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Recovery Curves as a Basis for Evaluation
Recovery Curves as a Basis for Evaluation CECILY PARTRIDGE PhD FCSP Director. Centre for Physiotherapy Re\earch, Department of PhyGology King’s College London
SUE EDWARDS MCSP Superintendent Physiotherapist. Royal Free Hospital. London
Key words: Evaluation,
recovery curves, physical disability
SUllllllary: It is suggested that recovery curves could be developed by collecting information about the timed recovery from the physical disability of different conditions. Data were collected from 368 patients who had suffered a stroke. noting the time taken to regain specific predetermined milestones. There were 16 items of performance of movement central to the disability of stroke. The data showed distinct time-related patterns of recovery for patients of different levels of starting severity. This method of monitoring patterns of recovery in substantial numbers of patients with conditions involving physical disdbihty could be used a5 a basis against which recovery of patients with similar conditions, but receiving different methods of treatment and evaluation, could be compared and evaluated. Biography:
Cecily J Partridge was a clinical physiotherapist specialising in the treatment of neurological conditions and care ofthe elderly for IS years; she has been in full-time research since 1975. Her research interests include community physiotherapy. psychological factors in physical disability. treatment and management of stroke, and measurement and evaluation of phyaiotherapy practice. Susan Edwards is a Bobath tutor in adult hemiplegia, and also lectures on other aspects of neurology, in particular head injuries and spinal cord injuries. She was a part-time research associate at King’s College London from January 1985 until December 1986. In September 1987 she was elected to Council and serves on the Professional Practice Committee.
introduction PATIENTS with physical disabilities of different kinds form a major part of the workload of physiotherapists, from those with sports injuries and soft tissue conditions t o those with major trauma, neurological conditions and arthropathies. Despite the amount of time spent with these patients there has been little scientific evaluation of the methods of treatment and management that are used. One of the main difficulties in attempting t o evaluate any intervention is the lack of information about the natural history of recovery from the physical disabilities imposed by the condition. Information about the natural history of conditions has long formed the basis for evaluating treatment approaches in medicine; careful descriptions of the manifestations and course of different diseases have been the baseline against which the effects of new treatments have been examined. But it would be difficult - if not impossible - to obtain information about recovery of people’s untreated physical disabilities now that physiotherapy is so widely available in this country. It is suggested that developing recovery curves from information about the recovery of substantial groups of patients could provide a basis for evaluation. Using information about substantial numbers of people as a basis for examining individual progress is analogous t o the Physiotherapy, March 1988, vol 74,no 3
use of developmental profiles in children. A child’s development in such things as motor control, speech, or height can be compared with developmental norms t o find whether the child is showing about average, slow or fast development. The normal curves against which individual children are compared are based on information from large samples of babies and children whose progress is monitored t o find the times at which different milestones are reached. Patients who had suffered a stroke and were left with residual physical disability formed the population who would be studied to test the feasibility of developing recovery curves. The first task was to identify and define milestones of recovery from stroke. These milestones would then be used t o form items in a scale t o monitor recovery. Methods Ten senior physiotherapists specialising in the treatment of neurological patients met over a period of 18 months t o define milestones of recovery from the residual physical disability of stroke, ie limitations in the performance of movements. The milestones had to be movements which were central t o the disability of stroke and capable of being clearly described and reliably assessed as docs or does not perform. The items also had t o be clearly recognisable as related t o everyday performance and be expressed in clear English - avoiding the use of physiotherapy words such as retraction or inhibition. Agreement was eventually reached on 20 items, which included both gross body and arm movements. All movements were those lost since the onset of stroke and central t o the disability. To test the validity of these items they were sent to a further 5 0 