Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 2, Issue 2, 2013
Editor-in-Chief
Umer Sheikh, MSc. Advancing Physiotherapy (UK), MSc. APA (Ireland/Belgium), MCSP (UK), SRP (UK), MAACP (UK), BSPT (PU), MPPS (PK) - Woking, UK
Associate Editor
Adnan Khan, MSc (UK), MCSP (UK), MICSP (Ireland), MAACP (UK), BSPT (PU) Staffordshire, UK
International Advisory Board
Editorial Board
Muhammad Atif Chishti, MSc. Musculoskeletal Physiotherapy (UK), MCSP (UK), SRP (UK), MAACP (UK), BSPT (PU), MPPS (PK) Middlesborough, UK Sameer Gohir, MSc Sports Physiotherapy (UK), MSc APA (Ireland/Belgium), MCSP (UK), SRP (UK), MISCP (Ireland), MSHC (KSA) - London, UK Rashid Hafeez M.Phil (Physiotherapy), MSc. APA (Belgium/Ireland), BSPT (PK) Dr. Fariha Shah, DPT (USA) - Lahore, PK Mohammad Bin Afsar Jan, MSPT (AUS), BSPT (PK) - Peshawar, PK
Shumaila Umer Sheikh, MSc Paediatric Physiotherapy (UK), MSc APA (Belgium/Ireland), MISCP (Ireland), BSPT (PU) - West Byfleet, UK Muhammad Atif Khan, BSc, MSc, Pgd (Ortho med), ESP, Spinal Practitioner, Berkshire, UK Muhammad Asim Ishaque, MSc Musculoskeletal Physiotherapy (UK), MCSP (UK), SRP (UK), BSPT (PK) London, UK
Dr Junaid Amin DPT (PK), BSPT (PK) KSA Shahbaz Iqbal MSc Physiotherapy (USA), tDPT (USA), McKenzie Cert.
Managing Editor
Beenish Zaman, tDPT (PK), BSPT (PK) Lahore, PK
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Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 2, Issue 2, 2013 Table of Content
Editorial.......................................................................................................................................01 A Unique Unreported Anomalous Muscle of Scapular Region and Its Clinical Implications - A Case Report…….………………………………………………………………………………………………………………….................08 Effect of Tailor Made Back Exercises on Depression in Subjects with Chronic Low Back Pain……………………………………………………………………………………..……………………………………..……………..14 Effect of Six Weeks of Play Therapy Skill Inventory on Cognition and Stress in Older Adults.............................................…………………………………….……………………………………………………..24 Gender Differences in Pain Perception and Coping Strategies among Patients with Knee And Or Hip Osteoarthritis…………………………………………………………....................................................................35 Professional Development of Physical Therapy and Frame work of Clinical Expertise in Pakistan……………………………………………………………………………………………………………………………………..45 Guidelines for Authors.................................................................................................................60
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
JOPSM Editorial Office | 13/3 New Civil Lines, Sargodha, Pakistan Tel: +92 (423) 2107625 E-mail: info@pgip.co.uk
[Guest Editorial]
Current Conservative Therapies in Lymphoedema Management Sheikh ZA1, Shahid SS2
Lymphoedema is the term used to describe
treatment
swelling which can occur anywhere in the
means that it is not uncommon for those
body, but most commonly affected are the
living with the condition to remain
limbs. It is important to note, that swelling
undiagnosed for many years or to be told
can occur for different reasons, and it is
that ‘there is nothing that can be done’ to
important that a diagnosis regarding the
aid them in its management. Although
underlying cause of swelling be made by a
lymphoedema is a long-term condition
qualified health care professional. Persons
which cannot be cured, its main symptoms
with this condition may have significant
of swelling and the risk of infection can,
problems, including discomfort, impaired
with appropriate treatment, be controlled
extremity
and often significantly improved. If left
function
as
well
as
unsatisfactory cosmesis1.
there were at least 100,000 individuals living with lymphoedema in the UK2, however more recent research suggests more than twice that number are now in
the
UK.
Unfortunately,
this
untreated, the swelling over time becomes
Studies carried out in 2003 suggested that
affected
options.
Despite
this
prevalence, many health care professionals have very little experience of diagnosing the condition and are unsure about current
more permanent and the area begins to feel increasingly hard and solid. This is due to the build up of proteins and fat as well as fluid in the tissues. When detected early, therapeutic management is more likely to be effective3. Delaying intervention may result in poor functional outcomes, as well as
increasing
emotional
distress.
Lymphoedema may be classified as either
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 1
[Guest Editorial] primary
or
secondary4.
Primary
lymphoedema may be present at birth, develop at puberty or in mid-life, and relates to abnormal functioning of the lymphatic system. The highest incidence of lymphoedema, however, occurs during adolescence (also known as lymphoedema praecox)
which
accounts
for
approximately 80% of patients. The remaining 20% of cases are equally divided between the congenital form and lymphoedema tarda, which presents in middle age. Secondary lymphoedema may occur following treatment for cancer, surgery,
radiation
therapy,
recurrent
infections or trauma.
therapies for this disease for which allied medical staff have a central role. Conservative
therapies:
Conservative
therapy for lymphoedema involves a twostage treatment program5. The first phase consists of skin care, manual lymphatic drainage (MLD), remedial exercises and compression applied with multi-layered bandage wrapping. Second Phase (initiated immediately after phase 1) aims to conserve and optimize the results obtained in phase 1. It consists of compression
by
low-stretch
elastic
stockings or sleeves, skin care, remedial exercises,
and
repeated
manual
lymphoedema treatment as necessary6.
The primary treatment for both primary and secondary lymphoedema is nonsurgical. Although a variety of therapies are available which may significantly alter the course of the disease, no treatment option is completely and permanently curative. It is imperative that the patient understand that the condition can be lifelong as well as the importance of controlling the oedema and preventing complications.
Skin care: Appropriate skin care and
debridement is vital in the treatment of lymphoedema,
to
prevent
recurrent
cellulitis or lymphangitis7. The cause of most episodes of cellulitis is believed to be Group
A
β-haemolytic
streptococci.
Prompt treatment is essential in order to prevent
further
damage
which
can
predispose to recurrent attacks. Meticulous hygiene is necessary to remove keratinous debris and bacteria. Skin should
Surgery does have a place in the
be cleansed regularly and thoroughly
management of lymphoedema; however,
dried. Ordinary soaps, which usually
this review aims to take a broad look at
contain detergents and no glycerin, should
commonly
be avoided because they tend to dry the
used
current
non-surgical
skin. Natural or pH neutral soap can be
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 2
[Guest Editorial] used. Regular inspection is necessary to
three or more weeks, and may be repeated
identify any open wounds and treated
at intervals of three months to one year8.
appropriately.
Health professionals often teach patients a
Manual lymphatic drainage (MLD): This
simplified version of manual lymphatic
is a specialised, gentle type of massage
drainage which includes clearing of the
which aims to encourage extra lymph fluid
adjacent area and limb root followed by
to move away from the swollen area so it
sweeping strokes over the limb itself9.
can drain normally. This is done by increasing
the
activity
of
normal
lymphatics and bypassing ineffective or obliterated lymph vessels. Breathing techniques are also an important part of this treatment. There are a number of different techniques for MLD including the Vodder, Földi, Leduc and CasleySmith method. The different methods have several aspects in common: ■ performed for up to an hour daily ■ performed with the patient in the lying position ■ starts with deep diaphragmatic breathing ■ treats the unaffected lymph nodes and region of the body first ■ moves proximally to distally to drain the
Limb elevation: Simple elevation of a
lymphoedematous limb reduces swelling6. Ideally elevation should be above the level of the heart. It is thought to reduce capillary exudation into the tissues and promote lymphatic return. It is considered most useful in the earlier stages of lymphoedema10. Exercise:
Active,
resistance
exercises
isometric, are
and
advised
in
lymphoedema patients11. Limb
exercises
can
be
progressive,
resistive or sequential in nature and are recommended as a way of varying total tissue pressure to encourage lymphatic drainage and for improving range of movement and strength12.
affected areas
The
bandaging
achieves
■ Movements are slow and rhythmical
pressures
■ Gentle pressure is used
pressures at rest13. Passive forces are
■ ends with deep diaphragmatic breathing
already
MLD may be conducted daily or three
lymphoedema: manual lymphatic drainage,
times weekly. A course of therapy may last
massage therapy, sequential pneumatic
during promoted
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
exercise as
high
tissue
but
treatment
low for
Page 3
[Guest Editorial] compression pumping, elastic compression 14
phases as part of exercise to avoid
sleeves, and limb elevation . These
exacerbation of swelling
treatments mimic the passive forces of the
■ Compression should be worn during
body, such as skeletal muscle pumping,
exercise
respiratory
arterial
■ Expert patients can help to demonstrate,
pulsation. Exercise also stimulates the
teach and monitor exercise, and provide
skeletal muscle to pump venous and
information on access to local exercise
movement,
and
15
lymphatic fluid . This type of exercise should also stimulate the contraction of the lymph vessels themselves because these vessels are innervated by the sympathetic nervous system. Regaining control over these internal contractions by resetting the sympathetic drive to these vessels through upper-body exercise may assist in the long-term treatment for lymphoedema14. Patients should be instructed to avoid heat, cold, local compression or excessive exercise of the affected arm. A specific
programmes Types of exercise:
■ Start with low to moderate intensity exercise ■ Paralysed limbs can be moved passively ■ Walking, swimming, cycling and low impact aerobics are recommended ■ Heavy lifting and repetitive motion should be avoided ■ Flexibility exercises maintain range of movement Multi-layered
aimed at augmenting muscular contraction,
bandaging uses inelastic bandages which
enhancing
joint
produce a massaging effect and stimulate
mobility, strengthening the limb and
lymph flow. Elastic bandages can be used
reducing the muscle atrophy6.
which produce sustained compression with
lymphatic
flow
and
General guidelines on exercise:
bandage:
Multi-layer
exercise program performed once a day is
smaller variations during movement.
■ Patients should be encouraged to
The use of bandages is indicated in
maintain normal functioning, mobility and
patients who have marked skin changes or
activity
those that have limb distortion and skin
■ Exercise/movement should be tailored to
folds precluding the use of compression
the patient's needs, ability and disease
garments.
status ■ Patients should be encouraged to include
Principles of multi-layer bandaging:
appropriate warming up and cooling down [Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 4
[Guest Editorial] ■ Protect the affected area using tubular
have arterial insufficiency, acute cardiac
bandages and soft synthetic wool or foam
failure, very deep skin folds, extensive
■ Start bandaging distally and move
ulceration
proximally
neuropathy.
■ Ensure good fit of the bandages and prevent creasing ■ Apply additional padding to the popliteal fossa and the inside of the elbow ■ If elastic bandages are used, they are applied with 50% overlap ■ Minimise creases at joints by bandaging the limb in a slightly flexed position and using figure of eight turns at the joint ■ Extend partial limb bandaging beyond the area of swelling and ideally incorporate the knee or elbow joint to prevent
and
severe
peripheral
It is important to achieve accurate fitting custom
made
garments.
Therefore,
accurate measurements of limbs usually include circumferential measurements at several
given
sites
and
longitudinal
measurements between specified points. Garments should be replaced every three to six months, or when they begin to lose elasticity. Young or very active patients may
require
more
frequent
garment
replacement.
proximal displacement of fluid into the
Pneumatic pumps: These are pumps that
joint
are placed over affected limbs. The pump
Compression garment: The main use of
compression garments is in the long-term management of lymphoedema and has a similar mode of action as bandaging. It is essential to wear custom made low stretch garments during the day in order to preserve the results of manual lymphatic drainage6. In order for patients to wear
is inflated and deflated cyclically for a set period, usually about 30-120 minutes. This encourages fluid drainage from distal to the proximal end of the limb10. This technique is particularly effective in nonobstructive oedemas, e.g. those due to immobility,
venous
incompetence,
lymphovenous stasis or hypoproteinaemia.
compression garments, patients must be
Oral medication: Both benzopyrones and
motivated with good dexterity and intact,
diuretics
resilient skin. They must have no or
Benzopyrones are thought to stabilise
minimal pitting oedema and be able to
swelling
monitor their skin condition. Compression
filtration whereas diuretics encourage the
garments are not suitable in those who
excretion of salt and water. This in turn
may by
help reducing
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
lymphoedema. microvascular
Page 5
[Guest Editorial] reduces blood volume which reduces
percentage
capillary filtration and ultimately lymph
lymphoedematous limbs.
formation. Diuretics tend to be used in short courses in chronic oedema of mixed aetiology.
volume
Maintenance
reduction
therapies
in
(normally
undertaken by the patient), such as wearing a compression garment, limb
Low level laser therapy: Lasers with
exercises, elevation and self massage
wave lengths between 650–1000nm are
generally
used. It has shown greater potential in the
reductions. There is some research to
treatment of upper limb lymphoedema. It
suggest that undertaking therapies such as
is thought to promote lymph vessel
arm
16
smaller
percentage
rehabilitation and exercise may
and
prevent the onset of lymphoedema20, but
softening of both fibrous tissue and
further research is required to determine
surgical scarring18. Further research is
the true benefits of such programs.
regeneration ,
pain
reduction
17
yield
required to establish whether benefits can be demonstrated in the long term.
conservative modalities in the treatment of lymphoedema, ongoing research may help
Conclusion
Although
Although this review points out numerous
surgical
intervention
for
lymphoedema is gaining popularity, this should only be considered if conservative management has failed or found to be
identify further potential options.
References 1.
ineffective. The other aspect to take into account is how the disease affects patients psychologically.
Psychological
support
and quality of life improvement programs should be an integral component of any
2. 3.
treatment of lymphoedema19. Research has shown that treatments that
4.
are predominantly administered by health professionals, such as manual lymphatic drainage, laser therapy and pneumatic pump therapy generally yield a larger
5.
