DEVELOPMENTAL MEDlClNE AND CHlLD NEUROLOGY. 1978, 20

Congenital dislocation of the hip is the most important asymptomatic congenital abnorm- ality to be detected in the neonatal period, as treatment is extremely effective at that stage. The technique of the examination is not easy and the low incidence of the abnormality in Britain makes it difficult to teach and supervise junior staff effectively. The studies in Manchester, Uxbridge and Bristol have shown that, in this country, well trained and super- vised junior staff can detect nearly all the cases of congenital dislocation of the hip in the neonatal period. The results of the Norwegian study should not be used to salve our conscience when we see the missed cases in our wards being treated for several months in hospital by multiple orthopaedic procedures.

Northwick Park Hospital, Watford Road, Harrow HA1 3UJ.

TABLE

H. B. VALMAN

Author Corrn tr ) Incidence

L’nsrable hips in neonntul lo00 infants period ( O 0 )

Missed C D H per

E,srininted incidence of established CDH before screening progratnrnes

Cyvin ( 1977) Norway Bjerkreim (1974) N o w a y Fredensborg (1976) Sweden Barlow (1963) England Finlay et a/ . (1967) England Dunn (1977) England

I . 9 2 . 0 0 . 7 0.8 0.9 0.07 1 .8 0 . 2 0.5 0.0 1 . 5 0.2

? 0.12 0 .17 0 . 3 0.1 0 . 3

REFERENCES I . C‘yvin, K . B. (1977) ‘Congenital dislocation of the hip joint.‘ Acia Paediatricn Scandinavico, Suppl. 263,

1-61. 2. Fredensborg, N. (1976) ‘The effect of early diagnosis of congenital dislocation of the hip,’ Acta Pnediatrica

Scnndino vico .65,3 2 3 -3 28. 3 . Barlow. T. G. (1963) ‘Early diagnosis and treatment of congenital dislocation of the hip.’ Proceedings of

the Royal Society of Medicine, 56, 804-806. 4. Finlay, H. V. L., Maudsley. R . H., Busfield, P. L. (1967) ’Dislocatable hip and dislocated hip in the new-

born infant.‘ Brirish Mrdicul Juirrnul, 4, 377-38 I . 5 . h n n , P. M. (1977) ‘Congenital dislocation of the hip.’ British Medical Joitrnal, 2, 43-44. 6 . Wynne-Davies, R. ( I 970) ’Acetabular dysplasia and familial joint laxity: two etiological factors in

congenital dislocation of the hip. A review of 589 patients and their families.’ Journal of Bone and Joint Srrrgerr, 52B. 704-7 16.

7. Bjerkreim, I . (1974) ’Congenital dislocation of the hip joint in Norway. A clinical-epidemiological study.’ Acto Orfhopaedica Scondinavicu, Suppl. 157, 75-88.

PHYSIOTHERAPISTS AS FIRST-CONTACT PRACTITIONERS

ACSTRALIAN physiotherapists have taken a great step forward by adopting a revised code of ethics. Members of the Australian Physiotherapy Association need no longer treat only patients referred by a doctor. The patient now has the choice of consulting his doctor first, as before, or going directly to a physiotherapist. This decisive step was taken in August 1976, and many precedents are being set during this early stage: each is being examined with great care’.?.

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ANNOTATIONS

While physiotherapists may accept patients without medical referral, they are encouraged to work in close liaison with the medical practitioner. Their professional integrity dictates that they accept only those patients whom they feel competent to diagnose and treat: if further medical advice is needed they must accept the need for it.

This change in referral system was made only after many negotiations, discussions and some heart-searching: it is still in its infancy and only time will tell what effect the change has had on patient care. In effect, as yet little change seems to have occurred in the manner of referral : most patients still consult their doctor first, and very few are first referrals.

In the United Kingdom, the physiotherapists’ code of practice states that ‘No physio- therapist should treat a patient unless that patient has been referred to him by a registered medical practitioner or dental practitioner except in an emergency or unless he has direct access to the patient’s doctor’.

The training of the physiotherapist has changed enormously over the years, and although a greater range of theoretical subjects is now being taught, great emphasis is still given to clinical training; i.e. how to assess carefully and to select and execute the treatment appro- priate to the condition. Much greater importance is now attached to post-qualification training, and one has only to compare the physiotherapy journals of today with those of ten years ago to see the greatly increased opportunities for physiotherapists to further their knowledge and to specialise.

