|
|
Treatment ideas for adult ataxia
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Treatment ideas for adult ataxia - November 20, 2001 7:48:00 AM
|
|
|
DS
Posts: 3
Joined: September 10, 2001
Status: offline
|
I was wondering if anyone has any experience with adult ataxia. My client is 22 years old suffering from a brain injury from an MVA at 16 years old. He falls frequently and only has use of his left upper exremity due to spasticity in his right. I would welcome and treatment ideas or sources that might help me. Thanks.
PS I have some good treatment ideas on the ball for pediatrics but he is too big to put on a ball.
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 4, 2001 2:12:00 AM
|
|
|
Hirsch
Posts: 43
Joined: October 16, 2000
From: Germany
Status: offline
|
Hi DS: there actually is very little evidence based medicine for ataxia treatment. But what would your goal be by putting someone (child or adult) on a ball? Don't patients need to have better balance/postural control sitting in a chair, standing and walking? How does training on a ball transfer to these environments?
OK, specific treatment ideas for your patient (remember I have not seen your patient in the flesh so take it with a grain of salt ok). I did a liottle literature search just to show you how easy it is to find resources on the web i did a quick literature search on Medline
[URL=http://www.ncbi.nlm.nih.gov/PubMed/]http://www.ncbi.nlm.nih.gov/PubMed/[/URL]
using Ataxia and Neurological rehabilitation as key words.
The one I did took about 60 seconds and yielded roughly 60 articles. Here are two:
1: Fortschr Neurol Psychiatr 1989 Feb;57(2):74-80 Related Articles, Books, LinkOut
[Posturographic biofeedback training in equilibrium disorders.]
[Article in German]
Jobst U.
Ostertal-Klinik St. Wendel.
In addition to the usual physical training for treatment of ataxia, individually adaptable biofeedback training programs by means of a stationary posturographic platform and feedback via the screen of a connected microcomputer were developed, including not only static, but especially dynamic exercises. Through an open randomised study of 72 patients with ataxia of cerebellar, brainstem and vestibular origin the effect of this training was examined by analysing the training courses parameters, which were compared with the courses of 10 normal subjects, and by the patient and the physician rating the unsteadiness of stance and gait under everyday's conditions. In particular, a significant improvement of the common function could be shown at the biofeedback training group in comparison to the group only with physical training. It is therefore concluded, that this--highly accepted--training may be a valuable tool in neurological rehabilitation of atactic patients.
so biofeedback using a force-platform seems to do something positive for these patients...then it gets discouraging:
1: J Rehabil Res Dev 1999 Jul;36(3):183-8 Related Articles, Books, LinkOut
Gait characteristics of individuals with multiple sclerosis before and after a 6-month aerobic training program.
Rodgers MM, Mulcare JA, King DL, Mathews T, Gupta SC, Glaser RM.
Department of Physical Therapy, University of Maryland School of Medicine, Baltimore 21201, USA. mrodgers@maryland.edu
Individuals who have multiple sclerosis (MS) typically experience problems with physical activities such as walking, resulting from the combined effects of skeletal muscle weakness, sensory disturbances, spasticity, gait ataxia, and reduction in aerobic capacity. The aim of this study was to determine whether a 6-mo exercise program designed for aerobic conditioning might also affect gait abnormalities in individuals with MS. Subjects included 18 individuals with MS who presented a range of disability. Passive range of motion (PROM) in the lower limbs was measured and gait analyzed before and after exercise conditioning. Three-dimensional kinematics, ground reaction forces (GRF), and electromyographic information were acquired as subjects walked at self-selected velocities. Hip PROM increased following conditioning. Mean walking velocity, cadence, and posterior shear GRF (push-off force) decreased. During walking, maximum ankle dorsiflexion decreased and ankle plantarflexion increased. Total knee flexion/extension range during the walking cycle decreased slightly as did maximum hip extension.
Results suggest this 6-mo training program had minimal effect on gait abnormalities.