Brennan MD, et al., Postmastectomy lymphedema. Archives of Physical Medicine and Rehabilitation. Volume 77, Issue 3, Supplement, March 1996, Pages S74–S80 Moffatt et al, lymphoedema: an underestimated health problem. QJM med, 2003, 96: 731-738. P.T. Truong, et al., Clinical practice guidelines for the care and treatmentof breast cancer:16 Locoregional postmastectomy radiotherapy, CMAJ, 2004, 170(8), 1263-1273. Antoinette M, Susan R Harris, 1998. Physical Therapy, Physical Therapist Mnagement of Lymphoedema following treatment for breast cancer: A critical review of its effectiveness, 78 (12), 13021311. Ko, DS, Lerner R, Klose G, Cosimi AB. Effective treatment of lymphedema of the extremities. Arch Surg 1998; 133: 452– 458.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 6
[Guest Editorial] 6.
7. 8. 9.
10.
11.
12.
13. 14.
15.
16.
17.
18.
Veronika Fialka-Moser, et al. Cancer rehabilitation particularly with aspects on physical impairmaents. Journal of Rehabilitation Medicine. 2003; 35: 153– 162. Lerner R. What's New in Lymphedema Therapy in America?. Int J Angiol. May 1998;7(3):191-6. British Lymphology Society. Chronic Oedema Population and Needs, Sevenoaks, Kent: BLS, 1999. Piller NB, Packer R, Coffee J, Swagemakers S. Accepting responsibility for health management: Partner training as an effective means of managing chronic lymphoedema. Progress in Lymphology XV, 1996; 266–269. Brenan MJ, Miller LT. Overview of treatment options and review of the current role and use of compression, intermittent pumps and exercise in the management of lymphedema. Cancer 1998; 83 (suppl 12B): 2821–2827 Swedborg I, Voluminometric estimation of the degree of lymphoedema and its therapy by pneumatic compression. Scand J Rehabil Med. 1977, 9:131-135. Johansson K, Tibe K, Kanne L, Skantz H. Controlled physical training for arm lymphedma patients. Lymphology 2004; 37 (suppl): 37–39). Foldi E, Foldi M, Weissleder H. Conservative treatment of lymphedema of the limbs. Angiology 1985; 36: 171–180. Donald C. McKenzie and Andrea L. Kalda. Journal of Clinical Oncology, Effect of Upper Extremity Exercise on Secondary Lymphedema in Breast Cancer Patients: A Pilot Study. 2003, 21(3), 463466. Witte CL, Witte MH, 1987: Contrasting patterns of lymphatic and blood circulatory disorders. Lymphology 20:171-178. Lievens P. The effect of a combined HeNe and I.R. laser treatment on the regeneration of the lymphatic system during the process of wound healing. Lasers Med Sci 1991; 6(193): 193–199. S, Shiroto C, Yodono M et al. Retrospective study of adjunctive diode laser therapy for pain attenuation in 662 patients: detailed analysis by questionnaire. Photomedicine, Laser Surg 2005; 23(1): 60–65. Nouri K, Jimenez G, Harrison-Balestra C, Elgert G. 545-nm pulsed dye laser in the treatment of surgical scarring starting on
the suture removal day. Dermatol surg 2003; 29: 65–73. 19. A. L. Moseley, C. J. Carati & N. B. Piller. Annals of Oncology 18: 639–646, 2007 review A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment. 20. Box RC, Reul-Hirche HM, BullockSaxton JE, Furnival CM. Physiotherapy after breast cancer surgery: results of a randomised controlled study to minimise lymphoedema. Breast Canc Res Treat 2002; 75 (1): 51–64.
Corresponding Author Zeeshan Sheikh Department Of Plastic Surgery, St. John's Hospital, Livingston, EH54 6PP, tel : 01506523000, email: zsheikh@doctors.net.uk 1. 2.
Department of Plastic Surgery, St. John’s Hospital, Livingston, Edinburgh, UK Rehabilitation unit, The Christie, NHS Foundation Trust, Manchester, UK
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 7
[Case Report]
A Unique Unreported Anomalous Muscle of Scapular Region and Its Clinical Implications - A Case Report Dr. Takkallapalli Anithaš, Dr. Dattatray Dombe², Dr.P.Shanmugaraju3, Mr. Naresh Thaduri 4
Abstract: It is a well documented fact that the lower border of spine of scapula gives origin to deltoid muscle only. We report a case of anomalous muscle arising from the medial aspect of lower border of spine of scapula in the left upper extremity of a 59 year old male cadaver. The anomalous muscle is innervated by axillary nerve which also gave a motor twig to the long head of triceps brachii. This variation was unilateral. The morphological, embryological and clinical significance of the anomalous muscle is discussed. Keywords: Anomalous muscle, Triceps brachii, Latissimus dorsi, Axillary nerve
Introduction
radiodiagnostic and surgical procedures of
Anatomical variations of muscles and
the upper limb.
nerves of upper limb have been commonly reported
and
well
documented.
We
describe a rare neuromuscular variation of the scapular region of the left superior extremity hitherto not reported to the best of our knowledge. Awareness of these variations
is
necessary
during
the
Case Report During routine cadaveric dissections in the Department of Anatomy, Chalmeda Anand Rao
Institute
of
Medical
Sciences,
Karimnagar, India, we came across an anomalous muscle arising from the lower border of spine of left scapula close to the origin of deltoid muscle. The length of the
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 8
[Case Report] anomalous muscle was 8.1 cm and breadth
capsular ligament like the curved head of
was 4.5cm. The muscle arose by a fleshy
rectus femoris.
belly and coursed downwards superficial to infraspinatus and teres minor muscles. At the lower border of teres minor, the muscle split into two fleshy slips. The superior slip is bulky passed superficial to teres major and joined the lower border of latissimus dorsi. The inferior slip is slender and is continuous with the long head of triceps brachii muscle. The anomalous muscle is supplied by posterior division of axillary nerve which also gave a small motor twig to the long head of triceps brachii [Fig.1].
The existence of a slip from the tendon of latissimus dorsi has been seen several times. It was described by Bergman (1855); and it was also mentioned by Halberstsma under the name of anconeus quintus; this may occasionally come from the teres major3. Macalister2 has also reported a tendon of union from the lower border of latissimus dorsi to the long head of triceps brachii. He also observed a fleshy slip of connection from the costal fibres of latissimus dorsi into the same part of
triceps
brachii.
The
Discussion
latissimocondyloideus
The neuromuscular variations of the upper
dorsoepitrochlearis muscle is found in
limb are clinically important for surgeons,
about 5% of individuals and is described
orthopaedicians
anesthetists
as a part of the triceps brachii that attaches
performing pain management therapies on
proximally to the latissimus dorsi tendon
and
or
the upper limb. Anomalous muscle slips
of insertion4,5 any of the above description
from
brachii,
does not mention additional attachment to
latissimus dorsi and deltoid muscle have
spine of scapula which is seen in the
been reported earlier. A fourth head of the
present case.
long
head
of
triceps
triceps brachii may be found arising from various points in the humerus, scapula, shoulder joint capsule or the coracoid 1
process .
The continuation of the fibres of the deltoid muscle into the trapezius; fusion with pectoralis major; and the presence of additional slips from the vertebral border
Macalister2 has frequently seen the long
of scapula, infraspinous fascia, and the
head of triceps split, one attached to the
axillary
capsule and the other to the tricipital spine,
commonly reported variations of the
or the first slip was found spitting the
border
of
scapula
are
the
deltoid muscle6. We have not observed any
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 9
[Case Report] slips from the above mentioned sources in
muscle primordia disappear through cell
our present study.
death. Failure of muscle primordia to
Although anatomical variants of triceps, deltoid,
latissimus
dorsi
have
been
reported earlier none of the exisisting
disappear during embryonic development may account for the presence anomalous muscles slips8.
literature gives details regarding any
The variations of the nerves of the upper
anomalous muscle arising from medial
limb can be explained embryologically.
aspect of lower border of the crest of spine
The upper limb buds lie opposite to the
of scapula and becoming continuous with
lower five cervical and upper two thoracic
long head of triceps brachii and latissimus
segments. As soon as the buds form, the
dorsi.
ventral rami of spinal nerves penetrate into
The long head of triceps and the anomalous muscle are innervated by posterior division of axillary nerve from quadrilateral space [Fig 1] in the present case. A retrospective clinical study of traumatic injuries of the axillary nerve with associated paralysis of the long head of triceps suggests that the motor branch of the long head of triceps may arise from the axillary nerve7.
the mesenchyme of limb bud and establish intimate
contact
with
differentiating
mesodermal condensations. The early contact between nerve and muscle is a prerequisite for their complete functional differentiation9. As the guidance of the developing
axons
expression
of
is
regulated
chemo-attractants
by and
chemo-repellents in a highly coordinated site specific fashion, any alteration in signaling between mesenchymal cells of
Developmental Basis
limb buds and neuronal growth cones can
The origin of anomalous muscles may be
lead to significant variations10.
explained on the basis of embryogenesis of muscles of the arm. The intrinsic muscles of the upper limb differentiate in situ from the limb bud mesenchyme of the lateral plate mesoderm. At a certain age of
Clinical Significance Knowledge of anomalous muscles and their
innervations
is
of
interest
to
anatomist and clinician alike.
development, the muscle primordial within
The close relationship of this anomalous
the different layers of the arm fuse to form
muscle to the neurovascular structures
a single muscle mass; thereafter, some
found in the quadrilateral space may cause
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 10
[Case Report] compressive
neuropathy.
As
the
neurovascular bundle enters this space it may be compressed, eliciting clinical symptoms
characterized
by
i)
Pain
localized to the shoulder ii) Paresthesia in a non-dermatomal distribution iii) Discrete point/localized tenderness in the spatium axillare laterale (Quadrilateral space) and iv) An arteriogram showing compression of the posterior, circumflex humeral artery
is important to look for the paralysis of the long head of triceps brachii16. Transfer of latissimus dorsi to replace a paralysed anterior deltoid by a new technique using an inverted pedicled graft has
been
reported17.
An
additional
attachment from the anomalous muscle may be of more help in replacing some of the functions of a paralyzed deltoid.
with abduction of shoulder. Cahill and
Conclusion
palmer11 have recognized this constellation
Awareness of the anatomical variations of
of symptoms as the “Quadrilateral space�
anomalous muscles around shoulder joint
syndrome.
and their innervations is important while
The long head of triceps is used as a free functioning muscle graft12. The triceps musculo cutaneous flap is used for chest wall defects and to release axillary contractures13,14. In case of massive tear of the rotator cuff muscles, the long head of triceps is used as interposition muscle flap for the surgical correction of the rotator cuff muscles15. Anomalous muscle slip which continues with long head of triceps
performing shoulder brachial
traumatic injury involving axillary nerve, it
plexus
infraclavicular
block,
nerve
previous reports of this variant and hence this case report constitutes the first description of this anomaly.
References 1.
2.
supply of long head of triceps and the important. While examining patients with
during
of
review of the literature failed to reveal any
The knowledge of variations in the nerve anomalous muscle in the present case is
joint,
surgery
transplantation procedures. A thorough
in the present case is an added advantage in the above conditions.
arthroscopic
3.
Piersol GA (1907). Human anatomy including structure, development and practical considerations. JP Lippincott, Philadelphia, p: 558. Macallster. A (1875). Additional observations on muscular anomalies in human anatomy (third series), with a catalogue of the principal muscular variations hitherto published. Trans Roy, Irish Acad Sci 2; 1-134. Ronald A. Bergman, Adel K. Afifi; Ryosuke Miyauchi; Triceps Brachii; Illustrated Encyclopedia of Human Anatomic Variations: Opus I: Muscular System: Alphabetical listing of Muscles: T http/www.anatomy atlases.org (accessed in June 2007).
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
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[Case Report] 4.
Anson B (1966). Morris Human Anatomy. A Complete systematic treatise. 12th Edition. New York: Mc Grow- Hill, p: 482-484. 5. Tountas Cp and Bergman RA (1993). Anatomic Variations of the upper extremity. Churchill Livingstone; New York, p: 102-105, 98. 6. Standring S. The anatomical basis of clinical practice. International 39th ed. Churchill Livingstone; 2005. Gray’s Anatomy; p:836. 7. Deseze MP, Rezzouk J deseze M, Uzel M, Lavingnolle B, Midu D. Durandeau A. Does the motor branch of the long head of triceps brachii arise from the radial nerve? An anatomic and electromyogrpahic study. Surg Radiol Anat. 2004: 26:459461. 8. Girm M. Ultra Structure of the ulnar portion of the Contrahent muscle layer in the embryonic human hand. Folia Morphol (Praha) 1972; 20: 113-115 (pub med). 9. Brown, Mc, Hopkins, WG and Keynes, RJ. Essentials of neural development, Cambridge: Cambridge Universtity press, 1991; p:46-66. 10. Samnes, DH; Reh; TA and Harris,WA. Development of nervous system, New York: Academic press, 2000, p: 189-197.
11. Cahill BR and palmer Re: The quadrilateral Space syndrome. J Hand Surg (AM) 1983, 8:65-69. 12. Lim AYT, Pereira BP, kumar VP. The long head of the triceps brachii as a free functioning muscle transfer, plast Reconstr Surg. 2001;107:1746-1752. 13. Hartrampf CR, Elliot LF, Feldman S. A triceps musculo cutaneous flap for chest wall defects. J Reconst microsurg 1990; 86; 502-509. 14. Hallock GG. The triceps muscle flap for axillary contracture release. Ann. Plast. Surg. 1993; 30: 359-362. 15. Sundine MJ, Malkani AL. The use of the long head of triceps interposition muscle flap for massive rotator cuff tears. Plast Reconst Surg. 2002; 110;1266-1272. 16. Perimulter, Gary S, MD. Axillary nerve injury. Clinical Orthopedics and related research. (368); 26-36 November 1999]. 17. Yoshiyasu Itoh, Takashi Sasaki, Takashi Ishiguru, Kenichiro Uchinishi Yutaka yabe, Hiroaki Fukud a transfer of latissimus dorsi to replace a paralysed anterior deltoid: the journal of Bone and joint surgery. Vol – 69-B, No. 4, August 1987: 647-651.