In the United Kingdom, the reorganisation of the National Health Service has modified the concept of the hospital and the ‘outside world’ as being two separate entities. This has resulted in the bringing together of experts from all branches of medicine, and the provision of a truly National Health Service is gradually progressing towards reality. Increased attention is now given to the community and its health problems, and, perhaps most importantly, to the prevention of such problems.

In the same way, the r61e of the physiotherapist has changed, in that greater emphasis is now placed on community care : the physiotherapist plays an important part in prevention, early diagnosis and treatment, and there is growing awareness of the need for the patient to be treated as an individual and in his own home. It is perhaps in this area that physiotherapists in Britain feel most hampered by their present code of ethics. More and more physiothera- pists are being appointed to these newly devised posts in the community, but however expert and enthusiastic they may be they are still required to consult a medical practitioner before prescribing prophylactic treatment.

I t is not unknown for a physiotherapist to disagree with the medical practitioner and to feel that the treatment he has prescribed is contra-indicated. Until recently there has been little the physiotherapist could do about this situation, but in September 1977 the Depart- ment of Health and Social Security issued a circular3 which stated: ‘In asking for treatment from a therapist, the doctor is clearly asking for the help of another trained professional and the profession of medicine and various therapies differ. It follows from this that the therapist has a duty and consequential right to decline to perform any therapy which his professional training and expertise suggests is harmful to the patient’. Recommendations are also given that ‘the therapist should discontinue the therapy and discuss the needs of the patient if it becomes apparent to the therapist that inappropriate treatment is being given. They should also decide the nature of the treatment and advise on curtailment or pro- longation of treatment if they consider this necessary’.

This is a step forward, but it is still a long way behind our Australian colleagues. It is to be hoped that much thought will be given to this change in the Australian ethical code by

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DEVELOPMENTAL hlEDICINE AND CHILD NEUROLOGY. 1978, 20

those responsible for the training of physiotherapists and by the council of the Chartered Society of Physiotherapists. The questions they must ask themselves are:

(1) Does the training syllabus include enough training in the assessment of disability and in planning correction and treatment ? (2) With the new career structure (Halsbury) now over its teething problems, is it not recognised that specialisation is acceptable ? (3) Is there sufficient knowledge among members of the medical profession about the r6le of the physiotherapist? (4) Are physiotherapists now, as a profession, mature enough to accept the responsibili- ties which the change in the code of ethics would place upon them ?

When the answer to these (and other) questions is 'yes', then we may be able to go along \\ith our Australian colleagues. I f the answer to even one of these questions is 'no', then we still have a great deal of professional heart-searching to do.

Medical Advisory Unit, Martindale Road, Hounslow TW4 7HE.

JEAN BIDDLE

REFERENCES I . Galley, P. ( 1977) 'Physiotherapy as first contact practitioners.' Physiotherapj. 63,246-248. 2. Whitehouse, J . (1977) 'Advance Australia Fair.' Physiotherapy, 63, 245. (Editorial.) 3 . Department of Health and Social Security (1977) Health Service Developtitent: Relationship Between the

Medicaland Retnedial Professions. London: H.M.S.O.

SPEECH AND LANGUAGE DEVELOPMENT OF CHILDREN WlTH DOWN'S SYNDROME

THE language development of the child with Down's syndrome often seems disappointing. Just as the over-all developmental quotient of these children is relatively high in the first year' but fails to maintain its promise in the second and third years, so it is often only at the end of the 'babbling' stage that their communication falls behind2. Their language develop- ment is very variable-the appearance of the first words ranging from I2 months to six years. The average age at which these children start to use words is 30 months, and most can use phrases by five years3.

LENNEBERG and colleagues4 made a three-year study of 61 Down's syndrome patients aged from three to 22 years, who were living at home. They found that it was not IQ which best predicted language development, but chronological age and the passing of particular motor milestones. On verbal imitation tests, these children performed like younger normal children. LENNEBERG concluded that they were slower in maturational development and thus slower in acquiring language; they were arrested at a primitive but normal stage of language development, and did not show deviant language behaviour.

I t is often said about mental retardation that the developmental processes are the same as in normal children but that they proceed at a slower rate. Broadly speaking, the language of a child with Down's syndrome follows the same developmental pattern as for normal children. During the first year the vocalisations of Down's and normal infants do not dieer, and in early childhood the grammar of the Down's child is very general and non- specific : i.e. they develop language functions in the same sequence as ordinary children, although there is an increasing lag in achieving major developmental landmarks. A Down's child at 2+ years is unlikely to understand passive or negative sentences or negative/passive

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