T re a tm e n t of Burns at th e R e d C ro s s W a r M e m o rial C h ild r e n s H o s p it a l, C a p e To w n April, 1966 P H Y S I O T H E R A P Y Page 3 M . L. B R E T T , M . C . S . P . , P h y s i o t h e r a p i s t . R e d C r o s s W a r M e m o r i a l C h i l d r e n ’s H o s p i t a l T h e R e d C r o s s H o s p i t a l B u m s U n i l is t h e c e n l r e f o r i h e w h o l e o f t h e W e s t e r n C a p e f o r t r e a t i n g b u r n s i n c h i l d r e n u p t o t h e a g e o f 13, a n d o v e r t h e y e a r s , s i n c e t h e h o s p i t a l o p e n e d i n 1 9 5 6, h a s d e v e l o p e d i n t o a v e r y e f f i c i e n t a n d s u c c e s s f u l u n i t . T h e u n i t is s t a f f e d b y s u r g e o n s , a p a e d i a ­ t ri c i a n , a p l a s t i c s u r g e o n , a s i s t e r a n d C o l o u r e d n u r s e s , a n d d u r i n g t h e y e a r 1 9 6 5 , 3 8 0 c a s e s w e r e a d m i t t e d . A S E P T I C P R E C A U T I O N S G r e a t c a r e is t a k e n t o a v o i d t h e i n t r o d u c t i o n o f a n y i n f e c t i o n i n t o t h e u n i t , o r c r o s s i n f e c t i o n f r o m o n e c a s e t o a n o t h e r , a n d a l l p e r s o n s e n t e r i n g t h e u n i t i t s e l f , n o t o n l y t h e c u b i c l e s , m u s t w e a r a s u r g i c a l m a s k . T h e f l o o r s a r e n o t s w e p t , in o r d e r t o a v o i d c i r c u l a t i n g d u s t a n d g e r m s , b u t a r e s w a b b e d t w i c e d a i l y w i t h d i s i n f e c t a n t , a n d t h e u n i t is a i r - c o n d i t i o n e d . T h e t e m p e r a t u r e o f e a c h c u b i c l e is c h a r t e d d a i l y a n d c a n b e a l t e r e d a c c o r d i n g t o t h e p a t i e n t ’s c o n d i t i o n a n d t h e w e a t h e r . T h e s t a f f a r c g o w n e d w h e n t r e a t i n g t h e p a t i e n t s a n d m u s t w a s h w i t h g e r m i c i d a l s o a p b e f o r e g o i n g f r o m o n e c h i l d t o t h e n e x t . W h e n c e r t a i n o r g a n i s m s a r e r e p o r t e d in a b u r n s w a b c u l t u r e ( e s p e c i a l l y b e t a h a e m o l y t i c s t r e p t o c o c c u s o r p s e u d o - m o n a s ) t h e s e p a r t i c u l a r p a t i e n t s a r e s t r i c t l y i s o l a t e d , a n d s t a f f e n t e r i n g t h a t c u b i c l e m u s t b e g o w n e d a n d b o o l e d a s well a s m a s k e d . I n t h i s w a y i n f e c t i o n is k e p t t o a m i n i m u m , a n d o n e n o t i c e s t h e a b s e n c e o f t h e u n p l e a s a n t s m e l l u s u a l l y a s s o c i a t e d w i t h b u r n c a s e s . S k i n g r a f t i n g , w h i c h is e s s e n t i a l i n all f ul l t h i c k n e s s b u r n s , w il l f ai l i f u n d e r t a k e n i n t h e p r e s e n c e o f u n c o n t r o l l e d i n f e c t i o n , s o it is o f v i t a l i m p o r t a n c e t h a t s t r i c t a s e p t i c t e c h n i q u e s a r e o b s e r v e d . A s t h e h o s p i t a l c o l l e c t s p a t i e n t s f r o m s u c h a w i d e a r e a w e t e n d t o h a v e p a r t i c u l a r l y s e v e r e b u r n c a s e s a d m i t t e d , e s p e c i a l l y d u r i n g t h e w i n t e r m o n t h s w h e n f i r e s a r e m a d e i n s i d e t h e p o n d o k k i c s a n d s h a c k s . T h e s e c h i l d r e n a r e o f t e n in a p o o r p h y s i c a l c o n d i t i o n p r i o r t o b e i n g b u r n t , a n d t h o u g h t h e e x t e n t o f t h e b u r n m a y s e e m s m a l l t h e y a r e v e r y l i