So you may want to try a similar literature search to get more detailed information. Since you mentioned your patient has a spastic hand, I would suggest the following:
1. Forced-use, constraint induced therapy or repetitive training for the hand for his impaired, spastic hand. If you dont know what any of these are I can give you some literature sources..or just do a medline search on forced-use and ataxia or forced use and dystonia...i dont think there will be anything on FU and ataxia, but since there is so little research on ataxia and PT you could try FU experimentally with your ataxia patient...no harm done.
2. As far as the balance goes (good luck)...check the German abstract for ideas...you dont need to have posturography...foam and dome may do as well...id also try to put him on a treadmill with partial body weight support harness to practice walking at different unpredictable speeds. Hope this helps some. Mark Hirsch
[This message has been edited by Hirsch (edited December 04, 2001).]
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 4, 2001 3:07:00 AM
|
|
|
Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
Status: offline
|
I'd also add the Schindal and Hesse study published in Arch of PM&R to the mix. They got almost supernatural results using a PWBTT system (www.litegait.com).
Drew
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 4, 2001 3:34:00 AM
|
|
|
Hirsch
Posts: 43
Joined: October 16, 2000
From: Germany
Status: offline
|
Hi Drew, you know, I know Hesse personally. I was in his lab a few weeks ago.
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 4, 2001 4:50:00 PM
|
|
|
DS
Posts: 3
Joined: September 10, 2001
Status: offline
|
Hi Mark,
Thanks for the information. I have actually done searches and found the info. you gave me. I was really wondering if anyone had any new techniques up their sleeves that had worked for them(at least somewhat).
I went to Barbara Hype's course on Treatment of the Neurologic Child and she does alot of ball work. She demonstratd use of the ball with several different diagnoses, one being ataxia. One of the main ideas while treating a child with ataxia on the ball was about weight shifting on a stable and a mobile surface and its importance in balance. Also, the significance of extension and flexion with rotation for balance are greatly considered and easily achieved on the ball. She also went into components of balance and posture(righting reactions, protective reactions, tilting reactions, etc. etc.) and how they easily translate from the ball to the ground.
If you are interested in details of the above subjects, I'd be more than happy to write more. I just wanted to explain her rationale and my belief in it a little to answer your question.
Thanks again for your response.
DS
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 4, 2001 6:24:00 PM
|
|
|
Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
Status: offline
|
Wow!! That's pretty cool! I'm a total Hesse groupie . . . A Hessie so to speak.
My friend Ginny Paleg went over to see his lab a few months ago. I've not yet gone.
Drew
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 6, 2001 4:37:00 AM
|
|
|
Hirsch
Posts: 43
Joined: October 16, 2000
From: Germany
Status: offline
|
DS, thanks for responding. I read your post carefully and I know this is going to sound like I am repeating myself but there is no scientific evidence that working on a ball translates to sitting, standing or actually walking. So basically, if you use this approach in your clinic it may or may not "work". I tend to believbe that it is a total waste of time and money to do ball exercises because it is too abstract for the patients central nervous system to learn to transfer what it has learned during the "ball experience" to the sitting, standing or walking experience (without the ball there to help). So...if you can dig up studies showing that ball training is beneficial for function in ataxia, I'd be less skeptical and I'd say, go ahead and try what they (in their study) tried...ure pretty safe it might work with your patient...
I'm pretty skeptical when it comes to "authoritative opinions" and case studies without greater scientific evidence. The course you attended....was there any mention of literature (other than Books or review papers) actually showing the benefit and tranferabiulity of ball training for children with a variety of disabling conditions?
I would go with the recommendations I gave in my earlier post (although thats also only an opinion -- but at least forced use and biofeedback are techniques rooted in scientific evidence AND personal experience), and not with Ball Gymnastics. But, if you have time and money, and your patient is motivated to work with a ball, then you could offer your patient ALL (or as many as possible) treatments (FU, biofeedback, Ball etc) and if you get a long-lasting efect -- GREAT! You just wont know what did the trick, but thats ok too isnt it? I hope my comments do not offend you. Of course I appreciate the value of clinical experience in neurological rehabilitation, but I would be very skeptical if an authority tells me something works or doesnt and shows a few "best case" patients without proper scientific evidence. I know this will open a can of worms, but if I show you, say, 10 out of 100 patients for whom the Ball treatment worked, would u use the treatment or would u say the 10 improved due to chance alone...i.e. it just happened to happen that way by chance alone, which one might expect if one were to treat 100 patients with the ball and 10 do well enough to be shown in a video during a workshop or conference preseantation or your five star patients demonstrate the (short term)benefits of therapy X.
