74 F I S I O T E R A P I E SEPTEMBER 1981 if p o ssib le , n o t im m e d ia te ly a f te r a m e a l; t h a t th e f r e ­ q u e n c y sh o u ld b e ste p p e d u p if th e se c re tio n s in c re a s e , a n d th a t o n e tr e a tm e n t p e r d a y is e n o u g h if th e c h ild ’s c o u g h is u n p ro d u c tiv e . In th e case o f a y o u n g ch ild w ho o n ly show s signs o f m ild p u lm o n a ry in v o lv e m e n t, w e a d v ise th a t a s h o r t p ro g ra m m e o f p o s tu ra l d r a in ­ a ge a n d “ b r e a th in g e x e rc is e s” s h o u ld b e c a rrie d o u t o n c e a d a y . T h is is to a c c u s to m th e c h ild to th e tr e a t ­ m e n t so th a t it b e c o m e s sim p ly a p a r t 'o t h is d a ily life. H o p e fu lly , th is a p p r o a c h will m a k e it e a s ie r f o r th e c h ild to a c c e p t th e tr e a tm e n t w h e n it re a lly b e c o m e s n e ce ssa ry . W e stre ss th e i m p o r ta n c e o f p h y sic a l a c tiv ity — a n y a c tiv ity a p p r o p ria te to th e a g e o f th e c h ild . T h is is b o th f o r th e p u rp o s e o f m o b ilisin g se c re tio n s a n d p ro d u c in g a c o u g h , a n d f o r t h e se n se o f w e ll-b e in g t h a t a n y su c h a c tiv ity a lm o st in e v ita b ly b rin g s, p ro v id e d o f c o u rse th a t it is d o n e w ith in th e lim its o f th e c h ild ’s c a p a c ity . W ith o u t h a v in g d o n e a n y c o n tro lle d s tu d ie s o n th is s u b je c t, it is d iffic u lt to say w h e th e r a “ well c y stic ” jo g s b e c a u se h e is w ell, o r w h e th e r jo g g in g m a k e s a “ c y stic ” well. A n o th e r o f o u r re s p o n s ib ilitie s is to in s tru c t th e m o th e rs in in fe c tio n c o n tro l, te a c h in g th e m h o w to c le a n th e e q u ip m e n t u se d so as to m in im is e th e d a n g e r o f re in fe c tio n . W ith m o re a n d m o re “ cy stic s” su rv iv in g in to th e ir te e n a g e y e ars it is b e c o m in g o f p a r a m o u n t im p o rta n c e to in v e s tig a te , a n d te a c h w ays o f h e lp in g th e te e n a g e r to c le a r h is o w n lu n g s, th u s s e c u rin g as f a r as p o s ­ sib le th e in d e p e n d e n c e so n e c e ssa ry f o r th e tr a n s i­ tio n fro m a d o le s c e n c e to a d u lth o o d . T h e s e m e th o d s in ­ c lu d e s e lf-n e b u lis a tio n , s e lf-p o s tu ra l d ra in a g e u sin g th e fo rc e d e x p ira tio n te c h n iq u e , p o ss ib ly m e c h a n ic a l p e r ­ c u ssio n s, a n d se lf-a ss iste d c o u g h in g , s u c h as c o u g h in g a g a in s t a c lo sed g lo ttis. I t h a s b e e n su g g e ste d t h a t v ig o ro u s a n d s e lf-d ire c te d c o u g h in g m a y b e a ll t h a t is r e q u ir e d fo r e ffe c tiv e b ro n c h ia l to ile t. C o n ta c t w ith t h e c h ild o n a d m iss io n to h o s p ita l fo r tr e a tm e n t o f a n a c u te in fe c tio n is o f te n a tim e w hen th e ro le o f p h y s io th e ra p y c a n be r e in fo rc e d . H e r e a g a in , th e a c tu a l p h y s io th e ra p y tr e a tm e n t is sim p le , b u t it is c o m p lic a te d b y th e fa c t th a t th e c h ild h a s, in a sense, b e c o m e a p ro d u c t o f h is d ise a s e in te rm s o f h is b e ­ h a v io u ra l re s p o n s e s to it. N o c h ild c a n a c tu a lly e n jo y b e in g h o o k e d u p to a n in tra v e n o u s d rip , b e in g tip p e d , p e rc u ss e d a n d m a d e to c o u g h v ig o ro u sly , a n d th e “ c y stic ” c h ild re n a re n o e x