LOW BACK PAIN AN OVERVIEW IN THE GOLD MINING INDUSTRY IN SOUTH AFRICA ■ b^Re^ina C Bester BSc Physiotherapy INTRODUCTION A ccording to stud ies done in the U SA in 1993, researchers cam e to the follow ing conclusions: Low back pain (LBP) is the leading cause o f disability for people under 45 years o f age and it is the second leading cause of industrial absenteeism , upper respiratory tract infections being the m ajor cause . A bou t 60% o f all em ployees experience som e LBP at som e time in their em ploym ent careers. A lthough 90% of these em ployees experience relatively short episodes o f incapaci­ tation, long-term (m ore than 4 w eeks) or perm anent disability resulting from LBP d evelops in 10% o f employees^. D isability due to LBP increased at a rate 14 times the p o pulation grow th betw een 1957 and 1976. This increase w as m u ch greater than for disability due to other cau ses1. To prevent chronic cases o f disabling occu pational LBP, it m ust be know n not only w hy som e em ployees experience LBP, b u t also w hy som e get b etter after a short period and others do not. Despite four decades o f research on spinal disorders, the d eterm inants of long term disability associated w ith LBP essentially are unknow n. The studies that do exist have on e thing in com m on: physical exam inations, biom echan ical factors and m edical diagnosis have little pred ictive value regard ing return to w ork bu t a range of p sychosocial factors seem to be significantly involved in the dis­ abling process^. The hypothesis exists that factors other than the spine itself play an im portant role in the disabling process of LBP. An increas­ ing bod y o f literatu re suggests that occupational disability is a result of m ultiple risk factors related to the individual, the w ork environm ent, the non -occu pational social environm ent, the m edi­ cal system , the legal system , the system s of w orkers' com pensa­ tion disability insurance and the econom ic environm ent, includ­ ing social secu rity and w elfare1. A lthough m o st o f the current research is being done in other industries, very little is k now n about the occurrence o f LBP in the m ining industry and esp ecially in South Africa. Risk factors in the ^ABSTRACT ^ An analysis of the occurrence of low back pain in the Gold Mining Industry was done retrospectively by the author for a period of one year using the patients’ physiotherapy treatment cards for information. The most common mechanism of injury was identified as spontaneous onset of low back pain and th e hig h est risk o ccu pa tio ns w ere d rille rs, m ining team and scraper/winch operators. The treatment protocol which the Physiotherapy ^ department follows as well as the outcome of the programme are described^ ^ABSTRAK ^ Die skrywer het ’n retrospektiewe analise van die voorkoms van lae rugpyn in die goudmynbou industrie gedoen vir ’n tydperk van een jaar waar die pasientkaarte gebruik is vir inligting. Die mees algemene meganisme van besering is geldentifiseer nl. spontane ontstaan van rugpyn en die hoe risiko werk groepe was booroperateurs, mynbouspan werkers en skraper/wenas operateurs. Die behandelingsprotokol wat deur die fisioterapie departement gevolg word, word beskryf asook die uitkoms van die program. V _______________________________ _________________________________J m ining industry could be sub-grouped as ergono m ic (w orkplace design, physical w orkload , vibration) organisational (shift sys­ tem, job strain, quality o f supervisory support) or m otivational (job satisfaction). In order to m ake an inform ed decision on w h ere to direct our resources, the author has looked a t the occu rrence o f LBP am ongst the patients treated at the Freegold H ealth Service - P hysiotherapy D epartm ent. LITERATURE REVIEW Mining Industry: G eneral consensus throughout the literature is that the m ajor reason for the high prevalence and incidence o f low back pain in this industry is biom echanical stress developed d uring the lifting and transferring o f heavy objects^. A d d itional areas o f concern are the asym m etrical trunk positions and un predictable velocities that accom pany heavy-object-m oving activities. A n other factor is the prolonged effect o f vibration on the spine. It w as found by G enaid y e l al (1993)4 thiat factors including age, gender, bod y w eight arid spinal com ponent explained betw een 42% and 74% of the variation in com pressive strength o f the lum