Journal of Physiotherapy & Sports Medicine Dec 2013

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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

This journal subscribes to the principles of the Committee on Publication Ethics http://publicationethics.org/

The Journal of Postgraduate Institute of Physiotherapy Visit the journal website at http://www.pgip.co.uk/jopsm

JOPSM Editorial Office | 13/3 New Civil Lines, Sargodha, Pakistan Tel: +92 (423) 2107625 E-mail: info@pgip.co.uk


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]

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[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]

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[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]

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[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]

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[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]

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[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]

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[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]

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[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]

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[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]

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[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]

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[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]

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[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

“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 ADL’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

people’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 “to undo� 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.

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[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 ‘coping’, 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 one’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; 12:118–23. Bennell K.L and Hinman R.S. (2011): A review of the clinical evidence for exercise in osteoarthritis of the hip and

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[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]

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[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 therapist’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]

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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]

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[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]

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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 learner’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 (APTA’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]

Page 57


[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.

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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.

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[Research Report] 14. Jensen GM, Shepard KF, Gwyer J, Hack

15. 16.

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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

[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]

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DA, eds. Clinical Reasoning for Manual

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Therapists. Edinburgh, UK: Butterworth

Petty NJ, Bach TM, Cheek L. Accuracy of

Heinemann;

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[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 2][Dec 2013]

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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


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