R E S E A R C H A R T I C L E T h e I m p a c t o f C e r v ic o g e n ic H e a d a c h e o n Pa t ie n t s A t t e n d i n g a P r iv a t e P h y s i o t h e r a p y P r a c t i c e i n C a p e T o w n A B ST R A C T : H eadache (HA) disorders constitute a public health problem which impacts on individuals an d on society. The fu n c tio n a l limitations and participation restrictions caused by chronic H A ’s m ay be a more reliable indi­ cation o f the severity o f the disorder than the intensity a n d HA pattern itself. Evaluation o f all these param eters m ay assist holistic assessment, with impact on the health care o f chronic HA sufferers. A quantitative retrospective study o f 450 p a tie n ts’ perceptions o f the im pact o f chronic recurrent cervicogenic HA (CRCHA) was done by reviewing clinical notes m ade a t fir s t consultation. Bio-dem ographic data, Total Pain Pattern an d im pact o f H A ’s on function, relationships an d em otions were recorded using Likert scales. High scores were reported f o r severe fu n ctio n a l disability (60% o f the subjects), f o r considerable em otional handicap (41%) and f o r negative impact on close relationships (86%). D ecreased productivity was reported by 89% o f the population studied. Subjects expressed emotions o f anxiety (75%), anger (48%) and helplessness (62%). CRCHA has a severe im pact on the health-related quality o f life o f individuals. A combination o f these results and existing instruments is currently being used to develop a m easuring instrum ent reflecting a bio-psychosocial approach to assessment. This m ay improve physiotherapy m anagem ent o f CRCHA patients and m ay fa cilita te outcom e-based research in this field. K E Y W O R D S: CERVICO G ENIC HEADACHE, FU N C TIO N AL LIMITATION, PARTICIPATION RESTRICTION, Q U A LITY O F LIF E A SSE SSM E N T INTRODUCTION This study was done as part o f a process o f d ev elo p in g a h o listic in stru m en t to assess the severity and im pact of chronic (longer than one year), recurrent (once a m onth or m ore) cervicogenic headache (As described by Edeling, 1994; Jull, 1997) on patients. W hen using a biopsychosocial approach to health care, the im pairm ent as well as the im pact on functional activities and participation in life situations m ust be addressed. T he World Health Organisa­ tion (W H O ) refers to the consequences o f im pairm ent (abnorm ality o f body function) in term s o f lim itation o f acti­ vities (previously described as function­ al disability) and restriction o f participa­ tion (previously described as handicap) (W H O , 1999). M easuring headache- related disability may provide physio­ therapists with inform ation that can help in determ ining w hich treatm ent options m ay be optim al for the patient. This process is challenging because o f the wide spectrum o f intensity and frequency o f attacks, and variation in im pact o f the im pairm ent on individuals. There is a dearth o f inform ation on the im pact o f headache (HA) on the quality o f life o f individuals suffering from m igraine and ten sio n -ty p e head a ch e (T T H A ) (Blom kvist et al, 1997; D avies et al, 1999;Fishman and Black, 1999; M ichel et al, 1999; Peterson-B raun and Gobel, 1994). However, no studies were found which included a group o f individuals suffering from CRCHA. T he author, w hile assessin g HA patients, experienced a need fo r an in stru m en t sp e cifically d esig n ed to m easure the im pact o f C R C H A on the quality o f life o f p atien ts. P h y s io ­ therapists see them selves, in a broad context, as trying to influence the ability o f the patient to function, to cope with the disorder and to m anage the associated distress. A lthough several instrum ents developed to m easure disability result­ ing from low back pain, neck pain and chronic pain are currently used by physiotherapists, these do not include specific questions to m easure the func­ tional and psychosocial im pact usually reported by individuals seeking treatment for CRCHA. Instrum ents to assess the quality o f life and functional lim itation in individuals with m igraine (described as sev ere, ep iso d ic, sho rt d u ratio n episodes o f HA) have been developed and valid ated (D avies et al, 1999; Stewart et al, 1999; M ichel et al, 1999). Instrum