I understand that you "believe" Mrs. Hype's opinion on postural reflexes, and how eliciting them on a ball will transfer to other environments (admirable - wishful - positive thinking, not rooted in scientific evidence). I'll shut up now. Mark
[This message has been edited by Hirsch (edited December 06, 2001).]
[This message has been edited by Hirsch (edited December 06, 2001).]
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 7, 2001 4:42:00 AM
|
|
|
gerry
Posts: 235
Joined: July 6, 1999
From: Montgomery, AL, USA
Status: online
|
Thanks Bobcat. I have been telling PT students that there is no majic in a therapy ball for a long time. It is a tool that can be useful to elicit muscle activity, entertain to keep a child focused, and many other things. The ball in itself is not the treatment modality, at least in how I use it.
You said it very well.
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 8, 2001 7:15:00 PM
|
|
|
walker852
Posts: 1
Joined: December 8, 2001
Status: offline
|
What suggestions do you have for a home setting? I do home health PT, and have a patient w/severe LE ataxia w/all weight bearing; good strength UE/LE's; poor dynamic balance; amb. w/rolling walker. She is approx. 55 y/o.
Any tips for treatment would be appreciated!!
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 10, 2001 4:38:00 AM
|
|
|
Hirsch
Posts: 43
Joined: October 16, 2000
From: Germany
Status: offline
|
Guru Bobcat,
FYI, Political correctness is a waste of time, IMHO. Nothing I say in this or other posts regarding DS's question was meant to be rhetorical. Why not ask me if it was menat to be rhetorical instead of telling me?
I appreciate you taking the time to give me your opinion on ball exercises. I meant no disrespect by referring to therapeutic ball exercises as "ball gymnastics".
My point is still: is there any -- scientific -- evidence from studies that working with a "ball, or a cycle, or a loop suspended at the end of a sling" actually improves function in persons with ataxia?
Your logic is appealing on an intuitive level, but since it's an opinion based on years of clinical experience -- I respect that! -- I'm even more skeptical now because there's apparently no hard evidence (other than your opinion/theory) that working with a ball either as a diagnostic or as a "therapeutic" tool improves short or long term function in persons living with ataxia. One or two studies wouldnt be enough to make me a believer anyway. At least we have your statement claiming that/how ball exercises might affect function and your challenge to present/future generations of PT's to find out.
My original intent in responding to DS's original querry was to encourage DS to experiement with therapeutic modalities allready validated scientifically (forced-use and biofeedback using foam or a movable platform being two I suggested), conduct a literature search on medline which she said she allready did -- and NOT bow to another opinion...mine or even from the allmighty Guru Bobcat.
If you re-read my original post you'll see that there are a few studies that have looked at PT for ataxia but working with a ball has not been looked at (at least it didnt come up on a MEDLINE search). So now we have your opinion, my opinion, and the opinion of other Rehabedge members to help DS. But ultimately DS will have to make his/her own experiences, and hopefully will not become another physical therapy foot soldier.
"evidence-based research is not necessary [in this case] because the mechanical principles combined with principles of control systems is adequate, because the cause-effect relationship between use of a ball, or some object, and improvement in motor control and function, is not occult, subdued or obscure"
Are you serious, Guru Bobcat? Help! Translation please!
Guru Mark has a different point of view. You may think something is cause-and-effect but you won't know that with certainty until you put the therapy (and your opinion/theory) to the test of science and I dont see any science on ball exercises for the treatment of ataxia, so you might as well be doing anything that sounds logical, or nothing at all, or let the patient decide on the mode of therapy...so as far as I'm concerned, it may be the ball thats helping or it may be any number of variables and a well-educated "guess-therory" backed by years of clinical experience just doesn't cut it with me anymore without, at least, one or two well designed randomized trials, and neither should it for DS.
