- BUT FOR HOW LONG SHOULD IT BE HELD? L A Hale, M sc (Physiotherapy) V U Fritz, PhD (Med), MBBCh, FCP (South Africa) M Goodman, PhD (Physiotherapy). INTRODUCTION U pper m otor neurone (U M N ) lesions com m only result in spasticity w hich m ay hinder the p atien t's ability to m ove nor­ m ally and thus reduce their fu nctional abilities1. T e c h n iq u e s w h ic h d e c r e a s e spasticity are therefore o f great interest to the physiotherapist involved in rehabilita­ tion. There are m any techniques available2,3, one o f w hich is prolonged m uscle stretch (PM S)4. The spastic m uscle is stretched to the end o f its available pain-free range and the stretch is m aintained until the therapist " f e e l s " th e r e d u c t io n o f to n e in the stretched muscle. In a sim ilar w ay, patients are taught how to stretch their m uscles on their own. Several authors have show n clinically th a t p ro lo n g e d m u s cle s tre tc h s ig n ifi­ cantly reduces spasticity4"7. These studies have concentrated on d em onstrating that the m ethod does indeed w ork. H ow ever, as yet, no w ork has been done on estab­ lishing for how long the stretch should be held. M ost o f the stud ies used stretch tim es of thirty m inutes, althou gh durations o f five seconds, and o f one and a h alf m inutes have been used. In all cases, no criteria w ere given regarding the choice o f stretch duration, and times appeared to have been arbitrarily chosen. In order for the physiotherapist to be able to w ork efficiently, a know led ge of how long to hold a tone-reducing stretch is necessary. If a stretch is held for too short a time, enou gh reduction in the m uscle tone m ay n ot be gained. A stretch held for too long will w aste time, som ething w hich can be ill-afforded in a b u sy physiotherapy departm ent. Patients also like to be given a set time in w hich to stretch at hom e, and not to be told to stretch until they " fe e l" looser. Physiology The physiology underlying the use of prolonged m uscle stretch in the decrease o f spasticity is controversial. It appears to affect both the stretch reflex com ponent, and the structure o f the m uscles and co n ­ nective tissue. T h re e m e ch a n o re ce p to rs w ith in the m uscle have been suggested as effecting the neural com ponent: the golgi tendon organs; the group II or flow er-spray affer- ents in the m uscle spindle; and the free nerve endings w ithin the m uscle spindle, and the free nerve endings w ithin the m us­ cle belly itself. They all respond to stretch 8 11and can cause autogenic inhibition ’ . M any studies show that spasticity leads to alterations in m uscle structure as the m uscle is m aintained in a shortened posi­ tion. The m ain effects being a d ecrease in the num ber of sarcom eres and an increase in the sarcom ere length. Prolonged m uscle stretch m ay reverse these changes12’14. It m u st be em p h asised th at P M S is slow ly executed until the m uscle is fully stretched and then held there for a period. Aim of study To investigate w hich o f the follow ing times o f PM S - two, ten or thirty m inutes - is optim al in reducing spasticity in spas­ tic quadriceps m uscles of adult patients follow ing a cerebral lesion. Spasticity w as evaluated prim arily with the pendular test15. Passive m ovem ents of the knee are pro­ duced b y gravity w hen the leg to b e tested is dropped from the fully extended posi­ tion, the thigh being supported. In a relaxed norm al su b ject, the leg sw ings in a pendular fashion for about six to seven times b efore com ing to rest at approxim ately 90° o f knee flexion. Spastic- u ity usually arrests this m ovem ent o f the leg a lot sooner so that the angles o f sw ing are sm aller and there are few er sw ings. R ead ­ ings are obtained from an electrogoniom e- 15-18ter attached to the sw inging leg In 1985, B oh an n o n and L arkin su g­ gested the use o f the C ybex II isokinetic d ynam om eter ("C y b e x ") as a m ethod of recording the m ovem ent o f the leg. The m achine has a built-in electrogoniom eter A ABSTRACT The rehabilitation of patients with upper motor neurone lesions often necessitates the reduction of