bar spine. T h e co m p ressiv e strength of. the: spine w as found to decrease b y 10% to 20% w ith each decade o f life beyon d 29 years. Com pressive strength w as also found to increase w ith an increase in bod y w eight. It is w idely accepted that injuries occu r w h en the physical dem ands of a jo b exceed a w o rk er's strength. In order to establish problem areas in the m ining industry, the author has investigated all patients w ith b ack .p ain treated as outpatients in the p h y sio­ therapy departm ent at the Ernest O ppenheim er H ospital (total of 2 67 patients) from M ay 1994 to M ay 1995. Anatomic/Physiologic origins of findings in the low back Low back pain m ay arise from several stru ctures in the lumbar spine, including the ligam ents that interconnect vertebrae, outer fibres of the annulus fibrosus, facet jo in ts, vertebral periosteum , paravertebral m u sculature and fascia, blood vessels and spinal nerve roots'’ . The causes o f low back p ain generated through these structures include: 1) m u sculoligam entous injuries 2) d egenerative changes in the intervertebral discs and facet jo ints 3) herniation o f the nucleus pulposus o f an intervertebral disc, w ith irritation o f adjacent nerve roots 4) spinal stenosis (this usually results from hypertrophic d egen­ erative changes in the discs, ligam entu m flavu m and facet joints) 5) anatom ic anom alies o f the spine eg (scoliosis) 6) underlying system ic disease 7) visceral diseases unrelated to the spine. Prevalence of diseases that produce low back pain Up to 85% o f patients cannot be given a d efinitive diagnosis because o f w eak associations am ongst sym ptom s, pathological changes and im aging results. W e assum e that m any of these cases are re la ted to m u s c u lo lig a m e n to u s in ju ry o r d e g e n e ra tiv e c o n tin u e d o n p a g e 1 4 ... SA J o u r n a l P h y s io th e r a p y , V o l 5 2 N o 1 F e b r u a r y 1996 P a g e 11 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. ) For nSflID power that goes to u/ork immediately, and continues to work for up to 1Z hours, nothing's got a patch on this... 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. ) oBOOTSHEALTHCARE Flurbiprofen 40 mg 1 T he B oots C om pany (S o u th A frica) (Pty) Ltd Reg No 05/20124/07 4 0 E le ctro n A v e n u e , Is a n d o 1 6 0 0 , P O B o x 4 2 7 , Isa n d o 1600. F a c s im ile : (0 1 1 ) 9 7 4 -7 5 2 0 . j] Tram/Vt wi. t« h patch conioins40 mg flurbiprofen. Beg. Ho.28/5.1/0268. T e le p h o n e (0 1 1 ) 9 7 4 -1 6 3 1 .T e le x : 7 4 5 8 0 3 SA T R A 1 0 9 5 K 0 3 7R 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. ) .. .c o n t i n u e d fr o m p a g e 11 changes. A natom ic evidence o f a herniated disc is found in 20% to 30% o f im aging tests am ong norm al persons . These hernia­ tions are asym ptom atic and result in no clinical disease. Since a specific cause frequently cannot be identified, diagnostic efforts are often d isappointing. Instead o f seeking a precise cause in every case o f back pain, it m ay be m o st useful to answ er three basic questions:^ 1) Is there a serious system ic disease cau sing the pain? 2) Is there neurologic com prom ise that m ight require surgical evaluation? 3) Is there social o r psychological distress that m ay am plify or prolong pain? These q uestions can generally be answ ered on the basis of history and physical exam ination alone and a m inority o f patients require fu rther d iagnostic testing. Is there evidence o f social o r psychological distress that m ay am plify Or p ro lo ng pain? D eyo et al cam e to the conclu sion that som e features o f patient history influence m anagem ent regardless o f the exact spinal p a ­ thology. C hronic p ain and d ep ression m ay b e indications for the use o f anti-d epressant m ed ication rather than opiates. A lcohol or drug abuse influences the choice o f m edications and requires specific intervention. D isability com pensation claim s or litigation m ay affect initial evalu ation and prognosis and patients seeking com pen sation often respond poorly to a variety o f treatments. Patients w ith chronic low b ack pain ( 3 m onths duration) present com plex p ro blem s and often a pathoanatom ic cause is not apparent. U nlike acu te pain, chronic pain often is not associated w ith on-going tissue injury, serves no biological usefulness and is not accom panied b y the autonom ic response o f sym pathetic over-activity. Vegetative