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Hydrotherapy Courses
UItrasound Effects
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MADAM With reference to the study on the effectiveness of ultrasound using a hydrocortisone coupling medium by L K Holdsworth and D M Anderson (January, pages 19-25), Iwas surprised to find that the article contained no reference to the extensive research carried out by Dr James Griffin when director of physical therapy and professor of physiology and health science at Ball State University, Indiana, USA. The full results of this research.were presented at the InternationalSymposium on Therapeutic Ultrasound in Winnipeg, Canada, in September 1981. In brief, Dr Griffin, with his colleague Dr Touchstone, a steroid chemist, developed the technique of measuring hydrocortisone levels in skeletal muscle and peripheral nerve excised from anaesthetisedanimals. Dr Griffin experimented with ultrasound equipment to establish the most effective frequencies and found that the lower frequencies were more efficient in deliverina hvdrocortisone to the deeper levels of iissbe. He carried out extensive clinical trials of these techniques on human
Bagging and Percussion MADAM -This letter is in response to the study by Jones etal ‘Effects of bagging and percussion on total statk compliance of the respiratory system’, Physiotherapy (1992) 78, 661-666. The authors conclude that mean total static compliance was significantly improved after bagging, chest wail vibrations and airway suctioning, but was significantly reduced 75 minutes after the combination of chest wail percussion, vibrations and airway suctioning. In contrast, Mackenzie et a1 (1980, 1985) demonstrated significant improvements In total lunghhorax compliance after cardiothoracic physiotherapy that included postural drainage, chest wall percussion, vibrations and airway suctioning. There are several issues with these studies that deserve further discussion. Jones et a1 (1992) investigated 20 mechanically-ventilated and paralysed patients. Mackenzie et a1 (1980, 1985) investigated mechanically-ventilated patients who were sedated but not paralysed. Paraiysing agents inhibit voluntary muscle contraction and reflexes including the cough reflex and therefore severely impair airway secretion clearance (Mackenzie et a/, 1989). The absence of significant improvement in total lunghhorax compliance after physiotherapy that included chest wall percussion, vibrations and airway suctioning (Jones et a/, 1992) may be due to the paralysed state of the patients, impairing the cough reflex. The combination of lung hyperinflation and chest wall vibrations may have hastened the removal of airway secretions due to the increase in exDiratorv flow rates [Maclean et a/, 1989). ‘Headdown posidoning or horizontal side lying was used as required in the study by Jones et a1 (1992). As the patients in the study by Jones et a1 (1992) were paralysed, the regimented use of headdown positioning(ChOPm et al, lsn) with chest wall percussion, vibrations and
Phydotherapy, March 1993, VOl79,
no 3
patients, finding that 100 mg of hydrocortisone per gram of vehicle produced excellent results. Previously, Klelnkort and Wood (1975) described results of clinical trials using phonophoresiswith 1% versus 10% hydrocortisone, the latter being significantly more effective. They concluded that phonophoresis with 10% hydrocortisone offers a safe, alternative method for the delivery of concentrated anti-inflammatory agents to tissue without the risks involved in percutaneous injection. Dr Griffin retired in 1988 and when I last contacted him provided a further list of references, none of which appeared in the article by Holdsworth and Anderson. it seems unfortunate that this important work is being overlooked, particularly when a number of present-day practitioners regularly make use of these techniques in the successful treatment of a variety of soft tissue lesions.
Rhona M Watson
Hydrotherapy Courses MADAM -The Association Of Swimming Therapy ( A S )is the organising body of the Halliwlck Method in the United Kingdom and has registered lecturers who are based throughout the country. Only registeredAssociation of Swimming Therapy lecturers are officially able to give courses on the Haiiiwick Method and have access to the most up-to-date information and videos. The Association would be wiiiing to provide lecturers for hydrotherapy courses for study days to give participants an introduction to the Haiiiwick Method. The basic Haliiwick course (parts A and B) is held over four days, usually split into two weekends. Anyone wishing to arrange a lecturer or to organise a course should contact the secretary of the Association of Swimming Therapy education committee - Mrs P Scott, 42 Goodhew Close, Yapton, West Sussex BN18 (MA.
