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I FOUND the article ‘Mitchell's relaxation technique: is it effective?’ by Bell and Saltikov (2000) ratherpuzzling. Laura Mitchell's book SimpleRelaxation: The physiological method foreasing tension was published by JohnMurray in 1977, but another title andpublisher were given in the reference list.It is a self-help book, written in thesimplest possible terms for easy access bythe layman.

Laura Mitchell devoted many years ofher highly successful professional careerto developing and perfecting a newmethod of reducing tension in people inall situations, in illness, childbirth, workand leisure. The basis of the method wasthe observation that tension involvescertain rigid postures throughout thebody, which can be eliminated by usingthe physiological laws of reciprocalinhibition or reciprocal relaxation. To testher method using only heart rateresponse as the criterion, with subjectswho were not identified as exhibiting thepostures of tension, seems inadequate.

In her book, Laura Mitchell used veryprecise instructions. She gave three basicstarting positions, one supine lying, twositting. In lying, the instruction was for thepatient to place the hands on theabdomen or thighs (in the hip region),

with elbows out, in order to perform theappropriate release for the arms. This isnot the arm position used in the study.

A tape is a useful substitute for apersonal teacher for healthy people in thehome setting, but not for patients. It is notnecessarily appropriate to transfer theresults of a study on healthy people topatients.

The conclusion that diaphragmaticbreathing alone might be enough forpatients is worrying partly because of thelimited nature of the study, and more sobecause it is adjusting practice toexpediency. Chest patients, for instance,invariably suffer from muscular tension.

Personal help in reducing this andpromoting better breathing patterns islogically better than a brief introductionto breathing by a busy therapist who maynot be concentrating on the individualpatient's difficulties. The therapist's handsplay an important role in promotingpatient confidence, accuracy andcompliance, in teaching controlledbreathing and other types of movementco-ordination. It is difficult to quantify thisfor the sake of evidence-based practice.Laura Mitchell had no doubts about hermethods, because she saw the results inhundreds of patients, and in those whowere treated by therapists she taught.

Mayston (2000) rightly points out thatskilled specialist Bobath practitioners havemoved forward rapidly, and possibly mightuse other titles, to avoid being fixedforever in practices published over 25years ago, in the case of paediatrictechniques, or 10 years for adulttreatments.

Clinical advances are always way aheadof written evidence showing theireffectiveness. Manual handling is complexand individual, and probably impossibleto study scientifically. If we reduce ouraccepted techniques to those done ‘by thebook’, but reduced to the simplest formatfor the purposes of accurate scientificstudy, our profession will decline. Dumb allegiance to evidence-basedpractice would have stifled theincalculably important advances in patientcare created by practitioners like MrsBobath and Miss Mitchell, just as, if we arenot careful, it will reduce practice in theNHS to robotics. True clinical freedomwill be the preserve of privatepractitioners. The implications of thatcould have serious consequences for theunity of our profession.

Vivian Grisogono MA(Oxon) MCSP London

I AM responding to the letters byMargaret Mayston and Patricia Shelley inresponse to the article by Victoria Sparkes(2000) in the July issue of Physiotherapy.While I totally agree with the commentsmade by Patricia Shelley I cannot supportmany of the statements made by MargaretMayston – in particular:

� ‘Handling in itself cannot changespasticity.’

� ‘Therapists cannot directly inhibitspasticity.’

� ‘There is no good evidence to show thatstopping a person from being activewill prevent spasticity.’

From my own observations of patientsbeing handled by Bobath-trained tutorsand from feeling patients’ tone changingunder my own hands I cannot believe thefirst two statements are always true.

At the 1999 CSP Congress both JohnRothwell and Nigel Lawes referred tospasticity as a ‘multi-causal syndrome’.One of the causes has to be compensatoryprogramming of muscle spindles afterbrain injury.

Physiotherapy handling can change thisabnormal programming. Guiding orplacing a patient to move from a differentbase of support can do this. Automaticmotor function thus changes from beingspastic to being quite normal.

The third statement particularly worriesme. I strongly feel that patients should notbe allowed to push themselves beyondtheir capabilities. Tackling a task that istoo difficult will only force a patient to usecompensatory strategies and toprogramme his muscle spindlesabnormally. This will only make spasticityworse.

Over 40 years of treating stroke patientsI have witnessed many sad incidences ofspasticity increase and motor functiondeterioration. These patients either havebeen discharged too soon, or they haveactually learnt compensatory strategieswhile in hospital.

Indeed more research is needed, but

Evidence-based Practice Must Be Questioned

Handling and Spasticity

Letters

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please let us base our practice onevidence, both from written research andfrom what we observe and feel under ourhands.

Jackie Wright MCSPWymondham, Norfolk

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References to the letters from Miss Grisogono and Mrs Wright

Bell, J A and Saltikov, J B (2000).‘Mitchell's relaxation technique: Is it effective?’ Physiotherapy, 86, 9, 473-478.

Mayston, M (2000). ‘Motor learningnow needs meaningful goals’ (letter)Physiotherapy, 86, 9, 492-493.

Mitchell, L (1977). Simple Relaxation:The physiological method for easingTension, John Murray, London.

Sparkes, V (2000). ‘Physiotherapy forstroke rehabilitation: A need forevidence-based handling techniques’,Physiotherapy, 86, 7, 348-356.