a b l e t o d e v e l o p b r o n c h o p n e u m o n i a , a c o m m o n c o m p l i c a t i o n i n b u r n s . I N I T I A L T R E A T M E N T O n a d m i s s i o n , t h e p e r c e n t a g e o f t h e b u r n is a s s e s s e d b y t o t a l l i n g t h e a r e a o f b o d y s u r f a c e a f f e c t e d , a n d t h e n e c e s s a r y m e d i c a l t r e a t m e n t is s t a r t e d t o c o m b a t s h o c k a n d l o s s o f b o d y f l u i d s . T h e r e is n o d i f f e r e n c e i n t h e t r e a t m e n t o f a b u r n c a u s e d b y f ir e f r o m o n e c a u s e d b y s c a l d i n g l i q u i d s s u c h a s w a t e r , t e a o r p o r r i d g e , e x c e p t t h a t i f i n t h e l a t t e r c a s e b l i s t e r s o c c u r t h e s e a r e l e ft u n t o u c h e d , t h e r e b y a v o i d i n g t h e p o s s i b l e i n t r o d u c t i o n o f i n f e c t i o n t h r o u g h a n y b r e a k i n t h e s k i n a n d d i s c o u r a g i n g f u r t h e r f l u i d l o s s . D e p e n d i n g o n t h e l o c a t i o n o f t h e b u r n a n d t h e d e g r e e o f s e p s i s t h e p a t i e n t is n u r s e d e i t h e r b y t h e “ o p e n ” o r e x p o s e d m e t h o d , w h i c h is p r e f e r r e d i n m o s t c a s e s , o r b y t h e ' ' c l o s e d " m e t h o d , w h e n d r e s s i n g s a r e a p p l i e d . T h e o b j e c t o f t h e " o p e n ” m e t h o d is t o a l l o w t h e b u r n s t o d r y a n d f o r m t h e i r o w n p r o t e c t i v e c r u s t s , b a c t e r i a l c o l o n i s a ­ t i o n m e a n w h i l e b e i n g r e d u c e d b y s p r a y i n g f o u r - h o u r l y w 'i t h a n a n t i - b a c t e r i a l s p r a y s u c h a s P o l y b a c t i n . T h e ‘‘c l o s e d ” m e t h o d is u s e d f o r a l l b u r n s o f t h e h a n d s a n d f e e t , f o r b a d l y i n f e c t e d c a s e s , a n d f o r c i r c u m f e r e n t i a l b u r n s . O c c a s i o n a l l y a n o l d b u r n c a s e is s e n t i n f r o m t h e c o u n t r y , h a v i n g a l r e a d y d e v e l o p e d d e f o r m i n g s c a r s a n d c o n t r a c t u r e s , o r w e b b i n g o f f i ng e r s a n d t o e s , a r e s u l t o f n o t b a n d a g i n g e a c h d i g i t s e p a r a t e l y . T h e s e c a s e s o f t e n r e q u i r e y e a r s o f p l a s t i c s u r g e r y a n d m u c h p h y s i o t h e r a p y a n d c o r r e c t i v e s p l i n t i n g , t o r e p a i r a n e a s i l y p r e v e n t a b l e d e f o r m i t y . C hild with a h u m over the chest wall, which could cause a chest com plication. C H E S T C O M P L I C A T I O N S I n t h e i n i t i a l s h o c k s t a g e t h e f ir s t c o n s i d e r a t i o n is t h e p r e s e r v a t i o n o f l i f e, w h i c h i n t h e f ie l d o f p h y s i o t h e r a p y i n v o l v e s t h e p r e v e n t i o n a n d t r e a t m e n t o f c h e s t c o m p l i c a ­ t i o n s . O f t e n t h e b u r n m a y e x t e n d o v e r t h e c h e s t w a l l , c a u s i n g t h e c h i l d t o b r e a t h e s h a l l o w ' l y t o m i n i m i s e t h e m o v e m e n t a n d c o n s e q u e n t p a i n . T h i s c a n l e a d t o a c o l l a p s e d l o b e o r l u n g . T h e s k i n m a y b e s c o r c h e d t o t h e c o n s i s t e n c y o f h a r d l e a t h e r i n a s e v e r e b u r n , w i t h n o e l a s t i c i t y a t a l l , a n d a l l o w i n g v e r y l i t t l e e x p a n s i o n o f t h e c h e s t . I n t h e s e c a s e s t h e b u r n t t i s s u e h a s