c e p tio n . A s w ith a n y c h ild w h o h a s a c h ro n ic d e b ilita tin g a n d so c ially u n a c c e p t­ a b le illness, re s e n tm e n t a n d la c k o f c o -o p e ra tio n m a y o fte n b e p re se n t. I h e se b e h a v io u r p a tte rn s s h o u ld be re c o g n iz e d fo r w h a t th ey a re, a n d we s h o u ld try, if n e c e s­ sa ry w ith th e h e lp of th e p s y c h ia tris t a tta c h e d to the te a m , to se c u re th e c o -o p e ra tio n o f th e c h ild . A ll o f this m e a n s th a t we a re n o t d e a lin g w ith a c h ild w h o sim p iy re q u ire s “ c h e s t p h y s io th e ra p y ” . W e h a v e fo u n d t h a t o n e m u s t se t a c h ie v a b le goals, d e p e n d in g o n th e c h ild ’s c o n d itio n a t t h a t m o m e n t, a n d th e n v ery firm ly a n d g e n tly , in sist o n h is c o -o p e ra tio n . I t is a lso v ery n e c e s­ sa ry to a llo w th e m o th e r to p a r tic ip a te in th e c a re of h e r c h ild , w h ile still e n su rin g t h a t she h a s th e re st th a t sh e n e e d s as w e ta k e o v e r th e re s p o n s ib ility f o r c le a rin g his c h est. F in a lly , in th e te rm in a l sta g e s of th e dise ase, th e p h y s io th e r a p is t’s r o le sh o u ld b e c o m e m o re su p p o rtiv e . P h y s io th e ra p y s h o u ld n o t b e w ith h e ld b u t s h o u ld b e te m p e re d w ith th e u n d e rs ta n d in g th a t o n e ’s ro le no w is to t r y a n d a c h ie v e m a x im u m c o m fo rt fo r th e d y ing c h ild . l I n th is p a p e r it is o b v io u sly im p o s sib le to go into" th e m e th o d s o f p h y s io th e ra p y e m p lo y e d in e a c h o f th e a g e g ro u p s o f c h ild re n s u ffe rin g c y stic fib ro sis. H o w ­ e v er, it is a p p a r e n t t h a t p h y s io th e ra p y a n d th e p h y s io ­ th e r a p is t play c e n tra l ro les in th e h a n d lin g o f c h ild re n w ith c ystic fib ro sis. I t is o u r h o p e t h a t th is a rtic le h a s h e lp e d in d e fin in g th e e x te n d e d ro le s o f t h e p h y ­ s io th e ra p is t a n d in o u tlin in g th e p a th o p h y s io lo g y of th e lu n g d ise ase a sso c ia te d w ith c y stic fib ro sis. R e fe re n c e s B u rto n L. (1 9 ? 4 ). T o le ra tin g th e in to le ra b le — th e p ro b le m s fa c in g p a r e n ts a n d c h ild re n fo llo w in g d ia g ­ n o sis in: C a re o f th e ch ild fa c in g d e a th . R o u tle d g e a n d K e g a n P a u l. L o n d o n . P p 16 - 34. H a lle r, J. A. (1970). A h e a lth y a ttitu d e to w a rd s c h ro n ic illn e ss — q u o te d by B u rto n L. (1974). T o le ra tin g th e in to le ra b le — th e p ro b le m s fa c in g p a r e n ts a n d c h ild re n fo llo w in g d ia g n o s is in: C a re o f th e child fa c in g d e a th . R o u tle d g e a n d K e g a n P a u l. L o n d o n . P p 1 6 - 3 4 . R e id L . (1980). C a r d io p u lm o n a ry P a th o lo g y , in: P e r ­ sp e c tiv e s in C y stic F ib ro s is — P ro c e e d in g s o f th e 8 th I n t e r n a ti o n a l C y stic F ib ro s is C o n g re ss. E d . J. M . S turgess. C a n a d ia n C y stic F ib ro s is F o u n d a tio n . T o ro n to . P p . 1 9 8 - 2 1 4 . T R E A T M E N T N O T E : A CASE O F INTRACTABLE PRURITIS VULVAE T R EA TM EN T WITH PULSED ULTRASOUND C. A . L IG G 1 N S , M .C .S .P ., H .T ., D ip .T .P .