physiotherapists. This group agreed that 1 6 of the items represented milestones in recovery from stroke. The four items on which agreement was not reached were discarded and the remaining 1 6 items used t o form the scale. These 1 6 items were similar to those in many forms used in stroke rehabilitation (Fugl Meyer et a / , 1975; Lincoln and Leadbitter, 1979; Katz eta/,1970; Stichbury, 1975). To test the reliability of the dichotomous doesidoes not method of scoring, ten pairs of therapists assessed ten patients with 1 0 0 % agreement on each item. Subjects People included in the study were over 1 8 years of age with residual hemiplegia following a stroke w h o were referred for physiotherapy rehabilitation. Procedure Forms containing the scale were sent t o 200 members of the Association of Chartered Physiotherapists Interested in Neurology (ACPIN), asking for their co-operation in collecting information about stroke patients. Detailed instructions were given about h o w t o undertake each assessment. Therapists were to ask each patient t o perform each item, demonstrating the movement where appropriate. If the movement was not performed, one more attempt was allowed, and . first performance was then scored as does or does ~ o tThe assessment was on referral for treatment and subsequently 141
after one, two, four, six and eight weeks. The date of onset of stroke, age and sex were noted. Other information about sensory and perceptual loss and other associated problems was noted on the form; these notes could not be used in later analyses because the extent of their reliability was not known, and no agreed way of assessing and measuring these aspects could be found. Results
Four hundred completed forms were returned from 1 8 6 therapists. It was possible t o analyse data from 368 patients who survived eight weeks. The ages of the patients ranged from 42-89 years. The easier items of the scale were performed by more people in the early stages of recovery after stroke and were regained more quickly. The order of difficulty of items was retained for nearly all patients.
I
Discussion The results suggest that recovery from the physical disability of stroke follows a predictable timed pattern and that it would be possible t o build profiles of recovery for patients with conditions of different starting severity. These profiles could then be used in a number of ways by providing baseline data about recovery. A t present, starting severity and individual experience are the basis for predicting recovery but if, for example, it could be shown that 50% of the patients who could not perform items 1 - 4 on the scale post-onset were able to do so four weeks later, this would help the patients and their relatives and enable more appropriate goal-setting in treatment. Work in departments could also be monitored. If, for example, in the larger sample, 50% of patients who cannot
Reduction in disability in gross body and arm movements over time: number (percentage) of patients passing each milestone (n=368) On referral
Week 1
2
4
6
8
341 192.1) 329 (89.4) 21 7 (59.0) 214 (58.2) 211 (57.3) 135 (36.7) 119 (32.3) 105 (28.51 101 (27.4) 98 (26.6) 83 (22.6) 66 (17.9) 53 (14.4)
363 (98.6) 355 (96.5) 280 (76.1) 272 (73.9) 265 172.0) 201 (54.6) 189 (51.4) 158 142.9) 167 (45.4) 165 (44.8) 142 138.6) 122 (33.2) 101 (27.4)
365 (99.2) 363 (98.6) 31 5 (85.6) 305 (82.9) 298 ( 8 1 .O) 235 (63.9) 233 (63.3) 193 (52.4) 198 (53.8) 204 (55.4) 178 148.4) 162 (44.0) 138 (37.51
367 (99.7) 364 (98.9) 334 (90.8) 320 (87.0) 314 (85.3) 258 (70.1) 260 170.7) 230 (62.5) 232 163.0) 232 (63.0) 207 156.3) 193 (52.4) 166 (45.1)
367 (99.7) 364 (98.9) 337 (91.6) 327 (88.91 326 (88.6) 270 (73.4) 273 (74.2) 243 166.0) 250 (67.9) 246 (66.8) 223 (60.6) 210 (57.1) 181 (49.2)
367 (99.7) 364 (98.9) 338 (91.8) 328 (89.1) 329 (89.4) 277 (75.3) 279 (75.8) 260 (70.7) 262 (71.2) 258 (70.1) 241 (65.5) 223 (60.6) 196 153.3)
1 ( 0.3) 4 ( 1.1) 30 ( 8.2) 40 (10.9) 39 110.6) 91 (24.7) 89 (24.2) 08 (29.3) 06 (28.8) 10 (29.9) 27 (34.51 45 (39.4) 72 146.7)
121 (32.9)
174 (47.3)
198 (53.8)
208 (56.5)
220 (59.8)
231 (62.8)
137 (37.2)
mouth
99 (26.9)
140 (38.0)
163 (44.3)
181 (49.2)
192 (52.2)
198 (53.8)
170 146.2)
position
90 (24.5)
144 (39.1)
167 (45.4)
190 (51.6)
206 (55.9)
216 158.7)
152 (41.3)
Function
1 Lying, turn head t o right 2 Lying, turn head t o left 3 Maintain sitting balance for 2 min 4 Lying, roll on to left side 5 Lying, roll on to right side 6 Get up from lying t o left side 7 Get up from lying to right side 8 Stand up t o free-standing position 9 Transfer bed t o chair to right 10 Transfer bed to chair t o left 11 Two steps forward 12 Two steps backward 13 Independent walking inside 14 Sitting, clasp and unclasp affected
hand
15 Sitting, place affected hand to 16 Lying, hold arm in elevated
Details of numbers of patients passing each milestone at the set time intervals are given in the table. Recovery curves for the 13 gross body movement items over the eight-week period are given in the figure below.
