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Chest Physiotherapy
111
Chest Physiotherapy MADAM - Congratulations to the Glasgow Physiotherapy Research Group for approaching the important subject of post-operative chest physiotherapy (August 1993, page 547). However, I wish to make some comments and suggestions. 1. The majority of subjects in the study were patients with low abdominal incisions, under the age of 60 and non-smoking. I believe that it is well established that this group of patients are of low risk for developing pulmonary complications. A study of clinical significance would require a large number of high risk patients, ie after upper abdominal or major surgery with or without complicating factors, eg smoking, COPD. obesity, poor general condition, advanced age, etc. 2. As there are no details in the study of the post-operative techniques, it is very difficult to reach any real conclusion. It is essential to know the techniques, duration and number of treatments - whether positioning, mobilisation, walking, and respiratory adjuncts (as CPAP and inhalation) were used. Possibly in some cases post-operative treatment may only include verification of the effective carring out of the pre-operative programme. In conclusion I believe the patients require assessment both pre- and postoperatively as to the type and extent of CPT that would be required. In most cases I would expect that ‘high risk’ patients would need more ‘hands-on’ physiotherapy and for a longer period.
Richelle Shem-Tov Patah Tikrah Israel Mrs K D Hack MSc MCSP, a co-author of the research report, replies: I wish to thank Ms Shem-Tov for her comments regarding our article and to respond to the points raised. We acknowledge that the large number of subjects who had lower abdominal surgery is a limitation of our study. It is of interest to note, however, that although there was a higher incidence of postoperative chest infection in patients with upper abdominal incisions, the provision of supervised post-operative chest physiotherapy did not significantly reduce the incidence of chest infection in the treated group. As concluded in the paper, further work is required to evaluatepost-operative chest physiotherapy in non-smokers undergoing major abdominal surgery. The aim of the trial was not to investigate the efficacy of individual respiratory techniques but to question the value of an established prophylactic treatment programme for patients undergoing elective abdominal surgery. As stated, this programme consisted of positioning, breathing exercises, huffing and coughing. These are recognised treatment techniques in the post-operative manage-
ment of surgical patients (Gaskell and Webber, 1980). There were problems with standardisationof this programme. These were highlighted in the ‘limitations of the study’ section of the paper, and included the valid points raised regarding duration, number of treatments and lack of information about the exact positions used during treatment. I agree with Ms Shem-Tov that any postoperativesurgicalpatient who is seen must be assessed and the treatment tailored to the needs of that patient. But two key questions still remain: 0 Who should be seen post-operatively? If a patient receives post-operative prophylactic chest physiotherapy but does not develop a chest complication, has our management been a success or would the patient not have developed a problem even in the absence of physiotherapeutic intervention?
was vital when attempting to defend senior (and other) posts. The CSP Industrial Relations Department is not against change, and has taken a pro-active stance on a large number of issues. Change must, however; be justified and shown to lead to improvement. This is not the case with the loss of many posts. Members, at all levels, rightly expect and receive full IR support if their post is under threat. FinallH the money ‘saved‘ when senior posts are cut is often lost to the physiotherapy department, and the consequence in many cases is onen unrewarded additional responsibility and even higher workload for the remaining staff.
