Classification of problems, clinical findings and treatment goals in patients with low back pain using the ICIDH-2 beta-2.

PURPOSE: This study aimed to explore problems, clinical findings and treatment goals presented by patients with low back pain and their physiotherapists, and to which extent this information could be classified according to the ICIDH-2 Beta-2. METHOD: An explorative field trial of 12 physiotherapists and 28 patients with low back pain in outpatient practices. RESULTS: Pain and impairments related to muscles, joints and structures of the lower back, pelvis and hips were most often presented. Functioning related to daily activities and participation in society was often described in the treatment goals, but vaguely formulated. Most of the problems and clinical findings could be classified according to the ICIDH-2 Beta-2. However, several treatment goals could not be classified. CONCLUSIONS: There was a lack of specification in several of the detailed codes of the Body, Function and Structure Dimension, particularly regarding classification of pain and muscle functions. The main limitation concerned the detailed version of the Body Function and Structure Dimension, which provided no additional precision compared with the short version when classifying pain and other impairments. However, the ICIDH-2 offers a tool to enhance the precision of clinical findings and the possibilities for performing a multidimensional evaluation of functioning related to patients with low back pain.     

Classification of problems,clinical findings and treatment goals in patients with low back pain using the ICIDH-2 Beta-2

Purpose: This study aimed to explore problems, clinical findings and treatment goals presented by patients with low back pain and their physiotherapists, and to which extent this information could be classified according to the ICIDH-2 Beta-2. Method: An explorative field trial of 12 physiotherapists and 28 patients with low back pain in outpatient practices. Results: Pain and impairments related to muscles, joints and structures of the lower back, pelvis and hips were most often presented. Functioning related to daily activities and participation in society was often described in the treatment goals, but vaguely formulated. Most of the problems and clinical findings could be classified according to the ICIDH-2 Beta-2. However, several treatment goals could not be classified. Conclusions: There was a lack of specification in several of the detailed codes of the Body Function and Structure Dimension, particularly regarding classification of pain and muscle functions. The main limitation concerned the detailed version of the Body Function and Structure Dimension, which provided no additional precision compared with the short version when classifying pain and other impairments. However, the ICIDH2 offers a tool to enhance the precision of clinical findings and the possibilities for performing a multidimensional evaluation of functioning related to patients with low back pain.     

Executive dysfunction post-stroke: an insight into the perspectives of physiotherapists

Abstract

Purpose: To gain an understanding of physiotherapy practice in relation to executive dysfunction (ED) post-stroke. Method: Three focus groups were conducted using semi-structured interview schedules to highlight how ED post-stroke was understood by 12 physiotherapists with greater than 1 year of experience working in the area of stroke care. The focus group data were analysed using qualitative data analysis. Results: The themes extracted from the data on physiotherapists’ self-reported knowledge of ED post-stroke were: physiotherapists’ lack of knowledge of ED post-stroke; current physiotherapy practice regarding ED post-stroke; the negative impact of ED on physiotherapy rehabilitation post-stroke and the future learning needs of physiotherapists regarding ED post-stroke. Conclusions: Current results demonstrate that ED has negative implications for physiotherapy rehabilitation post-stroke. Although further interdisciplinary research is warranted, the present results suggest that physiotherapists should be aware of the presence of ED in people post-stroke and develop strategies to minimise the impact of ED on physiotherapy rehabilitation.

• Implications for Rehabilitation

• Physiotherapists report a lack of knowledge of ED post-stroke and a requirement for future learning and training regarding the optimal management of people with ED undergoing physiotherapy rehabilitation post-stroke.

• ED has negative implications for physiotherapy rehabilitation post-stroke and physiotherapists should be aware of the presence of ED in people post-stroke and develop strategies to minimise the impact of ED on physiotherapy rehabilitation.

     

Physiotherapy practice in stroke rehabilitation: a survey

Objective : This survey aimed to provide an expert consensus view of the theoretical beliefs underlying physiotherapy practice in stroke rehabilitation the United Kingdom.