t o b e c u t i n t o s e v e r a l s t r i p s t o r e l e a s e t h e r e s t r i c ­ t i o n , w h e n t h e e x p a n s i o n wi ll i m p r o v e i m m e d i a t e l y , o f t e n b y a c o u p l e o f i n c h e s . I n h a l a t i o n b u r n s a r e a n o t h e r g r e a t c a u s e o f c h e s t c o m ­ p l i c a t i o n s , a n d a r e u s u a l l y t h e r e s u l t o f a p r i m u s s t o v e e x p l o d i n g i n t h e c h i l d ’s f a c e . N o t o n l y w il l t h e f a c e b e b u r n t , w i t h t h e r e s u l t i n g o e d e m a p a r t i c u l a r l y o f t h e l i p s a n d n o s t r i l s w h i c h c o n s i d e r a b l y l i m i t s a i r e n t r y , b u t t h e t r a c h e a a n d b r o n c h u s m a y a l s o b e a f f e c t e d d u e t o i n h a l a t i o n o f f u m e s a n d h o t a i r . T h i s c a u s e s i n f l a m m a t i o n , o e d e m a a n d s l o u g h i n g o f t h e m u c u s m e m b r a n e s o t h a t a c h e s t c o m p l i c a ­ t i o n is i n e v i t a b l e , a n d s o m e t i m e s a t r a c h e o t o m y h a s t o b e p e r f o r m e d . I t is a n a d v a n t a g e t o e l e v a t e t h e f o o t o f t h e c o t f o r a p e r i o d b e f o r e t r e a t i n g t h e c h i l d , e x c e p t i n c a s e s o f b u r n s o f t h e h e a d a n d n e c k , w h e n t h i s p o s i t i o n w o u l d i n c r e a s e t h e o e d e m a . I t is o f t e n n e c e s s a r y t o p e r c u s s t h e c h e s t t o l o o s e n t h e s e c r e t i o n s , a n d t h i s m a y h a v e t o b e d o n e w h e n t h e p a t i e n t is n u r s e d b y t h e “ o p e n ” m e t h o d , u s i n g a c o u p l e o f s t e r i l e d r e s s i n g t o w e l s o v e r t h e b u r n t a r e a . T h e a g e , c o n ­ d i t i o n a n d i n t e l l i g e n c e o f t h e p a t i e n t d e t e r m i n e s w h e t h e r t h e t r e a t m e n t is p a s s i v e o r w h e t h e r t h e c h i l d w i ll j o i n i n , b u t it is o f t e n p o s s i b l e w i t h p a t i e n c e a n d i n g e n u i t y t o g e t a v e r y s e v e r e l y b u r n t c h i l d t o c o - o p e r a t e i n b r e a t h i n g e x e r c i s e s a n d b l o w i n g g a m e s . A s u c t i o n m a c h i n e is u s e d d u r i n g t r e a t m e n t i f t h e c h e s t s o u n d s m o i s t , a n d a l w a y s i f a t r a c h e o ­ t o m y h a s b e e n p e r f o r m e d . 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. ) Page 4 P H Y S I O T H E R A P Y April, 1966 G o o d p o s i t i o n i n g o f t h e p a t i e n t i n t h e a c u t e s t a g e is a l s o i m p o r t a n t , t o p r e v e n t c o n t r a c t u r e s d e v e l o p i n g , p a r t i c u l a r l y o v e r t h e f l e x o r a s p e c t s o f a l i m b . T h e s h o u l d e r is a b d u c t e d i n a b u r n o f t h e a x i l l a r y r e g i o n — h a n d s a r e e l e v a t e d t o p r e v e n t o e d e m a , a n d t h e h e a d o f t h e b e d r a i s e d a n d a s m a l l p i l l o w p l a c e d b e t w e e n t h e c h i l d ’s s c a p u l a e t o e x t e n d t h e n e c k i n a b u r n o f t h e n e c k a n d f a c i a l a r e a s . A p a t i e n t w i t h a b u r n i n t h e g r o i n s h o u l d s p e n d a g o o d p o r t i o n o f I h e d a y i n a p r o n e p o s i t i o n . A large area o f sk in g ra ft showing a g o o d take. P R E -O P E R A T IV E O R IN T E R M E D IA T E S T A G E A f t e r t h e p a t i e n t h a s r e c o v e r e d f r o m t h e i n i t i a l s h o c k t h e p h y s i o t h e r a