spasticity before normal movement patterns can be taught. One proven technique is that of prolonged stretch to the affected muscle. How­ ever, the duration of the stretch has not been defined. This study aimed to investigate which of the following durations of prolonged muscle stretch - two, ten or thirty minutes - was optimal in reducing spasticity in spastic quadriceps femoris musc|es of adult patients following cerebral vas­ cular accidents or head trauma. The degree of spasticity was measured by the use of four methods, prior to, and after stretching. Twenty-nine spastic muscles were stretched for the three durations on different occasions, and the data analysed using the student's T-test. Results indicated that the most beneficial dura­ tion of prolonged muscle stretch in decreasing spasticity was ten minutes. Key Words: muscle tone, assessment, Cybex II isokinetic dynamometer. and record er, and is available in m any p hysiotherapy d ep artm ents. A graph of the m ovem ent o f the sw ingin g leg is ob ­ tained from w hich various objective p a­ ram eters can b e read 1518 (Figure 1). Control subject r L _ n _ i v _ r Experimental subject Figure 1. Graphs obtained from a Control and an _ _ _ _ _ _ _ _ Experimental (spastic) patient_ _ _ _ _ _ _ _ SUBJECTS In this stud y each patient w as his/h er ow n control, thus a control group as such w as not required. H ow ever, in ord er to establish the baseline p aram eters o f the "C y b e x " used in this study, thirty subjects w ere initially tested on it. T w e n ty -s ix a d u lt s u b je c ts w h o had spasticity o f one or b oth q u ad ricep s m u s­ cles as a result o f a cerebral lesion, such as m i g e 3 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. ) a head injury or a cerebral vascu lar acci­ dent (CVA ), w ere tested. They also had to fulfil the follow ing criteria: • be able to follow com m ands. • have full, p ain -free p assiv e range of their knee jo in t • have had no p rior traum a to the knee or quadriceps m uscle • have no active inflam m ation Their ages, sex and affected sid e were ji o t taken into accou nt in this study. T h e ag e o f th e tw e n ty -s ix s u b je c ts ranged from 22 to 81 years (m ed ian 56 y ears), and co m p rised five fem ale and tw enty-one m ale patients. The durations of d isability ranged from one m onth to 23 years (m edian 3.5 years), w ith 23 patients having had C V A s, tw o sustained head in­ ju ries and one suffering m ultiple sclerosis. The first tw enty-six patients referred w ho fulfilled the above criteria w ere used in the study. TECHNIQUES AND PROCEDURES E ach ex p e rim e n tal gro u p su b ject at­ tended a test session three times, the inter­ v al b e tw e e n s e s s io n s w a s m o re than tw enty-four hours (to p reven t any accu­ m ulative effect o f the stretching). After obtaining relevant personal data from each experim ental subject, their sp as­ ticity w as evaluated by the follow ing p ro ­ cedures: Analogue scale The subject indicated on a scale of 0-10, how spastic they perceived their affected thigh m uscles to feel (0 = no spasticity, and 10 = w orst they have experienced). Ashworth clinical test The tone w as assessed clinically, and the am ount o f resistance to passive m ove­ m ent rated (as described by A shw orth19) on a scale o f 0—4, w h ere 0 = no spasticity, and 4 = alm ost no m ovem ent available due to strong spasticity. Perform ance test In an attem pt to assess the effect sp as­ ticity had on the subjects m ovem ents, the time taken for each subject to flex and ex­ tend his/her leg ten tim es w as m easured w ith a stop-w atch. “Cybex” test The patient w as positioned in supine lying w ith h is/h er legs hanging over the edge of the cou ch o f the "C y b e x ", w ith the thigh fully supported and strapped to the couch. The leg to b e tested w as attached to the input shaft o f the m achine and then fully extended. The "C y b e x " w as adjusted so that it offered no resistance to the m ove­ m ent of the leg, and the paper speed o f the electrogoniom eter of the "C y b e x " set to ru n a t 5 m m / se c. T h e p a tie n t w as in ­ structed to relax com pletely, and