...continued from page 46 as p e c ts of the p atien t, b e ca u se in o r d e r to be fu n ctio nal, o n e has to re s to re th e p h y sical ability o f th e p a tie n t to its fullest exten t. H o w e v e r, m en tal ability o f th e p a tie n ts w a s also c o n sid ered im p o rta n t. P h y sio th e ra p ists s e e m to realise th at th e m en tal ability o f th e p atien t is o n e o f th e m o st c ritical a sp ects of su ccessfu l reh ab ilitatio n, as it w ill h a v e an effect o n the p hy sical o u tco m e. It w a s in terestin g to n o te tha t alth o u g h im p ro v e d q u ality of life w a s th o u g h t to b e an im p o rta n t a s p e c t of reh abilitation, m a x im u m in d ep en d en ce w a s ra te d h igh er. P a tie n ts ' resp on sib ility fo r their o w n h ealth w a s n o t re g a rd e d as v e r y im p o rta n t. H o w e v e r, if it is felt th at in o r d e r to be reh ab ili tated su ccessfu lly , th e p atien t sh o u ld b e co m e resp on sib le for him self, th en p atien t e d u c a tio n w o u ld p la y a vital role5. O nly th ree re s p o n d e n ts m en tio n ed the te rm " e d u c a tio n " in th eir defini tion o f reh ab ilitatio n. This w a s th e g re a te st w eak n ess the a u th o rs identified in the p h y sio th e ra p is ts' defin ition o f rehab ilitation. The v o ca tio n a l p o ten tial o f a p atien t w a s ran k ed by p h y sio th erap ists as the s eco n d least im p o rtan t. This finding is o n e th at is sh ared by R o y et a l (1 9 8 8 ) w h o b elieve th at v o catio n al reh ab ilitatio n is n o t a p rim a r y aim o f reh ab ilitatio n an d if p atien ts w ish to retu rn to w o rk , this d ecisio n w ill be in flu en ced m o re b y social factors and ft less b y m e d ic a l reh ab ilitatio n . T h e social p o ten tial o f a p atien t w a s co n sid ered reason ab ly im p o rta n t in the d efin ition, b u t p h y sio th erap ists ran k ed it as less im p o rta n t fo r su ccessfu l reh ab ilitatio n, than p hy sical o r m en tal ability (T ab le 1). W h e n ask ed w h o w a s in c h a r g e o f reh ab ilitatio n in the units w h e re th e y w e re w o rk in g , 8 2 ,3 % s ta te d th at the p h y sio th erap ists w e re . It w a s fe ltb y 3 9 .6 % o f re s p o n d e n ts th at the p h y sio th erap ists sh o u ld b e in c h a rg e o f reh ab ilitatio n a n d on ly 2 2 .5 % felt th at the d o c to r sh o u ld be in c h a r g e (F ig u re 2). L e h m a n (1982) w a s of the o p in io n h o w e v e r, that th e d o c to r sh o u ld be in co n tro l b e ca u se the p ro b le m u su ally b e g a n w ith a medicEil co n d itio n w h ich w o u ld d e te rm in e w h a t cou ld o r co u ld n o t b e d o n e fo r th e p atien t7. H e also s tressed th at a te a m req u ired a g o o d w o rk in g relatio n ship o f all h ealth p ro fessio n als in v o lv ed in reh ab ilitatio n c a re of p atien ts o n a d a y to d a y b asis w ith a c o m p le te u n d erstan d in g of th e p o ten tial co n trib u tio n o f e a c h m em b er. This o p in io n is co n sist e n t w ith v ie w s e x p re s se d b y S oric et a l an d C h am b erlain 8,9. P h y sio th e ra p is ts felt th at th ey an d the p atien t w e re :the m o st essen tial m e m b e rs o f th e reh ab ilitatio n te a m (99% ) b u t u n fo rtu n ately 9 7% re g a rd e d the fam ily o f the p atien t as n ot im p o rta n t at all. A cc o rd in g to S oric et a l (1 9 8 5 ), a fam ily th at is s u p p o rtiv e will m a rk e d ly influence the final o u tc o m e o f treatm