ents have also been developed for assessing and com paring quality o f life in groups w ith m igraine, cluster HA (described as short very severe episodic attacks o f HA), and TTH A (described as longer-lasting m oderate intensity HA) (Holroyd et al, 1997; Jacobson et al, 1994; K ryst and Scherl, 1994). The contents o f these and o f generic health- related quality o f life questionnaires m ay facilitate the developm ent o f a m easu rin g in stru m en t fo r C R C H A . A lthough the International H eadache S ociety (IH S )(1 9 8 8 ) has c lassified C O RRESPO ND EN C E TO: I D iener 16 Form osa Street, Stellenbosch 7600 Tel: (012) 887-1804 Fax: (012) 883-2108 E-m ail: idiener@ icon.co.za DIENER I , BSc1 1 Private Practice and part-time Lecturer at the University of the Western Cape SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 35 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. ) mailto:idiener@icon.co.za headaches into num erous categories, the im pact o f chronic recurrent HA o f any type on function, . social relations and em otional life is not dictated by the hypothesized origin/etiology o f the HA, but by its intensity, tem poral pattern, chronicity and response to therapy, as well as the psychological m ake-up o f the in d iv id u al (F ishm an and B lack, 1999). The severity o f the HA im pacts on the coping response in m ost patients. This was confirm ed in a study where a direct relationship was established betw een increased HA intensity and frequency, and decreased quality o f life, in individuals experiencing m igraine and TTHA (Jacobson et al, 1994). They also established that self-perceived dis­ ability resulting from HA was sim ilar for these two groups o f patients. In the p h y sio th erap y literatu re, headaches are m ostly assessed in term s o f pain intensity and tem poral pattern (E delin g, 1994; D iener, 1995; Jull, 1997; Niere, 1998). Intensity, frequency, duration and analgesic intake are used as outcom e m easures for the effect o f treatm ent. N iere (1998) also used sub­ jective findings, including the M cGill Pain Q uestionnaire, to predict physio­ therapy treatm ent outcom e in patients suffering from specific cervicogenic HA pain patterns. A study w as therefore initiated to develop an instrum ent to assess the im pact o f C R C H A in term s o f functional lim itations and socio-em otional restric­ tions. As a first step, the im pact o f HA on patients com plaining o f cervicogenic HA had to be com pared to w hat was found in the literature for other types o f HA. This current study was therefore d esig n ed to p erfo rm a retro sp ectiv e review o f data obtained from individuals w ith C R C H A seen in the a u th o r’s prac­ tice, to assess the im pact o f this type o f HA on their activities, social relation­ ships and em otions. METHOD A quantitative retrospective review o f the im p act o f H A on in d iv id u als com plaining o f CRCHA was done in February 2000. All available records (clinical notes on first physiotherapy consultation) o f patients w ith CRCHA w ho had v isited the a u th o r’s clinic from 1/1/1995 to 31/12/1999 (a total o f 450 patients) w ere review ed, and the follow ing inform ation w as recorded for each patient: 1. B io -d em o g ra p h ic d ata (age, sex, occupation/daily work) 2. C urrent Total Pain P attern (accord­ ing to Edeling, 1994) - D uring the interview the patient was asked to rate the pain, the frequency o f the headache episodes and the response to pain m edication. - Intensity o f pain was scored on a Likert scale as 1 = M ild, 2 = M ore than mild, 3 = M oderately severe, 4 = Severe, and 5 = Intolerable, suicidal. - Frequency o f episodes was scored as 1 = O nce per m onth, 2 = 2-3 per m onth, 3 = Weekly, 4 = Daily, and 5 = Continuous. - R esponse to analgesics was scored as 1 = M ild analgesic abates pain, 2 = M ild an algesic lessens pain, 3 = Strong analgesic abates pain, 4 = Strong analgesic lessens pain, and 5 = No m edication affects pain. 3. Self-perceived im pact o f the HA on the function, social relationships and em otions. - D uring the initial interview patients w ere asked how their function, rela­ tionships and em otions (in general) had been influenced by their HA. The responses w ere sco red on L ik ert scales as 1 = No im pact/influence at all, 2 = Yes, but little im pact, 3 = Yes, considerable im pact, and 4 = Yes, debilitating impact. - T he sp e c ific su b c a te g o r ie s for im pact on function w ere days absent from work, loss o f productivity in paid work, ability to do daily chores, restriction in taking part in sport and recreational activities, and ability to do future planning. T he subcategories for relationships included their clos­ est friend/spouse, dependants, friends and colleagues. - Em otions recorded included feelings o f depression, isolation, anxiety, helplessness, suicidal thoughts and anger. T hese were each scored with a yes or no response. - D escriptive statistics were used to analyse the results. RESULTS 1. Bio-demographic data T h e re c o rd s o f 4 50 p atien ts w ere review ed: 352 fem ales and 98 males. T h e av erag e age w as 38,9 years (range = 15-76). T he occupations o f the patients included office personnel w ork­ ing w ith com puters (31% ), housewives (22% ), m usicians playing the violin, piano or flute (16% ), students (16%), and in d iv id u als w o rk in g w ith their hands in studios and factories (15%). 2. Current Total Pain Pattern (intensity, frequency, response to analgesics) Table 1 portrays the percentages o f patients that com plained o f the different pain intensities, frequencies o f episodes and resp o n se s to an alg esics (See M ethod for explanation o f scores). Table 1 Sev en ty sev en p ercen t o f the 450 patients experienced severe (4) to into­ lerable (5) pain. T he mean score was 4.0 (sd = 0,7). Sim ilarly 47% o f the patients experienced HA either on a daily basis (4) or continuously (5). The m ean score on frequency o f episodes was 3.3 (sd = 1.1). Eighty percent o f the patients reported that they needed strong analgesics to lessen (4) or abate (3) the pain (M ean score = 3.6, sd = 0.8). Fourteen percent o f patients found no relief w ith any m edication. TABLE 1. Group's average HA intensity, frequency of episodes and response to medication. 1 2 3 4 5 Pain Intensity 0% 1% 22% 53% 24% Frequency o f episodes 8% 12% 33% 34% ■ 13% Response to pain medication 0% 6% 41% 39% 14% 36 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 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. ) TABLE 2. General impact of CRCHA on function, relationships and emotions 1 2 3 4 Function 0% 8% 32% 60% Relationships 0% 11% 54% 35% Emotions 3% 24% 41% 32% 3. Self-perceived impact of HA on function, social relationships and emotions. Table 2 portrays the percentages o f patients that com plained o f the different sco res o f im p act on th eir fun ction, relationships and em otions (See M ethod for explanation o f scores). Table 2 M ost (92% ) o f the patients com plained o f a considerable (3) to disabling (4) effect on their function ( mean = 3.5; sd = 0.6). A considerable negative (3) or debilitating (4) effect on their relation­ ships was reported by 87% (m ean = 3.2; sd = 0.6). A large percentage (73% ) o f patients com plained that their emotions were markedly (a score o f 3 or 4) affected by their H A (mean = 3.0; sd = 0.8). 4. Specific functional limitations and socio- emotional restrictions. G raph 1 dep icts the d istrib u tio n o f patien ts w ho p erceiv ed C R C H A to have an im pact on specific functions, relationships and em otions. Grafih 1 From this graph it can be seen that the aspect o f function perceived to be affect­ ed by the m ost patients was a loss o f productivity (89% o f subjects). All other aspects o f function as recorded in the physiotherapy notes, were perceived to be affected by a sm aller num ber o f patients. The relationship w ith a spouse or clo sest frien d w as p erceiv ed to be affected by more patients (86% ) than any o f the other relationships. R elation­ ships with colleagues were, however, also reported to be affected by a large num ber o f patients. Em otions o f anxiety and feelings o f h elplessness w ere exp erien c ed by a large percentage o f patients (75% and 62% respectively). It is notew orthy that 12% (54 out o f 450 patients) indicated that they experienced suicidal thought directly related to the CRCHA. See G raph 1 for other results. DISCUSSION A lthough this study was done retrospec­ tively, the results seem to agree w ith the literature on sim ilar research into the im pact o f other types o