Assessment & Intervention
Physiotherapy interventions for gross motor skills in people with an intellectual disability aged 6 years and over; a systematic review
Presenter: Mrs Judith Hocking
Authors: 1J. Hocking, 2J. McNeil, 2J. Campbell
Background: People with an intellectual disability (ID) may require specific therapeutic approaches to accommodate their cognitive and learning needs. People with an ID who suffer from GMS deficits can benefit from physiotherapy to help improve their GMSs. There is a lack of physiotherapy research for gross motor skills (GMSs) in people with an ID, and no prior systematic review.
Aim: The systematic review was undertaken to investigate the effectiveness of physiotherapy interventions for improving GMSs in people with an ID aged 6 years and older.
Methods: Data sources were PubMed, CINAHL, Embase, and ProQuest. Reference lists of relevant identified articles were also hand searched. Papers published in English from 1 January 2008 to 22 October 2014 were considered for inclusion.
Overall, 887 potential articles were identified, of which 42 were retrieved for full-text review, and seven were finally included. Critical appraisal was independently conducted by two reviewers using the Joanna Briggs Institute appraisal checklists; no articles were excluded following critical appraisal. Data extraction was performed using Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument data extraction instruments.
Results: High heterogeneity between the studies precluded meta-analysis of the results; a narrative synthesis was completed instead. Two RCTs, two pseudo-RCTs, two repeated measures studies, and one case report were included. Significant improvements were reported for cadence and nondimensionalized gait velocity following body-weight-supported gait training; cadence following lower limb strengthening exercises; and the Gross Motor Function Measure-88 measures following adapted judo training. These results suggest that task-specific training may be useful.
Discussion: The evidence identified by this systematic review supporting physiotherapy for improving GMSs in people with an ID was limited because of the low quality of studies. Given the current paucity of evidence, a future systematic review which sought to identify evidence regarding interventions used by a range of health and education professionals for improving GMSs in people with an intellectual disability, could provide a broader evidence base for clinical interventions which may be utilized by physiotherapists.
Conclusion: There is limited evidence to suggest that task-specific training is a useful physiotherapy approach to improving GMSs in people with an ID.
Improving assessment and early management of psychosocial risks in pain-related work injuries
Presenter: Ms Margaret Swincer
Authors: 1, 2R.Stratil, 1,3M. Swincer, 3T. Winefield
1Radek Stratil Consulting Psychologist
3University of South Australia, SA, Australia
Introduction/background: The negative impact of chronic pain-related work injury on costs, quality of life, work productivity and poor health outcomes is well documented. Recent evidence highlighted the role of psychosocial issues in the transition from acute injury to chronic disability.
Aim/objective: Firstly, to develop a risk assessment strategy to assist clinicians identify and manage key psychosocial risk issues in work injuries. Secondly to assess the accuracy of clinical judgment compared to using brief risk screening questionnaires in identifying individuals with increased risk of developing chronic pain.
Method: Over 3000 workers on the ReturnToWorkSA database with a recent primary back, shoulder or knee injury with incapacity for work at two weeks post injury were mailed psychometric questionnaires and invited to participate. This multi-phase prospective study was approved by the University of South Australia Human Research Ethics Committee. The participants were followed for more than one year since injury using ‘gold standard’ methods and instruments to identify risk factors for delayed return to function including work. Data included: relevant demographics; qualitative information about the injury, their job and workplace; and pain-related psychosocial questionnaires covering pain intensity, fear and avoidance beliefs, catastrophising, pain self-efficacy, negative mood and perceived disability. Participants and primary treating clinicians (medical and physiotherapy) provided additional qualitative information about the injury and their treatment.
Results: Prediction analysis of the 1400 responses identified that high self-perceived disability, low self-efficacy, excessive pain focus and catastrophising, beliefs about negative prognosis and fears of re-injury, high pain intensity and quality, prominent impact of negative mood and psychological distress predicted the likelihood of a disability outcome at six months. Qualitative analysis highlighted the support of the workplace supervisor and physiotherapists promoting self-management and reducing fears of re-injury during recovery.