signs, such assleep disturbance, appetite disturbance, and irritability appear and p ain is often reinforced or p erpetu ated b y social and psychological factors. Back p ain can affect em ploym ent, incom e, fam ily and social roles, produ cing psychological distress. R esulting som atic am pli­ fication can serve the p atients' need s for econom ic survival and m aintenance o f self esteem . METHOD This stud y w as perform ed in retrosp ect w here all the data was retrieved from the p atien ts' p hysiotherapy treatm ent cards from M ay 1994 to M ay 1995. Inpu t w as obtained from the O ccupational H ealth D ep artm ent in the form o f em ploym ent statistics o f the various m ines w hich m ake up Freegold O perations Lim ited. The O ccupational Therapy dep artm ent supplied inform ation of treat­ m ent ou tcom es ie n u m ber o f p atients successfully resum ing w ork, job changes and repatriations.The obtained inform ation w as sum m arized in table form at according to occupation and type o f injury and the percentages w ere calculated. Results and discussion Mining Population Free State C onsolid ated Gold M ines (O perations) Lim ited con­ sists of five m ines nam ely Free State Saaiplaas, Freddies, President Brand, Presid ent Steyn and W estern H oldings as w ell as the Freegold H ealth Service (FHS). In total this m ining group em ploys 6 9 1 7 5 people at p resent and m ost o f these em ployees receive their m edical treatm ent at the E rnest O ppenheim er H ospital (FHS). TABLE 1: BREAKDOWN OF EMPLOYEES MINE NUMBER OF EMPLOYEES Free State Saaiplaas 8 320 Freddies 15 931 President Brand 1 0 1 9 8 President Steyn 14 859 Western Holdings 18 592 ’ Freegold Health Service 1 2 7 5 TOTAL 6 9 1 7 5 TABLE II: SURFACE vs UNDERGROUND WORKERS MINE UNDERGROUND SURFACE Free State Saaiplaas 7 524 1 165 Freddies 14 855 1 857 President Brand 9 541 1 3 2 6 President Steyn 13 896 2 635 Western Holdings 16 996 2 661 TOTAL 62 812 9 644 The m ine m edical officers (1994) calculated that p hysiotherapy attendances (not only fo r back pain) accounted for 5% o f total lost shifts o n the Freegold m ines. (W here one p hysiotherap y atten­ dance = 1 lost shift). Prod uctivity can, therefore, be affected by w orkers w ith chronic low b ack pain. D uring the period M ay 1994 to M ay 1995, a total o f 5 772 patients, o f w hich 267 w ere patients w ith b ack pain, received physiotherapy treatm ent. Therefore b ack p ain p atien ts account for 4,6% o f the total nu m ber o f patients seen at the E rn est O p p en­ heim er hospital p hysiotherapy d ep artm ent in one year. A verage attendance o f p hysiotherapy for back patien ts w as 6,7 treatm ents (1,2 w eeks) - w hile the range varied from one treatm ent to 47 treatm ents (8,5 w eeks) This w id e range o f attend ances is a cause for concern as it has a significant financial im p lication for the m ining industry. Total time aw ay from w o rk varied from two days - 3,5 months. TABLE III: CLASSIFICATION BY DIAG NOSIS DIAGNOSIS NO OF PATIENTS PERCENTAGE Mechanical backache 113 42 ,3 Chronic low back pain 62 23,2 Contused back 31 11,6 Sprained back 43 16,1 Others: Sciatica 3 1,1 Stenosis 3 1,1 Spondylolisthesis 4 1,4 Spondylosis 2 0,7 Scoliosis 2 0,7 Prolapsed die 4 1,4 TOTAL 267 C ategories o f onset of back pain consisted o f trau m a, sponta­ neous onset and chronic low back pain. Forty four percent of patients experienced som e kind o f traum a to their spine w hile 32% claim ed they experienced sp ontaneo u s onset o f b ack pain w ith no previous history o f traum a. In the chronic group 24% o f patients had backache for longer than three m onths. O ccupations o f p atients w ere noted and divided into tw o m ain groups nam ely: Surface w o rkers (28% ) and underground w orkers (72%). O f the underground w orkers - d rillers and people in the m ining team w ere m ost at risk, accou nting for 19% and 18% B la d s y 14 F e b r u a r ie 1996 SA T y d s k rif F is io te r a p ie , D e e ! 