Alternative Attitudes to Therapy
MADAM - I read the article ‘Looking to the future: An alternative view’ in the Centenary Journal with much interest and fellow-feeling. The author, Susan Hollenbery, is to be congratulated on her Reference eloquence in writing a structured account Gaskell, D V and Webber, B A (1980). The of the approach to treatment which Brompton Hospital Guide to Chest Physiofacilitates a remarkable and beneficial therapy, Blackwell Scientific Publications, response to self-healing. Susan’s article on Oxford (revised 4th edn). cranio-sacral therapy published in In Touch describes this noninvasive, non-directive touch in a practical therapy. Empirically the same principles using reflextherapy also facilitate the individual Promoting the Union healing mechanism. The ’treatment’ is MADAM - With reference to David preceded by a careful holistic case history Fleming’s remark on taking collective which not only gains the necessary grievance action on loss of top grade posts background beyond the symptoms to past at the Council meeting on December 12 history and lifestyle functions. It gives the (Physiotherapy, January 1994, page 29) practitioner the opportunity to use the I would like to make the following two intuitive faculty in sensing any emotional suggestions: implications. This time is also ,beneficial 1. Instead of directing union energy into in building trust and empathy. Reflextherapy is applied in a gentle resisting change, direct energy into promoting union representation at top-level manner, the practitioner aware that any physical trauma or imbalance may also management meetings. hold the memory of the associated event 2. With the extra funds released from with shock, guilt, grief, fear or other such cutting top grade posts negotiate how debilitating stress. The mind of the these funds should be spent. practitioner remains open, without expectCould not the extra funds be used to help ation, so as not to override the needs of individual physiotherapists manage their the recipient by the desire or will of the own clinical training and help them ‘observer’ (as in the Observer Effect, well participate in union activity? Individual recognised in many sciences). physiotherapists would thus be given more We must therefore keep our minds open autonomy in their own personal develop- and allow the patients’ bodylmind healing ment. Management would gain. Improve- procedures to follow their own path: the ment in expertise would be improvement less we become actively involved and the in overall efficiency. more we act as passive support, the more profound and in depth the responses we J W Wright MCSP observe. Only then is the healing more Wymondham, Norfolk thorough, ongoing and sustained in the health and balance of mind and body. Richard Griffin, joint director of industrial This attitude to therapy would be an relations, observes: important area for research. It would be Concern was expressed by all Council interesting to know how many other members at the loss of senior managerial physiotherapists have similar experiences posts in the NHS, and the consequence of using other modalities. this for patient care and the profession as Christine Jones MCSP a whole. David Fleming explained that Midland School of Reflextherapy support from members, on the ground, Warwick
I suggest that these are key considerations and require ongoing investigation and evaluation
Physiotherapy, February 1994, vol80, no 2
Chest Physiotherapy MADAM - Congratulations to the Glasgow Physiotherapy Research Group for approaching the important subject of post-operative chest physiotherapy (August 1993, page 547). However, I wish to make some comments and suggestions. 1. The majority of subjects in the study were patients with low abdominal incisions, under the age of 60 and non-smoking. I believe that it is well established that this group of patients are of low risk for developing pulmonary complications. A study of clinical significance would require a large number of high risk patients, ie after upper abdominal or major surgery with or without complicating factors, eg smoking, COPD. obesity, poor general condition, advanced age, etc. 2. As there are no details in the study of the post-operative techniques, it is very difficult to reach any real conclusion. It is essential to know the techniques, duration and number of treatments - whether positioning, mobilisation, walking, and respiratory adjuncts (as CPAP and inhalation) were used. Possibly in some cases post-operative treatment may only include verification of the effective carring out of the pre-operative programme. In conclusion I believe the patients require assessment both pre- and postoperatively as to the type and extent of CPT that would be required. In most cases I would expect that ‘high risk’ patients would need more ‘hands-on’ physiotherapy and for a longer period.
Richelle Shem-Tov Patah Tikrah Israel Mrs K D Hack MSc MCSP, a co-author of the research report, replies: I wish to thank Ms Shem-Tov for her comments regarding our article and to respond to the points raised. We acknowledge that the large number of subjects who had lower abdominal surgery is a limitation of our study. It is of interest to note, however, that although there was a higher incidence of postoperative chest infection in patients with upper abdominal incisions, the provision of supervised post-operative chest physiotherapy did not significantly reduce the incidence of chest infection in the treated group. As concluded in the paper, further work is required to evaluatepost-operative chest physiotherapy in non-smokers undergoing major abdominal surgery. The aim of the trial was not to investigate the efficacy of individual respiratory techniques but to question the value of an established prophylactic treatment programme for patients undergoing elective abdominal surgery. As stated, this programme consisted of positioning, breathing exercises, huffing and coughing. These are recognised treatment techniques in the post-operative manage-
ment of surgical patients (Gaskell and Webber, 1980). There were problems with standardisationof this programme. These were highlighted in the ‘limitations of the study’ section of the paper, and included the valid points raised regarding duration, number of treatments and lack of information about the exact positions used during treatment. I agree with Ms Shem-Tov that any postoperativesurgicalpatient who is seen must be assessed and the treatment tailored to the needs of that patient. But two key questions still remain: 0 Who should be seen post-operatively? If a patient receives post-operative prophylactic chest physiotherapy but does not develop a chest complication, has our management been a success or would the patient not have developed a problem even in the absence of physiotherapeutic intervention?