GradDipPhys MCSP Kidderminster, Worcestershire
Jane Stewart BA MCSP
airway suctioning may have improved treatment efficacy. Another issue of concern in paralysed patients is that with the movement of peripheral airway secretions more centrally, the inadequate clearance of these central airway secretions (absence of cough) may Increase airway pressures and airway resistance (Mackenzie et a/, 1989). George Ntoumenopoulos MAPA Victoria, Australia
total static lung compliance foilowing chest
London SW15
wail percussion, vibration and suctioning in our study was due to patient paralysis, inconsistentpatient positioning and failure to aspirate central airway secretions. For the reasons pointed out in our stud% it is inappropriate to compare Mackenzie’s findings with ours. An essential component of our study design was to use the patient as his own control to reduce intergroup variability The same patient received both bagging and percussion alternately. Therefore patient position, sedation, and Rekmnces muscle paralysis were essentially kept Chopra, S, Tapiin, G V, Simmons, D H, constant during measurements of lung Robinson, G D, Elam, D and Coulson, A compliance, making ‘treatment technique’ (1977). ‘Effects of hydration and physical the only variable. therapy on tracheal transport veiocity’, Respiratory muscular activity will reduce American Review of Respiratory Diseases, total lunghhorax compliance and 115, 1006-1114. furthermore will vary according to the Mackenzie, C F, Shin, 8, Hadi, F and Imie, degree of sedation and lung volume P C (1980). ‘Changes in total iunghhorax (Nunn. 1987). LastiK tracheal tube suctioning should compliance foilowing chest physiotherapy’, remow secretions which have been shifted Anaesthesia and Analgesia, 59,207-210. from the peripheral to the central airways. Mackenzie, C F and Shin, B (1985). Besides,.the most significant impediment ‘Cardio-respiratory function before and to an effective cough in both our and after chest physiotherapy in mechanically Mackenzie’s patients was tracheal ventilated patients with post-traumatic intubation. respiratory failure’, Critical Care Medicine, 13, 483-406.
Mackenzie, C F; Imie, P C and Ciesla, N (1989). Chest Physiotherapy in the Intensive Care Unit’(2nd edn), Williams i3 Wilkins, Baltimore. MacLean, D, Drummond, G, Macpherson, C, McLaren, G and Prescott, R (1989). ‘Maximum expiratory airflow during chest physiotherapy on ventilated patients before and after the application of abdominal blnder’, Intensive Care Medicine, 15, 396-399.
Jones and Professor Teik
we wish to thank Mr Ntoumenopoulos for
his interest in our article. He suggests that failure to demonstrate an improvement in
Alice Jones
MPhii DipED MAPA Hong Kong Polytechnic
Teik E Oh
MD(Qid) FRCP FRACP Professor and Head Department of Anaesthesia and Intensive Care Prince of Wales Hospital Hong Kong
Refemnce Nunn. J E (1987). . . ‘Elastic forces and lung volumes’ in: Applied Respiratory Physiotherapy (3rd edn), Butterworth, pages 33-45.
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MADAM With reference to the study on the effectiveness of ultrasound using a hydrocortisone coupling medium by L K Holdsworth and D M Anderson (January, pages 19-25), Iwas surprised to find that the article contained no reference to the extensive research carried out by Dr James Griffin when director of physical therapy and professor of physiology and health science at Ball State University, Indiana, USA. The full results of this research.were presented at the InternationalSymposium on Therapeutic Ultrasound in Winnipeg, Canada, in September 1981. In brief, Dr Griffin, with his colleague Dr Touchstone, a steroid chemist, developed the technique of measuring hydrocortisone levels in skeletal muscle and peripheral nerve excised from anaesthetisedanimals. Dr Griffin experimented with ultrasound equipment to establish the most effective frequencies and found that the lower frequencies were more efficient in deliverina hvdrocortisone to the deeper levels of iissbe. He carried out extensive clinical trials of these techniques on human
Bagging and Percussion MADAM -This letter is in response to the study by Jones etal ‘Effects of bagging and percussion on total statk compliance of the respiratory system’, Physiotherapy (1992) 78, 661-666. The authors conclude that mean total static compliance was significantly improved after bagging, chest wail vibrations and airway suctioning, but was significantly reduced 75 minutes after the combination of chest wail percussion, vibrations and airway suctioning. In contrast, Mackenzie et a1 (1980, 1985) demonstrated significant improvements In total lunghhorax compliance after cardiothoracic physiotherapy that included postural drainage, chest wall percussion, vibrations and airway suctioning. There are several issues with these studies that deserve further discussion. Jones et a1 (1992) investigated 20 mechanically-ventilated and paralysed patients. Mackenzie et a1 (1980, 1985) investigated mechanically-ventilated patients who were sedated but not paralysed. Paraiysing agents inhibit voluntary muscle contraction and reflexes including the cough reflex and therefore severely impair airway secretion clearance (Mackenzie et a/, 1989). The absence of significant improvement in total lunghhorax compliance after physiotherapy that included chest wall percussion, vibrations and airway suctioning (Jones et a/, 1992) may be due to the paralysed state of the patients, impairing the cough reflex. The combination of lung hyperinflation and chest wall vibrations may have hastened the removal of airway secretions due to the increase in exDiratorv flow rates [Maclean et a/, 1989). ‘Headdown posidoning or horizontal side lying was used as required in the study by Jones et a1 (1992). As the patients in the study by Jones et a1 (1992) were paralysed, the regimented use of headdown positioning(ChOPm et al, lsn) with chest wall percussion, vibrations and
Phydotherapy, March 1993, VOl79,
no 3
patients, finding that 100 mg of hydrocortisone per gram of vehicle produced excellent results. Previously, Klelnkort and Wood (1975) described results of clinical trials using phonophoresiswith 1% versus 10% hydrocortisone, the latter being significantly more effective. They concluded that phonophoresis with 10% hydrocortisone offers a safe, alternative method for the delivery of concentrated anti-inflammatory agents to tissue without the risks involved in percutaneous injection. Dr Griffin retired in 1988 and when I last contacted him provided a further list of references, none of which appeared in the article by Holdsworth and Anderson. it seems unfortunate that this important work is being overlooked, particularly when a number of present-day practitioners regularly make use of these techniques in the successful treatment of a variety of soft tissue lesions.