p i s t is a b l e t o c o n c e n t r a t e m o r e o n t h e m a i n ­ t e n a n c e o f m o b i l i t y a n d g o o d p o s t u r e , p r e v e n t i o n o f c o n ­ t r a c t u r e s a n d e n c o u r a g e m e n t o f h e a l i n g . M o v e m e n t s a r e c a r r i e d o u t i n t h e f u l l e s t p o s s i b l e r a n g e w i t h i n r e a s o n a b l e l i m i t s o f p a i n . T h e b u r n t c h i l d h a s a l o n g a n d p a i n f u l r o a d t o r e c o v e r y , a n d a s m o s t o f t h e p a t i e n t s a r e v e r y y o u n g s o m e o f o n e ’s p r e v i o u s i d e a s o f t r e a t m e n t h a v e t o b e m o d i f i e d s l i g h t l y , a n d t h e c h i l d ’s s t a y i n h o s p i t a l m a d e a s h a p p y a s p o s s i b l e s o t h a t h i s m i n d d o e s n o t b e a r p e r m a n e n t m a r k s o f h i s o r d e a l . U l t r a v i o l e t l i g h t is s o m e t i m e s r e q u e s t e d a t t h i s s t a g e , t o i m p r o v e t h e c i r c u l a t i o n a n d s p e e d u p t h e h e a l i n g p r o c e s s i n a s l i g h t b u r n , o r p e r h a p s p r i o r t o a g r a f t , t o h e l p c l e a n a n d s t i m u l a t e a n i n f e c t e d a r e a . T h e a p p r o p r i a t e e r y t h e m a d o s e is g i v e n , u s i n g a K r o m a y e r l a m p w h i c h h a s b e e n f o u n d t o b e f a r m o r e s u i t a b l e f o r u s e w i t h c h i l d r e n t h a n t h e l a r g e r a l p i n e s u n l i g h t l a m p . S K IN G R A F T IN G G r a f t i n g is u s u a l l y d o n e w i t h i n 15-21 d a y s o f t h e b u r n o c c u r r i n g , d e p e n d i n g o n h o w l o n g it t a k e s t o g e t t h e a r e a c l e a n e d , a n d t h e p a t i e n t ’s g e n e r a l c o n d i t i o n s u i t a b l e f o r s u r g e r y . T h e m a j o r i t y o f c a s e s r e q u i r e s k i n g r a f t i n g , e v e n v e r y s m a l l b u r n t a r e a s . T h e a d v a n t a g e o f t h i s t r e a t m e n t is q u i c k e r h e a l i n g a n d b e t t e r s k i n c o v e r a g e , e l i m i n a t i n g t h e t h i n i n e l a s t i c s k i n w h i c h is p r o d u c e d b y s p o n t a n e o u s h e a l i n g a n d w h i c h t e n d s t o u l c e r a t e a t a l a t e r d a t e . H o m o g r a f t s a r e o f t e n u s e d i n a n e x t e n s i v e b u r n w h e n a n a u t o g r a f t is di ff i cu lt t o o b t a i n a t a n e a r l y s t a g e d u e t o l a c k o f d o n o r a r e a . T h i s a l i e n s k i n is r e j e c t e d b y t h e p a t i e n t , u s u a l l y a f t e r 10 t o 14 d a y s , b u t it h a s s e r v e d t h e p u r p o s e o f p r o v i d i n g t e m p o r a r y s k i n c o v e r a g e , l i m i t i n g f l u i d l o s s , a n d o f t e n s t i m u l a t e s h e a l i n g i n t h e g r a f t e d a r e a . T h e g r a f t s a r e l a i d o n t h e b u r n t a r e a i n s h e e t f o r m , l e a v i n g n o g a p s b e t w e e n t h e s t r i p s o f s k i n w h i c h w o u l d b e c o m e s c a r r e d . W h e r e t h e r e is m o v e m e n t s u c h a s o v e r t h e a b d o m e n o r c h e s t , o r i f t h e r e is a n y l i k e l i h o o d o f t h e g r a f t s l i p p i n g it is s t i t c h e d i n t o p o s i t i o n a n d l e f t e x p o s e d — o t h e r w i s e it is j u s t b a n d a g e d i n t o p o s i t i o n w i t h d r e s s i n g s . T h e f i x a t i o n u s e d p o s t - o p e r a t i v e l y is g e n e r a l l y P l a s t e r o f P a r i s a s it is d i f f i c u l t t o i m m o b i