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.     

What is most and least useful in residential rehabilitation? A qualitative study of service users and professionals

Aims: Explore client and staff views of the most and least useful aspects of residential rehabilitation.

Methods: A qualitative study, involving interviews with clients who had attended residential rehabilitation and a range of relevant staff, conducted in the Wiltshire and Swindon areas of the UK.

Findings: All interviewees agreed there were many benefits to be gained from Residential Rehabilitation. There was considerable diversity of clients' experiences of the help provided to them in the community, and most criticism was reserved for what happened before and after residential rehabilitation.

Conclusions: Arrangements for care need to be considered before admission, not just before discharge, taking a comprehensive holistic approach to client needs, including childcare, housing, training and education, employment, family and relationship concerns. This implies skilled key‐working, effective inter‐agency collaboration and the setting of clear standards of quality. Residential rehabilitation has evolved from a service provided mainly for older people with alcohol problems, to those with heroin addiction and now those with dual or multiple addictions, notably involving crack cocaine. It may be that different types of ‘therapeutic community’ are needed for different problems.     

Framing new pathways in transformative exercise for individuals with existing and newly acquired disability

Purpose: This paper describes a continuum of customized exercise options for people with an existing and newly acquired disability or diagnosis referred to as the Transformative Exercise Framework. Background: The period directly after rehabilitation is a critical juncture where many individuals return to life with high rates of sedentary behavior. After rehabilitation discharge, people with newly acquired disability or diagnoses often never make the transition into usage of community-based exercise services that are tailored, safe and effective. Methods: Narrative review. Results: The Transformative Exercise Framework supports a patient-to-participant, rehab-to-wellness model that emphasizes a linkage between physical and occupational therapists and community-based exercise trainers. The four focus areas – Rehabilitation, Condition-specific Exercise, Fitness and Lifetime Physical Activity – emphasize a range of options for people with newly acquired disability and diagnoses, or for people with existing disability and/or chronic health conditions who have a new injury, secondary condition or are severely deconditioned. Conclusion: The concept of transformative exercise is to support people with disabilities and diagnoses with a seamless restore–improve–prevent continuum of programs and services. This continuum connects individuals to rehabilitation and exercise professionals in a dynamic framework, which maximizes the expertise of both sets of professionals and provides the most effective interventions to achieve the greatest gains in health and function and/or to avoid future health decline.

• Implications for Rehabilitation

• Patients discharged from rehabilitation should be transformed into participants in lifelong physical activity through a continuum of health services, which we refer to as Transformative Exercise.

• Transformative exercise is a continuum of individually tailored exercise strategies/programs that aims to improve the function of underperforming systems, which inhibit community and/or lifelong physical activity participation.

• The Transformative Exercise Framework can be used by a therapist or exercise trainer to design a program that maximizes performance and time and is based on a specific process for identifying short and long term goals.

     

The categorization and control of people with disabilities

Eighteen years' experience in the development of an innovative community-based regional vocational rehabilitation service has been described. The programme continues to develop with the recent introduction of a vocational consulting service offering employee assistive programmes to local employers, and with funding from the Solicitor General's Department to provide vocational assessment and retraining to women in conflict with the law. The success of this programme is due to the co-operative melding of the contributions of the university, the regional rehabilitation centre and broadly based community participation by employers and a variety of agencies.

Based on a presentation to WHO Consultation on Community-based Rehabilitation, Edinburgh, Scotland, June 1986.     

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.     

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.     

Barriers to implementation of stroke rehabilitation evidence: findings from a multi-site pilot project

Purpose: To describe the barriers to implementation of evidence-based recommendations (EBRs) for stroke rehabilitation experienced by nurses, occupational therapists, physical therapists, physicians and hospital managers. Methods: The Stroke Canada Optimization of Rehabilitation by Evidence project developed EBRs for arm and leg rehabilitation after stroke. Five Canadian stroke inpatient rehabilitation centers participated in a pilot implementation study. At each site, a clinician was identified as the “local facilitator” to promote the 6-month implementation. A research coordinator observed the process. Focus groups done at completion were analyzed thematically for barriers by two raters. Results: A total of 79 rehabilitation professionals (23 occupational therapists, 17 physical therapists, 23 nurses and 16 directors/managers) participated in 21 focus groups of three to six participants each. The most commonly noted barrier to implementation was lack of time followed by staffing issues, training/education, therapy selection and prioritization, equipment availability and team functioning/communication. There was variation in perceptions of barriers across stakeholders. Nurses noted more training and staffing issues and managers perceived fewer barriers than frontline clinicians. Conclusions: Rehabilitation guideline developers should prioritize evidence for implementation and employ user-friendly language. Guideline implementation strategies must be extremely time efficient. Organizational approaches may be required to overcome the barriers.

