74 F I S I O T E R A P I E SEPTEMBER 1980 T A B L E I CLASSIFICATION OF IN CIDENTS - A rea June 1979 July 1979 A Interpersonal I R elatio n sh ip w ith p a tie n t 46 33 79 I I R e latio n sh ip w ith fam ily 24 7 31 I I I R elatio n sh ip w ith h ealth team 24 17 41 B Assessment 41 21 + 1 63 new incident C Treatment 59 27 86 194 105 1 ♦EFFECTIVE/INEFFECTIVE F ro m y o u r experience, th in k o f a recen t situ atio n in w hich you observed o r you d id som ething w hich illus­ trated an adequate/inadequate* perfo rm an ce by a phy sio ­ therapist. 1. Briefly describe th e back g ro u n d to th e incident. 2. H ow experienced w as th e ph y sio th erap ist? Y ears since qualification. 3. H ow experienced w as th e observer? 4. D escribe exactly w h at the p h y sio th erap ist did. 5. W hat m o re effective/ineffective* b eh av io u r m ight be expected in a sim ilar situ atio n ? 6. W here was th e observation m ade? P lease tick th e a p p ro p ria te block. G en eral H o sp ital Special School P riv a te P ractice Special In s titu tio n O ther * Please delete th e one w hich is n o t a p p ro p riate. to m ine. T h is reaso n ab ly h ig h co rrelatio n led m e to assum e th a t a p an el o f th ree judges w ould be sufficient to so rt o u t an d categorise th e incidents in th e m ain study to be do n e in 1980. In o rd er to check the re li­ ab ility o f th e classification system, I re-classified a sam ple of the incidents tw o m onths afte r com pletion o f th e study. DISCUSSIO N F ro m the fav o u rab le results o f the p ilo t study, a full study is being p lanned in w hich p h y sio th erap ists fro m different p arts o f th e country will take part. A dditional in fo rm a tio n w ill be gathered concerning the in stitu tio n o r p ra c tic e in w hich th e observ atio n w as m ade an d the length of tim e since qualification o f the observer. A ran d o m sam ple o f a b o u t 200 physiotherapists will be app ro ach ed , th e n u m b er representing approxim ately 1/5 o f the total n u m b er of practising physiotherapists in S outh A frica. T hese w ill be draw n fro m different areas to ensure th a t all fields in w hich a p h y sio th era­ pist practises, are covered. Incidents w ill be collected an d classified u n til no m o re than one new b e h a v io u r is reported in every 100 incidents exam ined, in o rd e r th a t a sufficiently large an d representative sam ple o f behaviours is obtained. O nce all the incidents have been collected and clas­ sified, a list of effective an d ineffective beh av io u rs wiU- be draw n u p. * F ro m these specific observable b ehaviours, it is in ­ tended th a t a full set o f learning objectives w ill be established. By establishing th e k in d o f b eh av io u r a stu d en t should achieve to dem onstrate professional com petency, a cu rriculum can be planned w hich w ill m eet society’s needs. T h is will ensure th a t th e cu rriculum w hich has evolved som ew hat h ap h azard ly over th e years, is based on a m o re secure an d scientific fo u n d atio n . T h e in itial classification o f 194 incidents w as done in June, fro m th e first 106 retu rn ed form s. In July a fu rth e r 74 fo rm s w ere analysed and from the 105 incidents extracted, only one new in cid en t w hich re q u ire d an ad d itio n al sub-area w as found. References 1. B arham , V irg in ia Z. (1963). Id entifying effective b eh av io u r o f th e nursing in stru cto r th ro u g h critical incidents. E d. D . D issertation. U n iv ersity o f C ali­ fo rn ia, Berkely. 2. F lan ag an , Jo h n C. (1954). T h e critical incident tech­ nique P sychological Bulletin 51, 4. 3. Jensen, A lfred C. (1960). D eterm in in g critical re ­ quirem ents f o r nurses N ursing Research 9, 1. 