RE.,,,,,
i i T K S A r T E R RCFCRHliL
Recovery curves of 13 gross body movement items (n=368)
142
Not at week 8
perform items 1 - 4 on referral can do so by week 4, then if only 20% of your patients are achieving this by week 4, questions need t o be asked: Is the age of the patients very biased? Or do they all have multiple pathologies? Or do staff treatment and management need revising? If data are collected on patients receiving different methods of treatment ( A and B), the question can be asked: Are the patients receiving treatment A noticeably different in the time in which they reach each milestone from those receiving treatment B and if so in what way? Being able to identify individuals who are making faster and slower progress should enable their characteristics to be studied and be available for use as a basis for treatment plans t o help each individual t o achieve an optimal recovery. The items on the form are fairly crude and the relationship between them and more qualitative aspects of performance could also be examined. Questions could be asked about the relationship between early walking and later posture and gait patterns. One of the limitations of this approach is that it only applies t o patients referred for physiotherapy receiving current methods of treatment and management, but these are probably now a majority (Mulley, 1985). Another limitation is that data from these profiles refer only to movement and not t o function. Functional activity is more difficult to monitor because of the many different environmental and other factors Physiotherapy, March 1988, vol 74, no 3
w h i c h c a n influence p e r f o r m a n c e of functions. T h e s u p r e m e importance o f function as t h e end a i m of all physiotherapy i s recognised a n d another s t u d y i s planned t o link up these patterns o f recovery o f m o v e m e n t to actual f u n c t i o n a l performance in everyday life. Recovery will b e influenced by a great m a n y factors; t h e s e m a y include age, t y p e o f stroke, t i m e since o n s e t a n d o t h e r social a n d psychological variables, as w e l l as t h e t r e a t m e n t received. It i s also r e c o g n i s e d that p e r f o r m a n c e a t a n y o n e t i m e will reflect both a c t u a l cerebral d a m a g e a n d t h e e x t e n t o f t h e individual's ability to c o p e with h i s disability. N o r m a l patterns of r e c o v e r y c o u l d b e developed f o r other conditions involving physical disabilities s u c h as s o f t tissue injuries a n d conditions, a m p u t a t i o n , and o r t h o p a e d i c conditions. T h e s e p a t t e r n s of recovery are not m e a n t to b e static a n d will n e e d to be u p d a t e d f r o m t i m e t o t i m e . Despite their limitations t h e profiles will provide a sounder database o f actual recovery t h a n i s at present available, a n d p r o v i d e a starting p o i n t f o r other investigations. A further database on recovery of a larger sample o f stroke
p a t i e n t s is n o w being collected, with t h e help o f ACPIN members. F r o m this, profiles o f recovery will b e developed f o r different levels o f starting severity. ACKNOWLEDGMENT We would like to thank all the members of ACPlN who have helped so much with this work, both in early exploratory discussions and later collecting information for us. We should not have been able t o undertake this work without their help. REFERENCES Fugl Meyer, A R, Jaasko, L, Leyman, I, Olsson, S and Steglins, S (1975). 'The post stroke hemiplegic patients', Scandinavian Journal of Rehabilitation Medicine, 7 , 1 3 - 3 1 . Katz, S, Downs, T, Cash, H and Grotz, R C (1970). 'Progress in the development of an ADL Index', The Gerontologist, 10, Spring, Part I, 20-30. Lincoln, N and Leadbitter, D ( 1979). 'Assessment of motor function in stroke patients', Physiotherapy, 6 5 , 2, 48 - 51. Mulley, G P ( 1985). Practical Management of Stroke. Croom Helm, London. Stichbury, J ( 1975). 'Assessment of disabiiity following severe head injury', Physiotherapy, 61, 9, 2 6 8 - 272.