Figure 1
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
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[Research Report]
Corresponding Author * Dr. T. Anitha, MD (Anatomy) Associate Professor Department of Anatomy Chalmeda Anandrao Institute of Medical Sciences, Bommakal, Karimnagar, Andhra Pradesh, India. Ph. No : +91 98 490 36363 +91 0878 2222102 Fax No : +91 0878 2285318 E-mail : tanita.205@gmail.com. Š 2013 PGIP. All rights reserved.
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
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[Research Report]
Effect of Tailor Made Back Exercises on Depression in Subjects with Chronic Low Back Pain Dr. B.ARUN, * Dr.M.S.Nagarajan, ** S. Mohammed Auriff.***
ABSTRACT Low Back pain is the one of the most common disorders in the world. It ranked as second common disorder next to common cold. People in modern world injure their backs, gets recovered and move on with their lives. However, this is not the actuality for numerous patients troubled with constant or recurrent back ache. Depression is a specific and common form of emotional syndrome which affects millions of patients with chronic back pain. Many researchers reported that around 39% of the chronic low back pain patients were exhibited signs of pre-existing depression. Back exercises given to the patients with back pain are mostly no unique, it is not suitable for every individual. So our study focuses to find out the effect of tailor made exercises on psychological outcome. This is an experimental study design with 40 subjects were selected with chronic low back pain following inclusive and exclusive criteria. The subjects in the experimental group underwent Tailor made back exercises where as control group underwent medications and back care advices. The study was conducted for 8 weeks. Outcome chosen in this study are Back Depression Inventory for assessing depression following back pain and functional disability index for measuring disability. The results were computed using Student‘t’ test. The study concludes that following a tailored exercise program the pain and the depression following low back pain were reduced significantly.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 14
[Research Report] Keywords: Back depression Inventory, Chronic low back pain, Depression, Tailored back exercise, Visual Analog Scale (VAS)
Introduction
exists between the low back pain and the
Low back pain is one of the great human
psychological factors7. Depression was
afflictions. It is the commonest disorder in
found to be a significant factor in low back
the world. Low back pain is one of the
pain populations8.
major health problems in developing countries1. About 60% to 90% of adults experience low back pain at least once during their life time2. It is one of the commonest reasons for physician visit and most common visit after common cold3.
Pain
and
depression
are
closely
interrelated. Pain increases depression increases and it is highly correlated that depression increase which makes increase of pain. Pain may occur as a result of injury and the injury restricts the mobility
Low back pain is one of the most
which may pronounce to depression. 25 %
expensive conditions in the industrialized
of older adults are suffering with both low
countries.4 No person is immune to the
back pain and depression at the same time,
back pain. It occurs to all ages from child
lead to physical inactivity and loss of
to elders and one of the common
independence9.
conditions in person younger than 40 years. Both sex are equally affected by back pain5. Certain important causative factor for back pain includes maintain of abnormal posture in jobs like sitting in front of computer for more than 8 hrs or standing for more than 8 hrs or traveling 6
long distance with abnormal positions . Pain is the predominant symptoms which may be a causative factor for various symptoms like depression or anxiety and psychological distress.
Various studies
reported that there is a strong relationship
Depression and Chronic Low back pain are the most prevalent disorders in the world. It can affect both young and old. Low back pain may result in disability in both emotionally and mentally10. Depression is a risk factor for onset of severe neck and low back pain11. Around 39% of the patient with chronic low back pain exhibited signs of pre existing depression. Many researches show that depression was a causative for increase the risk for developing back pain problem12.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 15
[Research Report] NSAIDs are prescribed by various general
field. Exercise program designed for low
physicians
a
back pain are mostly same and more
management for Low back pain. But the
common, these exercises were sometimes
role of the medications is very limited.
best for some patients whereas least
More over there are numerous side effects
benefit for the others. This study focused
have been seen following NSAIDs13.
on tailor made exercises for low back pain
Diverse training is effective for the
subjects, and also to evaluate the effect of
treatment of chronic low back pain, but no
exercises on pain and depression.
around
the
world
as
consensus evidences has been found. Earlier studies have highlighted training of back strengthening and spinal mobility.14 Exercise therapy is another kind of method used to manage the low back pain. Effectiveness of the exercises for CLBP is shown very effective in reducing pain and
Methodology Study Design
is
experimental
study
design. A total of 40 subjects were selected by Simple random sampling method with age group range from 25—35 years. The subjects
included
are
subjects
with
disability 15.
recurrence of low back pain more than
Over last few decades, exercises for low
of more than 26 , Both sex were included,
back pain have been promoted well. There
subject pain level was not more than 6 in
is lot of systematic reviews which explains
Visual analog scale (VAS), Subjects who
the
effectiveness
8week duration, Subjects with BDI score
of
the
exercises16.
doesn’t
underwent
physiotherapeutic
Exercises have shown more beneficial
procedures prior to the study and Subjects
effect on low back pain. Regular activity
willing to participate. Study excludes
or even a leisure time activity helps in
subjects with spinal deformity, Recent
controlling pain. Most of the studies on
Fracture of lower limb and spine, Spinal
low back pain focused on pain reduction or
disorders
improvement of function ( ADL) or
Cardiovascular problems or Neurological
prevention of recurrences for back pain,
problems, Subjects with disc problems or
very few studies focused on relation
Radiating symptoms and obese subjects.
between psychological factor and back
The Parameters selected were Functional
pain, Although psychological factors are
ability and Depression, Outcome measures
important causative factor for back pain,
were Functional disability index & Back
researches are not extensively done in the
depression inventory.
&
arthritis,
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Subjects
with
Page 16
[Research Report] Procedure
times per week. Back care advices were
Subjects who come to department with
given twice a week, both groups were
chronic low back pain were assessed and
called up and Back care advices were
suitable subjects were selected based on
given. At the beginning of the study
the selection criteria. Functional disability
Exercise programme was initiated in the
index and Back depression inventory were
department. Once the subjects mastered
clearly explained to the participants and
the exercises they are advised to do it in
asked them to fill up, some patients needs
the Home or in their work place. Frequent
assistance in filling up the forms, and
review of the programme was conducted at
following this an Informed consent form
alternate Saturday evening for the total
was
individual
study duration (8 Weeks). Subject’s
participants, and they allowed to withdraw
queries were cleared during the review
from the study at any point of time. 40
sessions. The study was approved by
subjects were selected and they were
institutional ethical committee.
obtained
from
every
divided into 2 groups. Group A: 20 subjects: Subjects underwent only Tailor made back exercises for duration of 60 mins, following that a back care advices were given to individual subjects. Exercise program includes 10 minutes of warm up with bicycling or walking, which was
Result The Data were collected as Demographic, Functional
disability
and
Depression.
Following the collection of data’s, they were analyzed with the help of Student ‘t’ test.
followed by 45 mins of tailored back
The demographic representations of the
exercises
stretching,
groups are given in table I. Age group of
strengthening & Core stability and at the
the participants varies from 25yrs to 35 yrs
end cool down exercises done for 5 mins
and about 30 % are from 28—30 yrs, 27%
with
exercise
are from age group of 25—27 yrs, 25%
programme was designed by the study
from 32—33 yrs and 18% are from 34—
author with the help from stalwarts in
35 yrs. There are total of 40 subjects and
Physiotherapy. Group B: 20 subjects:
their Standard deviation is 2.16 and the
Subjects with medications, which was
mean age of 31.28. The pie chart explains
prescribed by an orthopedician and back
about the demographic data in figure I.
which
mild
includes
stretches.
The
care advices given by physiotherapist. Frequency of exercises programme is 3
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 17
[Research Report] The Paired‘t’ test analyses for the pre test
Paired ‘t’ test analyses for the pre test and
and post test variable for back depression
post test variable for functional disability
index was shown a significant difference
index was shown a significant difference
between the
Group A and Group B.
between the Group A and Group B. Un
Unpaired ‘t’ value for the Group A and the
paired ‘t’ value for the Group A and the
Group B was 3.32 at the p value of 0.05%.
Group B was 4.53 at the p value of 0.05%.
The graphical representation was shown in
The graphical representation was shown in
figure II. The result shows that there was a
figure III. The result shows that there was
significant
the
a significant improvement between the
Groups and the Group A shows better
Groups and the Group A shows better
improvement than that of Group B. The
improvement than that of Group B.
Discussion
greater in people with chronic low back
Back pain is the common costliest problem
pain,
in the world, it is recognized that
population20.
psychological, behavioral, cognitive and
Low back pain disturbs sleep intern which
affective factors play crucial role in the
cause day time sleepiness that may lead to
development of chronic low back pain.
depression. Low back pain and depression
Polatin et al., 1993, conducted a study
can be managed separately. Exercises play
which revealed that 39% CLBP patients
a major role in reducing pain and
suffered
improvement
from
between
depression12.
Increased
when
compared
with
general
depression21.
prevalence of Depression, anxiety and
Low back pain and depression are
personal disorders has been documented in
interrelated. Effective treatment can helps
patients with chronic low back pain
in reducing depression and manage pain
compared with general population.
well. Study published in 2005 found that
Linton 2000, revealed the other way
walking plays a major role in reducing
connection that wherein 14 out of 16
symptom of depression22. An episode of
studies indicated that depression increases
low back pain that last for more than two
the chances for development of low back
weeks results in muscle weakness. This
pain. Depression relates to low back pain
process leads to atrophy and weakening,
may inhibit the daily function of an
which causes more pain because the
individuals. The disability following low
muscles are poor in controlling the spine.
back pain was increased
19
. Studies show
23
.
that depression is thought to be 4 times
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 18
[Research Report] Exercises are very effective way to speed
Conclusion
up the recovery process from low back
Exercises
pain and strengthen back as well as
impairment
abdominal muscles15. Exercise and staying
Exercises mainly focus on reducing pain
active may relieve low back pain and can
and
16
are
useful
caused
improve
for by
improving back
function,
pain.
but
the
help in early recovery . An exercise helps
improvement of the function indirectly
in reducing depression quickly and helps
helps in the changes of mood. Thus this
to increase energy and renewed vitality.
study
Dan Dwyer explains that exercises helps to
exercise along with back care advices
increase the level of serotonin which helps
helps in improvement of psychological
in reducing pain and improve the mood.
state in subjects with chronic low back
Paluska 2000, shown in that strengthening
pain.
& flexibility exercises prove effective in treating depression
24
. Beta endorphins are
the mood regulating chemicals that lessen pain which secretes during exercises. Research shows that it has positive
concludes
that
Tailored
back
Acknowledgement There was no funding for the study was made by any of the agencies. My sincere thanks
to
Padma
shree
Dr.
G.
influence on depression25.
Bakthavathsalam,
The study was short term and focus only
Director of education, K.G Hospital,
on depression and functional disability. Since functional disability index has pain identity, separate pain assessment was not done. Other outcomes like range of motion,
muscle
endurance
were
not
considered. Long term study is needed to find out the long term benefits of exercises.
Chairman,
K.G.Hospital, Mrs.Vaijayanthi Mohandas, Mr.Prabhu
Kumar,
HRD
manager,
K.G.Hospital, Mr.V.Mohan Gandhi, Chief physiotherapist,
K.G.Hospital,
and
Mr.S.Ramesh, Principal, K.G.College of Physiotherapy, All my teachers who taught me physiotherapy, All the staffs in Department of Physiotherapy and College of
Physiotherapy.
participated
in
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
All
subjects this
who study.
Page 19
[Research Report] References 1.
Andersson, G.B., (1999). Epidemiological features of chronic low-back pain. Lancet, 354(9178): 581-585. 2. Maher, C.G., (2004). Effective physical treatment for chronic low back pain. The Orthopedic Clinics of North America, 35(1): 57-64. 3. Indahl, A., Velund, L., Reikeraas, O. (1995). Good prognosis for low back pain when left untampered. Spine, 20:473–477. 4. Walker, B. (2000). The prevalence of Low back pain : A systematic review of the literature from 1966 to 1998. Journal of Spinal disorders. 13(3);205-17. 5. Cunningham, L.S., Kelsey, J.L., (1984). Epidemiology of musculoskeletal impairments and associated disability. American Journal of Public Health 74 (6), 574–579. 6. John Ebnezer. (2012). Low back pain. New Delhi. Jaypee.184-188. 7. Andersson, G.B.J., (1997). The epidemiology of Spinal disorders. In frymoyer JW ed. The Adult spine : Principles and Practice 2nd Ed. Philadelphia. : Lippincott Williams. 93141 8. Altinel, L., Kose, K.C., Ergan, V., Isik, C., Aksoy, Y., Ozdemir, A., et al., (2008). The prevelance of Low back pain and risk factors among adult population in Afyon region. Turkey. Acta Orthop Traumatol Turc. 42(5). 328-333. 9. Becker, N., Bondegaard, T.A., Olsen, A.K., Sjogren, P., Bech, P et al., (1997), Pain epidemiology and health related quality of life in chronic non malignment pain patients referred to a Danish Multidisciplinary pain center. Pain. 73(3): 393-400. 10. Murray, C.J., Lopez, A.D., (1997). Alternative projections of mortality and disability by cause 1990—2020. Global burden of Disease study. Lancet.349: 1498-1504.