4. M iller, G eorge E. (1968). T h e orthopaedic training study J. A m er. M ed. Assoc., 206, 3. T R E A T M E N T N O T E : STRAIGHT LEG RAISE AS L O R N A A healthy fit 19 year old am ateur cyclist presented w ith low back and leg pain, w hich occurred only during cycle training. A diagnosis of b ilateral sciatica w ith general hypom obility w as made. In M arch 1978, th e p atien t kicked a ball and his leg becam e “ lam e” fo r a sh o rt tim e. H e h ad com plete recovery in tw o m onths. T h e first nine m onths of 1979 were spent cycling in E urope. In A ugust 1979 he lifted a heavy weight, resulting in severe p a in in b o th legs down to his heels th a t night. T his recovered th e next day. In th a t m o n th he also had a severe fall off his * F o u rth year stu d en t B.Sc (Physiotherapy) U .C.T. Received 8 A ugust 1980. A TREATMENT TECHNIQUE N EL SO N * bicycle. D uring subsequent chiropractic treatm en t in Belgium, the p atien t was told th at he had S ch eu erm an n ’s disease. H is back was m anipulated, after w hich he still h ad p a in in his legs but only on cycling. In O ctober 1979 he had chiropractic treatm en t in South A frica. H e was given massage and “pressing on th e spine” , w ith relief fo r two weeks, after which he developed cram ps in the legs. T h e p a tie n t presented at Back C linic in M arch 1980 w ith low back pain an d “ lam eness” of his legs. H e reported neither leg p ain n o r leg cram ps. Because o f his sym ptom s his cycle training h ad been reduced from 120 km to only 50 km a day. O n subjective exam ination, th e p a tie n t reported pain of sciatic and low back distribution, w hich was referred 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 1980 P H Y S I O T H E R A P Y 75 D A T E A t beginning of training SY M PT O M S M iddle of training N ear end of training T R A IN IN G S P E E D and d istance covered ________ (km) 3.4.80 + + + (no sym ptom s) 4.4.80 P ain in L quads. Pain in L buttock. 5.4.80 + + + 6.4.80 + + + 7.4.80 N o training 8.4.80 Slight pain in legs thro u g h ­ out training, m ore in R th an L 9.4.80 P ain in L ham string Stiffness and pain in back th ro u g h o u t training 10.4.80 Stiffness in back Pain in b o th ham strings and discom fort in b ack thro u g h ­ out 11.4.80 P ain in both ham strings th ro u g h o u t th e training 12.4.80 Pain in b o th ham strings th ro u g h o u t th e training 13.4.80 P ain in quads. 14.4.80 N o training 15.4.80 P ain in L T ib. A nt. m uscle 16.4.80 + + + 17.4.80 + + + 18.4.80 P ain in ham strings 19.4.80 + + + 2 0.4 .8 0 + + + 21.4.80 N o training 22.4.80 + + + 23.4.80 + + + 24.4.80 Pain in ham strings 25.4.80 N o training 26.4.80 P ain in ham string area th roughout th e training 27.4.80 P ain in ham strings, greater in R th an L, and discom ­ fo rt in back 28.4.80 + + + 29.4.80 + + + 30.4.80 P ain in quads. D iscom fort in the back th ro u g h o u t the training 1.5.80 + + + + + + Stopped training + + + + + + + + + + + + Pain in back C ram p in R ham string, Stopped, m assaged + + + + + + Pain in ham strings D iscom fort in back + + + Pain in back and ham strings Pain in ham strings, discom ­ fo rt in back P ain in ham strings D iscom fort in the back Pain in back P ain in back and R h a m ­ string Pain in R quads then pain in back Pain in back Pain in ham strings P ain in ham strings + + + P ain in ham strings P ain in ham strings D iscom fort in back P ain in back + + + Slow 100 A lm ost nil Sprints 50 + 50 Slow 55 Slow 90 Slow 80 Slow 70 Slow 60 Slow 60 Sprints 120 Sprints 85 Sprints 60 Slow 90 Slow 120 Slow 120 Slow 120 Sorints 60 Slow 90 Sprints 50 slow slow Slow 180 Slow 120 Sorints 60 Sprints 60 Sprints 50 Slow 90 and severe” . T his pain occurred only during cycling, disappearing a fte r cessation o f training and a