tte n d e d , th e p a ­ p e r will b e pu b lish ed in th e S A S o c ie ty of P h y s io th e ra p y J o u rn a l. (C a n d id a te s m ust th e re fo re e n s u re th at p e rm iss io n is o b ta in e d for the p a p e r to b e p u b lis h e d in th e S A S P J o u rn a l, from th e C o n g re s s S e c re ta ria t). • A p p lic a tio n s from a n y p h y s io th e ra p is t w h o will b e p re se n tin g a p a p e r at a c o n g re s s , m ust be su b m itted to th e H e a d O ffic e of th e S A S P , to g e th e r w ith a short C V a n d m o tiv a tio n b y 31 M arc h e v e ry y e a r (th e no tice for 1 9 9 5 a p ­ p e a re d in th e J o u rn a l in A u g u s t 1 9 9 4 ). T h e S o u th A frica n S o c ie ty of P h y s io th e ra p y is v e ry g ratefu l for this g e n e ro u s g e s tu re by S m ith an d N e p h e w , w h ic h will b e of p a rtic u la r v a lu e in th e s e difficult e c o n o m ic tim es. V ______________ _ ______________ J 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. )