Physical therapy education and provision in Cambodia: A framework for choice of systems for development projects

Purpose. Rehabilitation agencies, policy makers and donors are faced with the choice of the level of rehabilitation provider to promote in developing countries. This is particularly the case after conflict when new systems are considered and the need for rehabilitation becomes a priority. The complete decimation of medical services in Cambodia highlights the effects of both social change and development agency impact on the establishment of rehabilitation services. This paper discusses the factors that led to the development of four types of physical therapy provider levels in Cambodia with the goal of providing a framework for these decisions.

Methods. Case study analysis utilizing interviews, site analysis and literature review.

Results. There are four levels of physical therapy provider systems that were initiated at different stages of the rebuilding of the country. Rehabilitation workers were trained during the war in refugee camps and afterwards in rehabilitation centers, professional physical therapists were trained in a university programme after the conflict ceased and community follow-up workers and community-based rehabilitation workers were trained to address some of the geographic accessibility issues. Factors that affected the different systems include the post-conflict development agency philosophy, instructor availability and training, financial support, high school education standards, geographic and rural/urban distribution and cost and time for training. The community-based rehabilitation and community follow-up models also address referral systems and social and vocational support.

Conclusions. The comparison of the different types of provider and the initiating or driving forces that led to development of these systems are discussed in order to provide agencies which are planning to implement training of rehabilitation providers in developing countries with a decision-making framework. A combined system is the optimal approach; however, the choice of which type of provider level to promote will differ according to political stability, stage of development, presence of trained educators, rural vs. urban need, funding agency philosophy and educational standards in the country.     

Physical therapy education and provision in Cambodia: a framework for choice of systems for development projects

PURPOSE: Rehabilitation agencies, policy makers and donors are faced with the choice of the level of rehabilitation provider to promote in developing countries. This is particularly the case after conflict when new systems are considered and the need for rehabilitation becomes a priority. The complete decimation of medical services in Cambodia highlights the effects of both social change and development agency impact on the establishment of rehabilitation services. This paper discusses the factors that led to the development of four types of physical therapy provider levels in Cambodia with the goal of providing a framework for these decisions. METHODS: Case study analysis utilizing interviews, site analysis and literature review. RESULTS: There are four levels of physical therapy provider systems that were initiated at different stages of the rebuilding of the country. Rehabilitation workers were trained during the war in refugee camps and afterwards in rehabilitation centers, professional physical therapists were trained in a university programme after the conflict ceased and community follow-up workers and community-based rehabilitation workers were trained to address some of the geographic accessibility issues. Factors that affected the different systems include the post-conflict development agency philosophy, instructor availability and training, financial support, high school education standards, geographic and rural/urban distribution and cost and time for training. The community-based rehabilitation and community follow-up models also address referral systems and social and vocational support. CONCLUSIONS: The comparison of the different types of provider and the initiating or driving forces that led to development of these systems are discussed in order to provide agencies which are planning to implement training of rehabilitation providers in developing countries with a decision-making framework. A combined system is the optimal approach; however, the choice of which type of provider level to promote will differ according to political stability, stage of development, presence of trained educators, rural vs. urban need, funding agency philosophy and educational standards in the country.     

Rural access to vocational rehabilitation services: Minority farmers' perspective

Purpose. The paper documents the need for, and obstacles to effective access to rehabilitation services by minority farmers. It draws from the findings of a study * conducted in the Mississippi delta.

Method. Applying community-based participatory research approach (CBPR) the study trained farmers to conduct interviews and focus group discussions. They interviewed 1308 farmers and had 18 focus group discussions with 254 farmers. The study also interviewed 290 service providers and conducted 8 focus group discussions with 72 State Vocational Rehabilitation services (VR) counselors.

Results. The study found an unmet need for VR services in this population. Farmers were not aware of VR services or how to access them and VR was not aware of farmers' needs. Farmers felt marginalized and afraid that access to VR services would diminish their ability to earn a living on the farm.

Conclusions. Collaboration between VR and rural organizations, agencies and with rural people would help close the information and gaping service gap. One-stop service centers in rural areas could improve access to services. CBPR is an invaluable research tool especially among marginalized people.     