the foot w as dropped from the horizontal plane. The leg oscillated in a pend ular fashion until it cam e to rest, a graph o f this m ove­ m ent w as recorded. The spastic quadriceps m uscles o f each subject w as then stretched for one o f the follow ing durations at each session: two, ten, or thirty minutes. The sequencing of the times used for stretching w as rand om ­ ised. The position o f stretch w as supine lying w ith the legs hanging over the edge of the " C y b e x " co u ch , th ig h s u p p o rte d . The tested leg w as attached to the "C y b e x " input shaft and the knee flexed to the lim it o f the quadriceps pain-free flexibility and clam ped into position. The stop w atch was started and the leg rem ained in this posi­ tion for the selected duration o f the stretch. D uring this time the subject could either rest or talk quietly to the exam iner, accord ­ ing to their wish. The position o f stretch ch osen ensured that the rectu s fem oris m uscle w as also on stretch, and not ju st the other m uscles o f the quadriceps fem oris group. T he leg not b ein g tested w as flexed so that the foot rested on a chair near the foot end o f the cou ch to posteriorly tilt the pel­ vis into a m ore com fortable position. The stretch w as im m ediately follow ed b y the rem easurem ent of the spasticity by analogue, A shw orth clinical, and "C y b e x " m ethods, and the perform ance test. If pain w as felt d uring the stretch, the am ount o f stretch w as lessened slightly until com fortable again. If there w as still pain, the stretch w ould have b een d iscon­ tinued. H ow ever, this did not occu r in any o f the subjects. T he subjects w ere alw ays com fortably and w arm ly positioned to prevent any dis­ com fort altering the level o f their m uscle tone. No subjects had to be rem oved from the trial becau se of any knee injuries or inflam m ations, and none of them had any em otional disturbances that could have af­ fected their level of spasticity greatly. RESULTS From each "C y b e x " graph obtained, re­ cording of the m ovem ent of the leg as it falls, the follow ing data, w as calculated in 17accordance w ith previous studies (see Figure 2) _ _ _ _ _ _ _ _ Figure 2. Parameters PI to P4_ _ _ _ _ _ _ _ P I: R elaxatio n index - the angle at w hich the spasticity arrests the natu ral backw ard sw ing. As d ifferent patients have differing restin g an gles, w h ich m ay also change from day to day, this angle is norm alised by the difference in angles b etw een the resting and starting position. P2: the n u m b e r o f sw in g s the leg p er­ form ed - calculated by cou n tin g the nu m ­ b er o f m axim a on the graph. P3: the area b etw een the g rap h and the resting angle p rior to the first crossing over of the resting angle. P4: the first m axim a o f the g raph - this show s how strongly the sp asticity pushes back the limb tow ard s the starting angle. In norm al subjects, this is usu ally about 20° to 35°. The analysed resu lts from the control group established the norm al ranges for the param eters P I to P4 for the "C y b e x " m achine used in this study. T hey w ere as follow s: P I : 1.27 - 1.53 (<1.27 indicates spasticity) P2: 4.75 - 6.79 sw in gs (<5 sw in gs indicat­ ing spasticity) P3: 9.89 - 22.45m m (> 22.45m m indicating spasticity) P 4 :22.69° - 33.77° (<22.69° ind icating spas­ ticity) Statistical analysis o f the control group TABLE 1. THE MEDIANS OF THE RESULTS OBTAINED FROM BEFORE - AND AFTER - PMS CYBEX PI TEST ANALOGUE SCALE' B2 1 .0 5 B2 4 .7 5 A2 1 .0 7 A2 4 .2 5 B IO 1 .0 0 B IO 4 .2 5 A 10 1 .0 5 A 1 0 3 .5 0 B30 1.01 B30 4 .7 5 A 30 1 .0 9 A 3 0 4 .0 0 ASHWORTH CLINICAL TEST PERFORMANCE TEST B2 2 .0 0 B2 1 8 .5 A2 1 .5 0 A2 1 8 .0 B IO 1 .7 5 B IO 2 1 .5 A 10 1 .2 5 A 10 1 7 .0 B30 1 .7 5 B30 2 0 .5 A 30 1 .2 5 A 30 1 7 .5 B: before stretch. A: after stretch durations 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. ) data found that the P2, P3, and P4 results had to be read w ith som e caution, as this data w as slightly skew ed. Table I show s the m edians o f all the tests used to m easure the before- and after­ stretch m uscle tone. It can be seen from