hot bath. H e had no neurological sym ptom s. On objective exam ination all m ovem ents w ere full and pain free, except flexion, w here he could reach 20 cm above the ankles w ithout pain. N o signs of ten d er­ ness, nor any abnorm ality of hips or peripheral pulses were dem onstrated. T h ere w ere also no neurological signs. Straight leg raise was 45° on both sides. T he possibility of ankylosing spondylitis or o th er inflam m a­ tory disease was excluded, and th e presence, in mild form , o f S cheuerm ann’s disease was noted. H is problem s therefore appeared to be th a t o f tight m usculo-tendinous structures, a n d /o r lack of m obility of pain sensitive structures w ithin the spinal canal. A treatm en t program m e was initiated w ith th e a d ju st­ 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. ) 76 F I S I O T E R A P I E SEPTEMBER 1980 m ent by the orth o p aed ic surgeon of the racing bicycle. T h e handle bars were raised and the saddle lowered in o rder to decrease his flexed posture. H e had M aitland m obilisations th ree tim es w eekly for fo u r weeks. T he technique used was straight leg raise on right and left legs, grade IV , fo r three periods of th irty seconds fo r each leg. H e was taught M a cN ab ’s regim e of flexion exercises, as well as back extension exercises to co u n ter­ act his flexed p osture during cycling. H e had intensive counselling on how to avoid back stress situations during his daily activities. F inally, he was ta u g h t an active ham string-stretching exercise. H is subjective re ­ ports concerning his training show ed interesting v a ria ­ tions (see table); e.g. th e p atien t com m ented th a t he felt m ore im proved during the first and th ird weeks th an th e second an d fo u rth ; the sym ptom s were not consistent w ith either th e speed of training or the dis­ tance covered; the sym ptom atic areas varied frequently but, again, with n o consistent pattern. T h e fa c t th a t he had S cheuerm ann’s disease had been stressed by a chiropractor, and the p atien t was obviously concerned over this fact. O n radiological exam ination, although presence o f the disease could be detected, it was said to be of no consequence. It was felt how ever, th a t an eye should be kept on this clue to his habitual flexed posture during cycling. T h e final assessm ent o f straig h t leg raise w as 70° fo r both legs, i.e. still lim ited although im proved. T h u s it was felt to be im p o rtan t fo r the p atient to continue w ith the stretching exercise f o r the ham strings, w hich w ould also m obilise the structures in the spinal canal. A cknow ledgem ents D r. G. du T oit, M rs. N. G ilder, M iss V. B aart. THE THERABATH a light, portable, economically-priced W a x Bath Therabath provides effective paraffin heat treatment for arthritis, chronic joint Inflammation, stiffness, muscle spasm and athletic o r other injuries. Hands, feet or elbows are immersed, paraffin is brushed on other areas. Thermostatically controlled to hold the special Theraffin w ax at a beneficial 126° to 130°F. Portable for use any­ where. Uses less than 25 watts of electricity; operates for less than ten cents a day. Initial supply of Theraffin wax included. M E D I C A L D I S T R I B U T O R S Price R147.50 including wax plus G.S.T. P T Y LTD E D M S BPK •CAP E Y O R K ' | 252 JEPPE S T . | J O H A N N E S B U R G | D e W a a l H o u se, 172 V ic to r ia Road I W o o d s to c k . C.P. PLEASE A D D R E S S ALL C O R R E S P O N D E N C E T O P .O . BO X R IG A S S E B L IE F ALLE K O R R E S P O N D E N S IE A A N P O S B U S 337 8 J O H A N N E S B U R G 2000 TEL. A D D . 'D 1 S M E D ' PH O N E | FO O N 23-810 6 TELEX: 4 3-712 9 S .A . 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. )