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Management is Treatment
Responsibility for the Truth MADAM - May I comment on Alexandra Hough's letter (April page 267) in which she asserts that 'patients have a right t o the truth' and condemns relatives for 'protecting' patients from the distress of knowing their diagnosis is incurable. While I agree that paternalism is rife among the medical profession, equally so, all professionals, physiotherapists included, too often adopt the attitude that the professional knows best. The embarrassment that the medical profession feels over death - 'the scandal we are unable t o prevent' - probably accounts for the attitudes that are evident in the hospital setting where a 'cure' ideology prevails. No-one knows the patients better than their relatives and close friends and the powerful constitutional setting of a hospital is perhaps not the best place t o reveal a diagnosis of incurable illness t o a patient. It is well documented that hospitalisation itself causes increased anxiety and distress without the further stress of the diagnosis. Visiting times end, medical staff including physiotherapists go home, leaving no one to deal with the inevitable consequences of being told that an illness is incurable. Hospitals cannot meet the emotional needs of such patients - the severe degree of psychological and emotional distress that will inevitably be experienced cannot be dealt with adequately. While I am not advocating an evasion of the truth which could result in patients and their relatives being denied the opportunity t o come t o terms w i t h accepting death, nevertheless medical professionals including physiotherapists should be acutely aware of the importance of sensitive timing in the revealing of diagnoses. In this way w e can all work towards ensuring that the best interests of patients are met. When patients return home or perhaps go
Management is Treatment MADAM - I wholeheartedly endorse the views expressed by Elizabeth Condie in her paper 'A Therapeutic Approach to Physical Disability' (February, pages 72-77). After some years working in the field of severe and chronic physical disability I am aware that the concept of managing the condition as opposed t o treating the impairment is very slow t o take hold. There are a number of reasons for this. Perhaps the m o s t i m p o r t a n t is t h e n o t i o n t h a t management is less demanding on our professional skills and knowledge than 'treatment'. We are trained for better things! As much of the implementation of management procedures falls to the relatives and carers, the reasoning follows that if such skills can be readily taught to, and carried out by non-qualified people, this somehow diminishes our knowledge and professional status and detracts from jealously guarded techniques. Management, however, IS treatment in the broadest and most effective sense. It is only when the condition is satisfactorily managed that techniques appropriate t o treating the impairment can be most effective. There is little logic in treating the symptom while the
physiotherapy, May 1991, vol 77, no 5
Ankle Foot Orthoses
t o a hospice, supportive and honest discussions can then take place between them, their families and professionals.who have time! Patients are then able t o prepare themselves and die in a dignified fashion. SUSAN S ALLISON BA MCSP DipTP Manchester
M A D A M - We write in response t o a letter by Alexandra Hough published in the April issue of the Journal in which she comments upon our earlier article on role-play (Dickson, Maxwell and Saunders, February). In that article the point was made that role-play can be put t o a number of uses in the education and training of physiotherapy students, including the illumination and examination of moral issues surrounding professional practice. In this context an example was given of a scenario in which the physiotherapist has to deal w i t h a terminally ill patient whose family is adamant that he should not be informed of his condition. We are concerned that Alexandra Hough's letter may mistakenly give the impression of an assumption on our part that the physiotherapist should acquiesce in this conspiracy of silence. This is most decidedly not the case and indeed w e broadly concur with the moral stance taken by Miss Hough in the remainder of her letter. As stated, the purpose of including this particular example was t o suggest a situation imbued w i t h moral and ethical possiblities which could be addressed through the medium of role-play - at least w e seem t o have succeeded on that account! DAVID DICKSON PhD' M H CPsychol MAUREEN MAXWELL BA MCSP DipTP CHRISTINE SAUNDERS DPE DASE MPhil University of Ulster
condition of the patient deteriorates. Yet another fact leading t o a less effective approach is that, effectiveness, in general, is measured only in terms of functional recovery (Pope, 1988). By itself, such an outcome is largely inadequate when dealing with an incurable pathology, resulting in inappropriate treatment or even to belief that the patient is 'too bad t o treat'. Furthermore, students are not well versed in the concept of management, probably due t o the prevailing attitudes outlined above. I would suggest that, as a profession, w e rapidly rethink our approach t o severe physical disability, otherwise w e are dangerously close t o losing credibility in this ever expanding field. The cost t o the health service in treating the complications arising from mismanagement, eg contractures and pressure sores runs into millions of pounds per year. PAULINE M POPE MSc BA MCSP London SW15 REFERENCE Pope, P M (1988). 'A model for evaluation of input in relation t o outcome in severely brain damaged patients', Physiotherapy, 74, 12, 647-650.
