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Specific Stimulation for Spasticity MADAM - I would like to endorse the sentiments expressed by Dr Musa (February, 1993) in response to the study by Mrs Livesley on effects of electrical neuromuscular stimulation (December, 1992).

Dr Musa’s comments do highlight two very important points. The first is that in whatever field of technology is under consideration, programmes of treatment should be led by therapists and scientists and not by the manufacturers. Second, it cannot be assumed that protocols tested in one condition (especially in an uncontrolled study) can be transferred to another condition. This is particularly relevant in multiple sclerosis where there may be significant differences in both strength and spasticity in one leg compared with the other, and in agonist compared with antagonist muscle groups. Currently available commercial stimula- tors are unable to accommodate these differences appropriately.

There are a number 01 indications in the literature that when stimulation is aimed at functional use spasticity may be reduced and I am surprised that neither Mrs Livesley nor Dr Musa have quoted the excellent review of spasticity, its measurement and the outcome of stimulation by Stefanovska and colleagues (1991). This group has many years of experience and expertise In this field and points out the importance of understanding the different components of spasticity when looking at the potential of different treatment modalities.

It is of the greatest importance that research studies set out to define the outcome in terms of the aims of the study. Treatment of spasticity in order to enable the application of more extensive physio- therapy in an acutely relaxed patient is a very different goal from questioning whether muscle stimulation per se can produce a chronic reduction in spasticity. Dr Musa’s comments on spasticity somewhat confuse this issue, and I do not agree that studies in animal models are the best way of understanding human spasticity. Such studies have been misleading in the past, especially in quadrupeds where there may be much more reliance on local spinal circuits and where motor programmes may be highly conserved, compared with man where long latency pathways appear to be of greater significance.

Further I doubt that stimulus input must mimic the frequencies and patterns of ‘normal’ input. Our own studies (Jones el al, submitted for publication) and those of others (Young and Mayer, 1982; Rice el a/, 1992) indicate considerable changes in muscle properties in those with multiple sclerosis or following stroke. Bearing in mind that such differences may render muscles vulnerable to inappropriate levels of imposed activity and that, in any event, stimulation devices are not capable of the

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normal fine regulation of integrated activity of different motor units to maintain force without fatigue, the concept of ‘normal’ activity is not attainable. I agree that we are nowhere near being

able to define appropriate sites and modalities of treatment (we are currently concentrating our efforts on EMG re- cordings and the evaluation of movement in the presence of spasticity). Whether proximal or distal sites, or sensory or motor activities are more important has also to be determined. However, those studies that are available indicate that distal sltes are more effective (Stefanovska el a/, 1991).

I hope that open debate on the many issues relating to spasticity and its treatment will continue to add to the improvement of therapy and practice in this interesting but difficult area. Rosie Jones PhD Bristol

Refemnces Jones, R, Rees, D and Campbell, M (1992). ‘Tibialis anterior surface EMG parameters change before force output in multiple sclerosis patients’ (submitted for pub- lication). Livesley, E (1992). ‘Effects of electrical neuromuscular stimulation on functional performance in patients with multiple sclerosis’, Phpiolhempy, 78, 12, 914-917. Rice, C L, Vollmer, T L and Bigland-Rihie, B (1992). ‘Neuromuscular responses of patients with multiple sclerosis’, Muscle and Nerve, 15, 1123-32. Stefanovska, A, Reberesk, S, Bajd, T and Vodovnik, L (1991). ‘Effects of electrical stimulation on spasticity’, Clinical Reviews in Phvsical and Rehabilitation Medicine. 3, k59-99. Young, J L and Mayer, R F (1982). ‘Physio- logical alterations in motor units in hemiplegia, Journal of Neurological Sciences, 54, 401 -407.

Not Too Old MADAM - In response to the letter in the March edition of the Journal, ‘How old is too old?’ I would be most concerned, as a physiotherapy manager, if disadvantaging clinicians in such a way was common practice.

Age is clearly no barrier to someone’s ability to fulfil competently the requirements of a physiotherapy job. To some extent the physiotherapist in her forties provides the stable workforce for a department as her childbearing career is usually complete. This, combined with evidence of appropriate clinical skills, makes the ‘mature’ physiotherapist a worthy and valued senior member of staff. I would be

interested to know if a male physiotherapist of 43 has ever encountered similar prejudices! Anne Walker MCSP Chairman Association of Chartered

Physiotherapists in Management

MADAM - I was sorry, but not surprised, to read the letter from Sally French concerning short-term physiotherapy employment through medical agencies (March 1993, p 195).

I can only comment on the policy of one agency but I would expect most others to have similar selection criteria. Agency staff are usually employed where staffing levels are exceptionally low and supervision is rarely available. For this reason we rarely place new graduates. Similarly, depending on individual experience, we are cautious about placing anyone who has been away from clinical practice for more than two years, especially i f they are looking for a senior post.

In our experience, hospitals requiring agency staff are rarely, if ever, concerned with a person’s age. They are, however, concerned about getting a member of staff who can fit into the hospital system quickly and efficiently, and who will require minimum support especially i f the assign- ment is for only a limited time.

There Is a great shortage of physiother- apists who are willing to accept temporary posts and indiscriminate selection by some agencies is probably a far greater problem. It seems highly likely that the reason why both agencies felt unable to help Miss French was her lack of recent clinical experience and not her age. Debi Faulder MCSP Corinth Medical

Tributes to Paul Standing MADAM - May I take this opportunity to thank all those who so graciously attended the funeral of my husband, the late Paul Standing MSc MCSP DipTP I would also like to thank those who

gave so generously to the charities nominated by Paul. A total of €1,520 was collected and this was distributed as follows: €900 to The William Tayler Fund (Paddington Hospital) €600 to The Medical Oncology Research Fund (Southampton) €20 to Wessex Cancer Trust

The many letters I have received from friends, colleagues and students have been of a great comfort, and I thank you all for your recognition of Paul’s contribution to the profession. Sue Standing MCSP North Baddesley, Hants