11. Linda, J.C. David, C.J., Pierre Cote. (2004). Depression as a risk factor for onset of an episode of troublesome neck and low back pain. 107(1): 134-139. 12. Polatin, P.B., Kinney, R.K., Gatchel, R.J., Lillo, E., Mayer, T.G., (1993). Psychiatric illness and chronic low back pain. Spine. 18:66-71. 13. Maher, C.G., (2004), Effective Physical treatment for chronic low back pain. The Orthopedic clinics of North America. 35(1) 57-64. 14. Johannsen F, Remviq L, Kryger P, et al., (1995). Exercises for chronic low back pain: a clinical trial. J orthop Sports Phys Ther, aug: 22(2): 52-9. 15. Hayden, J.A., van tulder , A.V., Malvimvaara, B.K., (2005). Meta analysis. Exercise therapy for non specific low back pain. Ann. Internal Med. 142 (9). 765-775. 16. Van Tudler M, Malmivaara A, Esmail et al., (2000). Exercise therapy for low back pain. A systematic review within the frame work of the Cochrane collaboration back review group. Spine. 25:2784-96. 17. Bruns, D.,Disorbio J,M., (2004). The psychomedical theory behind the BHI 2.;Health Psychology and Rehabilitation. 18. Kent, P.M., Keating, J.L., (2005). The epidemiology of low back pain in primary care; Chiropractic & Osteopathy. 13:13. 19. Sethi. V., Pragyadeep. (2012). Impact of short duration (4 Weeks) of core stability exercises on depression, anxiety, and stress status of adult patients with chronic low back pain. Jour of Pharma and Biomedical sciences. 23(16). 20. Sullivan MJ, Reesor K, Mikail S, Fisher R. The treatment of depression in chronic low back pain: Review and recommendations. Pain.1992;52:249. 21. http://www.atlanticspinecenter.com/blog/v /depression-caused-by-chronic-back-pain 22. Michael Craig Miller,(2011). Low back pain and the psychological issues. Harvard Mental Health Letter, Harvard Medical School. 49 pages. 23. Carragee, E.J. (2005). Persistent low back pain. N Engl J Med. 352: 1891-1898. 24. Paluska, S.A, Schwenk, T.L., (2000). Physical activity and mental health.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 20
[Research Report] Current concepts. Sports Med. 29(3). 16780. 25. Artal, M. (1998). Exercise against depression. Phys sportsmed. 26(10). 5560.
Tables S.No
Age
Percentage of participants
1
25-27
27%
2
28-30
30 %
3
32-33
25%
4
34-35
18%
Mean
S.d
31.28
2.16
S.D
Student ‘t’value
2.62
3.32
S.D
Student ‘t’value
7.17
4.53
Table: 1 Demographic data S.No
Group
Mean
1
Group A
8.75
2
Group B
11.25
Table: 2 Back Depression Inventory S.No
Group
Mean
1
Group A
18.9
2
Group B
29.1
Table: 3 Functional Disability Index
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 21
[Research Report] FIGURES Figure I
Demographic Data
25-27
28-30
32-33
18%
34-35
27%
25% 30%
Figure II
Back Depression Inventory 11.25 12 8.75 10 8 6 4 2 0 Group A
Group B
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 22
[Research Report] Figure III
Functional Disability Index 29.1 30 25
18.9
20 15 10 5 0 Group A
Group B
I
Corresponding Author Dr. B.ARUN.,MPT,CMPT,MIAP, PhD* Dr.M.S.Nagarajan, PhD,** S.Mohammed Auriff,MPT,CMPT,MIAP.*** * Professor, K.G.College of Physiotherapy, KG ISL campus, Sarvanampatti. Coimbatore. 9994576111. barunmpt@gmail.com. ** Dean, Ramakrishna Mission Vivekananda University, srkv post, P.N.Palayam, Coimbatore. msnagoo@gmail.com *** Physical therapist, Kare partners and complete rehab inc. USA. md_auriff@rediffmail.com
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 23
[Research Report]
Effect of Six Weeks of Play Therapy Skill Inventory on Cognition and Stress in Older Adults Jasmine1, Gaurav Shori2
ABSTRACT Objective: To see the effect of six weeks of play therapy skill inventory on stress and
cognition in older adults. Design: Pre test – post test design. Setting: Old age home and community recreation center. Participants: A total of 42 older adults with age (65-90 years) were selected, keeping in
mind the inclusion and exclusion criteria. They were randomly divided into two equal groups, Group A (N=21) and Group B (N=21). Intervention: Group A (experimental group) received play therapy and dance movement therapy while group B (control group) received only dance movement therapy for 6 weeks. Main Outcome Measures: Pre-test measurement of cognition as well as stress was done
using MMSE (mini-mental state examination) and GDS (geriatric depression scale). Following the protocol of 18 sessions (3 sessions each week for 6 weeks), post-test measurement was done. Results: Statistically significant differences in gained scores were observed in MMSE scores
(P < 0.05) and GDS scores (P < 0.05) for the experimental group as compared to control group.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 24
[Research Report] Conclusion: Six weeks of play therapy skill inventory significantly improves cognition and
decreases stress levels in older adults. Keywords: Amyloidal load, dance movement therapy, neural-plasticity, play therapy, social-
emotional learning, transfer effect
Introduction
selected issues that needed to be resolved
Our cognitive function changes over our
and move towards self- actualization.12
lifetime.1,
Association
2, 3
Individuals move through
of
play
therapy
United
circular
Kingdom (2012) defines play therapy as
fashion, that is, as sensation and motor
â&#x20AC;&#x153;an interpersonal process where in a
skills develop, perception skills increases.
trained therapist systematically applies the
Each increase in perceptual sensory-motor
curative powers of play to help client
skills permit organization, integration and
resolve
accommodation of new learning with an
difficulties and help to prevent future
individual.4 Brain- plasticity also creates
ones.7
these
stages
in
hierarchical
an opportunity to strengthen cognitive abilities
as
investigated
by
several
studies.5, 6
their
current
psychological
However, most of the studies addressed the therapeutic benefits of play therapy for Children and Adolescents,4, 7, 8, 9, 13, 14,15,16,
For over 60 years, play therapy has been a
17, 18, 19
well established and popular mode of
adult play therapy can be demonstrated as
treatment in clinical practice for chidren.4,
effective with elderly, it should not be
7, 8, 9
ignored simply because a little research or
According to play therapy United
Kingdom, children of all ages (0-100 years) can participate in play. Play therapy techniques can just as easily be adapted for adults and their inner child.10 A little research or limited evidence exists for therapeutic use in adult and elderly.
11
if an innovative approach, such as
limited evidence exists.12 Maximum researches in play therapy for elderly focused on visual- reality games, which might not be cost-effective for community dwelling older adults.1, 20, 21, 22, 23
Although
play therapy
researches
Much like children, when encompassed by
showed positive outcomes, none of the
the
and
research has compared play therapy
relationships established in play therapy,
interventions with any other therapeutic
the adult is free to select the subconscious
interventions.
therapeutic
environment
4,7,8,13,16,17,18,19
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Therefore,
Page 25
[Research Report] this research aims to explore the effect of
firstly participated in 3 play therapy
play therapy skill inventory on stress and
activities, beat the clock (for attention),
cognition in older adults.
survival judgment task (for memory) 24 and weight and balloons (for stress and
Methodology 42 older adults from old age home and community recreation centers, New Delhi were selected based on inclusion criteria (age 65-90 years, MMSE score: 19-23, geriatric depression scale score: more than 9, cooperative subjects, subjects who can participate in ADLâ&#x20AC;&#x2122;s independently) and exclusion criteria (any musculoskeletal injury, cardio- respiratory complaints, neurological problems in past 6 months diagnosed by physician, any systemic disease diagnosed by physician, complaint of dizziness in past 1 month). After that, they were randomly divided into two groups. Group A (experimental group; n=21 and group B (control group; n=21) with
their
(79.95+7.00);
7
mean
age
height
(77.31+7.60), (161.23+7.36),
(160.73+6.46), and weight (63.95+7.36), (68.04+10.95) respectively. Pre test measurement of cognition and stress was done using MMSE and GDS respectively. All the procedures were explained to the participants and informed consent was obtained from them. The study was approved by local ethical committee prior to the commencement of the study. Group A (experimental group)
anxiety) 7. The play therapy session lasted for 40 minutes. A brief break of 10 minutes was given to the subjects before commencement
of
dance
movement
therapy session. It comprised of a brief warm up for 5 minutes, which included isolations, concentration of movement, and attention to single body part. Warm up was followed by locomotion for 30 minutes, which included activities for lower limb such as stepping, walking backward and forward, circling, lifting legs, tiptoeing with foot to the front, side and rear, heal raises and activities of upper limb such as stretching, circling, shrugging, abduction. The session was terminated by cool down phase for 5 minutes with activities same as warm up.25 Dance moment therapy session also lasted for about 40 minutes. Group B (control group) received dance movement therapy alone. Subjects were trained in a group of five individuals in each session of dance movement therapy and play therapy respectively. Post test measurement of stress and cognition was done again, after 18 sessions (3 sessions each week, for 6 weeks) of intervention.
Results
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 26
[Research Report] No significant differences in age, weight,
evidence suggests that performing some
and height as well as pre test GDS and
cognitive training
MMSE
games
were
detected
at
the
commencement of the study.
in
both
the
29,
30
and playing certain
could contribute to
improvement of cognitive functions in
Since the baseline characteristics of the subjects
28,
26, 27
groups
elderly1.
were
The mechanism of transfer effect proposes,
comparable, the outcome variable i.e.
the transfer effect could be induced, if the
difference of MMSE and GDS scores
process both during the training and the
(gained scores) were compared between
transfer task are over-lapped and are
group A (experimental group) and B
involved in similar brain regions.31,
(control group) using independent t-test.
perform these processes successfully, the
Significant differences were observed in
pre-frontal regions should be recruited1, 33.
levels of cognition (p=0.0001) and stress
The cognitive functions of the adult human
levels (p=0.033) between group A and
pre-frontal cortex are viewed as the
group B. (Table 1 and Figure 1)
culmination of biological processes that
Statistically significant differences were observed between pre and post readings of MMSE
and
GDS
within
group
A
(p=0.0001) and (p=0.0001) respectively. (Table 2 and Figure 2)
To
lead to the highest expression of temporal integration in language and intellectual performance.34 Previous studies have also proposed the possibility of feedback processes or experiencing new things to explain the possibility of transfer effect.
Statistically significant differences were observed between pre and post readings of MMSE and GDS in group B (p=0.0001) and (p=0.0001) respectively. (Table 3 and Figure 3)
1.
35.
Emerging theory suggests that, play facilitates healthy cognitive development by frontal lobe maturation,
30
facilitates
inhibitory skills or regulatory functions36 and
Discussion Present study results indicate that play therapy skill inventory is effective in reducing stress levels and improving cognition
32
in
older
adults.
Previous
by
through inhibition
promoting the due
pro-social
maturation to
the
of
minds behavior
presence
of
dopamine sensitive neurons which is reported to be associated with reward,
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 27
[Research Report] attention, short-term memory task and motivation.
3
with decrease in level of cortisol. Mood
Some researchers have also proposed an emotional hypothesis to account for the benefit of the survival judgment task (one of the play therapy intervention used in the study). The emotional hypothesis is based on the evidence that emotions could enhance
memory performance.24
Few
studies reported that higher levels of social emotional learning or emotional literacy can reduce subject stress levels and increase feeling of well-being, improve coping abilities, limit drug and alcohol addiction enhance
,
mood and recreation has been established
mediate
aggression
psychological
and
functioning.
Fredrickson and Joiner 2002 emphasized the role of positive emotions in broadening
elevation was reported after therapist directed recreational activity. Literature also suggest that mind-fullness based games leads to stress reduction, and significantly improves quality of life, relieves symptoms of stress and sleep in those, with early stage breast cancer and prostate
cancer.
When
researchers
measured cytokine changes, they found that T cell production of IL-4 increased and IF-y decreased. In addition, NK cell production
of
IL-10
also
decreased,
prompting them to conclude that there was a shift from one immune profile associated with depressive symptoms to a more normal immune profile.38
peopleâ&#x20AC;&#x2122;s capacity to learn. They explained,
In addition to that, physical strenuous play
positive
optimistic
can also synthesize the normal benefits of
thinking, which leads to more creative-
both exercise and play by simultaneously
problem solving capacities. Research also
providing physical, social and intellectual
demonstrates that positive emotions have
stimulation.
the ability â&#x20AC;&#x153;to undoâ&#x20AC;? the effects of stress
creates a positive challenge or stress to the
and surely encourage both emotional and
brain, which in turn causes the brain to
physical resilience.37
adapt, resulting in healthy cognitive
emotions
enhance
Preliminary evidence supports that nonpharmacological interventions like play can help facilitate autonomic nervous system and hypothalamus pituitary axis balance and thereby decreases stress and improve mood. Link between HPA axis,
This
synergy of
stimuli
development. In this respect, physically strenuous play constitutes an enriched environment,
which
entails
physical
activity, social interaction, and intellectual stimuli.30 Researches also suggest that an enriched environment is activity prone and
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 28
[Research Report] contributes to enhanced brain plasticity via
3. Park J, Carp J, Hebrank A, Park DC, Polk TA.
synaptogenesis,
Neural specificity predicts fluid processing ability
neurogenesis
and
attenuation of neural response to stress.
in older adults. The Journal of Neuroscience 2010; 30(27): 9253-9259. 4. Hurff J. A play skill inventory: A competency
Conclusion Play therapy with adults is a luminous trial
monitoring tool for 10 years old. The American Journal of Occupational Therapy 1980; 34(10):
which delves deeply into the theoretical
651-656.
and practical aspects of play. Observed
5. Wolinsky FD et al. Protocol for a randomized
outcomes
control trial to improve cognitive functioning in
of
therapy
reported
were
decreased depression, improved cognition, heighten
self-esteem,
improved
healthy older adults: The Iowa healthy and active minds study. BMJ OPEN 2011; 1(2): 218. 6. Lee DT, Swanson LR, Hall AL. What is repeated
socialization skills, and what appeared to
in a repetition? Effects of practice conditions on
be resolution of difficult issues. Therefore,
motor skill acquisition. Physical Therapy 1991;
it can be concluded that six weeks of play
71(2): 150-156.
therapy skill inventory is significantly effective in improving cognition and reducing stress levels in older adults.