Discussion and conclusions: This prospective study provided normative data about the key psychosocial risk assessment instruments within the Australian work injury domain. It highlighted the inaccuracy of clinical judgement compared to psychometric tools in predicting future disability. The results informed the development of a guide for optimal management by clinicians who are best placed to identify and manage psychosocial risks to prevent chronic pain disability
How much do patients walk in the first week after lumbar spinal surgery?
Presenter: Mrs Sarah Gilmore
Authors:1S. Gilmore,2J. McClelland,2M.Davidson,2A. Hahne
1St Vincent's Private Hospital, Melbourne
2La Trobe University, Victoria.
Background: Physiotherapists are routinely involved in patient care after lumbar spinal surgery. Post-operative physiotherapy typically focuses on achieving independent mobility and commencing a regular walking program, however advice about walking programs and returning to activity following lumbar surgery is highly variable. Little is known about how much patients walk, or should aim to walk in the immediate post-operative period.
This research aimed to establish the typical activity patterns of patients over the first six days after lumbar spinal surgery.
Methods: Patients admitted to St Vincent’s Private Hospital Melbourne for lumbar spinal surgery between April and November 2016 were invited to participate. Participants wore an ActivPAL3 accelerometer for the first six post-operative days, that recorded a daily step count and the time spent in active (standing and walking) and sedentary (sitting and lying) positions.
Results: A total of 249 participants were recruited. Thirty-three participants were excluded due to faulty or lost monitors, or inaccurate or short recordings. Of the 216 included participants, the mean age was 61 years (SD 13.85) and 51% were female. Forty one percent of participants had lumbar disc surgery, 32% had a lumbar fusion and 27% had a lumbar decompression.
Over the six-day period, a mean 87% of participant time was spent sedentary, 10% standing, and 3% walking. On the first post-operative day 1% of participant time was spent walking with a mean step count of 1141 steps (SD 1404). These figures gradually increased to 4% of time spent walking on day six, with a mean step count of 3823 steps (SD 2950).
Conclusion: As lumbar surgery directly affects the ability to perform active tasks such as walking, these results were as expected with low activity levels that gradually increased over the week. The data gathered in this research will now be used to determine whether the amount of walking patients do early after lumbar surgery has an impact on longer term recovery and quality of life. This will determine the importance of walking and physical activity in early post-operative multi-disciplinary rehabilitation programs, and inform the development of evidence based post-operative protocols.
The effectiveness of Biomechanical Taping Technique on visual analogue scale, static maximum handgrip strength, and Patient Rated Tennis Elbow Evaluation of patients with lateral epicondylalgia: A Cross-Over Study
Presenter: Dr Valentin Dones
Authors: 1VCIII. Dones, 1MA. Serra, 1PJ. De Jesus, 1LM. De Ocampo, 1AC Jr. Esteban, 1RJIII. Francisco, 1GOIII. Kamus, 1AM. Mercado, 1RG. Rivera, 1AC. Vergara
1Center for Health Research and Movement Science, College of Rehabilitation Sciences, University of Santo Tomas
Introduction: Lateral epicondylalgia (LE) is a musculoskeletal injury involving the common extensor origin in elbow manifesting as pain and ineffective handgrip affecting the daily activities of individuals with LE.
Objectives: This study determined the effectiveness of Biomechanical Taping Technique (BMT) on pain, grip strength and daily functions of individual with unilateral LE.
Methods: A cross-over study design was used. The senior investigator applied three BMT techniques namely: a. Standard Biomechanical Taping for muscles (SBMT), b. Vector Correcting Dysfunction Technique 1 (VCDT 1), and c. Vector Correcting Dysfunction Technique 2 (VCDT 2). On Day 1, SBMT and VCDT1 were randomly assigned. On Day 3, either SBMT or VCDT1 not performed on Day 1 was applied on LE elbows. On Day 5, VCDT2 was applied on LE elbows. Visual Analogue Scale (VAS), Static Maximum Handgrip Test strength (SMHGT) and Patient-Rated Tennis Elbow Evaluation (PRTEE) were used as outcome measures administered by three blinded junior investigators. On Days 1, 3, and 5, VAS and SMGHT were administered before and during BMT application. PRTEE was administered on Days 1 and 12.