5 2 N o 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. ) respectively o f all p atients seen w ith back pain. In addition, scraper/w inch op erators (12% ), m ining helpers (10% ), team lead­ ers (8%) and loco op erators (8%) w ere the m ajority o f occupations seen in underground w orkers. The rest (25% ), included jo b s such as engineering helpers, tim berm en, grouting assistants and artisans. Surface w orkers included occu pations such as cleaners, n u rs­ ing staff, clerks, artisans and shaft assistants. TABLE IV: MECHANIS M OF INJURY MECHANISM OF INJURY NO OF PATIENTS PERCENTAGE No history o f iniuiy 106 38 Lifted heavy objects 64 24 Minina O ccid e n t 41 15 Slipped and fell 13 5 Sports injury 7 3 Pathology 8 3 Others e.g. MVA, assault, non-ruining accidents 28 10 TOTAL 267 The m ajority o f the p atients seen had no history o f injury w hich could b e becau se o f factors such as repetitive strain injury, p ro­ longed effect o f vibratio n o n the spine and m uscle fatigue. The second m ost im portant cause o f injury is lifting heavy objects and 24% o f patients gave this as the cause for their back pain. M ining accidents included events such as b eing struck by rocks, fall from height, b reak in g rocks and b eing struck b y m a­ chines. As surfaces underground are slippery and w et, w orkers are m ore susceptible to slipping and falling dow n. Soccer and ru gby as w ell as ru nning m arathons w ere given as causes for sports injuries resultin g in backache. P atients w ith patho lo gy o f the spine presented w ith diagnoses o f osteoarthritis, spinal stenosis, scoliosis and prolapsed discs. O ther m echanism s o f injury included m otor vehicle accidents, gardening and assaults (non-m ining accidents). A nnual statistics taken at the Training C entre by the occu pa­ tional therapist w as that 84% o f patients w ith backache returned to their norm al place o f w ork, 15% had to have jo b changes and 1% o f all patients seen w ith backache had to b e repatriated b e ­ cause o f the severity o f their back pain. O ccupational back injury is clearly related to lifting activities. The injury rate is about 3-5 : 1 000 in light indu stry com pared w ith 200 : 1 000 in heavy industry.** A t this stage this is n ot the case in the Freegold m ining industry. CONCLUSION Back p ain is an im portant public health problem bu t there is a pau city o f know led ge about causes and un derlying mechanism s. A lthough a lot o f research has b een done in other industries, very little is know n about back pain in the gold m ining industry. In order to establish w h eth er there is a p roblem w ith chronic back pain, it w as necessary to look at all patients treated during the last year at the p hysiotherapy departm ent o f the E rnest O ppenheim er H ospital. The au th or's recom m end ation is that further studies should b e undertaken to investigate the prevalence o f back pain am ongst gold m ine w o rkers and to com pare prevalence o f back p ain w ith type o f w ork, age, w eight, sitting height, standing height, tribe, abdom inal m u scle strength, back extensor strength, occurrence o f trigger points, range o f m ovem ent, straight leg raise, num ber o f episodes o f back pain, duration o f sym ptom s, tim e aw ay from w o rk, jo in t tenderness, fam ily history, psychoso­ cial factors and w o rk environm ental factors. REFERENCES: 1. K rause N , R agland DR. O ccu p atio nal d isability due to low b ack pain: a n ew inter-discip linary classification based o n a p hase m od el o f d isabil­ ity. Spine 1994;19:1011-1020. 2. D eyo R A , R ainville J, K en t D L. W h a t ca n the histo ry and p h ysical exam ination tell u s about low b a c k pain? JA M A 1992;268:760-765. 3. A nd erson G B J, Sv ensso n H O , O d en A . T h e intensity o f w o rk recovery in low ba c k pain. Spin e 1983;8:880-884. 4. G enaid y A M , W aly S M , K halil T M & H ig alg o J. Sp in al com pression tolerance lim its for the d esig n o f m anu al m aterial han d lin g op eratio ns in the w orkp lace. E rgonom ics 1993;36:415-434. 5. Fry m o y er J W . B ack p ain & sciatica. N E n g l J M ed . 1988;318:291-300. 6. D eyo R A. E arly d iagn ostic ev alu ation o f low b a c k p ain. / G en Intern M ed. 1986;1:328-338. 7. H elew a A , G old sm ith C , Sm y the H & G ibson E. A n ev alu ation o f four different m easures o f abd om inal m u scle strength: P atien t, O rd er and In strum en t V ariation. / o f R heu m atology 1990:17:7:965-969. 