en t. This is con sist en t w ith the W H O 's v iew , w h ich co n firm s th at the p atien ts, their fam ilies an d the co m m u n itie s in w h ich th ey live sh o u ld be p a rt o f the reh ab ilitatio n p ro cess. This w o u ld g re a tly en h an ce the p a tien t's qu ality o f life8 . PANEL DISCUSSION PHYSIOTHERAPY IN THE FUTURE - CAN WE MAKE A CHANGE? A lth o u g h the q u estio n w a s n o t an sw e re d an d the tim e allow ed fo r a u d ie n ce p a rticip a tio n w a s -really n ot e n o u g h (p erh ap s w e w e re all tired b y the e v e n in g o f the fo urth d ay !) the panel d is c u ssio n , d u b b ed " r o le o r d o le " b y the c o n g re s s co m m ittee, g av e p le n ty o f fo od fo r th ou gh t. P ro fe s s o r B ru c e S p ark s, of the d e p a rtm e n t o f c o m m u n ity h ealth , w h o also c h a ire d th e d iscu ssio n , ou tlin ed the p ro b lem s to b e faced in the n e x t few y e a r s - th o se o f political a n d eco n o m ic u n certain ty , m a s s u n e m p lo y m e n t an d p o v e rty , in creasin g v i o len ce an d con flict, co llap se o f fam ily stru ctu re s , d e-racialisatio n and loss o f p riv ileg ed p o sitio n fo r m in o rity g ro u p s . A g ain st this b a ck g ro u n d w e shall also h a v e to c o p e w ith a s o c ie ty in w h ich first the y o u th a n d then the eld erly p re d o m in a te , an d w ith a p red icted W h en o n e co n sid ers su ccessfu l reh ab ilitatio n in term s o f im p ro v e d q u ality o f life an d an a c c e p ta n c e b y th e p atien t o f self resp onsib ility, th en the S ou th A frican p h y sio th e ra p ists d o n ot h a v e a cle a r u n d e rs ta n d in g o f reh ab ilitatio n . W ith o u t p atien t ed u catio n , the p atien t c a n n o t b e co m e resp o n sib le fo r h im self and this a s p e c t of reh ab ilitatio n w a s ra te d v e r y low b y th e p h y sio th e r ap ists. T h e c o n ce p t o f self-resp o n sib ility in reh ab ilitatio n h as b een d escrib ed b y m an y au th o rs. B ran d o n (1 9 8 5 ) s tates th at the p atien t sh o u ld b e in volv ed in his o w n reh ab ilitatio n p ro g ra m m e as a " c o -m a n a g e r " 10. T h e im p o rta n c e o f self-resp o n sib ility is fu rth er stressed b y L a n g e r an d R o d in w h o s ta te th at " p e rs o n s w h o are g iv en g re a te r p erso n al resp on sib ility an d ch o ice in life activ ities d e m o n s tra te h ig h er levels o f alertn ess an d m o re a c tiv e p a rticip a tio n " in their reh ab ilitatio n p r o g r a m m e 11. T he au th o rs w o u ld like to stre ss the p o in t again : th at fo r a p a tie n t to b e self-respo nsib le h e h as to b e e d u c a te d ab o u t his d isease. P h y sio th erap ists resp o n d in g to this q u estio n n aire sh o w little ap p reciatio n o f the im p o rta n c e o f e d u c a tio n as w ell as the ro le of th e fam ily an d the c o m m u n ity in th e su ccessfu l reh ab ilitatio n of a p atient. It is in terestin g to n o te th at a lth o u g h th ey h a v e a lim ited an d su p erficial k n o w led g e o f reh ab ilitatio n th ey feel th at they sho uld b e an d are the m o s t im p o rta n t m e m b e rs o f the reh ab ilita tion team . In v iew of the resu lts o f the q u estio n n aire an d th e fact that reh ab ilitatio n w as so p o o rly d efin ed, th e a u th o rs c o n c lu d e that the q uestion s p o sed b y D av id s c a n n o t b e an sw e re d m ean in gfu lly. B ecau se o f this, it is felt th at the tim e h as c e rta in ly c o m e to d e v o te m o re tim e to all the im p o rta n t as p e c ts o f reh ab ilitation. References 1. Davids LM. Rehabilitation restore to effectiveness or normal life by training. The South African Journal o f Physiotherapy X991;4X(1):2. 