Rhona M Watson
Hydrotherapy Courses MADAM -The Association Of Swimming Therapy ( A S )is the organising body of the Halliwlck Method in the United Kingdom and has registered lecturers who are based throughout the country. Only registeredAssociation of Swimming Therapy lecturers are officially able to give courses on the Haiiiwick Method and have access to the most up-to-date information and videos. The Association would be wiiiing to provide lecturers for hydrotherapy courses for study days to give participants an introduction to the Haiiiwick Method. The basic Haliiwick course (parts A and B) is held over four days, usually split into two weekends. Anyone wishing to arrange a lecturer or to organise a course should contact the secretary of the Association of Swimming Therapy education committee - Mrs P Scott, 42 Goodhew Close, Yapton, West Sussex BN18 (MA.
GradDipPhys MCSP Kidderminster, Worcestershire
Jane Stewart BA MCSP
airway suctioning may have improved treatment efficacy. Another issue of concern in paralysed patients is that with the movement of peripheral airway secretions more centrally, the inadequate clearance of these central airway secretions (absence of cough) may Increase airway pressures and airway resistance (Mackenzie et a/, 1989). George Ntoumenopoulos MAPA Victoria, Australia
total static lung compliance foilowing chest
London SW15
wail percussion, vibration and suctioning in our study was due to patient paralysis, inconsistentpatient positioning and failure to aspirate central airway secretions. For the reasons pointed out in our stud% it is inappropriate to compare Mackenzie’s findings with ours. An essential component of our study design was to use the patient as his own control to reduce intergroup variability The same patient received both bagging and percussion alternately. Therefore patient position, sedation, and Rekmnces muscle paralysis were essentially kept Chopra, S, Tapiin, G V, Simmons, D H, constant during measurements of lung Robinson, G D, Elam, D and Coulson, A compliance, making ‘treatment technique’ (1977). ‘Effects of hydration and physical the only variable. therapy on tracheal transport veiocity’, Respiratory muscular activity will reduce American Review of Respiratory Diseases, total lunghhorax compliance and 115, 1006-1114. furthermore will vary according to the Mackenzie, C F, Shin, 8, Hadi, F and Imie, degree of sedation and lung volume P C (1980). ‘Changes in total iunghhorax (Nunn. 1987). LastiK tracheal tube suctioning should compliance foilowing chest physiotherapy’, remow secretions which have been shifted Anaesthesia and Analgesia, 59,207-210. from the peripheral to the central airways. Mackenzie, C F and Shin, B (1985). Besides,.the most significant impediment ‘Cardio-respiratory function before and to an effective cough in both our and after chest physiotherapy in mechanically Mackenzie’s patients was tracheal ventilated patients with post-traumatic intubation. respiratory failure’, Critical Care Medicine, 13, 483-406.
Mackenzie, C F; Imie, P C and Ciesla, N (1989). Chest Physiotherapy in the Intensive Care Unit’(2nd edn), Williams i3 Wilkins, Baltimore. MacLean, D, Drummond, G, Macpherson, C, McLaren, G and Prescott, R (1989). ‘Maximum expiratory airflow during chest physiotherapy on ventilated patients before and after the application of abdominal blnder’, Intensive Care Medicine, 15, 396-399.
Jones and Professor Teik
we wish to thank Mr Ntoumenopoulos for
his interest in our article. He suggests that failure to demonstrate an improvement in
Alice Jones
MPhii DipED MAPA Hong Kong Polytechnic
Teik E Oh
MD(Qid) FRCP FRACP Professor and Head Department of Anaesthesia and Intensive Care Prince of Wales Hospital Hong Kong
Refemnce Nunn. J E (1987). . . ‘Elastic forces and lung volumes’ in: Applied Respiratory Physiotherapy (3rd edn), Butterworth, pages 33-45.