this table that there was a tendency for spastic­ ity to decrease after stretch. P ro o f o f a s ig n ifica n t d iffe ren ce b e ­ tw een the before- and after-stretch values w as supplied by the Stu d en t's T-test. T a­ bles II and III show only those results that w ere significant, the d ifferences betw een the rem aining before- and after-stretch re­ sults w ere insignificant. It can be seen from these tables that the b est results w ere obtained from the ten m inute PM S, as three results gave a signifi­ cant d ifference (pcO.OOl) b etw een the b e ­ fore- and after-results at the tw o-tailed sig ­ nificance level, and tw o results show ed a p robable significant d ifference (p<0.01). TABLE II. SUM M ARY OF RESULTS AT A TWO-SIDED SIGNIFICANCE LEVEL TEST TIME OF T-STATISTIC SIGNIFICANCE STRETCH LEVEL PI lO m in s 5 .2 2 0 .0 0 0 * * * Analogue scale 2 mins 2 .9 5 0 .0 0 0 * * * lO m in s 8 .8 2 0 .0 0 0 * * * 3 0 mins 2.61 0 .0 1 5 * * Ashworth Clinical Assessment 2 mins 6 .3 8 0 .0 0 0 * * * lO m in s 6.01 0 .0 0 0 * * * 3 0 mins 6 .8 2 0 .0 0 0 * * * * * = 1 x 0 .0 1 , * * * = p < 0 .0 0 1 TABLE III. SUMMARY OF RESULTS AT A ONE-SIDED SIGNIFICANCE LEVEL TEST TIME OF STRETCH T-STATICTIS SIGNIFICANCE LEVEL PI 2 mins 1.6 4 0 .0 6 ? * 3 0 mins 1.9 4 . 0 .0 4 * P3 lO m in s 1 .7 8 0 .0 4 * P4 lO m in s 1.7 2 0 .0 5 * Performance Test 3 0 mins 1 .8 5 0 .0 4 * * = p < 0 .0 5 , ? * = bordering on p < 0 .0 5 Thirty m inutes o f PM S w as the n ext best duration as it gave tw o results o f signifi­ cant d ifference (pcO.OOl) and tw o results o f probable significant d ifference (p<0.01). Tw o m inutes o f PM S also gave tw o re­ sults o f significant difference (pcO.OOl), bu t only one q uestionable result at the one- tail significance level (p<0.06). DISCUSSION It appears that the ten m inute stretch is the m ost effective in decreasing spasticity. The thirty m inute test clinically sug­ gested a dram atic decrease in the tone; how ever, the "C y b e x " test indicated other­ wise. This m ay have been due to the d iscom ­ fort the position o f the stretch gave a lot of the patients because of the low er lum bar spine being in lordosis for too long in spite o f flexing the opposite leg on a chair. The subsequent dropping o f the leg during the a f t e r - s t r e t c h " C y b e x " te s t m a y h a v e caused an additional strain on the lower lum bar spine resulting in m ore discom fort and thus increasing their spasticity again. The tw o m inute test did not appear tn d ecrease spasticity according to the "C y ­ b e x " test. H ow ever, the clinical and ana­ logue tests favoured it. There m ay be sub­ tle changes in the level o f the spasticity that can be picked up subjectively, bu t cannot be m easu red accu rate ly en o u g h o b je c­ tively. T he results o f the analogue scale m ay be debatable as m any of the patients did not really understand w h at w as being asked of them. Som e of the patients guessed and therefore did not give a true reflection of their perceived level o f spasticity. T he scale m ay b e better applied by us­ ing pictorial representations o f the varying intensities of spasticity w hich the patients may understand m ore easily than the ana­ logue scale. A n im partial assessor o f this test w ould help to prevent subjects from giving infor­ m ation w hich they think the researcher w ould like to hear. The A shw orth clinical assessm ent o f the patients' spasticity show ed that stretching w as very effective in the reduction o f h y­ pertonus. H ow ever, patients w ere tested b y only one o f the authors, and an elem ent o f subjective bias m ay have been intro­ duced. The perform ance test involved the time it took for the patient to flex and extend his/her affected lim b ten times. This test proved, both statistically and through o b ­ servation, to be unreliable. The effort o f the patients w as variable and there w as ab so­ lutely no standardisation o f the test at all. The results o f this test w ere therefore of dubious use in the analysis o f the data. The C ybex m ethod is objective, giving quantitative results. H ow ever, its sensitiv­ ity to sm all changes in m uscle tone has