Implications for Rehabiliation

• Despite increasingly strong evidence for stroke rehabilitation, there are delays in implementation into clinical practice.

• This study showed that lack of time, staffing issues, staff education, therapy selection or prioritization, lack of equipment and team functioning were the main barriers to implementation.

• Managers and stakeholders should consider these barriers and prioritize evidence when implementing.

     

Setting Disablement in Perspective

Purpose. Although rehabilitation is an integral part of the lives of many young people with physical disabilities, sexuality education and HIV and AIDS prevention services are not. The purpose of this study was to record the voices of disabled young people regarding their experiences of sexuality and HIV and AIDS and to determine the role of rehabilitation professionals in this regard.

Methods. Sixteen young people with physical disabilities, aged 15–24 years participated in the study. Individual in-depth interviews were conducted with each participant, followed by focus group discussions comprising four to six participants. Responses were audiotaped and transcribed verbatim. Textual and contextual features of the Atlas.ti computer programme were used to support the thematic analysis of the data.

Results. The results indicated that most participants had received some form of rehabilitation for their physical impairment, yet sexuality and HIV and AIDS matters were not part of the rehabilitation process. Although the majority were aware of sexuality and HIV and AIDS issues, their limited factual knowledge did not persuade them to change their sexual behaviour or take preventive measures against contracting HIV infection.

Conclusion. Rehabilitation professionals need to widen their scope of practice to include the promotion of good sexual and reproductive health for disabled young people.     

Community-based rehabilitation programme as a model for task-shifting

This article explores some of the implications of a non-governmental organisation (NGO) initiated community-based rehabilitation (CBR) programme, for HIV-related task-shifting programmes which have been recommended by the World Health Organisation (WHO) as an important aspect of HIV prevention, treatment and care programmes. The CBR programme is run by multi-skilled community rehabilitation facilitators (CRFs) in a low income, rural context in KwaZulu-Natal, South Africa, and explicitly recognises the multiple facets of disability. As such, the programme focuses on both the physical and social aspects of living with disabilities. A qualitative approach was used to conduct this study, and semi-structured interviews were conducted with beneficiaries of the programme (n == 35), home and community-based care givers (HCBCs) (n == 13), and managers (n == 2). A focus group discussion was conducted with CRFs (n == 5). We found that the CBR programme successfully delivered rehabilitation services at a community level and that multi-skilled CRFs are an effective means of implementing CBR programmes in low-income rural areas. The developmental focus of the programme created a range of benefits for people with disabilities, including: physical rehabilitation, emotional support and counselling, access to grants, social inclusion and accessing assistive devices. Central to the programme's success was the maintenance of relationships and partnerships at different levels in the community, these included relationships between HCBCs and CRFs, between CRFs and therapists, and between the NGO and the various participants in the programme. However, the NGO struggled to maintain a partnership with the relevant government departments and this had important implications for the programmes sustainability. In conclusion, we argue that this programme's use of multi-skilled mid-level workers who have undergone effective training programmes in CBR demonstrates that a wide range of rehabilitation activities can be effectively undertaken at a community level, and that this programme provides an important example of how the WHO's task-shifting guidelines for HIV treatment, care and prevention can be implemented.     

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).     

在大连郊区一个自然村开展社区康复

目的：探讨康复中心到社区提供技术支持，帮助社区开展社区康复的方法及效果。方法：选择大连市近郊的一个自然村为试点，以社区卫生所为基地。帮助社区进行社区康复调查、康复员培训、康复治疗、指导健康教育等。结果：为社区建立了一套普查资料，统计出该社区有残疾人232例，1604人次患有各种疾病，培训社区康复员5名；指导社区康复员深入居民家庭进行康复治疗20余人次，进行高血压病防治教育1次，健康教育及疾病咨询活动4次，数百名社区居民参加了健康教育及咨询活动；在社区建立了社区康复站。结论：社区康复有广阔的发展前景，很受社区居民的欢迎；效区居民仍较缺乏卫生保健知识，开展社区康复的经费来源是一个问题。     