* A 6 7 -y e a r-o ld m a rrie d A fric a n w o m a n w as a d m itte d to h o s p ita l o n 6 A p ril 1979 a f te r a g y n a e c o lo g ic a l in v e s­ tig a tio n . H e r m a in c o m p la in ts w ere v a g in a l p a in a n d itc h in e s s o f th e v u lv a o f 12 m o n th s d u r a tio n . P e lv ic e x a m in a tio n sh o w e d a tro p h y o f th e la b ia a n d v a g in a l m u c o s a a n d a c e rv ic a l p o ly p . A d ia g n o s is o f c h ro n ic v u lv al d y stro p h y a n d p ru ritis v u lv a e w as m a d e . W h ile a n in p a tie n t sh e w as fu lly in v e s tig a te d fo r * S e n io r L e c tu re r, H e a d o f D e p a r tm e n t o f P h y s io ­ th e ra p y , U n iv e rs ity o f D u rb a n -W e s tv ille . W h ile a n in -p a tie n t sh e w as fu lly in v e s tig a te d fo r R e c e iv e d 1 A u g u s t 1981. d ia b e te s ; g lu co se to le ra n c e test su g g e ste d d ia b e te s m elli- tu s in a m ild fo rm . T h e p o ly p w as re m o v e d u n d e r g e n e ra l a n a e s th e tic a n d a v u lv al b io p sy ta k e n ; th is p ro v e d to b e n e g a tiv e . T h e p a tie n t w as d isc h a rg e d on 10 A p ril. S he w as re -a d m itte d in M a y 1979 w ith a m a rk e d p r u r itis v u lv ae . A t th e tim e it w as c o n sid e re d th a t this c o u ld h a v e b e e n a g g ra v a te d by h e r d ia b e te s so sh e w as p u t on a d ia b e tic re d u c in g d ie t. In a d d itio n , lo ca l a p p li­ c a tio n o f o e s tro g e n to th e v u lv a w as trie d , b u t to no effect. S he w as th e n re fe rre d to th e S kin C lin ic a n d ste ro id c re a m w as p re sc rib e d . T h e re w as d im in u tio n of 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. ) SEPTEMBER 1981 P H Y S I O T H E R A P Y 75 the itc h b u t it d id n o t su b s id e c o m p le te ly . A fte r tw o w eeks sh e w as d isc h a rg e d w ith in s tru c tio n s to c o n tin u e using th e s te ro id c rea m . T h e p a tie n t w as a g a in a d m itte d to h o s p ita l o n 26 M a rc h 1980, still c o m p la in in g o f th e itc h w h ich h a d p e rsiste d d u rin g h e r tim e a t h o m e . T h e itc h a t this tim e w as o f su c h in te n siy th a t it c au sed h e r to s c ra tc h the v u lv a u n til it b led . S he w as a g a in tre a te d w ith ste ro id c re a m b u t w ith o u t success. In th e m id d le of A p ril she w as re fe rre d to th e P h y s io th e ra p y d e p a r t­ m en t w ith a re q u e st fo r ‘C u ra p u ls e t h e r a p y ’ (p u lse d sh o rt-w a v e d ia th e rm y ). T h e p h y s io th e r a p is t’s e x a m in a ­ tio n sh o w ed a d e p ig m e n te d a re a in v o lv in g th e lab ia , vulva, p e rin e u m a n d c lito ra l a re a . T h e p a tie n t ’s m a in c o m p la in t w as th e in tra c ta b le itch. A s th e C u ra p u ls e w as n o t a v a ila b le it w as d e c id e d to try p u lse d u ltra s o u n d . T h e p a tie n t w as tre a te d o n fo u r successive days. T h e first tr e a tm e n t c o n siste d of p ulsed u ltra s o u n d , in c o n ta c t w ith th e p r u r itic a re a , usin g g ly c e rin e as a c o u p lin g m e d iu m . T h e d o se was |0,5 w a t t/ c m 2 fo r 5 m in u te s. T h is re su lte d in so m e re lie f w hich la s te d f o r 16 h o u rs. T h e se c o n d tr e a tm e n t w as g iven a t th e s a m e in te n sity fo r 6 m in u te s a n d re lief laste d f o r 20 h o u rs a fte rw a rd s . T h e th ird a n d f o u rth tre a tm e n ts w ere p ro g re s se d by o n e m in u te in e a c h case. A fte r th e th ir d tre a tm e n t th e p a tie n t re p o rte d c o m p le te re lief o f th e itch. She w as 'd is c h a rg e d fro m h o sp ia l on 19 A p ril 