Results: The following were found in this study: a. significantly decreased VAS scores at Days 1, 3, and 5 of BMT application (p<0.05); b. significantly improved final VAS, SMHGT strength and PRTEE scores on Day 12 compared to baseline scores on Day 1 (p=/<0.01); and c. significantly decreased VAS scores when using SBMT compared to VCDT2 (p<0.05).
Discussion: BMT can be used as an adjunct treatment to physiotherapy. During handgrip, BMT may decrease lateral elbow pain. The authors recommend maximum of 3 hours of BMT application with a day of no tape in between days of BMT application, ensuring skin integrity during and after BMT application.
Conclusion: BMT is a novel taping technique effective in decreasing lateral elbow pain, increasing handgrip strength and improving function of patients with LE. The BMT skin tape through its elasticity may be effective in increasing slide in between fascia and muscle. The BMT fascia tape through skin-fascia lift may be effective in holding the hypoechogenicity in the CEO.
Clinical Practice Guidelines
Developing clinical practice guidelines for low-to-middle income countries: methods, experiences and lesson learnt in adapting, adopting or contextualising existing CPGs
Presenter: Mr Michael McCall
Authors: 1M. McCaul, 2B. de Waal, 3P. Hodkinson, 3J. Pigoga, 1T. Young, 3,4L. Wallis
1Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Stellenbosch University
2Department of Emergency Medical Sciences, Cape Peninsula University of Technology
3Division of Emergency Medicine, University of Cape Town
4Division of Emergency Medicine, Stellenbosch University
Background: Methods around developing de novo (new) clinical practice guidelines (CPGs) are well established with numerous guides, tools, resources and examples. With the growing number of existing CPGs and taking account of resource implications for de novo development, resource-limited settings need alternative methods to de novo CPG development. Using existing high quality CPGs to make recommendations relevant to local contexts through adopting, adapting or contextualising are such alternatives. However, limited examples exist showcasing the pragmatic application of this approach in settings where time and budget constraints are a real issue.
Objectives: To develop contextually appropriate, evidence-informed CPGs for pre-hospital emergency care providers in South Africa using alternative guideline development methods.
About the project: Following engagement with an expert panel to identify key questions, we searched for and appraised existing CPGs. A process of adapting, adopting or contextualising existing CPGs was used to develop the South African guideline.
Our experience and learning points: The final guideline included more than 270 CPGs culminating in over a 1000 recommendations for pre-hospital care. Challenges experienced included the lack of guidelines applicable to the African setting, issues in evidence synthesis, poor quality of some guidelines and heterogeneous level of evidence classifications. Learning points included focusing on key CPGs, clear knowledge translation strategies and stakeholder engagement. Key successes included easy and specific searching strategies, logical evidence mapping leading to easier content management and using an accessible online platform to incorporate expert panel and advisory board feedback.
Conclusions: Re-inventing the wheel by using de novo methods to produce CPGs is not always an option. Alternative methods exist that are systematic, transparent and rigorous – and, most importantly, within reach of resource limited guideline development teams.
Barriers and Enablers for the Development and Implementation of Allied Health Clinical Practice Guidelines in South African Primary Health Care Settings: A Qualitative Study
Presenter: Dr Janine Dizon
Authors: 1,2J.M. Dizon, 1,3K. Grimmer, 3Q. Louw, 4,5S. Machingaidze, 3H. Parker, 1H. Pillen
1International Centre for Allied Health Evidence (iCAHE), University of South Australia, City East Campus, North Terrace, Adelaide 5000, Australia.
2Centre for Evidence-Based Health Care (CEBHC), Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, 8000 Cape Town, South Africa.
3Department of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, 8000 Cape Town, South Africa.
4Cochrane South Africa, South African Medical Research Council, Francie van Zijl Drive, Parow Valley, 7505 Cape Town, South Africa.