Rehabilitation following cancer treatment

Abstract

Purpose: Cancer survivorship is increasing. However, life-saving treatments often leave people with physical, cognitive and emotional sequelae that contribute to activity and participation limitations. The purpose of this review is to summarize current evidence regarding rehabilitation interventions to address problems during survivorship. Method: Best evidence synthesis. The review took as its starting point a systematic review of patient needs and supportive care interventions following cancer treatment. The study team identified the needs which could be addressed by rehabilitation and suggested others not originally included. Then they built on the earlier review’s conclusions regarding effective intervention through extraction of results from subsequent systematic reviews and randomized controlled trials. Results: Evidence regarding the effectiveness of potential rehabilitation interventions was reviewed for physical functioning, fatigue, pain, sexual functioning, cognitive functioning, depression, employment, nutrition and participation. With the exception of physical rehabilitation interventions following breast cancer, this literature tends to focus on psychoeducational interventions, which have demonstrated limited effectiveness for rehabilitation outcomes. Conclusions: Most of the knowledge available regarding potential rehabilitation interventions comes from psychosocial oncology literature. While there are limitations, this literature provides an excellent starting point to examine the potential effectiveness of rehabilitation interventions within cancer survivorship programs.

• Implications for Rehabilitation

• Good evidence exists for the use of exercise/physical rehabilitation in reducing fatigue after treatment for most cancers, and improving upper extremity functioning following treatment for breast cancer.

• Preliminary evidence exists in a number of areas that may be improved by rehabilitation interventions, such as pain, sexual functioning, cognitive functioning and return to work, but further research is needed.

• No intervention studies addressing participation limitations were identified. Rehabilitation professionals are encouraged to take the lead in exploring participation limitations among cancer survivors and developing suitable interventions.

     

Establishing a training programme for rehabilitation aides in Haiti: Successes,challenges, and dilemmas

Background.?In Haiti, there are scarce resources available for physical rehabilitation. Healing Hands for Haiti International Foundation has established a rehabilitation aide programme as a means of providing rehabilitation services. This article illustrates some of the successes, challenges, and dilemmas that arise in the provision of such an education.

Methods.?Graduates and students answered a 23-item questionnaire designed to investigate respondents' perceptions of the training programme. These responses were then coded and quantified for analysis.

Results.?The author interviewed 32 of 49 graduates and current students. Forty-five percent of graduates were working as rehabilitation aides, and the majority of those were working in urban areas. Graduate's earnings differed greatly. Respondents suggested that the programme needed to help the graduates find employment after graduation and to provide continuing training. The most common limitation in education mentioned by the graduates was a need for basic nursing skills and first-aid education.

Conclusion.?The most common difficulties and dilemmas in providing a rehabilitation aide programme were: lack of resources including job opportunities for graduates, and lack of proper support available from supervising healthcare providers. Curricula for similar programs must be culturally sensitive, help create employment opportunities, and provide continuing educational opportunities for their graduates.     

Self-efficacy,disability level and physical strength in the injured workers: findings from a major factory disaster in Bangladesh

Introduction: In 24 April 2013, Rana Plaza – a high-rise building in Bangladesh where garments were being made for the Western markets collapsed. In this study, we report on the surviving workers’ physical strength, self-efficacy, and disability level one year after the disaster. Methods: This cross-sectional study took place at the Centre for the Rehabilitation of the Paralysed (CRP) which provided care for more than 600 victims. For this study, upper extremity strength among the survivors was assessed by dynamometer hand grip (HG) and lower extremity strength by five time sit to stand test (FTSST). The WHODAS tool measured level of disability and General Self-Efficacy questionnaire measured self-efficacy. Post-traumatic stress disorder (PTSD) prevalence was determined by the PCL-scale. Results: The study recruited 181 injured workers. The mean disability score among them was 49.8 (SD 17.5) and mean self-efficacy score was 24.9 (SD 6.9). In multivariate models, after adjusting for age, gender, education, injury profile, employment, marital status and job category, self-efficacy was found to be higher among those who scored above median HG test score [β=??2.32 (95% CI: ?4.63, ?0.01)] and FTSST performance score [β=??2.69 (95% CI: ?4.93, ?0.46)]. The disability level was found to be significantly associated with PTSD score [β?=?0.84 (95% CI: 0.62, 1.06)] and self-efficacy score [β=??0.45 (95% CI: ?0.78, ?0.13)]. Conclusions: There is an immense need to develop and deliver effective post-injury recovery, rehabilitation and return-to-work programs for injured workers in resource poor countries.

• Implications for Rehabilitation

• The study findings suggest that one year after the factory disaster in Bangladesh, the injured workers are suffering from a high degree of disability, low physical performance and reporting low self-efficacy. The national and international stakeholders including Western buyers, aid agencies, NGOs, worker advocacy groups, consumer associations and the government of Bangladesh can be updated on the progress made so far.