You know as well as I do that EBM is necessary to validate the use of therapeutic modalities, especially ones which are used so often in daily practice such as a ball or cane or brace. Dare I say, more EBM is necessary to validate the entire field of neurological rehabilitation, including Physical Therapy, Chiropractic care and most surgical and medical procedures? Burn me at the stake!
Back to the Ball:
"But getting back to the ball...to test the effectiveness -- simply establish a targeting pattern on the floor with tape, or on the wall as with a dartboard pattern. Test the accuracy of foot placement with some functional task before use of the ball, or whichever device selected, then test afterwards"
A test...Thats a great idea. The test should be repeatable and have ecological validity too. Why not test in the persons actual environment...like out on the street in front of the clinic. It's not enough to recreate an abstract environment in an artificuial laboratory setting (like a PT facility).
"The critical need for balance for standing and walking is dependent upon the control of the axis or column of the somatic mechanism which for upright locomoting chordates is the spine."
Textbook?
Visual, vestibular and proprioceptive mechanisms are critical as well.
"Once on the ball, it is possible to determine if the axis is having a difficult time both sensing and responding to changes in perfect upright alignment with gravitation and if its response, righting and recovery motor patterns are normal, abnormal, poorly coordinated dominated by synergy or some otherwise masked perceptual impetus which does not emerge except during single leg stance."
It sounds good. Bobcat, there is no well documented evidence that working on or with a ball transfers to walking, standing, sitting, or any other functional movement. Unless there is well documaented evidence that postural control diagnostic tests on a ball tell you something meaningful about a persons postural control mechanisms/behavior while standing and/or walking it is a waste of time for the therapist to be doing this, unless it is for research purposes or personal inquisitiveness and the client has been informed about this experiment.
"The answer would be that to just sit in a chair most people don't have to have any balance at all. "
Guru Bobcat has THE ANSWER! I meant people living with ataxia and not "most people". People with Parkinson's disease or following stroke have difficulty with sitting balance. I'm not sure what you mean here, anyway, and I just dont have enough time right now to list the sources of evidence showing that you are mistaken about sitting balance. Perhaps I meant equlibrium and postural control and used the term balance rather loosely...Anyway, Peace and look forward to your response.
Mark Hirsch
[This message has been edited by Hirsch (edited December 10, 2001).]
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 10, 2001 10:25:00 PM
|
|
|
Hirsch
Posts: 43
Joined: October 16, 2000
From: Germany
Status: offline
|
Hi Bobcat,
I really appreciate the efforts and time you have put into responding and I think this is an interesting conversation.
I also see -- from reading your post -- that I dont think I have been communicating very effectively my message to you. Are we on different planets...luckily in the same star system! I hope this does not sound patronizing but, research is not meant to PROVE anything, it never will PROVE anything and it never has PROVEN anything. To say that research or science proves this or that is a misconception about the purpose that science serves in clinical neurosciences.
Putting someone on a ball and observing if they fall or not fall isn't an accurate method as a diagnostic tool, and if you say it 1000 times, it doesnt make it any more accurate and it doesnt justify using it any more because you are giving your biased, subjective opinion and the Bobcat ball--diagnostic-method has not been subjected to the test of science, which doesn't set out to prove anything, as I have tried to point out to you above, but, assists clinicians make informed decisions by minimizing uncertainty based on the likelihood of a future event occuring or not occuring.
"there is plenty of evidence that practicing a motor task repetitively with feedback correction does improve performance of the motor task"
Translation: practice on the ball and you improve motor performance while ON THE BALL.