7. Hall TM, Kaudson HG, Schaefer CE. Fifteen effective play therapy techniques. Professional Psychology Research and Practice 2002; 33(6): 515-522. 8. Bratton et al. The efficacy of play therapy with
Acknowledgement
children: A meta-analytic review of treatment.
I would like to acknowledge, Ruchika
Professional Psychology, Research and Practice
Gupta,
2005; 36(4): 376-390.
Lecturer,
Department
of
Physiotherapy, I.T.S Paramedical College, for extending help in data analysis and interpretation.
References 1. Nouchi R et al. Brain training game improves
9. Phkhtina O, Balaam M, Wood G, Sue P, Olivier P. Designing for attention hyperactivity disorder in play therapy: the case of magic land. DISC 2012; 11-15. 10. Barnes M. An Introduction to Play Therapy. Kingston: Play Therapy Institute; 2001.Available from:
executive functions and processing speed in
http://www.playtherapy.org.uk/Resources/Articles/
elderly: A randomized controlled trial. PLos ONE
ArticleMBIntro1.htm
journal 2012; 7(1).
11. Kemoun G et al. Effects of a physical training
2. Gross AL et al. Word list memory predicts
programme on cognitive function and walking
everyday function and problem solving in elderly:
efficiency in elderly persons with dementia.
Results from the ACTIVE cognitive intervention trial. Aging, Neuropsychology, and Cognition: A
Dementia and Geriatric Cognitive Disorders 2010; 29: 109-114.
Journal on Normal and Dysfunctional Development
12. Cochran NH, Nordling WJ, Cochran JL. Child
2011; 18(2): 129-146.
Centered Play Therapy: a practical guide to
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 29
[Research Report] developing therapeutic relationships with children.
The third international conference on e-health,
Hoboken New Jersey: John Wiley & Sons; 2010
telemedicine, and social medicine. IARIA 2011:
13. Nigussie B. Efficacy of play therapy on self-
58-63.
healing and enhancing life-skills of children under
23. Halton J. Virtual rehabilitation with video
difficult circumstances: the case of two orphanages
games: A new frontier for occupational therapy.
in Addis Ababa, Ethiopia. Ethiopian Journal of
Occup Ther Now 2008; 9(6): 12-14.
Education and Sciences 2011; 6(2): 51-56.
24. Nouchi R. The effect of ageing on the memory
14. Levine et al. Early puzzle play: A predictor of
enhancement of the survival judgment task.
preschoolers’
Japanese Psychological Research 2012; 54(2): 210-
spatial
transformation
skill.
Developmental Psychology 2011; 48(2): 530-542.
217.
15. Kolehmainen et al. Participation in physical
25. Couper JL, Effects on motor performance of
play and leisure: developing a theory- and evidence
children
based
Therapy 1981; 61(1): 23-26.
intervention
for
children
with
motor
with
learning
disabilities.
Physical
impairments. BMC Pediatrics 2011; (11): 100.
26. Shinya U, Ryutu K. Reading and solving
16. Sueann G, Nozaiska K. The sexual abuse
arithmetic problems improves cognitive functions
literature & considerations for play therapists.
of normal aged: a randomized controlled study.
Association for Play Therapy Mining Report 2008:
American Ageing Association 2008; 30: 21-29
1-3.
27. Lustig C, Shah P, Seidler R, Patricia A, Lorenz
17. Lowenstein L. Creative interventions for
R. Aging, training, and the brain: a review and
children of divorce. Toronto: Champion Press;
future directions. Neuropsychol Rev 2009; 19: 504-
2006.
522.
18. Urquiza AJ. The future of play therapy:
28. Basak C, Boot WR, Voss MW, Kramer AF.
Elevating credibility through play therapy research.
Can training in a real time strategy video game
International Journal of Play Therapy 2010; 19(1):
attenuate cognitive decline in older adults? Psychol
4-12.
Ageing 2008; 23(4): 765-77.
19. Phillips RD. How firm is our foundation?
29. Torres ACS. Cognitive effects of videogames
Current play therapy research. International Journal
on older people. International Journal on Disability
of Play Therapy 2010; 19(1): 13-25.
and Human Development 2011; 10(1): 55-58.
20. Szturm T, Betker AL, Moussavi Z, Desai A,
30. Sattelmair J, Ratey JJ. Physical active play and
Goodman V. Effects of an interactive computer
cognition. An academic matter? American Journal
game exercise regimen on balance impairment in
of Play 2009: 365-374.
frail
31. Dahlin, E. (2009). Train Your Brain - Updating,
community-dwelling
older
adults:
a
randomized controlled trial. Physical Therapy
Transfer,
and
Neural
Changes.
Doctoral
2011; 91(10): 1449-1462.
dissertation from the Department of Integrative
21. Krampe J. Exploring the effects of dance-based
Medical Biology, section for Physiology, Umeå
therapy on balance and mobility in older adults.
University, S-901 87 Umeå, Sweden. ISBN: 978-
Western Journal of Nursing Research 2013; 35(1):
91-7264-834-0
39-56.
32. James NK et al. Mapping interference
22. Tous F. Play for health: videogame platform for
resolution across task domains: a shared control
motor and cognitive tele-rehabilitation of patients.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 30
[Research Report] process in left inferior frontal gyrus. Brain Res.
36. Hromek R, Roffey S. Promoting social and
2009; 56(12): 19-23.
emotional learning with games, “It’s fun and We
33. Kawshima R. A functional MRI study of simple
learn things”. Journal of Simulation and Gaming
arithmetic- a comparison between children and
2009; 40(5): 626-644.
adults. Brain Research Cong Brain Res 2004;
37. Fredrickson BL, Joiner T. Positive emotions
18(3): 227-233.
trigger upward spirals toward emotional well being.
34. Green CS, Bavelier D. Exercising your brain: a
Journal of Psychological Science 2002; 13(2): 172-
review of human brain plasticity and training-
175.
induced learning. Psycho Ageing 2008; 23(4): 692-
38. Russoniello CV, Brien KO, Parks JM. The
701.
effectiveness of casual video games in improving
35. Panksepp J. Can play diminish ADHD and
mood and decreasing stress. Journal of Cyber
facilitate the construction of the social brain? J Can
Therapy and Rehabilitation Spring 2009; 2(1): 53-
Acad Child Adolesc Psychiatry 2007; 16(2): 57-66.
66.
Appendix Tables
MMSE difference GDS difference
Group A (mean ±SD)
Group B (mean ± SD)
‘p’ value
4.00±1.24
1.71±1.38
.0001
5.52±2.14
4.20±1.57
.033
Table 1: Representing gained scores (pre-test, post-test difference in scores) MMSE and GDS between group A (experimental group) and group B (control group).
Pre-test (Mean+SD)
Post-test (Mean+SD)
‘p’ value
MMSE
20.42+1.42
24.42+1.64
.0001
GDS
17.52+3.62
12.0+3.86
.0001
Table 2: Representing comparison of pre-test and post-test scores of MMSE and GDS within group A (experimental group).
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 31
[Research Report] Pre-test (Mean+SD)
Post-test (Mean+SD)
‘p’ value
MMSE
20.33+1.06
22.42+1.77
.0001
GDS
16.80+3.72
12.57+2.94
.0001
Table 3: Representing comparison of pre-test and post-test scores of MMSE and GDS within group B (control group).
Figures 9 8 7
Score
6 5 Group A
4
Group B
3 2 1 0
Diff MMSE
Diff GDS
Group A
4
5.52
Group B
1.71
4.2
Figure 1: Representing gained scores (pre-test, post-test difference in scores) MMSE and GDS between group A (experimental group) and group B (control group).
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 32
[Research Report] 30 25
SCORE
20 15
Pre-Test Post-Test
10 5 0
MMSE
GDS
Pre-Test
20.42
17.5
Post-Test
24.42
12
Figure 2: Representing comparison of pre-test and post-test scores of MMSE and GDS within group A (experimental group). 30 25
SCORE
20 15 Pre-Test
10
Post-Test
5 0
MMSE
GDS
Pre-Test
20.33
16.8
Post-Test
22.42
12.57
Figure 3: Representing comparison of pre-test and post-test scores of MMSE and GDS within group B (control group).
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 33
[Research Report] Corresponding Author Gaurav Shori Assistant Professor Address: Department of Physiotherapy, I.T.S Paramedical College, Delhi-Meerut Road, Muradnagar, Ghaziabad, U.P, India201206 Email: gauravshori@its.edu.in Ph : +91-9999797466 Fax : 01232-260765, 225380 Š 2013 PGIP. All rights reserved
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 34
[Research Report]
Gender Differences in Pain Perception and Coping Strategies among Patients with Knee And Or Hip Osteoarthritis Olarogba Olalekan Bolaji 1*, Idowu Opeyemi Ayodiipo 1, Adegun Joel Adekunle 2 and Ajayi-Vincent O2
Abstract:
Background: Osteoarthritis (OA) is a common cause of functional disability, reduced quality
of life and economic burden worldwide. However published works on gender differences in the pain coping strategies engaged in by patients who experience pain as a result of hip and/or knee osteoarthritis are scarce. This study therefore aimed to explore this. Methods: Two hundred and fifteen patients receiving treatment at Federal Medical Centre,
Ido Ekiti, Ekiti state, Nigeria were surveyed. Socio-demographic data, BMI, pain intensity and joint affected were garnered from participants. Active and Passive Coping strategies were measured using the Pain Coping Inventory. Inferential statistics of t test and Man Whitney U were used to determine significant differences between genders. Significance level was set at p<0.05. Results: Out of the 215 patients (38.1% males vs. 61.9 % females) that were surveyed,
61(28.4%) had hip OA, 83(38.6%) had knee OA and 71(33%) had combined presentations. There was a statistical significant correlation between gender and each of BMI (p= 0.000) and perceived pain (p= 0.012). Overall, the use of passive coping strategies by men were
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 35
[Research Report] significantly higher (U= 4022.5, p= 0.001) than women with the use of resting as a coping strategy higher among males (U=4459.0, p= 0.023) than females. Conclusion: The results obtained from the study shows that passive pain coping strategies
were used by patients with hip and or knee osteoarthritis. A consistent finding emerging from research is that the frequent use of passive coping strategies is related to negative outcomes such as increased pain, depression, and physical disability. Keywords: Coping, Osteoarthritis, Pain. both direct (physician visits, medications,
Introduction: Osteoarthritis
(OA)
also
known
as
joint
replacement,
rehabilitation)
and
degenerative arthritis is caused by the
indirect costs (time lost from work). It is
breakdown and eventual loss of the
estimated that by 2020, the cost to society
joints.5
of lost productivity will approach 1% of
cartilage
of
one
or
more
Osteoarthritis is a common cause of pain,
the gross national product 7.
functional disability and reduced quality of
Systematic reviews have reported higher
life.1,10,16 Features of OA includes pain,
prevalence of OA in developing countries
reduced range of motion, joint stiffness,
compared to developed countries. They
joint instability, synovial effusion, and
have documented that it is a pointer
pain-related psychological distress and
therefore that developing nations may
decreased muscle strength.27-28 Several
suffer more from OA when compared to
factors which have been associated with
the western world
the development of OA include increase in
population ageing and rising obesity rates.
age, risk factor of obesity, due to
The knees, followed by the hips, are the
progressive
most commonly affected weight-bearing
sedentary
behaviour,
diet
4
due to the fact that
routine, work environment conditions
joints.
among adult population.5 OA can occur in
Cognitive and behavioral reactions to
all joints, but most frequently in the knee
chronic pain may affect pain, functional
and hip joints .10
capacity, and psychological functioning in
The burden of knee and hip OA are
patients with OA. These reactions to pain
increasing worldwide
5
. Perrot et al.,20
are commonly referred to as pain coping
reported a global knee and hip prevalence
strategies
20
estimate of 58.9% and 32.9% respectively.
generally
mean
The financial burden on society involves
unconscious efforts made by individuals to
. By â&#x20AC;&#x2DC;copingâ&#x20AC;&#x2122;, researchers both
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
conscious
and
Page 36
[Research Report] manage stress and negative feelings that
osteoarthritis duration, with pain intensity
are perceived as a drain on oneâ&#x20AC;&#x2122;s resources
having weaker effect 20.
11
. Hansson 14 , further divided pain coping
into
active
strategies,
where
you
Therefore Pain Coping Inventory (PCI) 17
overcome, handle and take control of your
designed by Kraaimaat and Ewers
pain and passive strategies, which include
developed to assess specific cognitive and
withdrawal, avoidance and negative self-
behavioural pain coping, active or passive,
18
, was
confidence. McKnight et al., posited that
to be applicable to all types of chronic pain
all interventions aim to either reduce a
patients. Hence the aim of this study is to
negative target or enhance a positive target
assess the use of different pain coping
18
that
strategies, active or passive among patients
Psychology embraces this two factor
with osteoarthritis and to determine the
approach with a surging interest in
association between perceived pain and
.