not yet been established. Its reliance on the patients ability to relax prior to the d rop­ ping o f the leg is an additional com plica­ tion. H ow ever, its m ain d isadvantage is that the test has a lim ited versatility as it can only really test the quad riceps fem oris m uscle group. T he sam e pend ular effect being difficu lt to obtain from other muscle groups. The param eter PI from the "C y b e x " test appeared to give reliable results, as has b e e n s h o w n b y p r e v io u s s tu d ie s 16,z0. H ow ever, the reasons for the param eters P2, P3 and P4 for giving variable, insignifi­ cant results are not clear. O f the four tests used to m easure sp as­ ticity, the "C y b e x " (P I param eter) test ap ­ peared to be the m o st objective. This test show ed that there w as a definite signifi­ cant difference b etw een the b efo re- and a fte r-s tre tc h re su lts o f the ten m in u te stretch (pO.OOl). CONCLUSION In order to d ecrease m uscle tone in the affected m uscles o f p atients w ith spastic­ ity, it is recom m ended that the m uscle be stretched for ten m inutes. It is felt that the "C y b e x " test using the P I param eter, is a good test for m easuring spasticity. It not only gives an objective result, b u t it is quick and easy to do. C linical testing rem ains a good indica­ tor, but has an elem ent o f subjective bias, 21-23as has b een found b y other authors ’ . In addition to its relaxation effect on the neural com ponent o f spasticity, prolonged m uscle stretch m ay also b e o f b en efit in m aintaining the flexibility o f the m uscle and in preventing the effects o f spasticity o n its structure. (T h is research w as approved b y the C om m ittee for R esearch on H u m an S u b ­ jects, the U niversity o f the W itw atersrand (No. 17/11/91), and w as part o f a d isser­ tation subm itted by M rs L A H ale to the U niversity o f the W itw atersrand in order to com plete her M asters d egree in P hysio­ therapy.) REFERENCES 1. Lehmann J F, Price R, de Lateur B J ct al. Spasticity: Quantitative measurements as a basis for assessing effectiveness of therapeu­ tic intervention. Arch' P hys M ed R ah ab il 1989;70:6-15. 2. Chan C W Y. Some techniques for the relief of sp asticity and their physiological basis. Physiotherapy Canada 1986;38(2):85-88. 3. Bobath B. The treatment of neuromuscular disorders by improving patterns of coordi­ nation. Physiotherapy 1969;5(l):18-22. 4. Odeen I, Knutsson E. Evaluation of the effects of muscle stretch and weight load in patients w ith spastic paraplegia. Scand J Rehab Med 1981;13:117-121. 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. ) P h y s i o t h e r a p y E x p e r t i s e Leslie Williams M emorial Hospital is a 4 3 0 bed h ospital fo r m ine em ployees, and is situated about 70 kms south w est o f Joh an n esb u rg n ear the tow n o f Carletonville. It serves m ainly as a traum a unit and boasts 4 state-of-the-art operating th eatres, a radiology departm en t and an ICU. The hospital has a vacan cy fo r a PHYSIOTHERAPIST To qualify for this ch allen g in g p osition, a B Sc (P h y sio) or eq u iv alen t diplom a is requ ired , w hilst three years' experience as -a Physiotherapist would be ideal. G ood interpersonal skills and the ability to relate to p eop le at all levels is essential. The in cu m b en t will be requ ired to apply their skills in the areas o f traum a, o rth o p aed ics and intensive care physiotherapy. A high standard o f liaison with other departments within the hospital will be required. A s a la r y b a se d o n q u a lifica tio n s a n d e x p e r i e n c e , b a c k e d b y a h o lid a y le a v e a llo w a n c e ( 1 3 t h c h e q u e ), is s u p p le m e n te d b y th e fo llo w in g b e n e fits: A s u p p o r tiv e te a m -o r ie n te d w o rk e n v ir o n m e n t U se o f d ie e x c e lle n t sp o rtin g a n d re cre a tio n facilities provid ed b y th e co m p a n y rJ&C>0 C o n t r i b u t o r y m e m b e r s h i p o f i n d u s t r y r e t i r e m e n t a n d m e d i c a l b e n e f i t s c h e m e s T h e b e n e f i t o f w o r k in g f o r a la r g e G r o u p w h ic h e m p h a s is e s s ecu rity o f e m p lo y m e n t P le a se su b m it w r itte n a p p lic a tio n s w ith fu ll p e r s o n a l a n d c a r e e r d e ta ils to th e C h ie f M ed ical O fficer, Leslie W illiam s M e m o ria l H o sp ita l, P riv a te B ag X 2 0 1 1 , C a rle to n v ille , 2 5 0 0 . A M e m b e r O f T h e G o l d F i e l d s G r o u p LESLIE WILLIAMS MEMORIAL HOSPITAL .. .continued from previous page 5. Odeen I. Reduction of muscular hypertonus by long term muscle stretch. Scan J Rehab Med 1981;13:93-99. 