was vital when attempting to defend senior (and other) posts. The CSP Industrial Relations Department is not against change, and has taken a pro-active stance on a large number of issues. Change must, however; be justified and shown to lead to improvement. This is not the case with the loss of many posts. Members, at all levels, rightly expect and receive full IR support if their post is under threat. FinallH the money ‘saved‘ when senior posts are cut is often lost to the physiotherapy department, and the consequence in many cases is onen unrewarded additional responsibility and even higher workload for the remaining staff.
Alternative Attitudes to Therapy
MADAM - I read the article ‘Looking to the future: An alternative view’ in the Centenary Journal with much interest and fellow-feeling. The author, Susan Hollenbery, is to be congratulated on her Reference eloquence in writing a structured account Gaskell, D V and Webber, B A (1980). The of the approach to treatment which Brompton Hospital Guide to Chest Physiofacilitates a remarkable and beneficial therapy, Blackwell Scientific Publications, response to self-healing. Susan’s article on Oxford (revised 4th edn). cranio-sacral therapy published in In Touch describes this noninvasive, non-directive touch in a practical therapy. Empirically the same principles using reflextherapy also facilitate the individual Promoting the Union healing mechanism. The ’treatment’ is MADAM - With reference to David preceded by a careful holistic case history Fleming’s remark on taking collective which not only gains the necessary grievance action on loss of top grade posts background beyond the symptoms to past at the Council meeting on December 12 history and lifestyle functions. It gives the (Physiotherapy, January 1994, page 29) practitioner the opportunity to use the I would like to make the following two intuitive faculty in sensing any emotional suggestions: implications. This time is also ,beneficial 1. Instead of directing union energy into in building trust and empathy. Reflextherapy is applied in a gentle resisting change, direct energy into promoting union representation at top-level manner, the practitioner aware that any physical trauma or imbalance may also management meetings. hold the memory of the associated event 2. With the extra funds released from with shock, guilt, grief, fear or other such cutting top grade posts negotiate how debilitating stress. The mind of the these funds should be spent. practitioner remains open, without expectCould not the extra funds be used to help ation, so as not to override the needs of individual physiotherapists manage their the recipient by the desire or will of the own clinical training and help them ‘observer’ (as in the Observer Effect, well participate in union activity? Individual recognised in many sciences). physiotherapists would thus be given more We must therefore keep our minds open autonomy in their own personal develop- and allow the patients’ bodylmind healing ment. Management would gain. Improve- procedures to follow their own path: the ment in expertise would be improvement less we become actively involved and the in overall efficiency. more we act as passive support, the more profound and in depth the responses we J W Wright MCSP observe. Only then is the healing more Wymondham, Norfolk thorough, ongoing and sustained in the health and balance of mind and body. Richard Griffin, joint director of industrial This attitude to therapy would be an relations, observes: important area for research. It would be Concern was expressed by all Council interesting to know how many other members at the loss of senior managerial physiotherapists have similar experiences posts in the NHS, and the consequence of using other modalities. this for patient care and the profession as Christine Jones MCSP a whole. David Fleming explained that Midland School of Reflextherapy support from members, on the ground, Warwick
I suggest that these are key considerations and require ongoing investigation and evaluation
Physiotherapy, February 1994, vol80, no 2