2. Nadolsky JN. The "1984" crisis in rehabilitation. Journal o f Rehabilitation Jan/Feb/Mar 1984;4-5. 3. Report of a WHO expert committee, Disability prevention and Rehabili tation. WHO Technical report series 668 Geneva W HO 1981:8-9. 4. Caradoc-Davies TH, Disler PB. Rehabilitation in New Zealand: now and the future. New Zealand Medical Journal 1990;103:210-214. 5. Oldridge NB. Cardiac Rehabilitation, Self-responsibility and quality of Life. Journal o f Cardiopulmonary Rehabilitation 1986;6:153-156. 6. Roy CW et al. Work of a Rehabilitation Medicine Service. British Medical Journal 1988;297(3):601-604. ' ■: / 7. Lehmann JF. Rehabilitation medicine: past, present and future. Archives o f physical medicine and rehabilitation i982;63:291V297: 8. Soric R et al. Rehabilitation Medicine: Its time has come. Post Graduate Medicine 1985;77(8):13-18. 9. Chamberlain MA. What is rehabilitation? British Journal o f Hospital Medicine 1989;4(1):311. 10. Brandon JE. Health promotion and wellness in rehabilitation. Journal o f Rehabilitation Oct/Nov/Dec 1985:54-57. 11. Sawyer HW, Crimando W. Self Management strategies in rehabilita tion. Journal o f Rehabilitation Jan/Feb/March 1984;50(1):27-31. 6 ,0 0 0 ,0 0 0 infected b y A IDS b y the y e a r 2 0 1 0 , m o st o f these in tht in co m e g en eratin g a g e -g ro u p . T h e challen ges facin g S ou th A frica in clu de: • defining a n ew S ou th A frican vision • a ch iev in g tran sitio n w ith o u t p o larisatio n • g en eratin g fertile o p p o rtu n ities fo r c o llab o ratio n • en co u ra g in g ec o n o m ic g ro w th • re s tru ctu rin g e d u catio n , h ealth a n d w elfare serv ices • in teg ratin g the "m a rg in a lis e d " y o u th of the c o u n try • tackling p eri-u rb an an d s lu m p ro b lem s • p lan n in g fo r ru ra l c h a n g e an d lan d refo rm s • m ain tain in g ju stice an d d e v e lo p in g an a c c e p ta b le p olicin g sy stem Th e h ealth challen ges to be faced are d ire c tly rela te d to the ab ove. H ealth costs are rising steep ly a t a tim e w h e n the d e v e lo p m e n t o f h ealth services, esp ecially p re v e n ta tiv e c a re , is n eeded Continued on page 52... Physiotherapy, August 1993 Mot 49 No 3 Page 49 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. ) WHEN MUCOCILIARY CLEARANCE IS A STICKY PROBLEM Every physiotherapist knows that effective clearance of the bronchial passages is virtually impossible without the help of their staunchest ally - the cilia. B u t ciliary activity is inhibited by the thick tenacious mucus associat ed with bronchial disease. And, to make matters worse, the microbes associated with bacterial and viral infections can release certain com pounds which slow ciliary beating(1). Luckily there’s Bisolvon 0,2 Solution - a proven enhancer of mucociliary clearance. REDUCES MUCUS VISCOSITY 2 3 4> • Interferes with the production of Acid Mucopolysaccharide molecules in the goblet cells • Helps break down existing mucus by increasing lysosome secretion(4) FACILITATES ANTIBIOTIC ACTION Oral Brom hexine significantly increases the penetration of various antibiotics into the bronchial secretions(5,6) 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. ) TRUST THE PROVEN SOLUTION TO SOLVE IT Two very good reasons