Care of the Elderly - Ringing the changes WENDY HAYWARD MCSP MAUREEN McNICOLL MCSP MARY BROWNLIE DipCot ANGELA EVERETT LCST THERAPISTS often express feelings of dissatisfaction and believe that 'things' could be better if only those in authority would do something! As therapists w e are not in a position t o instigate chgnge . . . or are w e ? Over the past t w o years w e have been invoked in a very exciting course which is going some way towards dispelling this myth. The Care of the Elderly course is designed t o help the basically competent therapist improve her/his professional practice. The programme of study focuses specifically on the therapist's o w n professional activities and seeks t o develop skills in problem-solving related t o the development of services t o the elderly. As well as extending knowledge this ccurse encourages therapists t o examine and explore their personal attitudes and attributes and increases their ability t o affect change in their o w n workplace. The course, which was designed and launched by the Education Development Unit for the Remedial Professions in 1984, was handed over t o the National Health Service Training Authority in 1985. It is aimed at physiotherapists, occupational therapists and speech therapists who already have some experience of working with the elderly at hospital or community level. This multidisciplinary aspect is an essential element of the course as it encourages the participants t o take a more holistic overview of patient care. It also improves teamwork and helps participants t o understand the role of other professionals. The key unifying theme throughout the course is the problemsolving sequence, and participants are encouraged t o examine real problems encountered in their o w n workplace. To this end, participants submit a work-related project demonstrating their ability t o follow the problem-solving sequence. On completion of the course participants are presented with a course profile and successful participants receive a certificate. Care of the Elderly courses run over a period of one academic year (three terms). Participants are divided into small local groups, meeting one day per fortnight. In addition, all groups come together each term for a three-day residential block. Physiotherapy, March 1988, vol 74, no 3
Local group?: The bulk of the work of an individual is centred on these tutorial sessions. The content of these sessions is negotiated by the group and its tutor, utilising local speakers and resources. Through these peer support groups, the therapists are helped t o advance their professional skills by building on previous experience and directing attention towards their current practice. Residential blocks: These provide general direction and inspiration for the term's work, bringing all the groups together for an intensive programme of lectures and workshops providing input from specialist speakers. The residential blocks also provide an opportunity t o explore various aspects of care of the elderly w i t h members of other local groups, enhancing and broadening currrent knowledge and thinking. They also help in establishing a network of useful contacts. Evaluation Having been involved in the course first as tutors then managers, w e continue t o be impressed by the rapid growth and development of the participants. Although it takes some time t o adjust t o the hard work and untraditional nature of this course, the participants all find it very stimulating. Some have not been involved in formal study for several years but respond well t o the challenge. The external assessor for this course is Dr Susan Hurley, Northern regional director of the Open University. In her report on the 1 9 8 6 course she commented: 'I continue t o be impressed by the overall standard of this course and the work which is undertaken by the students in their projects'. Conclusion The real importance of the whole activity lies in the later stages of the course w i t h the emphasis on the skills of independent study and initiating change. It was the intention of the course development team that successful participants will, at the completion of their formal studies, have the ability, confidence and enthusiasm t o continue t o develop their o w n professional competence and t o act as agents for changing and improving their professional role. Anyone interested in any aspect of this course is invited t o contact M r M Diaz, Administrator, Combined Training Institute, University Hospital of Wales, Heath Park, Cardiff CF4 4 X W (tel 0 2 2 2 7 6 3 1 60 - direct line).
