1
Driving Post-Stroke MADAM - May I draw the attention of your readers to their patients who return to car driving following a stroke. At Banstead Mobility Centre we have seen many such people during the last five years, and we are aware that some of them are getting conflict- ing advice from different professional groups. There are a few post-stroke patients who recover full or nearly full function in the affected upper limb; a second group has no usefut function in the upper limb; and the third, largest group has some function in the arm, but the hand in particular demonstrates co-ordination difficulties and a slower motor response time. If people return to driving post- stroke, those in the first group with full function steer with both hands and have no problems; those in the second group without use of the arm clearly need and use a steering aid for the unaffected limb (see photograph), but there are difficulties for people with partial function in the affected limb. In our opinion these people should be en- couraged to use a steering aid for safety reasons, because while they are able to grip the wheel bi-laterallyon a straight road, they Laser Training MADAM - We are both users of biostimula- tory soft lasers and are aware of the dearth of information on, or training facilities for the use of such equipment. It is therefore our intention to try and remedy this by providing, initially, one-day seminars. Since physiotherapists form a large group of those either currently or potentially using this kind of laser, we would like to find out what would be most helpful to them. The idea, at present, would be to present a minimum of technical scientific research information so,as to provide a background for workshop activities. There could be a forum for discussion of experience and problems plus guide lines as to the choice of a laser for those who might consider buying one. As well as venue we would need to con- sider choice of day for a seminar, financial aspects and the likely amount of interest. To enable the organisers to ascertain the interest in this project. we would be pleased to have comments and suggestions from those interested. GORDON CRAWFORD MCSP DipRG&RT Physiocare Limited At John Bell & Croyden 54 Wigmore Street London W 1 H OAU ANN WOOLLEY-HART MSC MB BS MCSP Arachnoiditis Self-help Group MADAM - We have recently formed a self- help group for arachnoiditis sufferers and can find very little information on the subject other than Professor Jayson's research at Hope Hospital, Manchester We wondered if any of your readers are doing research, or know of any being under- taken We are increasing our membership daily with referrals from consultants, GPs, social workers, and so on Any information or help would be greatly appreciated LISA ROWE Arachnoiditis Self-help Group PO Box 81, Sunderland Tyne and Wear SR6 9PA Evaluation of Electrical Stimulation MADAM - Cath Sackley MSc MCSP (Physrorhtrapy, December 1987) is quite correct to point out that the article by Shindo and Jones (October 1987) was not the report of a controlled experimental study - nor did it claim to be. Statistical analysis of the purely subjective data was not relevant, and the article was presented as a conference report and not a research study. We apologise for not including the Activities of Daily Living are unable to feed the wheel through quickly enough on cornering, and especially when correcting the steering coming out of a corner. With a steering aid they can corner safely and act quickly in an emergency using only the unaffected arm, but the affected arm can be used safely to assist steering at very low speeds when parking, thus reducing the steering effort. Some clients tell us openly at assessment that their therapist would be displeased to see them steering uni-laterally while others are told, post assessment, by their therapist, to remove the steering ball and use both hands. While we certainly support the idea of rehabilitation and treatment taking place throughout daily life and not merely during a therapy session, we do not support the idea of a bi-lateral approach when driving unless the patient can demonstrate sufficient func- tion to steer safely at all times. A network of Mobility Assessment Centres (Forum) is forming throughout the UK and further advice in individual cases can be sought from any of the addresses listed here. MORIGUE CORNWELL MCSP Mobility Officer Banstead Place Mobility Centre FORUM assessment used, which in fact was a modi- fied University of New York ADL that is essentially similar to the Northwick Park ADL assessment. 'Kite flying' exercises of this sort do not justify the expenditure of large sums of money on equipment, and surely physio- therapists would recognise this. They do, hopefully, provoke consideration of other possible approaches to problems that afflict large numbers of patients having to be treat- ed in an increasingly inadequately funded health system. The equipment used in the study is highly flexible with a variety of possible applications. If, with further study, some form of neuromuscular stimulation does prove to be valuable in the control of spasm and spasticity, less flexible but less expensive equipment will undoubtedly become available. Much more important are questions con- cerning the assessment of the efficacy of specific therapeutic strategies when the experimental verifiability of the efficacy of physiotherapy is questioned. Despite this, nobody would doubt the benefits of well designed and competently performed therapy! Clearly much more work needs to be carried out (and indeed is being done) to de- fine the precise nature of the changes that we observe. and to identify those patients most . - . . - . -. likely to benefit from th;s type of therapy. As Iris Musa rightly points out, the mechanism of chanae in segmental spinal excitability is Disabled Drivers' Assessment Centres Banstead Place Mobility Centre, Park Road, Banstead, Surrey SM7 3EE ftel 0737 3516741 8SM Disabiltty Training Centre, 81 Hartfield Road, London SW19 kel 01-540 8262 ext 201) Derby Disabled Driving Centre. Kingsway Hospital, Kingsway, Derby DE3 3Lz (tel 0332 371929) Mobility Advice and Vehicle Information Service (MAVIS), Department of Trans- port, TRRL. Crowthorne, Berks RG11 6AU (tel 0344 7704561 Mobility Information Service, Unit 2A Atcham Estate, Upton Magna, Shrewsbury SY6 6UG (tel 0743 77489) Northern Ireland Council on Disability (NICD). 2 Annadale Avenue, Belfast BT7 3JR (tel 0232 49101 1) Stoke Mandeville Hospital, Occupational Therapy Workshop, Mandeville Road, Aylesbury, Bucks HP21 8AL (tel 0296 841 11) Tehidy Mobility Centre, Tehidy Hospital, Camborne, Cornwall TR14 OSA (tel 0209 710708) Vehicles for the Disabled Centre, Astley Ainslie Hospital, 133 Grange Loan, Edinburgh EH9 2HL (telO31-447 6271, 031 667 3398) Wales Disabled Drivers' Assessment Centre, 18 Plas Newydd, Whitchurch, Cardiff (tel 0222 6152761 not undtktood 1 a point we have also made. Such objective measurements of spasticity as are available are either very expensive, inadequate - or both! (see De Souza and Musa, 1987). The only safeguard for the use of the various assessment protocols available is the employment of a second 'blind' assessor, which is not always practicable. Perhaps it is time to consider the use of specialised physiological measurement packages capable of providing values for movement performance that can usefully be linked to functional evaluation. One final comment concerns the protocol used in our report. Iris Musa's slightly mis- leading comment that treatment three times a week is unlikely to change spinal mechan- isms is undoubtedly true, and much more intensive periods of stimulation were used during the initial stages of treatment. How- ever, a protocol is by no means 'established', and at this stage should not be regarded as such, especially for patients with neurological disease rather than spinal injury. Many different strategies of electrical stimulation, mainly to stimulate sensory pathways via dermatomes or sensory nerves, have been employed in attempts to reduce spasticity. One advantage of using neuromuscular stimulation, regardless of its possible influ- ence on spinal mechanisms, is that properly applied it will improve muscle blood flow and metabolism, and in appropriate instances 22 Physiotherapy, January 1988, vol74, no 1