why you shouldn’t be sticky about using Bisolvon 0,2% Solution for your patients. THE PROVEN SOLUTION TO A STICKY PROBLEMBisolvon 0 ,2 % Solution B rom hexine HC1 |$2|Bisolvon 0,2 % Solution. Bromhexine' hydrochloride 10 mg/5 ml solution for oral or respirator use. Ref. N o ' Q 6 4 2 (A c t 101/1965) Boehnnger Innclhcim (Pty) Ltd. C o. Reg. N o 66/08619/07 Private Bag X 3 0 3 2 , Randburg 2125 ■ (i)Brfcvvis R A L, C ihson G J, Geddas DM Respiratory M edicine. [\ibhshecfbyBatUi6rc Tin d all, London, 1990: Page 732 (2 ) Norris Melvtll . JstnaiLS, irsealy C . T racheobronchial function in health and dise 4 0 ( 1 9 8 0 ) . 3 2 9 *3 3 6 (3 ) Today’s drugs. Br Med. J . Ju n e 5 (1 9 5 8 1 ,5 8 2 .( 4 ) H oubcn JJ G , van Rowum JM . Drug-Targeting door middel vati;cortiblfta6ietherapie. Journal for Drug Therapy and Research, S e p t a t e 1992: 2 1 3 -2 1 8 (5 ) Taskar V S , et al. Effect o f brom hexine on o ito x yc tllm levels in lower respiratory infections. Respir;*ro M e d i c m * , ^ (1 9 9 2 ) . 157-160 (6 ) M am ndale. T h e Extra Pharmacopoeia.. 2 9 th Bditton* Cost effectiv e« only R 0.82 per treatm ent B o e h rin g e r In g e lh e im 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. ) ...continued from page 49 u rgen tly in ru ral an d p e ri-u rb a n areas. The d ev elo p m en t o f in n er city slu m s, fam ily p sy ch o so cial p rob lem s, in creasin g n u m b ers o f y o u n g an d old p eo p le an d A ID S-re lated p ro b lem s are m o u n tin g p re s su re on alread y in ad eq u ate serv ices, an d this at a tim e w h en so cie ty in g en eral, facin g in creasin g p o v e rty , is m ak in g p ressin g d e m an d s for h ealth an d w elfare services. The h ealth c are s e cto r h as to m eet the challen ge of p ro v id in g accessible, affor dable, accep tab le, effectiv e an d equitable h ealth care. W e are g o in g to h a v e to m ak e decisions on the m o st a p p ro p ria te health c are p erso n n el to p ro v id e th ese services, on essen tial, m in im al d ru g lists an d even on non-eligibility for h ealth care. F o r the im m ed iate fu tu re w e are faced w ith the p ro b lem o f p ro v id in g a d eq u ate p rim a ry h ealth c a re w ith o u t the rig h t p erson n el. W e shall h a v e to in volv e co m m u n ities in p lan n in g an d accep tin g in creased resp o n sibility for h ealth c a re , w e shall h a v e to p r o v id e m o r e a p p r o p r i a t e tr a in in g o f health c a re p erso n n el a n d w e shall h a v e to d ecid e on the m a n a g e m e n t role o f local au tho rities an d o f the p rim a r y h ealth care d o cto r. A p p ro p ria te strateg ies w ill h a v e to b e d ev elo p ed to deal w ith AIDS, the aged an d the p oor. W a y s m u st be foun d to c o u n te r the lu re of p riv a te p ra c tic e an d to ac co m m o d a te p riv a te p ra c titio n e rs in n ew h ealth ser vices. C o sts w ill h a v e to be c o n tain ed an d this w ill in volve c o st a w a re n e s s, q u ality a ssu r ance an d au d itin g p ro g ra m m e s . P ro fesso r Sparks stressed the role o f p ro fe ss io n a l o rg an isatio n s- s u c h as o u r o w n in d e fin in g ro les a n d d e v e lo p in g strategies. W e sh o u ld b e ag en ts for p osi tive c h an g e in the p ro v isio n of h ealth ser v ices and m u st b e in volv ed in p o lic y -m a k ing, settin g an d m ain tain in g sta n d a rd s, e d u catio n , d esig n in g m a n a g e m e n t p ro to cols an d in a p p ro p ria te research . A s far as ed u catio n al p ro g