"As for how the ball can be useful for treatment, the simple response is as a means for training. It's as straightforward as: If one is not good at kicking a soccer ball, you practice kicking the soccer ball. A good coach helps, but repetition with error correction as with all motor learning is the basis. With the ball, the objective is to improve balance. To get good at staying on the ball, the mechanism must develop strategies to control the trunk in a coordinated manner to stay on the ball. Such strategies directly influence gait in training the trunk to acquire a motor pattern which can balance the trunk on a mobile pelvis without excessive shoulder sway, or trunk rigidity (once the trunk as acquired the ability to accomodate for perturbation on the ball)."
Right, Bobcat, to walk you need to practice WALKING -- alot of it -- with error correction, specificity and intensity and motivation are what count here, not lying face down on a mat and doing PNF...not sitting and practicing leg extension and ankle plantarflexion, not sitting on a ball because its not walking; although sitting on a ball will improve a patients ability to sit on the ball which would make any therapists heart beat faster because now we actually see that therapy with a ball improves motor control ON THE BALL.
Unless you can cite 2-3 well designed studies showing ball therapy transfers to gait and I can then check your references and find it believable, thats still your opinion.
"A research study could be done, as I suggested, but it would not be terribly useful, because the results are easily observable and reproducible. "
opinion. You won't "know" that unless you subject your theory to the test of science. And then you still wont "know" it but you'd be able to be less uncertain.
I'll stop tearing every little statement apart now, because I think I've made my point.
Using the ball as a diagnostic tool is not reliable for the same reasons (even an eloquent explanation wont make it more reliable) and you still have not convinced me it is a valid test of balance for any population. As to the use of a ball for therapy....I cant see any reason to use it and I cant see any reason not to use it so I'm still skeptical and curious -- which is good because those are the marks of a budding neuroscientist and they could be the hallmark of many therapists. But if therapists follow what the Gurus say, they become footsoldiers, and thats what happens, in my opinion, when you, Bobcat, give an opinion without backing it up with any clinical research data.
My view is that nothing (or very litttle) usefull is "learned" or retained by the CNS as the patient "experiences" the ball and little of this will transfer to the real world where people generally do not sit on balls - except for in the circus!
Finally, It's not the ball I care about actually. What I am after is that therapists stop following hear-say, opinions about what works and what doesn't, and start paying more attention to the contribution clinical neuroscience makes to motor learning and motor control and decisions to use/not use a certain tool, be it a ball, crutch, sling, foam, rubberband or whatever. They need to THINK. Listening to a Gurus recommendation does not help them think critically.
I think RehabEdge is an excellent tool for that.
[This message has been edited by Hirsch (edited December 11, 2001).]
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 11, 2001 11:22:00 AM
|
|
|
Diane
Posts: 1491
Joined: March 9, 2001
From: Vancouver, B.C., Canada
Status: offline
|
This discussion made me think of an interesting article that was mentioned on another discussion forum thread ("Control of instability: the nervous system can learn from experience" on Noigroup.com)
The article cited was "The Central Nervous System Stabilizes Unstable Dynamics by Learning Optimal Impedance" from Nature 414, 446-449, by Burdet E et al, 2001. I found it with google.
Maybe lateral thinking could engage here, re: balls and so on.
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 12, 2001 12:36:00 AM
|
|
|
Mark Hirsch
Posts: 101
Joined: December 11, 2001
From: USA
Status: offline
|
Bobcat,
I'm saying, yes training has the potential to improve motor skills, short and long term.
Working on the ball transfers to skilled movement on the ball.
Do you think -- give me your opinion -- therapy in sitting helps a person with ataxia walk? Research from stroke rehabilitation suggests there is little or no tranfer of skills learned on a mat, sitting, lying prone or supine or standing --to functional improvements in walking.
I can't understand question #1...so I cant answer it. Would you rephrase it for me?
"2. Would you happen to know what aspects of gait -- as it affects the pelvis and the spine -- are similar to aspects of the task of maintaining upright trunk stability on a semi-rigid ball?"
Bobcat, I see where you are going with this question. My thought is that walking and sitting have some similar neural and musculoskeletal components but that does not mean that practicing sitting -- even practicing components of walking in a sitting or supine or prone position -- will have ANY carryover effect on walking in ataxia. Is that were you and I are on different planets? Do you think there is noticeable and longterm carryover from therapy in sitting to walking in ataxia?