The system for medical rehabilitation in Croatia

Purpose. To describe the framework for medical rehabilitation in Croatia and to discuss its influence on the practice of the specialty.

Methods. Collection, analysis and interpretation of data pertaining to the need for medical rehabilitation in the country and to its elements of structure, process and outcome of care.

Results. The practice of medical rehabilitation in Croatia has evolved without strategic planning on the national level and therefore without a designed system. This lack in the present framework causes shortcomings in all three elements of rehabilitation care and impedes the advancement of the specialty.

Conclusion. Medical rehabilitation in Croatia needs a national strategic plan for a three-level system that incorporates inpatient, outpatient and community-based rehabilitation.     

Developing world rehabilitation strategy II: Flex the muscles, train the brain, and adapt to the impairment

Purpose. To understand some reasons behind the lack of medical rehabilitation resources in developing regions and to propose some actions that can change this problem.

Methods. Focused Medline literature review on AIDS disability in Africa. Editorial observation.

Results. Disability, rather than death or cost of treatment, is likely the greatest burden from AIDS. However only 0.05% of published research on AIDS in Africa relates to disability, so we cannot know this with certainty. This is a direct result of funding priorities, and a consequence of both traditional epidemiological methods and old-line 'cure or die' medical education. The disproportionate lack of medical rehabilitation specialists and facilities is a consequence of the same forces. Similar patterns are seen in rural and developing regions around the world.

Conclusions. Rehabilitation professionals must change healthcare service by using rehabilitation techniques: flexing muscle by insisting that governments, agencies, and philanthropists look at the cost of disability, not just disease; training the brains of young professionals who will practice, research and advocate locally; adapting intervention strategies to the impairments imposed by poverty and distance.     

Rehabilitation medicine in countries of Central/Eastern Europe

Purpose. To describe attributes of rehabilitation medicine common to the five countries of Central Eastern Europe (CEE) and their implications for future challenges.

Methods. Critical collection and study of pertinent data on evolvement and present state of rehabilitation medicine in CEE countries by a coordinated team of rehabilitation experts from each of the relevant countries.

Results. CEE countries are similar in their need for rehabilitation medicine, its evolvement, present state and current practice. Settings largely emerged without strategic planning on the national level and lagged behind those in Central and Western Europe both in time and content.

Conclusion. The framework that evolved in all except Slovenia is not appropriate to needs. In order to meet future challenges all five CEE countries need the incorporation of inpatient, outpatient and community-based rehabilitation into one system.     

Predictors of assistive technology use: the importance of personal and psychosocial factors

Objective. To validate an assistive technology (AT) baseline and outcomes measure and to quantify the measure's value in determining the best match of consumer and AT considering consumer ratings of their subjective quality of life, mood, support from others, motivation for AT use, program/therapist reliance, and self-determination/self-esteem.

Design. Prospective multi-cohort study.

Setting. Vocational rehabilitation offices and community.

Participants. Over 150 vocational rehabilitation counselors in 25 U.S. states with one consumer each receiving new AT.

Interventions. Counselor training in the Matching Person and Technology (MPT) Model and consumer completion of the MPT measure, Assistive Technology Device Predisposition Assessment (ATD PA).

Main outcome measures. Total and subscale scores on the ATD PA as well as counselor-completed questionnaires.

Results. ATD PA items differentiated consumer predispositions to AT use as well as AT and user match. There were no significant differences due to gender, physical locality, or age within this sample of working-age adult consumers. Vocational rehabilitation counselors exposed to training in the MPT Model achieved enhanced AT service delivery outcomes.

Conclusions. The ATD PA is a valid measure of predisposition to use an AT and the subsequent match of AT and user. Rehabilitation practitioners who use the ATD PA will achieve evidence-based practice and can expect to see enhanced AT service delivery outcomes.     

Work physical therapy and rehabilitation ergonomics: a review and discussion of the scope of the areas

Purpose. There has been a recent development of the work physical therapy area in Brazil. The relationship between work physical therapy and rehabilitation ergonomics needs to be highlighted to avoid segregation and fragmentation of these complementary fields. For these reasons, the purpose of this article was to review and clarify the scope of the areas of work physical therapy and rehabilitation ergonomics.