ra m m e s are co n cern ed , w e m u st m atch w h a t w e teach to the reality w h ich the s tud en ts w ill face. Dr D avid G reen (M A SA p o licy d ivi sion , E xecu tiv e D irector o f N A M D A ) a d d ressed the financial issu es in volv ed . H e p oin ted o u t th at to tre a t activ ely the p re d icted n um ber o f AIDS p atien ts in the y ear 2 0 0 0 w o u ld w ip e o u t th e en tire health b u d get. It is ob vio us th at p riorities w ill h a v e to be d eterm in ed , and it is alread y k now n th at the m ain th ru st of h ealth services will be in to p rim a r y h ealth c a re . A fu rth er p rio rity will be th at o f training staff - 1 4 8 clinics built in 1 992 stand e m p ty an d u n u sed d u e to lack o f staff. H e p o stu lated that pub lic h osp itals and clinics m a y b e tran s ferred to a D ep artm en t o f Public W ork s, an d th at the D ep artm en t o f H ealth m ig ht ch o o se to b u y services in stead o f p ro v id in g them . A t p resen t reso u rces in the p riv a te sec tor are being used in ap p ro priately , w ith too m a n y visits to d o cto rs an d specialists, too m a n y specialised tests o rd e re d an d too m an y p rescrip tion s issued. The M ed ical S ch em es A m en d m en t A ct, w h ich w ill be im p lem en ted to w ard s the en d o f this y ear, w ill c h a n g e th is s itu a tio n d r a s tic a lly . U n d e r this A c t m edical sch em es will be able to w ithhold p a y m e n t fro m p ro v id ers if th ey feel the serv ice p ro v id e d w a s unjus tified. These p ro v id ers include p h y sio th er ap ists, w h o up to n ow h a v e been p ro tected u n d er the A ct. The A c t p ro v id es incentive for the fo rm atio n of health m an ag em en t s c h e m e s a n d g r o u p p r a c tic e s , a n d b y Ja n u a ry 1 9 9 4 financiers of h ealth services w ill be able to pick "p re fe rre d p ro v id e rs" - th ose w h o p ro v id e the m o st cost-effective services. A s far as h ealth m a n ag em en t sch em es an d gro u p p ractices are co n cern ed , b u d getin g p o licy m a y w ell giv e in centive n ot to inclu de p h y sio th erap ists on their staff or ev e n to b u y their services! Som e balances w ill b e n ecessary in o rd er to en su re that p atien ts receiv e n e ce s sa ry tre a tm e n t, b u t p h y sio th erap ists w ill h a v e to m a rk e t the n ecessity for their serv ices. T h e ch an g es in th e a d v e r t i s i n g r u l e s , to b e g a z e t t e d s h o rtly , will allow us to d o this. A lth o u g h itis u nlikely th at the su p p ly o f p h y sio th er ap ists w ill e x c e e d th e c o u n tr y 's d em an d , w e shall h a v e to a c ce p t ch an g e. It m a y be n e ce s sa ry to re-lo cate o r to c h an g e from in dep end en t p riv a te p ra c tic e to w ork in g w ith a g ro u p p ra c tic e o r H M O . A b o v e all, p h y sio th erap ists w ill h a v e to le a rn to w ork cost-effectively . P ro fe ss o r B o w erb an k , P h y sio th e ra p y D e p a rtm e n t, U n iv e rs ity o f C a p e T ow n , took the th em e o f the c o n g re s s - F u tu re Shock - as the o p en in g p o in t for h er co n tribution. She p o in ted o u t th a t sho ck w as follow ed b y a p e rio d o f in ca p a city cau sed b y s u c ce s s iv e d en ial, b lam e, self-blam e an d u n certain ty . A ctio n is n eed ed n ow to avo id this dip in p e rfo rm a n c e an d to e m b ark alre a d y o n p ro b le m -so lv in g for the future. She ask ed w h a t vision w e h a v e for the fu tu re, an d