f HA on quality o f life. Functional impact In a study o f 177 (m ostly) m igraine sufferers by Stew art et al (1999), it was fou nd that h igh pain in ten sity and frequency led to high functional disabi­ lity, as portrayed in absenteeism and decreased productivity. Petersen-B raun and Gobel (1994) established that in 89% o f 4 7 0 su b jects m ig rain e and TTHA interfered with w ork efficiency. The current study reports that in 89% o f 450 patients productivity was influenced. A bsenteeism was reported by 25% o f their subjects, w hile the current study reports absenteeism in 47% o f patients. M ichel et al (1999) established that o f 231 w orking m igraineurs, 20% had at least one period o f absenteeism per month. T hese figures are confirm ed by other disability studies on individuals su ffering from m igraine and TTH A (Davis et al, 1999; Fishm an and Black, 1999). The cost o f providing healthcare for persons experiencing chronic HA is substantial (Fishm an and Black, 1999), and the econom ic consequences o f lost or reduced productivity in this group o f patients may be greater than previously believed. Functional disability m ay also emerge in day-to-day activities. In this study 34% reported interference w ith their daily chores, and 32% with their parti­ cip atio n in sp o rt/recreatio n . R egular cancellation o f fam ily and social activi­ ties as a result o f chronic TTHA has also been reported by Davis et al (1999). Petersen-Braun and Gobel ( 1994) found that m ost subjects reported their severe m igraines to be on w eek-ends. This interfered with norm al leisure activities. In the current study 49% o f patients reported interference w ith their ability to plan activities for the future. A ccording to B lom kvist et al (1997) recurrent HA sufferers (cluster and m igraine HA) often reported significantly poorer ability to anticipate future activities. A bsenteeism , productivity, ability to do h o u seh o ld ch o res, restric tio n o f GRAPH 1.Distribution of perceived impact of CRCHA on functions, relationships and emotions 0 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 0 1 0 0 F U N C T I O N Forced to toke time off work 1 1 1 1 1 1 1 1 m I 53 Loss of productivity * - | 11 Unable to do doily chores m | 6 6 Restricted in sport/recreation -i~ m | 6 8 Unable to do future plonnmg m 51 R E L A T IO N S H IP S To spouse or closest friend 14 To children/dependents m 1 58 To friends m 5 5 To colleogues I?- m , | 21 E M O T I O N S Feelings of depression M , 6 5 Feelings of isolohon m | 6 7 Anxiety ... m . " 1 25 Feelings of helplessness 3 8 Considering suicide m | 8 8 Angei ► 4® , 4 | 5 2 I Y e s □ ^ io n SA J o u r n a l o f P h ysio th e ra p y 2001 V o l 57 No 1 37 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. ) leisure activities and future planning seem to be im portant consequences o f C R C H A and th erefo re needs to be included in the assessm ent o f these patients. Socio-emotional impact The im pact o f C R C H A on social and em otional aspects o f p atients’ lives in the current study was sim ilar to results reported in the literature. Interestingly, the closest personal relationships were affected in the largest percentage o f patients, w ith work relationships follow ­ ing very closely. R elationships with children/dependants and w ith friends were also affected. The social and per­ sonal im pact o f HA was included in a national health survey done in Kentucky (K ryst and Scherl, 1994). The prim ary focus o f the research was on social dis­ ability or the im pact o f severe m igraine HA on interpersonal relationships with family, friends, co-w orkers and others. T heir findings suggest that serious HA sufferers m ay be adapting to their illness by restrictin g activity in areas they perceive m ore flexible than work, such as fam ily and social life. Since interper­ sonal relationships and social interaction often bring satisfaction to the individual and enhance quality o f life, HA patients who forgo these activities may experience a decrease in social support, perhaps leading to increased stress and isolation, and an increase in headache. Petersen- B raun and Gobel (1994) collected infor­ m ation from 47 0 m igraine and 321 T TH A patients. Both types o f HA were fo u n d to cause sev ere interferen ce with their quality