Method : Questionnaires (with sections related to: therapist background, physiotherapy management, theoretical beliefs and gait re-education strategies used) were posted to all senior level physiotherapists working in stroke care ( n =1022).

Results : The majority of respondents had more than 10 years experience overall, and at least 5 years experience in stroke care. The Bobath concept was the preferred approach ( n =67%) followed by an 'eclectic' approach ( n =31%). This survey identified four theoretical themes underlying current practice in neurological physiotherapy: the promotion of normal movement, the control of tone, the promotion of function, and the recovery of movement with optimization of compensation.

Conclusions : A consensus was obtained on 16 theoretical beliefs; however the evidence base underlying these beliefs remains sparse. Many of these beliefs require further debate within the physiotherapy profession such as the amount of time spent on preparation for function, the automatic translation of movement into function, carry over outside therapy, and the way in which tasks should be practised.     

The development of the Stroke Physiotherapy Intervention Recording Tool (SPIRIT)

Purpose: To develop a recording system that describes physiotherapy interventions for the rehabilitation of postural control post-stroke.

Methods: Design: A draft recording tool was developed using the method described by Edwards et al,¹² involving literature searches and collaboration with senior clinicians. It was piloted with stroke physiotherapists using a cross-sectional survey design to assess validity, utility and completeness. Participants used the recording tool to record five treatment sessions. Feedback regarding the utility and completeness of the system was obtained via short semi-structured interviews. Setting: 11 NHS Trusts. Participants: 35 stroke physiotherapists working in acute and rehabilitation settings recorded the treatment of 120 patients in 590 treatment sessions.

Results: A double-sided A4 form with a checklist of 79 physiotherapy interventions in 9 categories was produced: the Stroke Physiotherapy Intervention Recording Tool (SPIRIT). The participants found it quick and easy to use and reflective of clinical practice. There were a few missing interventions and some confusion regarding definition of terms. Revisions were to include the omitted interventions and to produce a user's booklet defining the categories and interventions.

Conclusions: SPIRIT provides a system for recording physiotherapy treatment for stroke patients which reflects current clinical practice in acute and rehabilitation settings.     

Intervention categories for physiotherapists treating patients with musculoskeletal conditions on the basis of the International Classification of Functioning, Disability and Health

The International Classification of Functioning, Disability and Health holds great promise for providing rehabilitation disciplines including physiotherapy, with a universal language. The aim of this study was to investigate the content validity of the International Classification of Functioning, Disability and Health intervention categories for physiotherapists treating patients with musculoskeletal conditions. The study was conducted as a retrospective cross-sectional multicenter study in Switzerland. It was performed with convenience samples of 300 clinical records of patients with musculoskeletal conditions. This study recommends three checklists with 38 second-level intervention categories for acute, 46 for rehabilitation, and 38 for the long-term context. The practical application of three lists, each containing second level intervention categories, should improve the standardization of documentation in physiotherapy practice. This may also provide the transparency increasingly demanded in the current political climate.     

The development of the Stroke Physiotherapy Intervention Recording Tool (SPIRIT)

Purpose:?To develop a recording system that describes physiotherapy interventions for the rehabilitation of postural control post-stroke.

Methods:?Design: A draft recording tool was developed using the method described by Edwards et al,¹² involving literature searches and collaboration with senior clinicians. It was piloted with stroke physiotherapists using a cross-sectional survey design to assess validity, utility and completeness. Participants used the recording tool to record five treatment sessions. Feedback regarding the utility and completeness of the system was obtained via short semi-structured interviews. Setting: 11 NHS Trusts. Participants: 35 stroke physiotherapists working in acute and rehabilitation settings recorded the treatment of 120 patients in 590 treatment sessions.

Results:?A double-sided A4 form with a checklist of 79 physiotherapy interventions in 9 categories was produced: the Stroke Physiotherapy Intervention Recording Tool (SPIRIT). The participants found it quick and easy to use and reflective of clinical practice. There were a few missing interventions and some confusion regarding definition of terms. Revisions were to include the omitted interventions and to produce a user's booklet defining the categories and interventions.