w h e th e r w e all sh are the sam e vision . W h a t is o u r resp on sib ility as a p ro fessio n in c a te rin g to th e n eed s o f the co u n try , an d h ow d o w e e n su re th at w e a c ce p t th a t resp o n sib ility ? W h a t is ou r v a lu e -s y s te m for th e p ro fessio n a s reg ard s b oth p atien t c a re an d the ed u catio n o f fu tu r e p h y s i o t h e r a p i s t s ? W h a t s tr a te g ic plan s sh o u ld w e b e m ak in g for the future an d h o w w ill th ese affect the special inter e s t g r o u p s w ith in th e p ro fe s s io n ? She p oin ted o u t th at w e h a v e to ackn ow led ge th at n o t all p h y sio th erap ists c a n w o rk in all fields - w e h a v e to feel p sy ch o lo g ically safe in o u r w o rk - b u t th at to g eth er w e can s u p p o r t o n e a n o t h e r in p r o v i n g th e p h y sio th erap y serv ices w h ich the co u n try n eed s. She closed w ith a quote: "If y o u d o n o t k n o w w h e re y o u are go in g , y o u m a y en d up so m e w h e re else an d n o t ev en k no w it." S Irwin-Carruthe FROM THE LITERATURE Title: Diagnostic Classification o f Patients with Low Back Pain. Author: Binkley e ta l. Journal: Physical Therapy 1993;75(3)138-144. A survey was undertaken to establish the le v e l o f a g r e e m e n t am on g o rth o p a e d ic physiotherapists on diagnostic classes of LBP and associated clinical findings. By use of the Delphi Technique, three diagnostic classes were agreed upon, thesebeing hypomotility dysfunc tion, nerve root adhesion and sacro-iliac dys function. There was less agreement regarding the other 22 diagnostic classes. Further survey w ill e x a m in e the r e lia b ility w ith w h ic h physiotherapists use the classification system. Title: The Effects of an Aids Education Program on the Knowledge and Attitudes of a Physical Therapy class ^ ■ 1 Author: Held SL Journal: Physical Therapy 1993;75(3)156-164 Undergraduate students were surveyed re garding their knowledge and attitudes to AIDS before and after an education programme on the disease. (Similar surveys were carried out by South African students and papers on their findings were given at the recent Congress). Title: Implications of Elbow Arthrodesis for Individ uals with Paraplegia Author: Young JH Journal: Physical Therapy 1993;75(3)194-201 The case report discusses the advantages and disadvantages of two different positions in which the elbow could be fused to allow for maximum independence. The author stresses the importance of the physiotherapist in con sidering the biomechanical needs of patients when options in surgical decisions are required. Title: Incidence of Injury in Rugby League Football Author: Gissom e e t al. Journal: Physiotherapy 1993;79(5)305-310 The number of injuries incurred at one pro fessional Rugby League club are recorded and the implications for physiotherapists working with such teams are discussed. The role of physiotherapy is not only one of rehabilitation but includes counselling and warning players and coaches of the potential for injury and the way of preventing these. The Norwegian physiotherapy journal for May 1993 covers various aspects of Physiology and its relevance to physiotherapy. These in clude articles on: • Muscle fatigue and preventive strategies • Weight training and osteoporosis • Behavioural and psychological factors which may influence components of the immune system. JC Beenhakker l rapie, Augustus 1993 Dee! 49 No 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. )