M A D A M - As a bioengineer with a strong interest in the clinical application of gait analysis I was interested t o read the article on 'The biomechanics of fixed ankle orthoses' (February, pages 81 -88). While noting the acknowledgement of the clinical manual published in Dundee in 1980 I was disappointed at the failure of the authors t o recognise t h e pioneering biomechanical studies carried out by m y erstwhile colleague Barry Meadows at the Dundee Limb Fitting Centre on this subject between 1980 and 1986 w i t h the financial support of the Scottish Home and Health Department. I can do no better than quote from Dr Meadows' conclusions, in his final report t o the SHHD, resulting from the analysis of biomechanical data obtained from thirty cerebral palsied children fitted w i t h ankle foot orthoses (AFOs): 'The use of AFOs and the associated modifications to the footwear influenced the biomechanical aspects of the gait in three main ways. 'Firstly the extremes of ankle plantarflexion were prevented, a more dorsiflexed range of motion maintained and the attitude of the lower leg relative t o the ground influenced. 'Secondly the point of origin on the foot of the ground-to-foot reaction force and its magnitude and direction were altered. 'Thirdly the combination of these t w o factors resulted in significant changes in the magnitude and direction of the external moments imposed on the joints and consequently the nature of the demand placed on the neuromuscular system.' DAVID N CONDIE BSc Area Rehabilitation Engineer Dundee REFERENCES Meadows, C B (1984). 'The influence of polypropylene ankle foot orthoses on the gait of CP children', PhD Thesis, University of Strathclyde, Glasgow. Meadows, C B (1986). An lnvesrigation into the Mobility of the Cerebral Palsied Child, Final report t o the Committee for Research on Equipment for the Disabled, Scottish Home and Health Department Project Ref R/LIMi14/75, Dundee.
Redundant View M A D A M - One of the first pages I turn t o on receiving my Journal is the feature entitled 'Personal View'. It is nearly always of a very high standard, both professionally and editorially. However, the inclusion of Gordon Smith's 'Rotations are redundant' seems t o be an exception. Are there no day hospitals in Mr Smith's region? Do neurological patients not attend out-patient departments any more? I am also very concerned t o find that the CSP seems t o be suffering from a surfeit of sand and dry-rot at the same time! Therefore please could the editor in future re-instate the 'Personal View' feature t o its previous high standard and banish personal cliche written letters t o the rightful place. Wherever that might be!
S J ROUSE MCSP DipTP Leeds
329
Management is Treatment MADAM - I wholeheartedly endorse the views expressed by Elizabeth Condie in her paper 'A Therapeutic Approach to Physical Disability' (February, pages 72-77). After some years working in the field of severe and chronic physical disability I am aware that the concept of managing the condition as opposed t o treating the impairment is very slow t o take hold. There are a number of reasons for this. Perhaps the m o s t i m p o r t a n t is t h e n o t i o n t h a t management is less demanding on our professional skills and knowledge than 'treatment'. We are trained for better things! As much of the implementation of management procedures falls to the relatives and carers, the reasoning follows that if such skills can be readily taught to, and carried out by non-qualified people, this somehow diminishes our knowledge and professional status and detracts from jealously guarded techniques. Management, however, IS treatment in the broadest and most effective sense. It is only when the condition is satisfactorily managed that techniques appropriate t o treating the impairment can be most effective. There is little logic in treating the symptom while the
physiotherapy, May 1991, vol 77, no 5
Ankle Foot Orthoses
t o a hospice, supportive and honest discussions can then take place between them, their families and professionals.who have time! Patients are then able t o prepare themselves and die in a dignified fashion. SUSAN S ALLISON BA MCSP DipTP Manchester