1980, free o f a ll s y m p to m s a n d n o t n e e d in g to p ic a l a p p lic a ­ tio n o f ste ro id c re a m . S h e w as g iven an o p e n a p p o in t­ m e n t to r e p o rt b a c k to th e P h y s io th e ra p y D e p a r tm e n t sh o u ld th e s y m p to m s recur. A fo llo w -u p h o m e visit o n e m o n th a f te r d isc h a rg e re v ea le d th a t m ild p ru ritis h a d d e v e lo p e d a g a in 3 w eeks a fte r th e p a tie n t ’s d is c h a rg e fro m h o s p ita l. A rra n g e ­ m e n ts w e re m a d e fo r a lo n g e r c o u rse o f u ltra s o u n d to be g iven b u t u n f o r tu n a te ly th e p a tie n t’s h u s b a n d re ­ fused to le t h e r a tte n d . D IS C U S S IO N A fte r th e th ird tre a tm e n t w ith p ulsed u ltra s o u n d the p a tie n t re p o rte d c o m p le te re lie f o f itch fo r the first tim e in tw o years. In e v a lu a tin g th e tre a tm e n t th e p la c e b o effect m u st b e c o n sid e re d b u t c a n p ro b a b ly be d is c o u n te d o n th e e v id e n ce th a t c h a n g e s o f tre a tm e n t e a rlie r d id n o t p r o ­ d u c e a n y sig n ific a n t effect. L o c a l a p p lic a tio n o f o e stro - jgen h a d n o effect a n d ste ro id c re a m s o n ly a p a rtia l effect; a t n o tim e d id th ey re liev e s y m p to m s c o m ­ pletely. G ro n ro o s e t al. (1979) re p o rte d on 25 p a tie n ts w ho h a d v a rio u s c h ro n ic v u lv a l lesio n s w ith c o n tin u o u s p r u ­ ritis, tre a te d by p u lse d sh o rt-w a v e th e ra p y . P a tie n ts w ere g iven 1 0 - 1 5 single tre a tm e n ts w ith in te rv a ls of tw o days. T h e ben eficia l effect o f th is th e ra p y was e ith e r d e fin ite o r g o o d in 8 0% o f a ll th e cases. T h e w rite r h a s fo u n d n o re fe re n c e to th e u se of p u lse d u ltra s o u n d in th e tre a tm e n t o f c h ro n ic p ru ritis vu lv ae . T h e n o tio n to use th is m o d a lity w as b a se d on th e f a c t th a t in s o n a tio n w ith u ltra s o n ic en erg y re su lts in re d u c e d c o n d u c tio n v e locity in n e rv e . T h u s it c a n be u sed in its p u lse d fo rm to tr e a t p a in fu l c o n d itio n s , p a r ­ tic u la rly th o se w hich h a v e re a c te d a d v e rse ly to the a p p lic a tio n o f h e a t (W a d sw o rth a n d C h a n m u g a n , 1980). P re s u m a b ly p a in re lie f is d u e to re d u c e d c o n d u c tio n v e lo c ity in n e rv e s c a rry in g p a in im p u lse s. S tim u li w h ich give rise to itch a re c a rrie d m a in ly in th e slow c o n ­ d u c tin g , u n m y e lin a te d C fibres, a n d it h a s b een p o s tu ­ la te d th a t p a in fibres c a rry th e s e n s a tio n o f itch in the se n so ry sp in a l n e rv e to th e s p in o th a la m ic tra c t a n d h e n c e to th e th a la m u s (L o tin c z, 1971). T h e fin d in g s of Y a m a m o to e t al. (1981) su g g est th a t c lin ic a lly , th e s e n ­ s a tio n s o f itc h a n d p a in a re clo sely re la te d . Itc h is u su a lly m a d e w orse by in c re a s e d lo ca l te m p e ra tu re , h o w e v e r w ith p u lse d u ltra s o u n d th e tre a tm e n t is re la ­ tively a th e rm ic . W ith o u t its th e rm a l influence, th e effect o f u ltra s o u n d is m a in ly m e c h a n ic a l; it c o u ld b e s p e c u la te d th a t the G a te C o n tro l T h e o ry o f M e lz a c k a n d W all (1965) co u ld h e lp to e x p la in th e re lie f o f itch e x p e rie n c e d by the p a tie n t. G ly c e rin e w hich w as used as