l i s e c h i l d r e n s u f f i c i e n t l y a n y o t h e r w a y t o p r e v e n t t h e m f r o m r u b b i n g o f f t h e n e w g r a f t . T h e f i r s t d r e s s i n g is l e ft i n p l a c c f o r 7 t o 8 d a y s , d u r i n g w h i c h t i m e n o m o v e m e n t s a r e g i v e n w h i c h w o u l d d i s t u r b t h e s k i n g r a f t , a n d t h e p h y s i o t h e r a p i s t s h o u l d c h e c k w h e t h e r t h e r e is a n y h e a v y f i x a t i o n o r t i g h t s t r a p p i n g r o u n d t h e c h e s t a r e a w h i c h w o u l d n e c e s s i t a t e b r e a t h i n g e x e r c i s e s . Post operative P.o.P. im m obilisation o f skin g ra ft on arm a nd trunk. 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. ) April, 1966 P H Y S I O T H E R A P Y Page 5 MIRROR SYNKINESES (C O N T R A L A T E R A L IM IT A T IV E A S S O C IA T E D M O V E M E N T S ) A . M . K . O B H O L Z E R , D is k o b o lo s , K im b e rle y O ne o f th e m a n y “ n ice th in g s” in life is th e a b ility to m ove the extrem ities o f th e le ft a n d th e rig h t side in d ep e n d en tly . One can w rite w ith th e rig h t h a n d a n d , a t th e sa m e tim e, guide a sa n d w ic h to th e m o u th w ith th e left h a n d ; o n e c a n also c arry a su itca se w ith th e left h a n d a n d b e c k o n a p o rte r with th e rig h t one. I n th is w ay, o n e c a n d o m a n y m o re a n d some very difficult th in g s like p lay in g th e violin. I n th is case the left h a n d a n d th e rig h t h a n d p e rfo rm co m p le te ly differ­ ent difficult m o v em e n ts sim u lta n eo u sly . W hile d o in g a n y of these m o v em e n ts n o o n e d o e s b y a n y m e a n s feel lik e th e late a n d h e re to u n b e a te n k ing o f th e ju g g le rs, R astelli. One tak e s th e s e ab ilitie s fo r g ra n te d , a n d th e r e a d e r m ig h t w onder w hy he sh ould b e b o th e re d w ith su c h a n all to o natural fact. P eople w h o re m e m b e r th e ir p h y sio lo g y fro m g o o d old high school o r m a y b e fro m v a rsity d a y s will b e q u ic k to tell you w hy one is a b le to m ove th e lim bs in d e p e n d e n tly : “ T h e re are tw o b ra in h alv es— he m isp h e res— a rig h t a n d a left one. They c o n ta in , a m o n g s t o th e rs , c e n tre s fo r m o v em e n ts. T h e left hem isphere reigns o v e r th e rig h t side o f th e b o d y a n d Burns— C ontinued fr o m p a g e 4 All dressings a re d o n e in th e tre a tm e n t ro o m , b o th fo r aseptic re aso n s a n d b ecause th is is less tra u m a tic p sy c h o lo ­ gically fo r th e o th e r c h ild re n in th e w a rd . L a rg e b u rn s a re soaked in a m o b ile b a th c o n ta in in g a m ix tu re o f w a ter, Cetavlon, a n d R in g ers so lu tio n , a n d a th in p e rfo ra te d pipe circles the base o f th e b a th th ro u g h w h ic h oxygen is b u b b le d . This helps to lo o se n th e dressings a n d c leanse th e b u rn . Both b a th a n d tre a tm e n t ro o m a re d isin fected b etw een patients. P O S T O PER A TIV E O R F IN A L H E A L IN G ST A G E A fter th e dressings h a v e b e en re m o v e d a n d th e g ra ft has taken exercises a re s ta rte d a g a in , p ro g re s sin g fro m gentle to m ore vigorous m o v em e n ts. L a te r th e c h ild re n a re a b le to go to th e P h y s io th e ra p y D e p a rtm e n t w h e re b a ll g am es, pedal toys a n d o th e r a p p a ra tu s c a n b e u sed to g a in m o b ility and confidence. T