Method. The available literature discussing the roles of the areas of interest was critically reviewed.

Results. Both areas are concerned with workers' health and safety and they complement each other.

Conclusions. Work physical therapy can be considered as rehabilitation ergonomics practiced by physical therapists with their specific interests. Hopefully, this paper will contribute to further interaction between the areas of work physical therapy and rehabilitation ergonomics not only in Brazil but worldwide. This may contribute to improved occupational disability prevention and rehabilitation.     

An introduction to the Korean Employment Promotion Agency for the Disabled

Purpose. The main aim of this article is to provide an introduction to the Korean Employment Promotion Agency for the Disabled (KEPAD), and to provide comparative thought regarding government-based vocational rehabilitation service delivery between South Korea and the USA.

Method. Relevant literature is considered, and current issues and comparative discussion in practice are highlighted.

Results. Introductory information in terms of organization, eligibility, services and programmes are presented. In addition, practical problems associated with the KEPAD system and a cross-cultural analysis is elaborated, comparing the USA and South Korean vocational rehabilitation systems.

Conclusion. KEPAD has successfully derived public support and acknowledgement of its national responsibility in ensuring vocational rehabilitation services for persons with disabilities. The KEPAD system demonstrates a unique approach in implementing vocational rehabilitation services by providing various benefits for both employers and persons with disabilities. However, considerable cautiousness in terms of cross-cultural analyses is required for international application. Furthermore, successive research of rehabilitation infrastructure is warranted.     

Rehabilitation psychology: meeting the needs of individuals with acquired disabilities in Ireland

Purpose. The current articles reviews the epidemiology of disability in Ireland, discusses the political and social factors which have increased focus on disability issues and offers training guidelines for rehabilitation psychology based on those of the APA's Rehabilitation Psychology Division.

Rationale. With the growing number of individuals with acquired (vs developmental) disabilities in Ireland, there is increased recognition of the need to train psychologists to assist persons with acquired disabilities (e.g. spinal cord injury, acquired brain injury, stroke, etc.) in adjusting to their impairments, reintegrating back into their communities and reducing the long-term financial costs associated with disability.

Conclusion. Social and political factors suggest that the time is right to develop rehabilitation psychology as a specialty in Ireland given the increased focus on disability in Ireland, including recently passed disability legislation (i.e. 2005 Disability Bill), international events (e.g. 2003 Dublin World Special Olympics) and increases in rehabilitation training programmes (i.e. medicine; physio, occupational and speech therapy).     

The demand for rehabilitation therapists in Beijing health organizations over the next five years

Purpose. To estimate the demand for rehabilitation therapists in Beijing health organizations over the next 5 years.

Methods. A literature search was carried out to confirm the distribution of rehabilitation therapists in Beijing health organizations in the past and to predict the demand for rehabilitation therapists in Beijing hospitals over the next 5 years by linear regression and logistic curve fitting.

Results. The total demand for rehabilitation therapists in Beijing in 2007 and 2010 will be 1480 - 1620 and 2240 - 2530, respectively.

Conclusions. The allocation and training of manpower specialized in rehabilitation therapeutics for the rehabilitation departments of polyclinics in Beijing should be improved.     

Psychological comorbidity in medical rehabilitation--the need for education

Purpose. Prevalence of comorbid mental disorders in rehabilitation patients is high. In spite of the bio-psycho-social approach in rehabilitation, recognition and treatment rates of comorbid mental disorders during rehabilitation are low. The purpose of the study was to raise specific information about current clinical practice concerning comorbid mental disorders and training needs of rehabilitation personnel.

Method. 435 questionnaires were sent out to medical personnel in 54 rehabilitation hospitals in south-west Germany.