Conclusions:?SPIRIT provides a system for recording physiotherapy treatment for stroke patients which reflects current clinical practice in acute and rehabilitation settings.     

Interaction between Physiotherapists and Patients in Stroke Treatment

This study forms part of a work-development project in eastern Finland. The aim of the project is to develop physiotherapy in stroke rehabilitation. The objective of this study was to investigate how, through conversation, physiotherapists and patients constructed their treatment interaction in stroke physiotherapy. The study was undertaken at a hospital, a rehabilitation centre, three health centres and a private clinic and involved ten physiotherapists. The data were collected by videotaping nine therapy sessions for patients with diagnosed stroke.The analytical approach used draws upon discourse analysis. Discourse formation was analysed according to how the participants defined their roles. The results showed that the physiotherapists typically used oral communication to organise and guide physical exercises and that the patients mostly responded to the instructions given.The physiotherapists scheduled the course of treatment but they did not talk to the patients about the goals of the therapy. They stated the reasons for their therapy by discussing effects of stroke such as spasticity, asymmetry or abnormal tone. Only occasionally was the initiative taken by the patients, in which case the physiotherapists had difficulty in giving them space.The patients proved to have problems in receiving due consideration, and speech defects in particular caused problems in being understood.The results of the study give cause to question the unequal role distribution and authoritarian use of power in physiotherapy.     

Goal Attainment Scaling: Is it appropriate for stroke patients and their physiotherapists?

Although much is known about the biological correlates of stroke there is a dearth of information regarding patients' expectations and physiotherapy outcomes in stroke units. Goal attainment scaling (GAS) is being used increasingly in the USA in rehabilitation facilities to measure outcome. This exploratory study aimed to determine the feasibility of physiotherapists and patients using GAS, and to discover the extent of congruence between patients' and therapists' goals. During a four-month period stroke patients and physiotherapists independently scaled goals. These were set and scaled successfully by all the patients in the pilot study, who were able to identify problems and scale goals with minimal guidance from a therapist. Physiotherapist-set goals related more often to a physical activity, whereas patients' goals related directly to functional outcome. Patients failed to reach their expected levels more frequently for their self-set goals, than for physiotherapist-determined goals. It is recommended that physiotherapists should explore further the use of GAS with stroke patients.     

Professional roles in physiotherapy practice: Educating for self-management,relational matching,and coaching for everyday life

The patient’s active participation in treatment and rehabilitation represents a cultural change in clinical practice as well as a major change in physiotherapist and patient roles. This article presents findings from a study aimed at gaining a better understanding of how physiotherapists in actual practice understand their interactions with patients during the treatment process. This article reports on the findings from focus-group interviews with physiotherapists working in three different settings. Analyses of the interview data identified three modes of physiotherapy practice. In one, physiotherapists educate their patients to be self-managing in conducting exercise programs based on sound evidence. Educational films available on the Internet are included in these efforts to teach patients. In another, physiotherapists emphasize the importance of a close relationship to the patient. A good personal chemistry is believed to improve the treatment process. And finally, what physiotherapists learn about the living conditions and the biographies of their patients was shown to be very important. Understanding the importance of the life-world and taking this into consideration in the treatment process were factors considered to be central to good practice. The article concludes with a discussion linking these findings to those of other studies identifying those factors contributing to our knowledge of what is involved in biopsychosocial practice in physiotherapy.     

New Concepts and Evidence Based Practice in Physiotherapy：Examples from Stroke Rehabilitation

