Análisis del contexto

patient’s ability to perform activities.

For each successive study of hemiplegic patients a new set of activities is usually described, and varying descriptions of levels of dependence are used (cf., e.g. Feldman et al, 1962; Gordon and Kohn, 1966; Stern, McDowell & Miller, 1970).

Consequently, the content of some assessments appears to be directed more towards the goals of the studies in which they were used than to the true functional capacity of thd patient. Some test a restricted range of abilities by repetitively

measuring the same dimensions of integrated purposeful function - for exarrpile, reach and grasp. Additionally, the differences between the variables used in these studies, and the consequent differences in measuring outcome from treatment, produce results which are not comparable.

The treatment being evaluated: There is little evidence in evaluative studies that physiotherapy and rehabilitation have been tailored to the individual needs of the patients who par­ ticipated. It is not always clear what treatment an individual received, other than that he received a standardised regime as a member of a particular group. Partridge (1980) has stressed that physiotherapy is a dynamic process which alters immediately in

response to change in the patient* Therefore, standardisation of treatment for the purpose of research can mean that the

"treatment” being evaluated bears little relationship to the physiotherapy an individual needs, and the evaluative study will have little value0

Future evaluation of physiotherapy: In assessing the results of treatment of peripheral, nerve injuries, Bowden (1954) em­ phasised that it was not enough to assess the extent of restor­ ation of motor and sensory function: success must be judged by,

"the patient’s ability to resume the enjoyment of a full and active life*"

The mechanism and process of resolution of neuromuscular

impairment following peripheral nerve injuries is well documented (cf. Seddon, 1954)» Conversely, the greater volume of litera­ ture about CVAs concerns functional recovery, which is observed more easily than is resolution of impairment* However, Bowden*s definition of success is still applicable to rehabilitation of stroke. Ultimately, the success of physiotherapy for hemiplegia will not be judged by the extent to which it alters the tone of

the patient's muscles or his patterns of movement0 It will be judged by his ability to perform the ordinary activities of his life o

However, in order to be more effective and to achieve such success, physiotherapy still requires both a description

of the sequence of restoration of motor function and a means of estimating its extento Consequently, the debate concerning the effectiveness of both physiotherapy and rehabilitation is unlikely to be resolved until data—gathering instruments are

standardised, tested for their reliability, and confirmed as valid for assessment of hemiplegia, or stroke, or both*

Essentially, there should be no difference between a research instrument and a clinical assessment* Therefore, for evalua­ tion of physiotherapy for hemiplegia, the data-gathering instru­ ment needs to be a valid clinical assessment for physiotherapy; and the procedure for gathering data for research should be compatible with the routine use of the assessment. Although

the success cf physiotherapy is judged on a patient*s functional ability, reliance on ADL and self-care activities deprives studies of the dimension which is important for evaluation of physiotherapy itself. That is, assessment of the quality of movement, or the effects of muscle tone on patterns of move­ ment and postural control, and its relationship to observable changes in patients1 functional ability brought about by physiotherapy•

Finally, it is necessary to return to the assertion of the proponents of the neurophysiological methods, that functional ability will improve as the impairment is reduced*. No

evaluative study has tested this assertion yet; although it offers an hypothesis for comparing the functional and neuro­ physiological approaches as well as the different neuro­ physiological methods•

SUMMARY

Hemiplegic patients who are referred for physiotherapy may be treated by functional or neurophysiological approaches.

Practitioners of the functional approach accept that the neuromuscular impairment is not going to alter significantlyo They aim to reduce disability by training the patient in

activities such as walking and negotiating steps. Practitioners of the methods of the neurophysiological approach aim to reduce the functional disability by improving the patient's control of his movement and balance.

The theories and models of recovery after lesion of the central nervous system do not appear to support any one approach or method of physiotherapy above another. They do appear to possess varying degrees of power to explain them. The functional

approach may be explained by "diaschisis theory'* (Monakow, 1914), since this theory views recovery as the reestablishment of

temporarily impaired neural mechanisms and as a function of the individualfs capacity to realise repair. Conversely, practit­ ioners of neurophysiological methods measure recovery by the quality of the performance, or recovery of execution of normal co-ordinated movement. They are supported by theories of the plasticity of the central nervous system which allow mediation by an undamaged area and restoration of patterns of movement which

are acceptable as normal function (Stein, Rosen and Butters, 1974).

There is some dispute over the efficacy of physiotherapy for hemiplegia; and contradictory evidence can be cited from the literature. There can be no doubt that the most effective rehabilitation is that which enhances the hemiplegic person*s capabilities outside the hospital or treatment centre. It is yet to be shown whether effective rehabilitation of stroke involves training of functional activities; or physiotherapy aimed at resolving the impairment; or a combination of these and other interventions, such as aids and adaptations in the home.

In order to evaluate the efficacy of physiotherapy in rehabili­ tation of stroke patients, a data-gathering instrument is

required which would be both a clinical physiotherapeutic assessment usable with all methods of physiotherapy and a measure of outcome from treatment.

FIGURE 5

AREAS OF NEED FOR A STANDARDISED PHYS10THERAPEUTIC ASSESSMENT