Results. Psychologists in rehabilitation spend most of their time on counselling (45%) and group interventions (29%). Physicians and psychologists both feel highly responsible for recognizing mental disorders and motivating patients to seek aftercare. Screeners are rarely used by psychologists and physicians. Seventy-six percent of the participants would take part in specific training sessions. High training needs were stated for affective, anxiety and somatoform disorders. A specific training session for mental health in rehabilitation should last at least half a day and cover affective, anxiety and somatoform disorders.

Conclusions. Taking these results into account, it is possible to put together a training program in diagnostics of comorbid mental disorders, which fits the needs of the professionals.     

Neurophysiological basis of rehabilitation of adolescent idiopathic scoliosis

Background. Knowledge on mechanisms of neurophysiological control of trunk movement and posture could help in the development of rehabilitation programs and brace treatment in adolescent idiopathic scoliosis (AIS).

Aims. Reviewing up-to-date research on neurophysiology of movement and posture control with the aim of providing basis for new researches in the field of AIS rehabilitation and background understanding for clinicians engaged in management of AIS.

Methods. Review of literature.

Results. We considered several neurophysiological issues relevant for AIS rehabilitation, namely, the peculiar organization of patterns of trunk muscle recruitment, the structure of the neural hardware subserving axial and arm muscle control, and the relevance of cognitive systems allowing mapping of spatial coordinates and building of body schema.

Discussion and conclusion. We made clear the reason why trunk control is generally carried out by means of very fast, feedforward or feedback driven patterns of muscle activation which are deeply rooted in our neural control system and very difficult to modify by training. We hypothesized that augmented sensory feedback and strength exercises could be an important stage in a rehabilitation program aimed at hindering, or possibly reversing, scoliosis progression. In this context we considered bracing not only as a corrective biomechanical device but also as a tool for continuous sensory stimulation that could help awareness of body misalignment. Future research aimed at developing strategies of trunk postural control learning is essential in the rehabilitation of adolescent idiopathic scoliosis.     

Pain, disability and rehabilitation practices. A phenomenological perspective

Purpose. Rehabilitation experts and disabled people are faced with the question of pain on a daily basis. This is a complex phenomenon with various different aspects: physiological, social, cultural and personal experience. In this article the author focuses on the personal experience of pain, i.e., the way in which it is experienced by the person in question and how it changes that person, his/her body and life; the author refers to cases of people who became disabled following a road accident or a neuromuscular illness, and takes a phenomenonological and philosophical standpoint.

Method. The article is based upon ethnographical observations made in three settings: assistance departments set up by an association, a wheelchair test centre and a rehabilitation centre.

Results and discussion. The experience of pain has been described as a rupture of a person's relationship with the outside world leading to a loss in capacity. Rehabilitation enables this link to be rebuilt by focusing on the body and thus changing the way in which the person feels his/her body.

Conclusions. This analysis highlights the importance of how pain is experienced and how it is taken into account in rehabilitation practices, whilst at the same time showing how rehabilitation changes this experience.     

Continuity, transition and participation: Preparing clients for life in the community post-stroke

Aims. To examine issues of continuity and transition facing clients as they return to life in the community following stroke and the role of rehabilitation in this process.

Key findings and implications. The sudden onset of disability following a stroke represents a major disruption to the continuity of a person's life experience. Rehabilitation has an important role in the transition from the non-disabled to the disabled state however current rehabilitation services and outcomes post-stroke focus on functional recovery rather than on a return to meaningful roles and activities and pay little attention to the transition from the non-disabled to the disabled self. Although some current rehabilitation models address the importance of involvement in a life situation, they do not adequately address issues of the role of the environment, the nature of community, the importance of meaning and choice when thinking about life situations, and change in abilities across the life course.

Conclusions. Models of rehabilitation service delivery need to move to a chronic disease management model that incorporates outcomes that are meaningful to clients, and not the assumed needs or outcomes as defined by rehabilitation professionals.     

Survey of the current status of cancer rehabilitation in Japan

Purpose. To elucidate the current status of cancer rehabilitation in institutions nationwide.

Method. A questionnaire survey regarding the current status of cancer rehabilitation in 1693 healthcare institutions was conducted by mail. The survey first asked whether rehabilitation was being conducted for cancer patients and, in facilities in which it was being conducted, it then asked about the content of the rehabilitation, the stage of the cancer patients, etc. Facilities in which cancer rehabilitation was not being conducted were surveyed in regard to whether there was a need for cancer rehabilitation.