he g rafted a re a is m assa g ed g e ntly w ith lan o lin , w hich is mixed w ith olive oil to a very so ft co n sisten c y as th e sk in is b oth d elicate a n d o f a re d u c e d se n sitivity a t th is stage. The grafted skin will te n d to c o n tra c t fo r a n y th in g u p to three m o n th s a fte r th e o p e ra tio n , p a rtic u la rly o v e r th e flexor aspects a n d th e p a lm o f th e h a n d , a n d it re q u ire s g re at supervision o n th e p a r t o f th e p h y s io th e ra p is t t o p re v en t deform ities developing w h ic h m ay re q u ire fu r th e r surgery. K eloid sc a rrin g m a y o c c u r, p a rtic u la rly in A fric a n p a tie n ts and this has to b e excised w h e n it h a s ceased b e in g active. Night splinting, a n d “ lively” h a n d sp lin tin g fo r d a y tim e use is o f g re at value, a n d lig h t p la s te r o f P a ris sp lin ts can be m ade w hich m a y be e asily a p p lie d by th e p a re n ts w h e n the child goes hom e. Unless th e p a tie n t lives fa r a w ay, h e a tte n d s th e h o sp ita l as an o u t-p a tie n t, b o th fo r p h y sio th e ra p y tre a tm e n t a n d check-up a t th e B u rn s F o llo w -U p C linic a t re g u la r in te rv als. M any o f these c h ild ren , a fte r su s ta in in g a severe b u rn , require a series o f c osm etic p la stic su rg e ry o p e ra tio n s w hich may have to be sp re ad o v e r a p e rio d o f several y ears. In conclusion, it c an b e seen th a t th e p h y sio th e ra p ist has a m ost im p o rta n t p a rt to p lay in th e g e n era l te a m w o rk of reh ab ilitatin g th e b u r n t child, a n d h e r w o rk is c o m p le ­ m entary to th a t o f th e s u rg e o n in re s to rin g th e p a tie n t to a norm al life. th e rig h t o n e o v e r th e left side. T h is is d u e t o th e fa ct th a t th e P y ra m id a l T ra c ts , w h ic h tra n s fe r th e in n e rv a tin g im ­ p ulses fro m th e m o to r c e n tre s o f th e b r a in to th e m uscles o f th e b o d y , c ro ss sides in th e D e c u s sa tio n . T h e tw o h em i­ sp h e re s a n d th e ir P y ra m id a l T ra c ts w o rk in d e p e n d e n tly . So, w h y sh o u ld th e r ig h t h a n d /a r m n o t b e a b le to c a rry o u t a m o v em e n t d iffere n t fro m t h a t o f th e le ft— ev en if these m o v em e n ts ta k e p lac e sim u lta n e o u s ly ? ” Y es, in d e e d , w h y n o t— if th e p re m ise t o th e c o n clu sio n is c o rre c t, i.e. if th e rig h t h e m isp h e re is re a lly o n ly re sp o n sib le f o r th e m o v e m e n ts o f th e left side o f th e b o d y a n d vice versa. T h e re is, h o w e v er, so m e r e a s o n fo r d o u b t c o n c e rn in g th e c o rre c tn e ss o f th is s ta te d p re m ise b e c a u se : Mirror Synkineses Associated with P athological Conditions T h e re a re p e o p le w h o a re in fa ct u n a b le to m o v e th e u p p e r e x tre m itie s in d e p e n d e n tly fro m e a c h o th e r. T h is p h e n o ­ m e n o n w e find n o t so ra re ly a m o n g s t sp a stic h e m iplegias. In th e s e cases a p a lsie d h a n d /a r m w h ich is o th erw ise u n a b le to m o v e a t all, m a y d o so if th e h e a lth y h a n d /a r m d oes a m o v e m e n t a g a in st s tro n g re sista n c e (O b h o lz e r)1. T h ese “ a sso c ia te d m o v e m e n ts” m ig h t b e so slight th a t th e y a re n o t re a lly a m o v e m e n t yet b u t o n ly a n in cre ase in m uscle to n e . B u t e v en th e n w e c a n re g a rd th is as