5European and Developing Countries Clinical Trial Partnership (EDCTP), Francie van Zijl Drive, Parow Valley, 7505 Cape Town, South Africa.
Background: The South African allied health (AH) primary care (PC) workforce is challenged with the complex rehabilitation needs of escalating patient numbers. The application of evidence-based (EB) care using clinical practice guidelines (CPGs) is one way to make efficient and effective use of resources. Although CPGs are common for AH in high-income countries, there is limited understanding of how to do this in low to middle-income countries. This paper describes barriers and enablers for AH CPG uptake in South African PH care.
Methods: Semi-structured individual interviews were undertaken with 25 South African AH managers, policy makers, clinicians and academics to explore perspectives on CPGs. Interviews were conducted by researcher dyads, one being familiar with SA AH PC practice and the other with CPG expertise. Rigour and transparency of data collection were ensured. Interview transcripts were analysed by structuring content into codes, categories, and themes. Exemplar quotations were extracted to support themes.
Results: CPGS were generally perceived to be relevant to assist AH providers to address the challenges of consistently providing EB care in South African PC settings. CPGs were considered to be tools for managing clinical, social, and economic complexities of AH PC practice, particularly if CPG recommendations were contextusalised. CPG uptake was one way to deal with increasing pressures to make efficient use of scarce financial resources, and to demonstrate professional legitimacy. Themes comprised organisational infrastructures and capacities for CPG uptake; interactions between AH actors, and interaction with broader political structures; the nature of AH evidence in CPGs; and effectively implementing CPGs into practice.
Conclusion: CPGs contextualized to local circumstances offer South African PH AH services with an efficient vehicle for putting evidence into practice. There are challenges to doing this, related to local barriers such as geography, AH training, workforce availability, scarce resources, an escalating number of patients requiring complex rehabilitation, and local knowledge. Concerted attempts to implement locally-relevant CPGs for AH primary care in South Africa are required, to improve widespread commitment to EB care, and to plan efficient and effective service delivery models.
Physiotherapy Students’ Perceived Abilities and Barriers in Implementing Evidence into Practice
Presenter: Mr Thirumalaya Balaraman
Authors: 1T. Balaraman, 1N. Swaminathan
1INTI International University, Malaysia
Background: Teaching the fundamentals of evidence-based practice (EBP) has become mandatory in the entry-level physiotherapy curriculum internationally. Though the learning outcomes are assessed at the end of the course, it will be useful to check the carryover effect during clinical training, which help in designing the curriculum for EBP at entry-level degree programmes.
Objective: To explore the final year (4th year) undergraduate physiotherapy student’s perceived abilities and barriers in implementing evidence into practice during their supervised clinical placements at INTI International University, Malaysia.
Methods: The participants of this cross sectional survey completed their structured course on EBP during their 4th (2nd year) semester as a part of their compulsory modules which exposed them to the process of EBP. We followed the same group of students during their clinical trainings in 7th and 8th semesters. The participants filled a questionnaire adopted from the previous studies after obtaining the informed consent. The questionnaire asked the students’ behaviors, perceived abilities and barriers in implementing EBP.
Results: Out of 22 participants in the survey, 64% asked focused (PICO) questions to some degree. The majority of the students often asked questions about the effects of intervention (90.91%), diagnosis (68.18%), harm or aetiology (68.18%) and patient experiences (45.45%). To answer their PICO, the respondents often referred textbooks (59.09%), clinical guidelines (54.55%), contacted their teacher (50%) and the fellow student (45.45%). Students preferred the Internet and World Wide Web (95.45%) for searching evidences than databases. Most of the students (54.55%) sometimes used a checklist to critically appraise the evidence. 72.73% changed the practice based on research evidence and 55% of the students perceived that they have the high ability to search evidence in the databases. The most reported barriers were related to the time to search for research evidence, critical appraisal skill, knowledge in scientific methods, treatment room quality and culture at the clinical placement.