143
SUE EDWARDS MCSP Superintendent Physiotherapist. Royal Free Hospital. London
Key words: Evaluation,
recovery curves, physical disability
SUllllllary: It is suggested that recovery curves could be developed by collecting information about the timed recovery from the physical disability of different conditions. Data were collected from 368 patients who had suffered a stroke. noting the time taken to regain specific predetermined milestones. There were 16 items of performance of movement central to the disability of stroke. The data showed distinct time-related patterns of recovery for patients of different levels of starting severity. This method of monitoring patterns of recovery in substantial numbers of patients with conditions involving physical disdbihty could be used a5 a basis against which recovery of patients with similar conditions, but receiving different methods of treatment and evaluation, could be compared and evaluated. Biography:
Cecily J Partridge was a clinical physiotherapist specialising in the treatment of neurological conditions and care ofthe elderly for IS years; she has been in full-time research since 1975. Her research interests include community physiotherapy. psychological factors in physical disability. treatment and management of stroke, and measurement and evaluation of phyaiotherapy practice. Susan Edwards is a Bobath tutor in adult hemiplegia, and also lectures on other aspects of neurology, in particular head injuries and spinal cord injuries. She was a part-time research associate at King’s College London from January 1985 until December 1986. In September 1987 she was elected to Council and serves on the Professional Practice Committee.
introduction PATIENTS with physical disabilities of different kinds form a major part of the workload of physiotherapists, from those with sports injuries and soft tissue conditions t o those with major trauma, neurological conditions and arthropathies. Despite the amount of time spent with these patients there has been little scientific evaluation of the methods of treatment and management that are used. One of the main difficulties in attempting t o evaluate any intervention is the lack of information about the natural history of recovery from the physical disabilities imposed by the condition. Information about the natural history of conditions has long formed the basis for evaluating treatment approaches in medicine; careful descriptions of the manifestations and course of different diseases have been the baseline against which the effects of new treatments have been examined. But it would be difficult - if not impossible - to obtain information about recovery of people’s untreated physical disabilities now that physiotherapy is so widely available in this country. It is suggested that developing recovery curves from information about the recovery of substantial groups of patients could provide a basis for evaluation. Using information about substantial numbers of people as a basis for examining individual progress is analogous t o the Physiotherapy, March 1988, vol 74,no 3
use of developmental profiles in children. A child’s development in such things as motor control, speech, or height can be compared with developmental norms t o find whether the child is showing about average, slow or fast development. The normal curves against which individual children are compared are based on information from large samples of babies and children whose progress is monitored t o find the times at which different milestones are reached. Patients who had suffered a stroke and were left with residual physical disability formed the population who would be studied to test the feasibility of developing recovery curves. The first task was to identify and define milestones of recovery from stroke. These milestones would then be used t o form items in a scale t o monitor recovery. Methods Ten senior physiotherapists specialising in the treatment of neurological patients met over a period of 18 months t o define milestones of recovery from the residual physical disability of stroke, ie limitations in the performance of movements. The milestones had to be movements which were central t o the disability of stroke and capable of being clearly described and reliably assessed as docs or does not perform. The items also had t o be clearly recognisable as related t o everyday performance and be expressed in clear English - avoiding the use of physiotherapy words such as retraction or inhibition. Agreement was eventually reached on 20 items, which included both gross body and arm movements. All movements were those lost since the onset of stroke and central t o the disability. To test the validity of these items they were sent to a further 5 0 physiotherapists. This group agreed that 1 6 of the items represented milestones in recovery from stroke. The four items on which