They
further
emphasized
preventing the occurrence of OA
18
coping strategies in persons with knee
Although medical treatment can alter the
and/or hip osteoarthritis as well as analyze
degree of inflammatory joint disease, it is
the differences between gender and other
not curative and only occasionally induces
background factors.
remission
24
. Studies have shown that
patients using passive coping strategies have higher levels of pain and disability 9. Many people do not readily seek medical care because of their belief that OA is an inevitable condition of the old for which little can be done and had resulted to several form of practices unknown to them in coping with the challenges of living with OA. It has also been seen that in people with osteoarthritis active and passive strategies differs significantly as a function
of
age,
body mass
index,
osteoarthritis involvement, professional and marital status, sport activities and
Methodology: Delimitation: The study was delimited to
patients diagnosed of hip and/or knee OA at
Federal
Medical
Centre
Ido-Ekiti
between the age of 25 and 85 years with more than three (3) months duration and have
not
taken
part
in
ongoing
Physiotherapy or undergone knee joint replacement. Research Design: This study was a
descriptive correlation study which was intended to compare the different coping strategies
employed
either
active
or
passive among male and female patients.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 37
[Research Report] Population: The population shall be a
therefore recommended for use in Nigeria.
representation
19
of
patients
with
osteoarthritis seen at Federal Medical Centre
Ido
Ekiti,
Ido-Osi
Local
Government Area, Ekiti state. Sample
and
Sampling
Patients
shall
Pain Coping Inventory (PCI): PCI was designed by Kraaimaat and Evers
17
, and
contains 33 claims which can be pooled Technique:
recruited
into two major dimensions of cognitive
using
and behavioral strategies for dealing with
All
chronic pain. These dimensions include
patients presenting to the clinic shall be
active pain-coping dimensions with a
screened for a history of knee pain by the
maximum
Physiotherapists. Eligible Patients who
transformation,
met the inclusion criteria shall be asked to
demands)
self-evaluate their average pain score using
dimensions with a maximum of 84
the Visual Analogue Scale (VAS). Also to
points(retreating, worrying and resting.
determine the patients´ knee pain coping
The frequency with each claim, when
strategies, patients shall be asked to fill the
feeling pain, is marked on a 4- point Likert
Pain
scale ranging from 1 (hardly ever) to 4
convenience
be
.
sampling
Coping
technique.
Inventory
(PCI)
questionnaire.
of
48
points
distraction,
and
passive
(pain reducing
pain-coping
(very often). The higher the score the more
Research Instruments: Visual Analogue
Scale (VAS): The visual analogue scale measures the amount of pain that a patient feels. Operationally a VAS is usually a horizontal line, 100 mm in length,
a certain strategy was used. Data on participants’ age, gender, height, weight, how long they have had hip and/or knee disability, affected joint, occupation, will be taken too.
anchored by word descriptors “no pain at
Administration
all” at one end and “worst imaginable pain
researcher approached patients who were
“at the other end. The patient marks the
identified as eligible for inclusion to
line on the point they feel represents their
discuss the study and given standard
perception of their current state
13
. The
information.
of
Those
Instruments:
who
agreed
The
to
VAS has reliable translated anchors in the
participate were asked for their written
Nigerian major languages: Yoruba (0.63),
consent and for patients who were unable
Igbo (0.93) and Hausa (0.98) and it is
to give informed written consent, assent was sought from the patients' relatives. To
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 38
[Research Report] determine the patients´ knee pain and their
used to describe to compare gender
coping strategies, at the first meeting
difference in clinical characteristics (pain,
before treatment is administered, the
BMI
patients were asked to fill in the two
statistics of Unpaired t-test shall be used.
instruments, PCI and VAS and also an
Mann-Whitney U-test shall be used to
individual background form.
compare gender differences in PCI and
and
joint
affected)
parametric
VAS scores. To evaluate if there were
Data Analysis
correlations between pain coping strategies
SPSS version 16 (Illinois, USA) shall be
and background factors, spearman rank
used
correlation shall be used.
for
data
analysis.
Descriptive
statistics of frequency and mean shall be
Results:
There
The study comprised 215 participants
correlation between gender and each of
(38.1% males vs. 60.9% females) with
BMI (p= 0.000) and perceived pain
mean ages of 53.54 SD 13.27 years.
intensity (p= 0.012). There was however
Majority of the respondents (62.3%) were
no correlation between BMI and perceived
married and more than half of the
pain intensity (p= 0.171). Non parametric
respondents
statistics of Man Whitney U showed a
(56.3%)
were
employed.
was
a
statistical
significant
were
statistically significant difference in the
overweight (59.5%) with 22.3% being men
use of passive (p= 0.001) but not active
and 37.2% being women. Percentages of
(0.425) coping strategies between gender.
those who had knee OA, hip OA and both
However, in each of the sub-domains of
knee and hip OA were 38.6%, 28.4% and
the coping strategies, significant statistical
33%
differences were found in each of resting
Majority
of
the
respectively.
participants
Characteristics
of
patients are presented in table 1.
(p=0.023) and reduced demand (p=0.014) between gender.
Discussion:
intensity. Pain coping scores for all
This study provides data that was got from
domains were higher for men with the
215
Physiotherapy
exception of pain transformation and
treatment at the Federal Medical Centre,
reduced demands. This suggests that men
Ido Ekiti. Pain coping strategies in patients
use a more diverse range of strategies than
with lower extremity OA (hip and/or knee)
women when faced with pain due to OA
was analyzed with the perceived pain
and the reason why men employ the use of
patients
attending
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 39
[Research Report] passive
coping strategies
more
over
strategies between patients with hip and
women. The pain generated by OA leads
knee OA. For instance, Steultjens, Dekker
to a decrease in physical
function,
and Bijlsma 25 demonstrated that the use of
disability, and poor quality of life, and has
passive coping strategies predicted a
a major impact on functioning
20
. The
higher level of disability in patients with
population
studied
knee OA and that active coping style
demonstrated lower active pain coping
predicted a high level of pain intensity.
strategies and much higher passive pain
They also showed that resting was a
coping scores as described in the article by
prospective determinant of disability for
Kraaimaat and Evers 17.
knee OA, but not for hip OA.
The site of OA was found to have a
Conclusion:
significant effect on coping strategies.
The results showed men tend to make
Score for passive coping strategies were
wider use of all types of pain coping
significantly higher in patients with OA
strategies.
affecting both knees and hips than in
factors
patients in whom only one of these sites
strategies. Furthermore, certain personal
was affected. It was also found that passive
characteristics, such as professional status,
pain coping score was significantly higher
marital status, and sports activities, may
in patients with knee OA than in patients
also influence pain coping strategies.
with hip OA following adjustment for sex
Hence, knowledge of the methods by
and BMI. These differences in pain coping
which patients cope with OA use may
strategies
make
of
may
OA
be
patients
associated
with
Demographic
may
it
influence
possible
to
and
clinical
pain
coping
improve
OA
differences in functional consequences,
management, thus integrating pain coping
consistent with the results reported by
strategies specifically adapted to age, sex,
3
Allen, Golightly and Olsen . Other studies
BMI,
have found differences in pain coping
impairment.
References 1. 2.
Altman RD (2010): Early management of osteoarthritis. American Journal of Managed Care. 16: 41-47. Akinpelu A.O, Alonge T.O, Adekanla B.A & Odole A.C. (2009): Prevalence and pattern of symptomatic knee osteoarthritis in Nigeria: A community based study. The
3.
4.
site
of
OA,
and
functional
Internet Journal of Allied Health Sciences and Practice, 7(3), 1-7 Allen K.D, Golightly Y.M, Olsen M.K (2006): Pilot study of pain and coping among patient with osteoarthritis: a daily diary analysis. Journal of Clinical Rheumatology; 12:118â&#x20AC;&#x201C;23. Bennell K.L and Hinman R.S. (2011): A review of the clinical evidence for exercise in osteoarthritis of the hip and
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 40
[Research Report] 5.
6. 7.
8.
9.
10.
11.
12.
13. 14.
15.
16.
knee. Journal of Science and Medicine in Sport; 14: 4–9 Bhatia D, Bejarano T and Novo M. (2013): Current interventions in the management of knee osteoarthritis. Journal of Pharmacy and Bioallied Sciences; 5(1): 30-38 doi: 104103/09757406.106561 Bijlsma, J. W. (2002): Analgesia and the patient with osteoarthritis. American Journal Therapy, 9, 189-197 Bohsali K.I. (2007): Contemporary Medical and Surgical Management of Osteoarthritis. Northeast Florida Medicine; 58(2): 45-48. www .DCMS online.org Brand C, Elkadi S and Amatya B. (2005): A Literature review of public health interventions for Rheumatoid Arthritis, Osteoarthritis and Osteoporosis. Clinical Epidemiology & Health Service Evaluation Unit, Melbourne. Covic T, Adamson B, Hough M. (2000): The impact of passive coping on rheumatoid arthritis pain. Journal of Rheumatology; 39:1027-30. Dreinho¨fer K, Stucki G, Ewert T, Huber E, Ebenbichler G, Gutenbrunner C, Kostanjsek N and Cieza A. (2004): ICF core sets for osteoarthritis. Journal of Rehabilitation Medicine; Suppl. 44: 75– 80 Franco .R.L, Garcia C.F and Picabia B.A. (2004): Assessment of chronic pain coping strategies. Actas Esp Psiquiatr 32(2): 8291 Gignac Monique (2008): Coping and Adaptation of Older Adults with Osteoarthritis. Arthritis Community Research and Evaluation Unit, Toronto. Gould D (2001). Visual Analogue Scale. Journal of Clinical Nursing Hansson M. (2011): Active or passive pain coping strategies among participants before hip school. Published Master’s thesis, Linneaus University, Kalmar. Hochberg M.C, Altman R.D, April K.T, BenkhaltI M, Guyatt G, Mcgowan J,Towheed T, Welch V, Wells G and Tugwell P. (2012): American College of Rheumatology 2012 Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care & Research 64(4), 465–474 DOI.10.1002/acr.21596 Hunter D.J, McDougall J.J, Keefe F.J (2008): The symptoms of osteoarthritis and the genesis of pain. Rheumatic
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Disease Clinics of North America 34: 623643. Kraaimaat F.W and Evers A.W.M. (2003): Pain-coping strategies in chronic pain patients: Psychometric characteristics of the pain-coping inventory (PCI). International Journal of Behavorial Medicine 10 (4):343-63 McKnight P.E, Afram A, Kashdan T.B, Kasle S. & Zautra A. (2010): Coping selfefficacy as a mediator between catastrophizing and physical functioning: treatment target selection in an osteoarthritis sample. Journal of Behavioral Medicine. DOI 10.1007/s10865-010-9252-1 Odole A.C and Akinpelu A.O (2009). Translation and alternate forms reliability of the visual analogue scale in the three major Nigerian languages. The internet journal of allied health sciences and practice. Perrot S, Poirraudeau S, Kabir M, Bertin P, Sichere P, Serrie P, Rannou F. (2008): Active or passive pain coping strategies in hip and knee osteoarthritis. Arthritis Care Research; 59(11):1555–62 Picavet H. S, & Hazes J. M. (2003): Prevalence of self reported musculoskeletal diseases is high. Annals of the Rheumatic Diseases, 62, 644-650 Peat G, McCarney R, Croft P (2001): Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Annals of Rheumatic Diseases 60: 91-97 Peat G, Thomas E, Duncan R. (2006) Clinical classification criteria for knee osteoarthritis: performance in the general population and primary care. Annals of the Rheumatic Diseases 65: 1363–7. Sawyer M. G, Whitham J. N, Roberton D. M, Taplin J. E, Varni J. W. and Baghurst P. A. (2003): The relationship between health-related quality of life, pain and coping strategies in juvenile idiopathic arthritis. British Society of Rheumatology, 43:325–330. doi:10.1093/rheumatology/keh030 Steultjens M.P, Dekker J, Bijlsma J.W. (2001): Coping, pain, and disability in osteoarthritis: a longitudinal study. Journal of Clinical Rheumatology; 28:1068–72. Symmons D, Mathers C and Pfleger B. (2000): Global burden of osteoarthritis in the year 2000. Global burden of disease. http://www.who.int/healthinfo/statistics/bo d_osteoarthritis.pd
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
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[Research Report] 27. van Baar M.E, Dekker J, Lemmens J.A, Oostendorp R.A, Bijlsma J.W. (1998): Pain and disability in patients with osteoarthritis of hip or knee: the relationship with articular, kinesiological, and psychological characteristics. Journal of Rheumatology; 25:125-33. 28. van Dijk G.M, Veenhof C, Spreeuwenberg P, Coene N, Burger B.J, van Schaardenburg D, van den Ende C.H, Variables
Age Body Mass Index Pain Scale Site of pain Hip Knee Both
Lankhorst G.J, Dekker J. (2010): Prognosis of limitations in activities in osteoarthritis of the hip or knee: a 3-year cohort study. Archives of Physical Medicine and Rehabilitation; 91:58-66. 29. Woolf A, Pfleger B. (2003): Burden of major musculoskeletal conditions. Bull of the World Health Organization; 81(9):646-56.
Male (n=82) X (SD)
Female (n=133) X (SD)
54.77(10.78)
52.78(14.58)
26.42(2.64)
28.82(3.15)
6.35(1.32) n (%) 32(14.9%) 27(12.6%) 23(10.7%)
6.81(1.43) n (%) 29(13.5%) 56(26.0%) 48(22.3%)
Total (n=215) X (SD)
53.54(13.27) 27.91(3.18) 6.64(1.40) n (%) 61(28.4%) 83(38.6%) 71(33.0%)
Marital status 60(29.7%) 74(34.4%) 134(62.3%) Married 6(2.8%) 25(11.6%) 31(14.4%) Single 16(7.4%) 34(15.8) 50(23.3%) Widow Profession 58(27.0%) 63(29.3%) 121(56.3%) working 24(11.2%) 70(32.6%) 94(43.7%) retired Table 1: Background data for the study population (n=52). X: mean, SD: standard deviation, BMI: Body Mass Index (kg/m2)
Spearman's rho
Body Mass Index
Pain scale
Sex
BODY MASS INDEX
PAIN SCALE
SEX
1.000
.094
.436**
. 215 .094
.171 215 1.000
.000 215 .171*
.171
.