Results. Valid replies were obtained from 1045 (62.0%) institutions and 864 (82.7%) of them conducted rehabilitation for cancer patients. A high proportion of the content of the rehabilitation was found to be related to physical function. Activities of daily living guidance and training were also found to be conducted in a high proportion. Low proportions of the facilities conducted content that was specialized for cancer. Of the 181 facilities in which rehabilitation was not being conducted for cancer patients, 171 (94.5%) replied that they felt that rehabilitation was needed for cancer patients.

Conclusions. Based on the results of this fact-finding survey it will be necessary to consider strategies for popularizing and developing rehabilitation programmes for cancer patients in Japan.     

The use of classification models in the evaluation of CBR programmes

Classification models for community-based rehabilitation (CBR) create conceptual order in the many types of rehabilitation programmes that exist in developing countries. Several models have been developed but none of the models appears to be widely accepted or being used in the evaluation process.

Purpose. To review classification models and assess its usability.

Methods. Literature review.

Results. Sixteen documents were found describing 11 different models. These models vary from simply listing different types of CBR to multidimensional configurations encircling principles, methods and outcomes of CBR. The models are only incidentally used in the evaluation of CBR programmes. The more recent models have been used to develop, select and group indicators.

Conclusions. Classification models can indeed structure the evaluation and comparison of CBR programs that are, by nature, very different from each other. Indicators can be developed within a theoretical framework provided by the classification model. In order to be widely accepted the models should be made less complex and focus on outcomes that are meaningful for the people involved in the evaluation as well as for policymakers and researchers.     

Falling between two stools; how a weak co-operation between the social security and the unemployment agencies obstructs rehabilitation of unemployed sick-listed persons

Purpose. To explore significant factors behind the weak co-operation between local social insurance and unemployment agencies impairing the rehabilitation of unemployed sick-listed persons.

Method. Individual, semi-structured face-to-face interviews with main actors directly involved in the sick-listing and rehabilitation process were conducted in the year 2000. In all 39 persons were interviewed: 25 professionals (physicians, public employment and social insurance officers) and 14 clients. Data were analysed according to Grounded theory method.

Results. The majority of unemployed sick-listed persons were declared too sick to work and were erased from the unemployment registers. This measure weakened the incentives for co-operation between the two main rehabilitation actors. The implication was that the unemployed sick-listed persons lost the opportunity of the co-ordinated rehabilitation they were entitled to. Three significant factors behind this process were identified by the main actors: indistinct regulation of co-operation, shifting political goals over time and conflicting goals between agencies; the last factor mainly a consequence of the other two.

Conclusions. The findings suggest that labour market changes and manifest political goals influence the rehabilitation efforts giving low priority to difficult-to-place individuals such as unemployed sick-listed persons. In fact, a labour market problem turns into a medical problem. The hypothesis needs further testing in quantitative studies.     

Coordinated multidisciplinary rehabilitation after hip fracture

Purpose: To review the topic of coordinated multidisciplinary rehabilitation after hip fracture from a research perspective and to provide information to guide the provision of rehabilitation services for patients with hip fracture.

Methods: Literature review including searches of Medline, Embase, Cochrane Collaboration and evidence based clinical guidelines, checking of references of publications and consultation with researchers.

Results: The research evidence is heterogeneous and remains inclusive. Programs that assist patients with hip fracture to regain function and return home as soon as feasible are likely to be effective as they appear to increase the percentage of patients who return home and remain there after hip fracture. Rehabilitation programs that achieve this are likely to be cost effective. These programs involve health professionals from multiple disciplines (nurses, allied health professionals and medical practitioners) who work collaboratively, may operate in several settings, and routinely provide specific treatments that are supported by strong evidence of effectiveness.

Conclusions: Patients with hip fracture should be offered a coordinated a multidisciplinary rehabilitation program with the specific aim of regaining sufficient function to return to their pre-fracture living arrangements.