o f life, their fitness for work, and leisure-tim e activities. Significantly reduced intra-fam ily open­ ness w as fo u n d in fam ilies w here the m o th er suffered from m igraine (B lom kvist et al, 1997). In this study several patients reported that they experienced feelings o f depres­ sion (35% ), isolation (33% ), anxiety (75% ), helplessness (62% ), anger (42%) and thoughts o f suicide (12% ) as a result o f their HA. Depression as a self-perceived result o f chronic m igraine and TTH A was reported in several quality o f life assess­ m ent studies (Jacobson et al, 1994; K ryst and Scherl E, 1994; H olroyd et al, 1997). T he develo p m en t o f specific personality characteristics as a conse­ quence o f suffering from episodic HA is su g g ested by stu d ies in the field (B lom kvist e t a l , 1997; Niere, 1998). The societal burden o f headaches m ay be enorm ous, but the significance o f this disorder has long been over­ looked, probably because o f the episodic nature and the lack o f m ortality attri­ buted to the condition. In patients with chronic HA disorders, physical, labora­ tory, and radiographic exam inations are generally norm al. For this reason clini­ cians often perceive the lim itations asso­ ciated w ith HA as less significant than those asso ciated w ith o th er ch ro n ic conditions. Pain, in itself, is not a reliable m easure for dysfunction nor for the outcom e o f m anagem ent. The indivi­ d u al’s perception o f pain is greatly influ­ enced by previous experience o f pain, em otional factors and cultural beliefs. It was found that the p h y sio th erap ists’ perception o f p atients’ pain and other evaluative findings, are also influenced by personal and professional experience and in dividual psy ch o lo g ical factors (A skew et al, 1998). If the outcom e o f physiotherapy (and likew ise m edication and other regim es o f m anagem ent) is m easured by im provem ent in function, social participation and em otional state, in addition to changes in pain intensity and tem poral pattern, it will m ake m uch m ore sense to therapist and patient. A reliable and valid m easure o f outcom e o f physiotherapy treatm ent m ay contribute to the p ro fession’s credibility and public im age and m ay fa c ilita te o utcom e research in physiotherapy. CONCLUSION It can be concluded from the results o f this retrospective study, and from the literature review ed, that individuals with C RCHA experience considerable restriction o f daily function, lim itation o f social participation and em otional distress. If questions about all these effects are com bined in a single ques­ tionnaire, it might be possible to m easure the total im pact o f C R C H A on indivi­ duals. The addition o f this to assessm ent o f intensity and tem poral pain pattern may be a m ore reliable indication o f the severity o f the disorder. Such an instrum ent is currently being developed to reflect this bio-psychosocial approach to assessm ent. T his m ay facilitate out- co m e-b ased m anagem ent o f p atients suffering from the disabling and som e­ tim es debilitating im pact o f CRCHA on their quality o f life. ACKNOWLEDGEMENTS Prof- D ele A m osun, D ep artm e n t o f Physiotherapy, U niversity o f the Western Cape, for his m uch appreciated advice. REFERENCES A skew R, K ibelstis C, O verbaugh S, W alker S, N ixon-C ave K, Shepard K F 1998 Physical th erap ists' perception o f p atien ts’ pain and its e ffe c t on m an a g e m e n t. P h y sio th e ra p y R esearch Journal 3:37-57 B lo m k v ist V, H a n n e rz J, O rth g o m e r K, T heorell T 1997 C o p in g sty le and social su p p o rt in w om en su fferin g fro m c lu ste r h ea d ach e o r m igraine. P s y c h o th erap y and P sychosom atics 6 6:150-154 D avies G M , S a n tan e llo N, G erth W, L em e r D, B lock G A 1999 V alidation o f a m igraine w ork and p ro d uctivity loss questionnaire for use in m igraine studies. C ep halalgia 19:497-502 D iener I 1995 H eadache: R e lie f is possible. South A frican F am ily P ractice 16:734-737 E deling J 1994 M anual T herapy for C hronic H eadache (2nd edit). B utterw orth-H einem ann Ltd, O xford England F ishm an P, B lack L 1999 Indirect costs o f m ig ra in e in a m a n a g e d ca re p o p u latio n . C ep ha lalgia 19:50-57 H olroyd K A, O ’D onnell