agreement was not reached were discarded and the remaining 1 6 items used t o form the scale. These 1 6 items were similar to those in many forms used in stroke rehabilitation (Fugl Meyer et a / , 1975; Lincoln and Leadbitter, 1979; Katz eta/,1970; Stichbury, 1975). To test the reliability of the dichotomous doesidoes not method of scoring, ten pairs of therapists assessed ten patients with 1 0 0 % agreement on each item. Subjects People included in the study were over 1 8 years of age with residual hemiplegia following a stroke w h o were referred for physiotherapy rehabilitation. Procedure Forms containing the scale were sent t o 200 members of the Association of Chartered Physiotherapists Interested in Neurology (ACPIN), asking for their co-operation in collecting information about stroke patients. Detailed instructions were given about h o w t o undertake each assessment. Therapists were to ask each patient t o perform each item, demonstrating the movement where appropriate. If the movement was not performed, one more attempt was allowed, and . first performance was then scored as does or does ~ o tThe assessment was on referral for treatment and subsequently 141
after one, two, four, six and eight weeks. The date of onset of stroke, age and sex were noted. Other information about sensory and perceptual loss and other associated problems was noted on the form; these notes could not be used in later analyses because the extent of their reliability was not known, and no agreed way of assessing and measuring these aspects could be found. Results
Four hundred completed forms were returned from 1 8 6 therapists. It was possible t o analyse data from 368 patients who survived eight weeks. The ages of the patients ranged from 42-89 years. The easier items of the scale were performed by more people in the early stages of recovery after stroke and were regained more quickly. The order of difficulty of items was retained for nearly all patients.
I
Discussion The results suggest that recovery from the physical disability of stroke follows a predictable timed pattern and that it would be possible t o build profiles of recovery for patients with conditions of different starting severity. These profiles could then be used in a number of ways by providing baseline data about recovery. A t present, starting severity and individual experience are the basis for predicting recovery but if, for example, it could be shown that 50% of the patients who could not perform items 1 - 4 on the scale post-onset were able to do so four weeks later, this would help the patients and their relatives and enable more appropriate goal-setting in treatment. Work in departments could also be monitored. If, for example, in the larger sample, 50% of patients who cannot
Reduction in disability in gross body and arm movements over time: number (percentage) of patients passing each milestone (n=368) On referral
Week 1
2
4
6
8
341 192.1) 329 (89.4) 21 7 (59.0) 214 (58.2) 211 (57.3) 135 (36.7) 119 (32.3) 105 (28.51 101 (27.4) 98 (26.6) 83 (22.6) 66 (17.9) 53 (14.4)
363 (98.6) 355 (96.5) 280 (76.1) 272 (73.9) 265 172.0) 201 (54.6) 189 (51.4) 158 142.9) 167 (45.4) 165 (44.8) 142 138.6) 122 (33.2) 101 (27.4)
365 (99.2) 363 (98.6) 31 5 (85.6) 305 (82.9) 298 ( 8 1 .O) 235 (63.9) 233 (63.3) 193 (52.4) 198 (53.8) 204 (55.4) 178 148.4) 162 (44.0) 138 (37.51
367 (99.7) 364 (98.9) 334 (90.8) 320 (87.0) 314 (85.3) 258 (70.1) 260 170.7) 230 (62.5) 232 163.0) 232 (63.0) 207 156.3) 193 (52.4) 166 (45.1)
367 (99.7) 364 (98.9) 337 (91.6) 327 (88.91 326 (88.6) 270 (73.4) 273 (74.2) 243 166.0) 250 (67.9) 246 (66.8) 223 (60.6) 210 (57.1) 181 (49.2)
367 (99.7) 364 (98.9) 338 (91.8) 328 (89.1) 329 (89.4) 277 (75.3) 279 (75.8) 260 (70.7) 262 (71.2) 258 (70.1) 241 (65.5) 223 (60.6) 196 153.3)
1 ( 0.3) 4 ( 1.1) 30 ( 8.2) 40 (10.9) 39 110.6) 91 (24.7) 89 (24.2) 08 (29.3) 06 (28.8) 10 (29.9) 27 (34.51 45 (39.4) 72 146.7)
121 (32.9)
174 (47.3)
198 (53.8)
208 (56.5)
220 (59.8)
231 (62.8)
137 (37.2)
mouth
99 (26.9)
140 (38.0)
163 (44.3)
181 (49.2)
192 (52.2)
198 (53.8)
170 146.2)
position
90 (24.5)
144 (39.1)
167 (45.4)
190 (51.6)
206 (55.9)
216 158.7)
152 (41.3)
Function
1 Lying, turn head t o right 2 Lying, turn head t o left 3 Maintain sitting balance for 2 min 4 Lying, roll on to left side 5 Lying, roll on to right side 6 Get up from lying t o left side 7 Get up from lying to right side 8 Stand up t o free-standing position 9 Transfer bed t o chair to right 10 Transfer bed to chair t o left 11 Two steps forward 12 Two steps backward 13 Independent walking inside 14 Sitting, clasp and unclasp affected
hand
15 Sitting, place affected hand to 16 Lying, hold arm in elevated
Details of numbers of patients passing each milestone at the set time intervals are given in the table. Recovery curves for the 13 gross body movement items over the eight-week period are given in the figure below.