6. Tremblay F, Malouin F, Richards C L et al. Effects of prolonged muscle stretch on reflex and voluntary muscle activations in children with spastic cerebral palsy. Scand ] Rehab Med 1990;22:171-180. 7. Carey J R. Manual stretch: effect on finger movement control and force control in stroke subjects with spastic extrinsic finger flexor muscles. Arch Phys Med Rehabil 1990;71:888- 894. 8. Patton H, Fuchs A, Hille B et al. Textbook o f Physiology, W B S a u n d e r s C o m p a n y , 1989;1:510-521. 9. Till D. The uses of reflexes in the restoration o f n o r m a l m o v e m e n t. Physiotherapy 1969;55(1):208. 13. Ganong W F. Review o f M edical Physiology, 12 ed. California: Lange Medical Productions, 1985. 11. Delwaide P J, Oliver E. Short-latency auto­ genic inhibition (lb inhibition) in human spasticity. / o f Neurol Neurosurg Psychiatry 1988;51:1546-1550. 12. Grossman M R, Sahrmann S A, Rose S J. Review of length-associated changes in mus­ cle. Phys Ther 1982;62(12):1799-1807. 13. Botte M J, Nickel V L, Akeson W H. Spasticity and contracture: physiological aspects of for­ mation. Clin Ortho Relat Res 1988;233:7-18. 14. Williams P E. Effects of intermittent stretch on im m obilised muscle. Ann Rheum Dis 1988;47(12):1014-1016. 15. Bohannon R W, Larkin P A. Cybex II isoki­ netic dynamometer for the documentation of spasticity. Phys Ther 1985;65(l):46-47. 16. Bajd T, Bowerman B. Testing and modelling of spasticity. ] Biomed Eng 1982;4:90-96. 17. Bajd T, Vodovnik L. Pendular testing of spas­ ticity. J Biomed Eng 1984;6:9-16. 18. Bohannon R W. Variability and reliability of the pendular test for spasticity using a Cybex II is o k in e tic d y n a m o m e te r. P h y s T her 1987;67(5):659-661. 19. Ashworth B. Preliminary trial of carisopro- d ol in m u ltip le s c le r o s is . Practitioner 1964;192:540-542. 20. Brar S P, Smith M B, Nelson L M et al. Evaluation of treatment protocols on mini­ mal to moderate spasticity in multiple scle­ rosis. Arch Phys Med Rehabil 1991;72:186-189. 21. Bohannon R W, Smith M B. Inter-rater reli­ ability of a modified Ashworth scale of mus­ cle spasticity. Phys Ther 1987;67(2):206-207. 22. Blake P F. Spasticity: can it be measured. Proceedings IXth International Congress of the World Confederation for Physical Ther­ apy, Stockholm, 1982. 23. Burry H C. Objective measurement of spas­ ticity. Develop Med Child Neurol 1972;14:508- 523. ___ _________________CWPC 0179__________ BUSINESS O P P O R T U N IT Y P H Y S IO TH ER A P Y Finsch mine, one of the flagships o f the De Beers group, is situated in the tranquil rural setting o f Lime Acres, some 160 kilometres North West o f Kimberley in the Northern Cape. We currently have a challenging oppor­ tunity for a business minded person who is in possession of a Bsc in Physiotherapy, and is registered w ith the Medical and Dental Council. The incumbent will be required to oper­ ate an existing, fully equipped, physio­ therapeutic practice as a completely independent business unit. The success­ ful candidate should therefore have the necessary drive and initiative to ensure a high level o f service to the community. Given that this opportunity represents a private business initiative the individual will be responsible for all costs associated w ith maintaining the practice and equip­ ment. Residential accom m odation is available at a nominal rental. Should this, potentially highly rewarding, opportunity appeal to you, please fax a detailed CV to the Labour Relations Offi­ cer (Admin) on (05982) 29595 or post your details to P O Box 7, Lime Acres 8 4 10. Tydskrif F is io le ra p ie , D e a l 51 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. )