.012
N
215
215
215
Correlation Coefficient Sig. (2-tailed)
.436**
.171*
1.000
.000
.012
.
N
215
215
215
Correlation Coefficient Sig. (2-tailed) N Correlation Coefficient Sig. (2-tailed)
Table 2. Spearman’s correlation between gender and each of body mass index, pain scale and sex. **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed).
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 42
4965. 500
4459 .000
5100.5 00
4022.500
Asymp. Sig. (2-tailed)
.528
.953
.014
.061
.265
.023
.425
.001
Passive
Resting
4632 .000
Active
Worrying
4390. 000
demand
5427. 500
Reduced
Retreating
Whitney U
Distraction
5176.500
Pain Mann-
Transformation
[Research Report]
Table 3:Test Statisticsa : a. Grouping Variable: Sex Ranks Sex
N
Mean Rank
Pain
male
transform
female
133
Total
215
Distraction
male
Sum of Ranks
82
104.63
8579.50
110.08
14640.50
82
108.31
8881.50
female
133
107.81
14338.50
Total
215
Reduce
male
82
95.04
7793.00
demand
female
133
115.99
15427.00
Total
215
male
82
118.01
9677.00
female
133
101.83
13543.00
Total
215
male
82
113.95
9343.50
female
133
104.33
13876.50
Total
215
Retreating Worrying Resting Active Passive
male
82
120.12
9850.00
female
133
100.53
13370.00
Total
215
male
82
103.70
8503.50
female
133
110.65
14716.50
Total
215
male
82
125.45
10286.50
female
133
97.24
12933.50
Total
215
Table 4: Mann-Whitney Test
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 43
[Research Report] 2.
Corresponding Author Olarogba Olalekan Bolaji*rogba_lekan@yahoo.com* 07030301714. 1. Department of Medical rehabilitation, Federal Medical Centre, Ido-Ekiti, Nigeria. Department of Human Kinetics and Health Education, Ekiti State University, Ado-Ekiti, Nigeria. . Š 2013 PGIP. All rights reserved.
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
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[Research Report]
Professional Development of Physical Therapy and Frame work of Clinical Expertise in Pakistan Atif Dustgir, Dr. Ahmad Raza
Abstract Clinical expertise constitutes a core competency for quality patient care. It is an area of consideration for both patient and physical therapist. In an evidence-based world, one needs to know more about physical therapistâ&#x20AC;&#x2122;s approach for professional development especially in developing country like Pakistan. The process of being expert is not a naturally evolved process but rather it is a consciously learned process that involves meaningful engagement in purposeful activities acquired by experience over time. It is very important to establish the framework of the process of being clinically expert for establishing professional recognition to its standards. We will discuss this process with the models of professional development and clinical expertise for physical therapy profession. There is need of understanding on how to be an expert as an individual physical therapist as well. To frame the process of clinical expertise, we will also explain different phase of learning towards the clinical decision making skills in physical therapy as an essential component of EBP. Key words: Clinical decision makings, Clinical expertise, Clinical reasoning, EBP,
Evaluation & Prognosis.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 45
Introduction
council. A framework has been proposed for
Background: Physical therapy is concerned
the establishment of governing body as
with
and
Pakistan Physical Therapy Council (PPTC).
movement potential within the sphere of
At present, Pakistan Physical Therapy
promotion,
Association (PPTA) is acting as an advisory
maximizing
quality of
life
prevention, and
body to that proposed council.2 The main
rehabilitation1. The physical therapy is a
function of PPTA is to make guidelines for
profession which adds to the quality of life.
proposed PPTC. In the absence of PPTC,
Therefore, the main focus of various steps in
PPTA is to providing a platform to physical
professional
therapist for representation and promotion of
treatment/intervention,
habilitation
development
is
“Quality
improvement which attempts to change
Physical
clinician behavior. Those changes lead to
international recognition and affiliation of
more consistent, appropriate, and efficient
PPTA
application
clinical
Physical Therapy (WCPT) 3 opened up new
interventions, resulting in improved care and
avenues for PPTA. It has helped it to gain a
patient outcomes”.2 Quality reflects the
status
standard and integrity of pathways of effort
representation of physical therapist in
for the achievement of those standards in
Pakistan.
of
established
every day practice. The process of quality improvement is emphasized as a necessary part of good clinical practice. Defining standards and ensuring quality assurance within profession is a challenging task. In order to enhance the role of profession to its maximum level there must be an intact regulatory system for help and support of professionals.
Therapy with
of
World
a
profession.
The
Confederation
platform
for
for
national
PPTA’s mission is to suggest the most appropriate
map
for
professional
development and to suggest steps to enhance the competency of physical therapist in the evaluation and treatment of the patients requiring rehabilitation and management of physical problems4. This advisory body is committed to suggest the layouts to promote a culture of learning in physical therapy
There is no regulatory council to represent
professional among its members through
physical therapy profession in Pakistan.
evidence
However at official level efforts are on the
synthesized American Physical Therapy
go for the legislation of physical therapy
(APTA)’s 2020 Vision and Banner’s five
based
approach.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
PPTA
has
Page 46
[Research Report] step model of Professional excellence to find
Evidence-Based Practice, and Practitioner of
its way of professional development and
Choice.”6
recognition in Pakistan. The advisory effort of PPTA to promote physical therapy in Pakistan needs to be recognized by all stake holders, local as well as international. It is high time for physical therapist especially in developing countries to know international standard of professional excellence which might enable them to be effective physical therapy professional and practitioner.
In Pakistan, since 2005 direct access and autonomy of profession were core issues. However
the
development
concept
of
professional
groomed
in
2007
after
inception of Doctor of physical therapy (DPT) program. It became a milestone achievement in 2011 after approval of uniform curriculum by Higher Education Commission (HEC) for entry level DPT as
Professional
physical therapy graduation. The curriculum
PPTA
is
was designed to international standards with
working on (American Physical Therapy
focus on the vision of autonomous practice
Association) APTA’s Vision 2020 for
and enhanced clinical decision making
physical therapy professional development.
skills.
PPTA’s
Model
Development
in
of
Pakistan:
This Vision has the following significant elements: autonomous physical therapist practice, direct access, the doctor of physical therapy degree and lifelong education, evidence-based practice, practitioner of choice, and professionalism5. Massey BE Jr, President APTA during annual address in 2003 said that “we need a physical therapy culture
that
cultivates
and
promotes
activism. If we are to achieve our Vision — a vision of becoming an autonomous Profession—we must focus our efforts on 5 key areas: Professionalism, Direct Access, Doctor
of
Physical
Therapy
(DPT),
Clinical decision making is a very complex, scientific
process.7
The
strategies
for
professional development are focused to make decisions that include all aspects of expert practice, including knowledge, core values,
clear
clinical
reasoning,
and
excellent clinical practice skills emphasized on providing high-quality, patient-centered care8. The application of these clinically enabling strategies can greatly enhance the clinical competencies of PT particularly in the development countries like Pakistan where physical problems are generally
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 47
[Research Report] overlooked by the population. Clinical
predicaments, rights, and preferences in
decision making (CDM) skills are the
making clinical decisions about their care”. 9
hallmark of autonomous physical therapy
According to the APTA’s guidelines, as an
practice.
2020
autonomous clinician, the competency of a
emphasized on evidence based practice
physical therapist lies in diagnosis and
(EBP) as a necessary component of clinical
designing plan of care that is confirms to
The
APTA’s
expertise. Sackett D et al
vision
9
have presented
expertise in assessing the cause of problem
the concept of EBP and commented that
and design a purposeful and effective
“evidence based medicine is the integration
rehabilitation protocol which ideally should
of best research evidence with clinical
comprise of various interventions on the
expertise and patient values.” It simply
basis of best available evidence in the best
means that the practice of evidence-based
interest of patient. This whole process is
physical therapy requires integration of
characterized by decision making skills and
physical and cognitive abilities of the
is termed as evaluation process.
physical therapist. These abilities are,
process, the fundamental skills of the
individual
in
physical therapist which forms the basis of
implementation of one’s therapeutic skills
clinical expertise in evidence base practice
(physical ability) with the best available up
(EBP) is to analyze, identify and solve
to date clinical reasoning, evidence and
problems related to mobility dysfunction.
clinical
expertise
psychosocial understanding of patient’s need (cognitive ability).
In this
In Our Point of View, the metaphor of relationship
between
Clinical
decision
According to Sackets D et al, “By individual
making skills, evidence based practice and
clinical expertise, we mean the proficiency
professional expertise is an umbrella (Figure
and judgment that individual clinicians
1) which serves a physical therapist a
acquire through clinical experiences and
protection and safety within field of
clinical practice. Increased expertise is
practice. The word umbrella came from
reflected in many ways, but especially in
the Latin word umbra, meaning shade or
more effective and efficient diagnosis and in
shadow. The domain of EBP is comparable
the more thoughtful identification and
with
compassionate use of individual patients’
expertise of physical therapist within this
circumference
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
of
Umbrella.
The
Page 48
[Research Report] domain is the quality of umbrella’s canopy
Process” while the other side is “Therapeutic
which offers protection and gives benefit of
Interventional Process”. “The point of
safe actions.
Diagnosis” serves as the centre of Umbrella.
evaluation
In the
process
clinical has
settings,
range
from
presentation of patient with complaint to achievements of possible outcome for resolution of complaint. The process is centered on making diagnosis which is considered strength of an expert physical therapist and focus for clinical evaluation. If we consider this umbrella around a central axis, it comprises of two half i.e. one from patient
presentation
functional
diagnosis
up
to
and
making other
a
from
diagnosis to achieving outcomes. The first side
constitutes
“Clinical
Examination
The Examination Process consists of three components 8: 1) History 2) Systems review 3) Tests and measures. Similarly there are three component of a physical therapy intervention8. 1) Application of one or more direct Interventions 2) Patient-related Instruction 3) Coordination, Communication and Documentation
Figure 1 Umbrella of EBP, a metaphor of clinical expertise
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 49
These
components
the
therapist. The loci of clinical evaluation
infrastructure for clinical expertise and serve
process are to arrive at make functional
as network of wires (CDM skills) that
diagnosis.
stretch
(EBP)
components of the whole process to be
functional. These components channelize
integrated through a structural network of
findings in the evaluation process from
various
observation to diagnosis in first half and
component under a mechanism of decision
than from diagnosis to outcomes in second
making.
out
to
make
represent
umbrella
half. The quality of canopy of umbrella is
already
infrastructure (all components of clinical
within
each
discussed
two
components
of
clinical evaluation process. Each component
evaluation process) to be effective and valid
half
approach to process information between the
Expertise) covers and adheres to the
making
subcomponents
two
decision making skill requires an integrated
physical therapist. This canopy (Clinical
(in
requires
The competency for mechanism of clinical
comparable with the level of expertise of
purposeful
This
is applied in its domain as a complete
clinical
process while as a phase during the
examination and prognosis). We can say that
execution of whole clinical evaluation
the focus in clinical evaluation process is to
process.
attain competency in clinical expertise. This leads to the conscious learning process of developing clinical expertise in the physical Identification Integration
Analyzing
Problem Solving Process
Process Clinical
Decision
Making
skills
CLINICAL EXPERTISE
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 50
The clinical decision making skill also
him or her by patient through effective
involves a physical therapist in the process
communication skills coupled with sound
of integration of his or her therapeutic
clinical reasoning and attitudinal judgment . 7
knowledge and the information provided to (Phase
Therapeutic
of
Clinical Effective
Knowledge of physical judgment)
skills and cultural sensibility
Integration
therapist
process to interact with the patient
through (Knowledge
(Skilled
based clinical reasoning
clinical skill)
communication
based
clinical
expertise)
critical judgment creative decision-making
We can say that
developing
clinical
of musculoskeletal system in term of
expertise is an ongoing process which
mechanism
requires integration of two phases of
pathology of a physical problem. The
evaluation in everyday practice of physical
therapeutic skills in problem solving process
therapy.
are characterized by integration of attributes
The therapeutic skills in analytic process are characterized
by
attributes
of
clinical
analysis, judgment and clinical reasoning. The professional expertise in this phase of clinical evaluation leads to successful physical examination and ultimately to purposeful
diagnosis.
The
clinical
evaluation requires background knowledge of anatomy and functions of musculoskeletal system. The physical therapist need to interpret
the
effects
of
traumatic
of
trauma
or
underlying
of clinical reasoning along with enhanced physical physical
and
cognitive
therapist.
capabilities
This
leads
of to
implementation of learned skills in analytic process into clinical practice. This ability of continuous up gradation of knowledge through recent available evidence and understanding the circumstances is basic requirement of any interventional strategy in a clinical situation.
or
biological stresses on different components
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 51
[Research Report] In
addition,
Continuing
educational
clinical outcomes. Clinical reasoning is a
courses related to critical thinking and
multidimensional approach. It is based on
clinical reasoning are needed to improve
clinician’s way of thinking on ground of
the accuracy of diagnosis. The attitude of
therapeutic knowledge, previous clinical
Clinical reasoning in the practice through
practice and its interpretation in term of
Clinical reflection and mentorship are
therapeutic
routinely
important
outcome of any clinical intervention.
10
Clinical reflection is a powerful tool in
recognized
as
components of professional development
Jones & Rivett (2004)11 referred Clinical reasoning as thought processes used in patient diagnosis and management. This technique
is
universally
applied
by
clinicians. Clinical reasoning includes the application of cognitive and psychomotor skills based on theory and evidence. The reflective thought process is significant part
of
clinical
individual
inference
changes
and
to
direct
modifications
called for in specific patient situations.
12
Current research in clinical reasoning suggests that the process of applying therapeutic skills integrated with the intuitive ability to vary among clinicians. However an affective clinical examination followed by outcome based treatment based is deeply shaped by clinician’s reflection and interaction with individual patient.