RE.,,,,,
i i T K S A r T E R RCFCRHliL
Recovery curves of 13 gross body movement items (n=368)
142
Not at week 8
perform items 1 - 4 on referral can do so by week 4, then if only 20% of your patients are achieving this by week 4, questions need t o be asked: Is the age of the patients very biased? Or do they all have multiple pathologies? Or do staff treatment and management need revising? If data are collected on patients receiving different methods of treatment ( A and B), the question can be asked: Are the patients receiving treatment A noticeably different in the time in which they reach each milestone from those receiving treatment B and if so in what way? Being able to identify individuals who are making faster and slower progress should enable their characteristics to be studied and be available for use as a basis for treatment plans t o help each individual t o achieve an optimal recovery. The items on the form are fairly crude and the relationship between them and more qualitative aspects of performance could also be examined. Questions could be asked about the relationship between early walking and later posture and gait patterns. One of the limitations of this approach is that it only applies t o patients referred for physiotherapy receiving current methods of treatment and management, but these are probably now a majority (Mulley, 1985). Another limitation is that data from these profiles refer only to movement and not t o function. Functional activity is more difficult to monitor because of the many different environmental and other factors Physiotherapy, March 1988, vol 74, no 3
w h i c h c a n influence p e r f o r m a n c e of functions. T h e s u p r e m e importance o f function as t h e end a i m of all physiotherapy i s recognised a n d another s t u d y i s planned t o link up these patterns o f recovery o f m o v e m e n t to actual f u n c t i o n a l performance in everyday life. Recovery will b e influenced by a great m a n y factors; t h e s e m a y include age, t y p e o f stroke, t i m e since o n s e t a n d o t h e r social a n d psychological variables, as w e l l as t h e t r e a t m e n t received. It i s also r e c o g n i s e d that p e r f o r m a n c e a t a n y o n e t i m e will reflect both a c t u a l cerebral d a m a g e a n d t h e e x t e n t o f t h e individual's ability to c o p e with h i s disability. N o r m a l patterns of r e c o v e r y c o u l d b e developed f o r other conditions involving physical disabilities s u c h as s o f t tissue injuries a n d conditions, a m p u t a t i o n , and o r t h o p a e d i c conditions. T h e s e p a t t e r n s of recovery are not m e a n t to b e static a n d will n e e d to be u p d a t e d f r o m t i m e t o t i m e . Despite their limitations t h e profiles will provide a sounder database o f actual recovery t h a n i s at present available, a n d p r o v i d e a starting p o i n t f o r other investigations. A further database on recovery of a larger sample o f stroke
p a t i e n t s is n o w being collected, with t h e help o f ACPIN members. F r o m this, profiles o f recovery will b e developed f o r different levels o f starting severity. ACKNOWLEDGMENT We would like to thank all the members of ACPlN who have helped so much with this work, both in early exploratory discussions and later collecting information for us. We should not have been able t o undertake this work without their help. REFERENCES Fugl Meyer, A R, Jaasko, L, Leyman, I, Olsson, S and Steglins, S (1975). 'The post stroke hemiplegic patients', Scandinavian Journal of Rehabilitation Medicine, 7 , 1 3 - 3 1 . Katz, S, Downs, T, Cash, H and Grotz, R C (1970). 'Progress in the development of an ADL Index', The Gerontologist, 10, Spring, Part I, 20-30. Lincoln, N and Leadbitter, D ( 1979). 'Assessment of motor function in stroke patients', Physiotherapy, 6 5 , 2, 48 - 51. Mulley, G P ( 1985). Practical Management of Stroke. Croom Helm, London. Stichbury, J ( 1975). 'Assessment of disabiiity following severe head injury', Physiotherapy, 61, 9, 2 6 8 - 272.
