CHALLENGES FACING THE NEW SOUTH AFRICA

■ Professor M uriel Goodman
The 1980's had "in fan t stim " a term 

coined by Ferry in 1981 bu t the 1990's 
have heralded "pre-school stim ". As 
part of the team dealing with school 
readiness and/or learning problem s 
p h y s io th e r a p is ts ' tr e a tm e n t is d i­
r e c te d  to w a rd s lo w -m u s c le -to n e d  
children.

Can it b e possible that in som e nurs­
ery schools as m any as 50%  of children 
have low m uscle tone and/or incoor­
dination problem s which need atten­
tion? How do we assess m uscle tone 
and how  low is too low? Is it possible 
for physiotherapists to change m uscle 
tone? If so, will it really im prove con­
centration, learning and hyperactiv­
ity?

Som e of these children do im prove 
with exercise and learning problem s 
seem to diminish. Exercise and m ove­
m ent m ay well im prove body image, 
se lf c o n fid e n c e  an d  m o tiv a tio n  to 
learn. It is not the therapy per se that 
w orries m e so m uch, but rather the 
unsubstantiated claim s that im prove­
m ent is due to the changes in m uscle 
tone.

M ost parents will do anything to 
assist their children to im prove per­
form ance - we have a captive source of 
referral for treatm ent. I have seen far 
too m any parents who adm it to per­
sisting w ith treatm ent for their chil­
dren for m any m onths and even years 
as they are "afraid  to sto p " or "in  any 
case it w on't do any h a rm "o r "it m akes 
me feel that I am doing som ething".. Is 
that a good enough reason for long 
protracted treatm ent and w hat of the 
time and cost for such treatm ent? In 
the m a jo rity  o f situ a tio n s it is no 
longer justifiable for physiotherapists 
in South A frica to carry out treatm ents 
on a one to one basis over extended 
periods o f tim e on the assum ed belief 
that it is necessary and effective.

W hat about the m aturation of the 
n erv o u s sy stem ? N o rep u ta b le re­
search has yet shown that the m atura- 
tional pro cess can b e influenced. I 
have confirm ed again and again that 
children im prove as they m ature by 
follow ing their developm ent and see­
ing them im prove w ith no or m inim al 
input - nevertheless regular therapy 
continues especially in private prac­
tice, for children with developm ental 
disorders, as therapists cling to old be­
liefs.

In A ugust 1994 a Physical Therapy 
Editorial note by Jules M Rothstein, 
refers to our endorsem ent of ideas, not 
because of proven evidence but rather 
by the strength of the purveyors and 
their ability to m ake presum ptive ar­
guments. He states "C ults based on 
dogma, no m atter how widespread, 
do not bring honour upon anyone". 
C o in c id e n ta lly  th is  s itu a tio n  h a s 
arisen at a tim e when there is research 
e v id e n c e  to su g g e s t th a t ch ild re n  
benefit m ost when services include a 
w orking partnership betw een thera­
pist and patient or caregiver. This situ­
ation applies to all areas of physio­
therapy and a good technician for one 
to two hours a week is inconsequential 
without appropriate teaching counsel­
lin g  and co n su ltin g  w ith all team  
members.

O ur energies m ust of necessity be 
directed towards the vast m ajority of 
needy children who receive no physio­
therapy at all. In keeping w ith the 
AN C H ealth Policy, the South African 
Society of Physiotherapy has recently 
d e fin e d  n ew  s tra te g ie s  an d  g o a ls 
w hich prioritise services to unders­
erved com m unities at prim ary, secon­
dary and tertiary care levels. It also 
advocates strengthening the role of 
p h y sio th e ra p y  in a com p rehensiv e 
health care system  by providing an 
e ffic ie n t an d  e ffe c tiv e  p a rtn ersh ip  
w ith m id level workers, in a milieu

where we know  there are not suffi­
cient professionals now  or in the fore­
seeable future. I w ould like to acknow ­
ledge the clinical expertise of our pri­
vate practitioners whose input how ­
ever sm all would enhance the difficult 
task of extending our services into all 
com m unities in this country - do we 
not ow e som e com m unity service to 
those who were deprived of services 
by our ow n om ission?

How can we know  w hat to treat and 
what not to treat? Dr Tw om ey at the 
W o r ld  C o n f e d e r a t io n  o f P h y s io ­
therapy in 1991 alluded to the ability 
of physiotherapists to assess, treat and 
m anage a vast variety of conditions 
efficiently w ith a m inim um  fuss. Only 
recen tly  h a v e  p h y sio th e ra p is ts b e ­
com e involved in their ow n research 
and developm ent w hich is an essential 
com ponent of a true profession.

I believe that every child has a right 
to be given every opportunity to de­
velop to their fullest potential. This 
often requires specialised assessm ent, 
d evelopm ental guidance or in some 
a re a s  re le v a n t th e ra p y . H o w e v e r, 
overservicing of children w ith devel­
opm ental disorders w ill h ave to stop. 
W e w ill be forced to ju stify our very 
e x iste n ce  in  th e new  So u th  A frica 
where resources are so lim ited and de­
m ands so great. To quote D orothy 
J e w e ll in  th e  A u s t r a lia n  P h y s io ­
therapy Editorial 1994 Vol 40, N o 3, "If 
we continue to produce highest qual­
ity clinical activity backed by the high­
est quality research, we have no need 
to fear the threats to our pro fession ". I 
believe we have m uch to fear in South 
A frica as the challenges facing our 
profession are enorm ous.

No w here and at no other tim e has 
the need for research in physiotherapy 
been m ore im portant than in South 
Africa today.

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