th e c o u p lin g m e d iu m is a c le ar, c o lo u rle ss s y ru p y liq u id u se d as a m o is te n in g a g e n t a n d a so lv e n t fo r c e r ta in d ru g s; it is n o t k n o w n to h a v e a n y a n ti- p r u r itic p ro p e rtie s . T h e tro u b le s o m e a n d o fte n d istre s sin g c o n d itio n o f p r u r itis v u lv a e c a n be re s is ta n t to a w ide ra n g e o f c o n ­ v e n tio n a l tre a tm e n ts . A lte rn a tiv e a p p ro a c h e s usin g p u lse d sh o rt-w a v e d ia th e rm y a n d th e m o re e asily a p p lie d p u ls e d u ltra s o u n d m a y p ro v e ben eficia l. It is in te n d e d to stu d y f u r th e r th e effects o f p u lse d u ltr a ­ s o u n d in th e tr e a tm e n t o f c h ro n ic p r u r itis vulvae. A ck n ow led gem en t 1 w ish to th a n k M rs. L. G u m e d e , L e c tu re r in P h y s io ­ th e ra p y a n d th e S taff o f th e K in g E d w a rd V III P h y s io ­ th e ra p y D e p a rtm e n t fo r th e ir a ssista n c e w ith th is case. R eferen ces G ro n ro o s , M . (1979). T r e a tm e n t o f v u lv a l e p ith e lia l lesio n s by p u ls e d h ig h -fre q u e n c y th e ra p y . A c t a O b s te t. G y n e c o l. S c a n d . 58, 187 - 189. M e lz a c k , R . a n d W a ll, P . D . (1965). P a in m e c h a n is m s : A n e w th e o ry . S c ie n c e , 150, 971 - 979. L o tin c z , A . L. (1971). N e u ro p h y s io lo g ic r e a c tio n s o f th e s k in : P a th o p h y s io lo g y o f p ru r itis . In : F itz p a tr ic k , T . B., A rn d t, K . A ., C la rk , W . H . e t al., eds. D e r m a ­ to lo g y in g e n e ra l m e d ic in e . M c G ra w -H ill. N e w Y o rk . (P. 212.) W a d s w o rth , N . a n d C h a n m u g a n , A . P . P , (1980). E le c tr o ­ p h y sic a l a g e n ts in p h y s io th e ra p y . S c ien c e P re ss, (p. 494.) REPORT ON FOURTEENTH GENERAL MEETING OF THE NATIONAL COUNCIL OF THE SOUTH AFRICAN SOCIETY OF PHYSIOTHERAPY HELD ON 27th & 28th MARRCH 1981 IN PRETORIA Office B e a re rs, m e m b e rs o f th e N a tio n a l E x e c u tiv e C o m m itte e , B ra n c h d e le g a te s, re p re s e n ta tiv e s o n N a ­ tio n a l a n d In te r n a tio n a l O rg a n isa tio n s, m e m b e rs o f the P ro fe ss io n a l B o a rd a n d v a rio u s o b se rv e rs a tte n d e d the 14th N a tio n a l C o u n c il M e e tin g . M rs. A . M a th ia s , C h a irm a n , in tro d u c e d P ro fe s s o r F. G . G e ld e n h u y s , P re sid e n t o f th e S o u th A fric a n M e d ic a l a nd D e n ta l C o u n c il, P re s id e n t o f th e S o u th A fric a n M e d ica l A s so c ia tio n a n d D e a n o f th e F a c u lty o f M e d i­ cine, U n iv e rsity o f P re to ria . In his o p e n in g a d d re ss P ro fe s s o r G e ld e n h u y s e x p la in e d th e re la tio n s h ip b e ­ tw een M e d ic a l C o u n c il a n d th e P ro fe s s io n a l B o a rd , a n d o u tlin e d th e d e v e lo p m e n ts sin c e 1947, w h e n th e re g is te r w as first e sta b lish e d . T h e B o a rd w as e s ta b ­ lish ed in 1972, th e sc o p e o f th e p ro fe s s io n g a z e tte d in 1977, th e w h o le c o u n try p re s c rib e d in 1979 a n d a T a riffs C o m m itte e h a d ju st c o m p le te d its h e a rin g . T h e P re s id e n t, M rs. M . L evy, th a n k e d P ro fe s s o r G e ld e n h u y s a n d th e n d e liv e re d h e r P re s id e n tia l a d d re ss . M rs. M a th ia s p a id tr ib u te to th e m e m o rie s o f P ro fe s s o r B. 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. )