• There is an immense need to develop and deliver effective post-injury recovery, rehabilitation and return-to-work programs for injured workers in resource poor countries. International organizations like ILO, WHO, World Bank can help developing countries in building these capacities.

     

Returning to work – a long-term process reaching beyond the time frames of multimodal non-specific back pain rehabilitation

Abstract

Purpose: To explore and describe health professionals’ experience of working with return to work (RTW) in multimodal rehabilitation for people with non-specific back pain. Method: An interview study using qualitative content analysis. Fifteen participants were interviewed, all were working with multimodal rehabilitation for people with non-specific back pain in eight different rehabilitation units. Results: The participants experienced RTW as a long-term process reaching beyond the time frames of the multimodal rehabilitation (MMR). Their attitudes and, their patients’ condition, impacted on their work which focused on psychological and physical well-being as well as participation in everyday life. They often created an action plan for the RTW process, however the responsibility for its realisation was transferred to other actors. The participants described limited interventions in connection with patients’ workplaces. Conclusions: Recommended support in the RTW process in MMR comprises the provision of continuous supervision of vocational issues for the health care professionals, the development of guidelines and a checklist for how to work in close collaboration with patients’ workplaces and employers, the provision of long-term follow-up in relation to the patients’ work, and the development of proper interventions in order to promote transitions between all the different actors involved.

• Implications for Rehabilitation

• Rehabilitation programs targeting return to work (RTW) for people with non-specific back pain needs to include features concretely focusing on vocational issues.

• Health and RTW is often seen as a linear process in which health comes before RTW. Rehabilitation programs could be tailored to better address the reciprocal relationship between health and work, in which they are interconnected and affect each other.

• The RTW process is reaching beyond the time frames of the multimodal rehabilitation but further support from the patients are asked for. The rehabilitation programs needs to be designed to provide long-term follow-up in relation to the patients’ work.

     

State of the science on postacute rehabilitation: setting a research agenda and developing an evidence base for practice and public policy: an introduction

The Rehabilitation Research and Training Center on Measuring Rehabilitation Outcomes and Effectiveness along with academic, professional, provider, accreditor and other organizations, sponsored a 2-day State-of-the-Science of Post-Acute Rehabilitation Symposium in February 2007. The aim of this symposium was to serve as a catalyst for expanded research on postacute care (PAC) rehabilitation so that health policy is founded on a solid evidence base. The goals were to: (1) describe the state of our knowledge regarding utilization, organization and outcomes of postacute rehabilitation settings, (2) identify methodologic and measurement challenges to conducting research, (3) foster the exchange of ideas among researchers, policymakers, industry representatives, funding agency staff, consumers and advocacy groups, and (4) identify critical questions related to setting, delivery, payment and effectiveness of rehabilitation services. Plenary presentation and state-of-the-science summaries were organized around four themes: (1) the need for improved measurement of key rehabilitation variables and methods to collect and analyze this information, (2) factors that influence access to postacute rehabilitation care, (3) similarities and differences in quality and quantity of services across PAC settings, and (4) effectiveness of postacute rehabilitation services. The full set of symposium articles, including recommendations for future research, appear in Archives of Physical Medicine and Rehabilitation.     

Effectiveness of a community-based low intensity exercise programme for ambulatory stroke survivors

Purpose.?To establish the feasibility and effectiveness of a community-based exercise programme for ambulatory patients with stroke discharged from rehabilitation

Method.?Eighteen participants were recruited 3–12 months after onset of first stroke. Using a time series experimental design, the group completed a baseline period of 4 weeks (A1), a group exercise programme of low-intensity progressive resistive exercise and functional tasks for lower limb muscles (B) and repeat assessment after cessation of exercise (A2). Fitness instructors delivered sessions at Leisure Centres twice weekly for 14 weeks with physiotherapy support and the minimum attendance requirement was 16 sessions. Measures included muscle strength, gait velocity, Berg Balance Scale and Nottingham Extended Activities of Daily Living.

Results.?Lower limb muscle strength improved after training (ANOVA, p?<?0.02). Paretic knee extension strength increased from 43.4?±?5.9 to 60.4?±?6.8 Nm after 16 exercise sessions. Walking velocity increased significantly (ANOVA, p?<?0.001), from 0.54?±?0.07 to 0.75?±?0.08 m/s (t?=??3.31, p?<?0.01). Balance and everyday function were also significantly improved (p?<?0.003). There were marked individual variation in the response to training, and those who completed additional training did not show benefit.

Conclusions.?This community-based exercise programme was feasible and delivered positive improvements in physical function for participants. Further issues raised for investigation include the individual response to training and the benefits of extended training.