a n a b o rtiv e co p y o f th e m o v e m e n t o f th e c o n tra la te ra l side. I f th e c o p ie d m o v e m e n t is well e x ec u te d th e n w e sp e a k o f a M ir r o r S ynkinesis (M .S .). T h e re is a lso a special c o n d itio n called K lip p el-F e il s y n d ro m e w h ic h show s M irro r S y nkineses (M .S .). H e re , m a in ly th e c ervical v e rte b ra e a re m isfo rm e d , cau sin g n e ck m o v em e n ts to b e re s tric te d . B a u m a n 2 stu d ie d six su c h cases, a n d fo u n d M .S . in f o u r o u t o f th e six cases. B efore B a u m a n , p a p e rs o n a b o u t 30 cases o f K lip p e l-F e il sy n d ro m e h a d b e e n p u b lis h e d , b u t n o th in g w as m e n tio n e d r e : M .S . I t is believed th a t M .S . w e re n o t n o tic e d in th e s e cases o n ly b e ca u se n o o n e w as o n th e lo o k o u t fo r th e m , th e c o n n e c tio n b etw een K lip p el-F e il sy n d ro m e a n d M .S . n o t b e in g k n o w n a t th a t tim e . M .S . c a n o fte n e asily be d isguised a n d th u s o v e rlo o k e d . T h e re is a lso a fam ilia l tre n d w h ic h is n o tic e a b le in M .S. A n e x a m p le : S m ith 3 re p o rtin g o f a 2 3-year old fa th e r a n d h is o n e -y e a r o ld so n , b o th sh o w in g M .S . A case w h e re M .S . w ere lin k e d w ith m e ta b o lic d istu rb a n c e s (p h e n y lp y ru v ic a c id u ria ) h a s b e e n r e p o rte d b y F rie d m a n a n d L e v in so h n 4. M .S . u su a lly exists fro m b irth , a n d sufferers “ le a rn ” to su p p re ss th e m in la te r life m o re a n d m o re . T h e in n a te c o n ­ d itio n , h o w e v er p e rsists th r o u g h o u t life. M .S . in NeurologicaUy Norm al Cases T h e re a re a ls o n e u ro lo g ic a lly n o rm a l p e rso n s w h o a re u n a b le to m o v e th e u p p e r e x tre m itie s in d ep e n d en tly . T h e re is th e case o f a rig h t-h a n d e d p e rs o n w h o w h e n h e w ro te w ith th e rig h t h a n d , c o p ie d th e m o v em e n t w ith th e le ft h a n d . W h e n h e trie d to sto p th e m o v e m e n t o f th e left h a n d by s ittin g o n it, h e w as u n a b le to c o n tin u e w ritin g w ith th e rig h t h a n d . If, h o w e v er, h e t o o k a p e n in th e le ft h a n d as well a n d s ta rte d w ritin g w ith th e rig h t h a n d , th e left h a n d c o p ie d w h a t th e r ig h t h a n d w ro te . . . b u t m irro rw ise, i.e. fro m rig h t to le ft a n d w ith in v e rte d le tte rs. A s o n e c a n re a d w h a t th e left h a n d h a d w ritte n o n ly w ith th e h e lp o f a m irro r, w e call th is ty p e o f w ritin g “ M ir r o r W ritin g ” (C ritc h le y 5, T h is m a n , I c a n a ssu re y ou w as n o t to o h a p p y a b o u t his “ g ift” . W h e n h e c a rrie d a b u c k e t o f w a te r in his le ft h a n d a n d w a n te d to o p e n a d o o r w ith th e rig h t h a n d , h e h a d to p u t th e b u c k e t d o w n first, o th e rw ise , h e w o u ld h a v e d ro p p e d th e b u c k e t w h e n tu r n in g th e h a n d le . W e a lso k n o w o f th e case o f a y o u n g m a n w ith th is ty p e o f M .S ., re p o rte d b y B u rr a n d C ro w 6. H e e n te re d th e n avy b u t p ro v e d to b e u n a b le to clim b a la d d e r, as every tim e h e re le ased a b a r w ith o n e h a n d in o rd e r to g ra b th e n ext h ig h e r o n e , th e o th e r h a n d a ls o o p e n e d . . . a n d h e fell d o w n . 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. )