Diane, thanks for the reference. I read the article and I'm not sure how the article is relevant to this discussion...help please! Mark
[This message has been edited by Mark Hirsch (edited December 12, 2001).]
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 12, 2001 2:19:00 AM
|
|
|
Mark Hirsch
Posts: 101
Joined: December 11, 2001
From: USA
Status: offline
|
Bobcat,
I just thought of something. I recently read that Hippotherapy improved walking in children with CP. Now how do you explain that?
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 12, 2001 3:21:00 AM
|
|
|
Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
Status: offline
|
Mark,
That has to do with CPG's in the spinal cord. Hippotherapy works in very much the same manner as PWB-TT.
Drew
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 12, 2001 4:33:00 AM
|
|
|
Mark Hirsch
Posts: 101
Joined: December 11, 2001
From: USA
Status: offline
|
Maybe I'm somewhat confused here...Hippotherapy takes place on a horse, right? So the patient is NOT walking during therapy, right? Maybe I'm missing something here.
[QUOTE]Originally posted by Andrew M. Ball MS MBA PT:
Mark,
That has to do with CPG's in the spinal cord. Hippotherapy works in very much the same manner as PWB-TT.
Drew[/QUOTE]
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 12, 2001 5:48:00 AM
|
|
|
Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
Status: offline
|
Mark,
What a great question. I think many pediatric PT's have missed the specifics of this issue. At least that's often a feeling that I get when I teach on this subject at continuing education courses.
That's true, they are not walking, but the body is facilitated through the same trunk movements/balance responses, and CPG reflexes that occur during independent ambulation.
A VERY GOOD article that may clear this issue up for you is:
Haehl, Victoria, Carol Giuliani, and Cynthia Lewis. Influence of Hippotheray on the Kinematics and Functional Performance of Two Children with Cerebral Palsy. Pediatric Physical Therapy 1999; 11: 89-101.
Let me know if you'd like a faxed copy, or contact Dr. Hael directly at vhaehl@indiana.edu.
The following is a GROSS oversimplification, but it goes like this . . . Due the anatomy of the horse, the child is basically on a slight downward slope, this helps the child sit upright due to anterior balance reactions of the trunk. This effect occurs before the horse moves at all. (This is a static reflex, having nothing to do with CPG's)
When the horse takes a step and the right hindquarter rises, the child must execute a reflexive equilibrium reaction in order to maintain balance (concave to the right, weigh bearing and trunk lengthening on the left). As the horse takes a step and the left hidquarter rises, the contralateral equilibrium reaction occurs. The rhythmical stimulation of these alterating balance reactions constitutes simulation of CPG's in the spinal cord.
This is essentially a more developed, hyper-efficient form of NDT, because NDT tends to produce a less of a fluid alternation between reactions and doesn't tap into CPG's. Furthermore, using hippotherapy, you can get thousands of very fluid reactions during a 60 minute session. Handling techniques simply don't allow as high a frequency of stimulation.
It has been argued that PWB-TT works in a similar manner in that by placing the child over the treadmill and holding them at the pelvis, the same alterntating equilibrium reactions can be produced --- and by extention, similar CPG stimulation is achieved.
[This message has been edited by Andrew M. Ball MS MBA PT (edited December 12, 2001).]
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 12, 2001 7:03:00 AM
|
|
|
Mark Hirsch
Posts: 101
Joined: December 11, 2001
From: USA
Status: offline
|
Thanks Drew, unfortunately, her email address doesnt work for some reason...do you think you can email me a copy? I'll try to find out our fax number here if that doesnt work. Thanks. Mark
|
|
|
|
|
Re: Treatment ideas for adult ataxia - December 12, 2001 7:35:00 AM
|
|
|
Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
Status: offline
|
Sure. Send me your fax number to my e-mail address Andrew.Ball@ncmail.net. I'm going to see Vicky in late February in Boston. If you have further questions for her, I'll try to track her down then.
Drew
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.156
|
Printable Version