F, Hill K, L ipchik G, Pinnell C, M alinoski P 1997 A ssessing headache severity in treatm ent planning and o utcom e assessm ent. H eadache 3 7 : 3 1 2 - 3 1 6 International H eadache S ociety - H eadache C lassification C om m ittee (1988) Classification and diagnostic criteria for h eadache disorders, cranial neuralgias and facial pain. C ephalalgia 8(suppl 7): I -96. Jacobson GP, R am adan N M , A ggarw al S and N ew m an C 1994 T h e H enry F ord H ospital H ead a ch e D isab ility In v e n to ry (HD1). In: O lese n , J (E d ): H e a d a c h e c la ssific a tio n and epidem iology, pp335-344. Raven Press, N ew York Jull G A 1997 M an ag em en t o f cervical headache. M anual T herapy 2:182-190 38 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 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. ) K ryst S, Scher] E 1994 A population-based survey o f the social and personal im pact o f h eadache. H eadache 34:344-35 M ichel P, D artigues JF, D uru G, M oreau, S alam on R, H enry P 1999 Increm ental a b sen teeism due to h eadaches in m igraine: R esults from the M ig-A ccess F rench national cohort. C ep halalgia 19:503-510 N iere K R 1998 C an subjective characteristics o f b e n ig n h e a d a c h e p re d ic t m a n ip u la tiv e physiotherapy treatm ent outcom e? A ustralian Journal o f P hysiotherapy 44:87-93 Petersen-B raun M , G obel, H 1994 D egree o f disability, affliction, loss o f free tim e, and loss o f w orking hours in patients w ith m igraine and tension-type headache in G erm any. In: O lesen J (edit) H eadache classification and epidem iology. 4: 351-354. R aven Press. N ew York S te w a rt W F, L ip to n RB, K o lo d n e r K, L iberm an J and S aw yer J 1999 R eliability o f the m igraine d isability assessm ent score in a p opulation-based sam ple o f headache su ffer­ ers. C e p ha lalgia 19:107-14 W orld Health O rganization 1999 International C lassification o f functioning and disability. IC ID H -2. B eta-2 D raft. G eneva South W est L ondon C om m unity NHS Trust QUEEN MARY’S HOSPITAL PAEDIATRIC PHYSIOTHERAPY SERVICE SENIOR I PHYSIOTHERAPIST Full tim e - 36 hours per w eek (part-tim e/ jo b share considered) £23,444 - £27,049 pro rata (inc. o f Inner London W eighting & Supplem ent) T h is is an e x c e lle n t o p p o rtu n ity fo r an e x p e rie n c e d P a ed ia tric S e n io r II p h y sio th e ra p ist lo o k in g fo r new c h a lle n g e s, o r an e x is tin g S e n io r I keen to fu rth e r d e v e lo p th eir skills w ithin the d y n am ic , forw ard th in k in g P a ed ia tric C o m m u n ity T eam b ase d at Q u een M a r y ’s H o sp ital, R o e ha m p to n . Y our resp o n sib ilitie s w ill inclu de :- • M a n a g in g a team o f p h y sio th e ra p ists at a sch o o l fo r c h ild ren w ith sp ecial ed u c a tio n a l needs. • M an a g in g a varied caselo a d o f ch ildren in m ain stre am schools, c h ild re n ’s ce n tre s, nurseries and at hom e. T h e p o st w ill p ro v id e you w ith th e o p p o rtu n ity to fu rth e r d e v e lo p y o u r c lin ica l and m an a g erial sk ills w o rk in g a lo n g sid e a team o f ex p e rie n c e d clin ic ia n s usin g a variety o f ap p ro a c h e s in clu d in g B o b ath , C o n d u c tiv e E d u catio n and H are. T h e ab ility to w o rk closely w ith c h ild ren and th eir c a re rs, ed u c atio n and h ealth p ro fessio n a ls as p art o f a team to d evelop c o n tin u in g high sta n da rd s o f clinical c a re is essen tia l. T h ere is a stro n g co m m itm e n t to c o n tin u in g p ro fessio n a l d ev e lo p m e n t, c lin ica l effe ctiv e n ess and resea rc h . A ssista n c e w ith arra n g in g a w o rk p e rm it is ava ilab le . For further inform ation and/or an inform al visit, please contact: E dw ina Falls, Superintendent Paediatric P hysiotherapist, L eon Gillis C hild ren’s Centre Tel: 020 8355 2443 e-m ail: E d w in a.Falls@ sw lct.stham es.nhs.uk C losing Date: 28 February 2001 S o u th West London Community NHS Trust has m an y o f the pro fessio na l benefits a sso c iated w ith an acute trust but w ithin a co m m u n ity setting. 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SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 39 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. ) mailto:Edwina.Falls@swlct.sthames.nhs.uk