Objective:The purpose of this paper is to give an overview of new concepts and evidence based physiotherapy practice in stroke rehabilitation in the acute,post acute and chronic stage of stroke. Background:Historically physiotherapy has developed through the years from a focus on health,beauty,and equilibrium between spiritual,moral and physical powers,to a client centered service to people and populations to develop,to maintain and to restore maximum movement and functional ability throughout the lifespan. Still the health perspective is strong and divided into first,second and third prophylaxis. New concepts like Evidence Based Medicine,Evidence Based Practice,International Classification of Function and research within neurophysiology have had a deep impact on physiotherapy services,practice and education. The highest levels of documentation are Meta analyses and Randomised Controlled Trials,and today many of the physiotherapy methods used in rehabilitation of neurological conditions are tried out in different trials,bringing up-to date knowledge into practice. This paper focuses on rehabilitation of persons with stroke and physiotherapy methods in particular. Result:Physiotherapy in the acute stage improves motor function and enhances mobility. Rehabilitative efforts within the first few weeks as opposed to later favors better recovery. Type of physiotherapy in the acute stage is task oriented training with a focus on intensity and variability. Post acute therapy-based rehabilitation services targeted towards stroke patients living at home appear to improve independence in personal activities of daily living. In the chronic stage there is good evidence that aerobic exercise is beneficial for improving aerobic capacity in people with mild and moderate stroke. Progressive resistance strength training programmes reduce musculoskeletal impairment after stroke,without increasing tone or spasticity.     

Exploring the decision-making process in the delivery of physiotherapy in a stroke unit

Abstract

Purpose: The aim of this study was to explore the decision-making process in the delivery of physiotherapy in a stroke unit. Methods: A focused ethnographical approach involving semi-structured interviews and observations of clinical practice was used. A purposive sample of seven neurophysiotherapists and four patients participated in semi-structured interviews. From this group, three neurophysiotherapists and four patients were involved in observation of practice. Data from interviews and observations were analysed to generate themes. Results: Three themes were identified: planning the ideal physiotherapy delivery, the reality of physiotherapy delivery and involvement in the decision-making process. Physiotherapists used a variety of clinical reasoning strategies and considered many factors to influence their decision-making in the planning and delivery of physiotherapy post-stroke. These factors included the therapist’s clinical experience, patient’s presentation and response to therapy, prioritisation, organisational constraints and compliance with organisational practice. All physiotherapists highlighted the importance to involve patients in planning and delivering their physiotherapy. However, there were varying levels of patient involvement observed in this process. Conclusions: The study has generated insight into the reality of decision-making in the planning and delivery of physiotherapy post-stroke. Further research involving other stroke units is required to gain a greater understanding of this aspect of physiotherapy.

• Implications for Rehabilitation

• Physiotherapists need to consider multiple patient, therapist and organisational factors when planning and delivering physiotherapy in a stroke unit.

• Physiotherapists should continually reflect upon how they provide physiotherapy, with respect to the duration, frequency and time of day sessions are delivered, in order to guide current and future physiotherapy delivery.

• As patients may demonstrate varying levels of participation in deciding and understanding how physiotherapy is delivered, physiotherapists need to adjust how they engage patients in the decision-making process and manage patient expectations accordingly.

     

To what extent are family members and friends involved in physiotherapy and the delivery of exercises to people with stroke?

Purpose. To examine the views of people with stroke, their ‘family members/friends’ and physiotherapists on the role of the family in physiotherapy and the delivery of exercises following stroke.

Methods. A self-report questionnaire was administered to 100 ‘family members/friends’ and 75 people with stroke. Two focus groups were conducted with 10 expert physiotherapists working in the area of stroke rehabilitation.

Results. Family members of people with stroke are willing to participate in the delivery of unsupervised exercises in the hospital and the home setting (n = 91). Furthermore, this is also acceptable to people with stroke (n = 65) as an adjunct to routine physiotherapy. Physiotherapists highlighted a number of factors that influenced participation in physiotherapy such as; level of interest and motivation of the family (n = 5), availability (n = 3) and importance of education (n = 2). ‘Family members/friends’ identified reasons that would also limit participation such as work commitments (n = 24), lack of confidence (n = 20) and unsuitable treatment times (n = 13). The expert practitioners outlined a number of areas that family involvement can have an impact, such as treatment carry-over, assisting the family unit to cope on discharge and improving handling skills.

Conclusions. Our study identifies an under-utilised role for ‘family members/friends’ in the rehabilitation of people with stroke. Family mediated exercises can maximise the carry-over outside formal physiotherapy giving patients the opportunity for informal practice. This study highlights the need to examine the value of a structured programme of exercises that can be delivered to people with stroke by their ‘family members/friends’.