8. Fry m oy er J W & C ats-Baril W . P red ictors o f low b a c k p ain disability. Clinical O rthopaedics 1987;221:89-98 Current protocol for the treatment of backache at Ernest Oppenheimer Hospital By the tim e the patient w ith low b ack p ain reaches the Physio­ therapy D epartm ent for treatm ent, he n o rm ally has b ee n o n sick leave for seven days, preferably inclu ding bed rest for at least tw o days. T he m edical officer at the m edical station w ill have assessed the patient, prescribed the appropriate m ed ication or w ould have referred the patient to the orthopaed ic d ep artm ent at the hospital for further m anagem ent dep end ing upon the severity o f the back pain. As som e o f the back p ain w ill have cleared up after seven days, only patients w ith persistent b ack p ain are referred to the Physiotherapy D epartm ent for treatm ent. The Physiotherapy De­ partm ent then follow s a protocol: 1. P erform a thorough assessm ent to establish n eurological in­ volvem ent, soft tissue involvem ent, range o f m ovem ent, v er­ tebral jo in t signs and m uscle strength o f the abdom inal muscles as w ell as the back extensor. O ccupation, duration o f sym p­ tom s, m echanism o f injury and previous episodes o f back pain are all noted. ! 2. Patients are divided into tw o m ain groups n am ely those w ith m echanical b ackache and b ackache w ith n eurological involve­ m ent. 3. M uscle spasm is treated w ith acupressure, ultrasound , hot p acks and interferential therapy as ap propriate (norm ally for 2-3 days) 4. M aitland m obilisation o f the lum bar sp ine once m uscle spasm is relieved in order to relieve p ain and increase range o f m ove­ m ent in the lum bar spine (norm ally for 3-5 days). 5. Patients w ith m echanical b ackache progress into the b ack reha­ b ilitation exercise class consisting o f M cK enzie extension exer­ cises, strengthening exercises for the abdom inal m u scles and back extensor, as w ell as stretching exercises o f paravertebral muscles. 6. Patients are norm ally d ischarged after tw o w eeks o f p hysio­ therapy (ten treatm ents) to the Training Centre (an area set up to sim ulate actual w o rking cond itions underground and run b y an occupational therapist w ith v ocational training b eing the m ain aim.) 7. Patients w ith neurological involvem ent receive M aitland m o­ bilisations as w ell as traction (13-20 kg) or stretching o f n euro­ logical tissue daily b u t do not p articipate in the b ack rehabili­ tation class until neurological signs decrease. SA J o u r n a l P h y s io th e r a p y , V o l 5 2 N o 1 F e b r u a r y 1996 P a g e 15 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. ) 8. If, after tw o w eeks (ten treatm ents), there is n o im provem ent in the p atien t w ith n eurological signs, the physiotherapist will refer the p atien t b ack to the orthopaed ic d epartm ent. If, after reassessm ent, the p atient is referred b ack to physiotherapy again, w e w ill con tin u e treatm ent for a fu rther tw o w eeks (ten treatm ents) o r until neurological signs decrease. 9. If there are no fu rth er p o sitive results w ith physiotherapy, the p atient is referred b ack to the orthopaed ic surgeons. 10. All p atien ts w ith backach e are tau ght a hom e exercise p ro­ gram m e w h ich they should d o 2-3 tim es a day. 11. C h ronic b ack ach e p atients (m echanical) n orm ally have very w e ak abdom inal and b ack exten sor m u scles and therefore need strengthening exercises rather than electrotherapy. Elec­ trotherapy is applied w h ere indicated for p ain and m uscle WCPT - AFRICA The execu tiv e m eeting o f W C P T -A frica w as held in H arare over the w eekend o f N ov em ber 4 and 5. R epresentatives from Ethiopia, South A frica, Tanzania, Z am bia and Z im babw e at­ tended and this allow ed for som e discu ssion o f the problem s facing the central and sou thern regions. C ountries still offerin g training at diplom a level are seeking w ays o f up grad ing their ed u cation to B achelor's level. South A frica and Z im bab w e w ere requested to find w ay s o f assisting their colleagues, p articu larly those from Z am bia. Inform ation regard ing research d esign and . m ethod is also requested, and on ce again South A frica is in the position to draw up an inform ation p ack o r o f offerin g to presen t an introductory cou rse at the n ext regional congress to b e held in H arare. R egional In terest G roup - A s three physiotherapists from the region, w h o attended the cou rse o n p hysiotherap y for the aged held in M alta, are living in Sou th A frica, they do need to com bine their ideas o f settin g up a viable interest group for the region. P hysiotherapy salaries and cond itions o f service still rem ain an e n o rm o u s p r o b le m fo r th e re g io n . T h e a v e r a g e s a la r y o f p hysiotherapists ranges fro m 35 to 300 U S d ollars per m onth, w ith som e o f the gov ernm ents