Discussion and conclusion: Based on this survey more than half of the students in this group reported effective use of evidence based practice in their clinical placement. But reported barriers related to critical appraisal skills and knowledge need to be considered in the future courses
The Cost Of Waiting
Establishing the important factors when measuring the impact of waiting for care
Presenter: Ms Joanne Morris
Authors: 1J. Morris, 1S. Milanese, 1K. Grimmer, 1A. Twizeyemariya, 2R. Marshall
1University of South Australia, SA, Australia
2Knowledge Teams International Pty Ltd, ACT, Australia
Introduction/background: Concerns have been expressed for over 30 years regarding individual and societal impact of waiting for a specialist opinion. Our recent systematic scoping review found limited information about the impact of waiting for orthopaedic care in cost and quality of life (QoL) terms. We found no specific QoL measures that are relevant, and sensitive to, this population.
Aim/objective: To develop a new QoL outcome measure that aims to establish what really matters to patients waiting for specialist orthopaedic care, and how waiting impacts their lives.
Methods: A “card sort” methodology is applied. This is found in leadership and change management research, but less often in health research. Patients waiting for greater than three months for an orthopaedic appointment at the Canberra Hospital are included. Individual interviews and discrete choice methodologies are applied. Discrete choices are based on a list of concerns generated from key words, outcome measures and reports of impact of waiting as identified in the scoping review. Each issue is listed on a card. Participants are asked to sort the cards into three piles (real concerns, moderate concerns, non-concerns). Participants are then asked to prioritise the cards in the ‘real concern’ pile in descending order. The score rankings for each concern over the entire group will be analysed by sociodemographic factors, such as gender, employment status and age, and type of orthopaedic complaint.
Results: ANOVA and logistic regression models will be constructed to identify key concerns. This will determine whether people with different orthopaedic conditions have different concerns, different priority rankings, whether comorbidity (and type) has an impact, and whether age group, gender and postcode are independently associated. The prioritised list of concerns will underpin a purpose-built outcome measure that sensitively captures the impact of waiting.
Discussion: This study presents the underpinning methodology of the development of a new QoL outcome. This tool will allow health care providers to monitor patients on waiting lists and measure the impact of interventions provided to this group.
Conclusion: This study will provide new knowledge regarding the priority concerns regarding the impact of waiting for orthopaedic care.
Trials and tribulations of an attempt to address waiting list concerns in a high risk population
Presenter: Ms Patricia O’Dea
Authors: 1S. Sheehy, 1P. O’Dea
1Child and Family Health Service, South Australia
Background: This paper outlines the development, running and evaluation of a 6 week group program for parents and infants that were on the waiting list for an Allied Health Therapy Service within the Child and Family Health Service in South Australia. The Allied Health Therapy Service within CaFHS focuses on working in partnership with parents to build and develop their relationship with their infant.
Methods: This group was a trial response to address the growing waiting list for the Allied Health Therapy service and the clinical risk of vulnerable families this posed. This 6 week group program was adapted from the 20 week Lighthouse MBT-Parenting Programme under the guidance and supervision of Gerry Byrne, Consultant Nurse and Consultant Child and Adolescent Psychotherapist and his colleague Clare Meins, Psychologist. The Lighthouse MBT-Parenting Programme was designed to support families where relational difficulties between an infant and parent have been identified. It was developed to enhance parents’ capacity to mentalize their children, to enhance attunement in parent-child relationships, to promote secure attachment and reduce the risk of harm and trans-generational transmission of psychopathology. (Byrne, 2016)
Two 6 week groups were run concurrently in the Northern and Southern regions of Adelaide by clinicians trained in the Lighthouse program. Self-report questionnaires were given before and after participants attended the group. These included measures of parental reflective functioning (PRFQ-1); Depression, Anxiety and Stress (DASS 21); and parenting and life stress ( Brief Parental Self Efficacy Scale);( Parenting Stress Inventory -4 Short Form).
Conclusions: Preliminary evaluation findings indicate this group format has potential application for therapeutic intervention particularly with high risk families however unaccompanied is unlikely to be an effective way of managing the waiting list demands.