M A D A M - We write in response t o a letter by Alexandra Hough published in the April issue of the Journal in which she comments upon our earlier article on role-play (Dickson, Maxwell and Saunders, February). In that article the point was made that role-play can be put t o a number of uses in the education and training of physiotherapy students, including the illumination and examination of moral issues surrounding professional practice. In this context an example was given of a scenario in which the physiotherapist has to deal w i t h a terminally ill patient whose family is adamant that he should not be informed of his condition. We are concerned that Alexandra Hough's letter may mistakenly give the impression of an assumption on our part that the physiotherapist should acquiesce in this conspiracy of silence. This is most decidedly not the case and indeed w e broadly concur with the moral stance taken by Miss Hough in the remainder of her letter. As stated, the purpose of including this particular example was t o suggest a situation imbued w i t h moral and ethical possiblities which could be addressed through the medium of role-play - at least w e seem t o have succeeded on that account! DAVID DICKSON PhD' M H CPsychol MAUREEN MAXWELL BA MCSP DipTP CHRISTINE SAUNDERS DPE DASE MPhil University of Ulster
condition of the patient deteriorates. Yet another fact leading t o a less effective approach is that, effectiveness, in general, is measured only in terms of functional recovery (Pope, 1988). By itself, such an outcome is largely inadequate when dealing with an incurable pathology, resulting in inappropriate treatment or even to belief that the patient is 'too bad t o treat'. Furthermore, students are not well versed in the concept of management, probably due t o the prevailing attitudes outlined above. I would suggest that, as a profession, w e rapidly rethink our approach t o severe physical disability, otherwise w e are dangerously close t o losing credibility in this ever expanding field. The cost t o the health service in treating the complications arising from mismanagement, eg contractures and pressure sores runs into millions of pounds per year. PAULINE M POPE MSc BA MCSP London SW15 REFERENCE Pope, P M (1988). 'A model for evaluation of input in relation t o outcome in severely brain damaged patients', Physiotherapy, 74, 12, 647-650.
M A D A M - As a bioengineer with a strong interest in the clinical application of gait analysis I was interested t o read the article on 'The biomechanics of fixed ankle orthoses' (February, pages 81 -88). While noting the acknowledgement of the clinical manual published in Dundee in 1980 I was disappointed at the failure of the authors t o recognise t h e pioneering biomechanical studies carried out by m y erstwhile colleague Barry Meadows at the Dundee Limb Fitting Centre on this subject between 1980 and 1986 w i t h the financial support of the Scottish Home and Health Department. I can do no better than quote from Dr Meadows' conclusions, in his final report t o the SHHD, resulting from the analysis of biomechanical data obtained from thirty cerebral palsied children fitted w i t h ankle foot orthoses (AFOs): 'The use of AFOs and the associated modifications to the footwear influenced the biomechanical aspects of the gait in three main ways. 'Firstly the extremes of ankle plantarflexion were prevented, a more dorsiflexed range of motion maintained and the attitude of the lower leg relative t o the ground influenced. 'Secondly the point of origin on the foot of the ground-to-foot reaction force and its magnitude and direction were altered. 'Thirdly the combination of these t w o factors resulted in significant changes in the magnitude and direction of the external moments imposed on the joints and consequently the nature of the demand placed on the neuromuscular system.' DAVID N CONDIE BSc Area Rehabilitation Engineer Dundee REFERENCES Meadows, C B (1984). 'The influence of polypropylene ankle foot orthoses on the gait of CP children', PhD Thesis, University of Strathclyde, Glasgow. Meadows, C B (1986). An lnvesrigation into the Mobility of the Cerebral Palsied Child, Final report t o the Committee for Research on Equipment for the Disabled, Scottish Home and Health Department Project Ref R/LIMi14/75, Dundee.
Redundant View M A D A M - One of the first pages I turn t o on receiving my Journal is the feature entitled 'Personal View'. It is nearly always of a very high standard, both professionally and editorially. However, the inclusion of Gordon Smith's 'Rotations are redundant' seems t o be an exception. Are there no day hospitals in Mr Smith's region? Do neurological patients not attend out-patient departments any more? I am also very concerned t o find that the CSP seems t o be suffering from a surfeit of sand and dry-rot at the same time! Therefore please could the editor in future re-instate the 'Personal View' feature t o its previous high standard and banish personal cliche written letters t o the rightful place. Wherever that might be!
S J ROUSE MCSP DipTP Leeds
329