offering hou sing and travel allow ances and m edical aid. P hysiotherapy needs to b e reclassified in m any o f these cou n tries and ap propriate ad ju stm ents m ade w h ich are consistent w ith the d escrip tion and responsibility o f the w ork entailed. T he region need s to lobby the various governm ents so that p hysiotherap ists m ay b e recognised as the professionals that they are. Second Regional Congress, Harare, September 1996 P rep arations are in hand for this congress and hopefully a good contingent o f Sou th A frican s w ill p articipate in the various w o rk ­ shops and p aper p resen tation sessions. The costs have been re­ duced to allow fo r a larger attend ance and 50 U S d ollars has been suggested fo r the early b ird registration fee. This is only 62% of the fee paid for the previou s congress b u t late registration w ill result in tw ice the am o u n t at 100 U S dollars. It w as suggested that Sou th A frica could possibly host on e o f the evening events d u rin g congress and suggestions as to w h at m ay be p ossible and ap propriate are requested. If any o f our readers have innov ativ e ideas, please let us know . A s the oldest association in the region, the SA SP should play a prom inent role in the W C P T -A frica region and offer the expertise and skills o f its m em bers. spasm . 12. K inetic hand ling as w ell as final strengthening exercises are d one by m eans o f lectures and d em on stration s at the Training C entre. Patients are retrained to do their original jo b s from a kinetic hand ling p o in t o f view . It is v ery im p ortant that all p atients go through the T raining C entre. C om pu terised re­ cord s are kept on each p atien t so that w e can id entify patients w ith nu m erou s back ach e episodes. T h e p ro gram m e at the Training C entre is n orm ally com pleted in tw o w eeks. (Total tim e aw ay from w o rk = 1 w eek sick leave, 2 w eek s at p hy sio­ therapy, 2 w eeks at T raining C en tre = 5 w eeks if there are no com plications and p atient respond s w ell to treatm ent.) 13. P atients are sent b ack to their norm al place o f w o rk o r the job m ay b e changed dep end ing o n the o u tcom e o f the program m e. EXECUTIVE DIRECTOR T he Society m et their new E xecutive D irecto r w h en D r Lise de Blois w as introduced to m em bers o f the N ational A ssem bly and the N ational Executive C o m m ittee at their jo in t m eetin g on 28 and 28 January. W hen she takes office on 1 Febru ary, D r de Blois b rin gs to the p osition o f SA SP C h ief Executive O fficer n o t on ly the know led ge o f tw o D octorates, a W its M B A and several other acad em ic quali­ fications, b u t also the experien ce o f corp orate finance and special p rojects m anagem ent at the SA BC , group finance and b usiness d evelopm ent at A n glo A m erican 's Boart International, and ad­ m inistrative and financial m anagem ent o f tw o b u ild in g and e n ­ gineering com panies. Dr d e Blois' appointm en t as Executive D irecto r ushers in the new , restructured Society, and w ith our w elcom e and congratu ­ lations w e also o ffer our best w ish es for a su ccessfu l and m utually satisfying association. 7 SPA PICA AWARDS In presenting a sum m ary o f the scores and com m en ts o f the ju d ges for the 1994 and 1995 Pica aw ards, the E ditorial Board hopes to indicate how ou r Jo u rn al is perceiv ed b y independent assessors. The m o st notable im provem en t is seen in the d esign o f the Journal althou gh at 62% there is ob viou sly still ro om for im p ro ve­ m ent. W hat is m ost pleasing is that w h ereas in 1994 the Journal w as considered archaic and ou td ated, now the attem p t in im prov­ ing the design is acknow ledged. G reat effo rts are being m ad e b y all concerned to en h an ce both the visual im pact o f the Journal as w ell as its E ditorial, so that the Journal m ay m eet the challenges facing it. If ou r m em bers m ade a special effort to subm it m anu scrip ts for p u blication , the E d ito­ rial Board w ould b e in a good p o sition to build up a b ank of articles and thereby im prove the scientific con ten t o f the research and review articles. A rticles relating to case stu d ies and treatm ent notes w ill how ever, also be w elcom ed as our readers do w an t practical updating as well. B la d s y 16 F e b r u a r ie 1996 SA T y d s k rif F is io te r a p ie , D e e l 5 2 N o i 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. )