Care of the Elderly - Ringing the changes WENDY HAYWARD MCSP MAUREEN McNICOLL MCSP MARY BROWNLIE DipCot ANGELA EVERETT LCST THERAPISTS often express feelings of dissatisfaction and believe that 'things' could be better if only those in authority would do something! As therapists w e are not in a position t o instigate chgnge . . . or are w e ? Over the past t w o years w e have been invoked in a very exciting course which is going some way towards dispelling this myth. The Care of the Elderly course is designed t o help the basically competent therapist improve her/his professional practice. The programme of study focuses specifically on the therapist's o w n professional activities and seeks t o develop skills in problem-solving related t o the development of services t o the elderly. As well as extending knowledge this ccurse encourages therapists t o examine and explore their personal attitudes and attributes and increases their ability t o affect change in their o w n workplace. The course, which was designed and launched by the Education Development Unit for the Remedial Professions in 1984, was handed over t o the National Health Service Training Authority in 1985. It is aimed at physiotherapists, occupational therapists and speech therapists who already have some experience of working with the elderly at hospital or community level. This multidisciplinary aspect is an essential element of the course as it encourages the participants t o take a more holistic overview of patient care. It also improves teamwork and helps participants t o understand the role of other professionals. The key unifying theme throughout the course is the problemsolving sequence, and participants are encouraged t o examine real problems encountered in their o w n workplace. To this end, participants submit a work-related project demonstrating their ability t o follow the problem-solving sequence. On completion of the course participants are presented with a course profile and successful participants receive a certificate. Care of the Elderly courses run over a period of one academic year (three terms). Participants are divided into small local groups, meeting one day per fortnight. In addition, all groups come together each term for a three-day residential block. Physiotherapy, March 1988, vol 74, no 3
Local group?: The bulk of the work of an individual is centred on these tutorial sessions. The content of these sessions is negotiated by the group and its tutor, utilising local speakers and resources. Through these peer support groups, the therapists are helped t o advance their professional skills by building on previous experience and directing attention towards their current practice. Residential blocks: These provide general direction and inspiration for the term's work, bringing all the groups together for an intensive programme of lectures and workshops providing input from specialist speakers. The residential blocks also provide an opportunity t o explore various aspects of care of the elderly w i t h members of other local groups, enhancing and broadening currrent knowledge and thinking. They also help in establishing a network of useful contacts. Evaluation Having been involved in the course first as tutors then managers, w e continue t o be impressed by the rapid growth and development of the participants. Although it takes some time t o adjust t o the hard work and untraditional nature of this course, the participants all find it very stimulating. Some have not been involved in formal study for several years but respond well t o the challenge. The external assessor for this course is Dr Susan Hurley, Northern regional director of the Open University. In her report on the 1 9 8 6 course she commented: 'I continue t o be impressed by the overall standard of this course and the work which is undertaken by the students in their projects'. Conclusion The real importance of the whole activity lies in the later stages of the course w i t h the emphasis on the skills of independent study and initiating change. It was the intention of the course development team that successful participants will, at the completion of their formal studies, have the ability, confidence and enthusiasm t o continue t o develop their o w n professional competence and t o act as agents for changing and improving their professional role. Anyone interested in any aspect of this course is invited t o contact M r M Diaz, Administrator, Combined Training Institute, University Hospital of Wales, Heath Park, Cardiff CF4 4 X W (tel 0 2 2 2 7 6 3 1 60 - direct line).
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