12–14
Reasoning
response
or
measure
of
developing clinical reasoning skills and professional growth.10,15 Reflection is a necessary
skill
in
learning
and
metacognition.16 Metacognition is defined as an “awareness or analysis of one’s own learning or thinking processes.”17. This “thinking about thinking” has been linked to the cultivation of clinical reasoning strategies.10,16 Schon described reflection as occurring either “in action,” during the event, or “on action” after the event.18 Both
processes
require
metacognitive
ability. This ability can be enhanced by special instructive techniques. Mentorship is
a
cornerstone
of
professional
development. In the practice of health care, many disciplines have written about the importance of the mentoring relationship in professional growth and development. 19,20
Likewise, from a physical therapy
perspective, mentorship is a key element in includes
integration
of
the advancement of clinical decision
knowledge, experience and emotions. The
making skills, the promotion of both
clinical reasoning involves integration of
reflection
objective or goals of treatment and desired
professional development .
in
and
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
on
action,
and
Page 52
[Research Report] It is well recognized, that the development
Novice
of
and
Advanced Beginner
fellowship programs have allowed for
Competent
Proficient
Expert
physical
structured
therapy
residency
mentorship
experiences.
21
During residency or fellowship programs, practicing clinicians receive a planned learning
experience
designed
to
significantly advance their preparation to provide patient care in a defined area of practice. The post professional clinical education programs may more quickly develop an advanced practitioner. This can potentially accelerate
the process of
professional development.22 The structured reflection and mentorship is fundamental to the success of these programs.
Pakistan: The Process of developing
clinical expertise in EBP practice requires knowledge
and
clinical
practice. The physical therapy academic should create real life clinical context in order
to
enhance
the
professional
therapeutic skills of the new learners. The stages
of
clinical
competency
for
professional development can be explained by using Benner’s Novice to Expert Continuum levels
of
(1984)23.She clinical
professional service structure in Pakistan on the basis of this model24. The actual structure of PPTA’s proposal is different from the model presented below and is based on number of years spend as a practitioner as marker of clinical expertise (available
in
the
appendix
section).
Clinical expertise is an outcome of integrated chain of events taking place in the approach of Clinician therefore time
Model of Professional Excellence in
therapeutic
Recently, PPTA laid out a proposal of
described
competency
5 as
frame alone is not a good indicator of individual’s
expertise
in
term
of
professional development. From our Point of view, on the basis of PPTA’s proposal we can categorized Benner’s continuum of clinical competency into level of academic qualification, level of skills in practice and level of experience in the professional practice .This Model presents a much broader picture of Banner’s continuum of clinical expertise and its applicability in physical therapy profession in Pakistan.
description of professional development as:
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
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[Research Report]
Table 1 Modal Based on Proposed physical therapy Service Structure of PPTA This five step model of excellence
Change in learnerâ&#x20AC;&#x2122;s perception of situation
provides
as whole part rather than in separate
stages
of
professional
competency. Every level has its own significance.
The
professional
development through different level of competency reflects changes in 3 aspect of physical therapy performance25: Movement
from
principles
to
relying using
on
past
abstract concrete
pieces. (Skilled to Experienced) Passage from detached observer to an involved performer, no longer outside the situation but now actively involved in participation. (Experienced to expert). Model
of
Clinical
Expertise
as
a
experiences to guide actions. (Beginner to
clinician: Both guidelines adopted for
Skilled)
professional growth in Pakistan (APTAâ&#x20AC;&#x2122;s Model of professional development and
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 54
[Research Report] Banner’s
Model
of
Professional
Phase of Analysis & Judgment
excellence) incorporate evidence based
Phase of Reasoning
practice (EBP). They have a sharp focus
Phase of Expertise
on clinical expertise of physical therapists. Clinical expertise is a progressive change in approach which by our point of understanding
emerges
through
4
integrated phases of clinical decision making skills. The journey of a physical therapist towards clinical expertise should pass through a sequence of integrated phases which are described as:
Phase
of
Thinking
Clinically
oriented
knowledge
&
experience is the hallmark of clinical decision
makings.
Each
Phase
is
characterized by different step of clinical practice and integrated with each other to attain level of clinical expertise (Figure 2). We can describe these phases in terms of their characteristics as:
&
Understanding
Figure 2
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 55
[Research Report] The professional development refers to
clinical expertise. The clinical reasoning is
skills based on concepts and practices
an extensive process which has its roots in
attained for both personal development
the whole process. The reasoning skills are
and career advancement 26. We can say
enhanced by reflection and mentorship
that the achievement of professional
therefore clinical reflection, supported by
development within scope of clinical
mentorship,
practice is emphasized throughout the
developing clinical decision making skills.
phases in the process of developing
(Figure 3)
is
a
core
element
in
Figure 3 Model of Clinical Expertise
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 56
[Research Report] The clinical oriented knowledge forms the
was being placed on enhancing skills in
basis of clinical skills. The clinical
the process of clinical decision making and
expertise of a physical therapist relies on
professional education in order to achieve
these clinical skills. In the field of practice
Doctor of Physical Therapy (DPT) as
e.g. Musculoskeletal Physiotherapy, the
graduate level education and Evidence-
most important skill of physical therapist
Based Practice in the field.
is
to
understand
biomechanics
of
movement and functions of different components of musculoskeletal system. This
clinical
skill
enables
physical
therapist to rationalize the impact of pathological or traumatic stresses on these components of musculoskeletal system. These stresses disturb the biomechanics and affect the movement pattern. The capability to problem
leads
identify to
musculoskeletal
successful
clinical
decision making. This forms cornerstone in the approach of clinical reasoning. It helps problem solving and ultimately clinical expertise in the scope of clinical practice.
Discussion The physical therapy has a long way to go as an autonomous profession in Pakistan .The PPTA is committed to establish internationally recognized framework of actions for physical therapy development in Pakistan. After 2007, the journey of professional development in the country was facilitated by taking measures to implement APTA’s vision. The emphasis
The next goal is to establish layouts of steps for recognition of professional excellence within profession. Banner’s model explains the hierarchy of clinical competency and fills the gap between professional development and recognition. The level of professional excellence (Banner’s
Model)
marks
aims
and
objective be achieved within profession by physical therapist by doing effort along the lines recognized for its growth and development (APTA’s Vision). In the absence of regulatory council, PPTA has its limitation to implement its mission in Pakistan but it is doing its job of an advisory body by laying out standardized roadmap for upcoming structured council. It is responsibilities of physical therapists to achieve standards of practice required for the efficient results. There is a lot of effort and professionalism involved to understand the process of being expert as a physical
therapist.
Advanced
clinical
decision making skills are characteristic of an expert and evaluation process is the domain of decision makings in clinical
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
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[Research Report] practice. The clinical expertise in practice
the stage of expertise in practice with the
throughout evaluation process requires
element of time coupled with empirical
integrated
approach
of
working
evidence (Research) and experimental
background
knowledge
and
evidence
evidence (clinical practice). It can be
based clinical practice and consequently
concluded that clinical expertise is an
this integrated approach leads towards
outcome of reflective practice with an
clinical expertise in the field of practice.
ability
The first three phases of learning clinical
knowledge and experience into clinical
skills
practice on the basis of clinical reasoning.
are
background
focused knowledge
on
developing i.e.
clinical
to
take
skills
learned
from
It is a sequential, ongoing interactive
thinking & understanding (Phase 1),
journey
by
through
a
process
analyzes & judgment for examination and
professional
prognosis (Phase 2), clinical reasoning for
“Novice
planning intervention & re-evaluation
Practitioner” to “Experienced Practitioner”
(Phase 3). The integration of skills
to ultimately “Expert in the field of
acquired through these phases into clinical
Practice”.
development Practitioner”
i.e. to
of from
"Skilled
practice (constitute the phase 4). It leads to
References
7. Watts NT. (1989) Clinical decision
1. Shahzada Junaid Amin (2012). Perception
8.
2.
3.
4.
5.
6.
of Physical Therapist about Professional Growth & Development in developing countries: Example from Pakistan. Journal Of Physiotherapy & Sports Medicine 2: 62-79 Batalden PB, Davidoíf F (2007): What is "quality improvement" and how can it transform healthcare? Ouat SafHealth Care. 16:2-3 Message from President.[Internet], Islamabad [ISB]: Pakistan Physical Therapy Association. Retrieved 27 Feb 2013, from: http://www.pakpta.org Our Mission [Internet], Islamabad [ISB]: Pakistan Physical Therapy Association. Reterived 27 Feb 2013 from: http://www.pakpta.org APTA Vision Sentence and Vision Statement for Physical Therapy 2020. Retrieved 21 Dec 2012, from t: http://www.apta.org/vision2020 Massey BE Jr. (2003) APTA Presidential Address: Making vision 2020 a reality. Phys Ther.; 83:1023-1026.
9.
10.
11. 12.
13.
analysis. Phys Ther.; 69:569–576. Guide to Physical Therapist Practice. 2 nd ed. Phys Ther. 2001;81:9 –746. Sackett D et al.( 2000) Evidence-Based Medicine: How to practice and Teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, Shepard KF, Jensen GM. (2002) Techniques for teaching and evaluating students in academic settings. In: Shepard KF, Jensen GM, eds. Handbook of Teaching for Physical Therapists. 2nd ed. Boston, MA: Butterworth- Heinemann; :71–132. Jones M A, Rivett D A (2004) Clinical reasoning for manual therapists. Butterworth Heinemann, Edinburgh Palisano RJ, Campbell SK, Harris SR. (2006) Evidence-based decision making in pediatric physical therapy. In: Physical Therapy for Children. 3rd ed. St Louis, MO: Saunders- Elsevier;:3–32 Jensen GM, Gwyer J, Shepard K. (2000) Expert practice in physical therapy. Phys Ther.;80:28–43.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]
Page 58
[Research Report] 14. Jensen GM, Shepard KF, Gwyer J, Hack
15. 16.
17.
18. 19.
20. 21.
LM. (1992) Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedic settings. Phys Ther.;72:711–722. Edwards I, Jones M, Carr J, et al. (2004) Clinical reasoning strategies in physical therapy. Phys Ther.;84:312–330. Banning M. (2008) The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students. Nurse Educ Today.;28:8 –14. Merriam-Webster Online Dictionary. Metacognition definition. Retrieved at 22 Feb 2013 from: http:// www.merriamwebster.com/dictionary/metacognition Schon DA. (1983) the Reflective Practitioner. New York, NY: Basic Books;. Schrubbe KF. (2004) Mentorship: a critical component for professional growth and academic success. J Dent Educ.;68: 324–328. Gandy JS. (1993) Mentoring. Journal of Orthopaedic Practice. 5:6 –9. Tichenor CJ, Davidson JM. (2002) Postprofessional clinical residency education. In: Shepard KF, Jensen GM, eds. Handbook of Teaching for Physical Therapists. 2nd ed. Boston, MA: Butterworth-Heinemann:473–502.
1
22. Godges JJ.( 2004) Mentorship in physical
therapy practice. J Orthop Sports Phys Ther.; 34:1–3. 23. Developing competence [Internet] Benner's stages of clinical competence : Retrieved at 02 March 2013 at http://www.jcu.edu.au/wiledpack/modules /performance/JCU_090559.html 24. Pakistan Physical Therapy Association. Recommended service structure for physical therapist in different institutions: [Internet] Islamabad (ISB). Pakistan physical therapy research foundation. Retrieved at 27 Feb 2013 from http://ptrf.net/ppta_structure.php 25. Patricia Benner's From Novice to Expert [Internet] Nursing theories: a companion to nursing theories and model. Retrieved at (Cited at 02 March 2013 from: http://currentnursing.com/nursing_theory/ Patricia_Benner_From_Novice_to_Expert. html 26. Professional development.[Internet] Wikipedia, the free encyclopedia. Retrieved at 27 Feb 2013 from : http://en.wikipedia.org/wiki/Professional_ development
Corresponding Author Atif Dustgir, B.S.P.T. PP DPT*(PAK), COMT (AUS), Mulligan Certification Level 1 (AUS) Level 2 & 3 (UAE) 2 Research Fellow, University of Management and Technology, Lahore Pakistan 1 Senior Physical Therapist, Sports & Spine Professionals, 194 Y DHA Phase III Lahore Visiting Faculty Member, Riphah College of Rehabilitation Sciences, Lahore Campus Pakistan Email dptatif@yahoo.com.au © 2013 PGIP. All rights reserved.
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
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Welcome to the Postgraduate Institute of Physiotherapy, we are the team of professional physiotherapists working in United Kingdom promoting and uplifting the physiotherapy profession in developing countries particularly in South Asia. Our well trained and qualified physiotherapists conduct postgraduate courses in various countries. The courses ranged from Musculoskeletal Manual Therapy to Sports Physiotherapy. The basic aim is to provide evidenced based way of practice and education to physiotherapy societies of developing nation so that they can uplift the profession and become the contributors to the profession. Date: 00/00/00
Time: 00:00
www.pgip.co.uk
Encouraging Better Education Ob j e ct ive s
Co ur se s:
Provision of education and training in 1. Spinal Examination and physiotherapy to the public at large Enabling patients to relieve or assist in relieving their own suffering/conditions To persons (professionally qualified or not) providing paid or voluntary care to any person in need of physiotherapy Promotion of research and the dissemination to the public at large of the results of research in the field of physiotherapy
Diagnostic Assessment 2. Management of Neck Disorders 3. Neurodynamics and Neuromatrix 4. Lumbar Spine 5. Cervical Spine 6. Treating Cervicogenic Headaches 7. Low back pain and evidence base approach 8. Spinal Manipulation 9. Evidence Based Practise 10. Clinical Reasoning 11. Professionalism, Empowerment and Autonomy 12. Sports Rehabilitation and injuryIPrevention