Hemiarthroplasty for displaced femoral neck fracture: good clinical outcome but uneven distribution of occupational therapy

Purpose.?To assess rehabilitation, type of follow-up visits and outcome after bipolar hemiarthroplasty for femoral neck fracture.

Method.?Two hundred thirty-six consecutive patients with femoral neck fractures treated with hemiarthroplasty were followed for 30 months.

Results.?One hundred sixty-eight (71%%) were women, 175 (74%%) over 80 years old and 53 (22%%) were demented. Of 150 patients with available 3-month data, 7 patients (5%%) had not regained their walking ability. Seventy (47%%) were pain-free and 112 (75%%) were back in their original habitat. A hip-related complication leading to a contact with the orthopaedic department occurred in 20 of all patients (8%%), and 7 (3%%) of these underwent a revision surgery. One hundred eighty-seven patients (79%%) received occupational therapy (OT). Demented patients received OT more seldom (p < 0.001), as did patients aged 90 and older (p == 0.049).

Conclusion.?Due to the low rate of orthopaedic complications, these patients are now referred to their general practitioners, without any further follow-up at the orthopaedic department. Rehabilitation efforts are unevenly distributed. The need of increased rehabilitation efforts for demented or ‘old old’ patients is discussed.     

Implementation of multidisciplinary advice to allied health care professionals regarding the management of their patients with neuromuscular diseases

Purpose.?Patients with neuromuscular diseases (NMDs) do not always receive appropriate allied health care. This is partially because of the large heterogeneity among these conditions, some of which are quite rare. Individual allied health care professionals, therefore, have relatively little opportunity to develop relevant experience with these patients. To overcome this problem, we developed specialist multidisciplinary advice regarding management of patients with NMD for occupational therapy (OT), physical therapy (PT) and speech therapy (ST) in a primary care or rehabilitation setting. The aims of the study were to explore to what extent this allied health care advice was implemented with a focus on the amount of therapy received and to explore possible barriers to implementation.

Methods.?One-hundred two patients visited the Neuromuscular Centre Nijmegen for OT, PT and ST consultations. Integrated allied health care advice was written on the basis of these consultations and a multidisciplinary meeting. All patients, their therapists and rehabilitation physicians received this advice. Following the advice, questionnaires were sent out at baseline and at 6 months follow up, collecting data on implementation of the amount of therapy suggested and on possible barriers for adherence.

Results.?Advice for ST and OT was fully implemented in primary care, but only partially (58%) in a rehabilitation setting. Advice to reduce the amount of PT was implemented in only 15% of the cases. Possible barriers were related to the advice itself (feasibility of treatment duration, correctness and completeness), the patient (motivation) and the professional (experience in treatment of NMDs). Therapists expressed a desire to have the opportunity to discuss the treatment advice with the multidisciplinary team.

Conclusions.?The extent to which multidisciplinary advice was implemented differed for OT and ST compared to PT and for the setting (primary care or rehabilitation). Possible barriers were identified at different levels. We recommend follow-up telephone calls to provide therapists opportunity for discussion.     

Referral of patients with neuromuscular disease to occupational therapy,physical therapy and speech therapy: Usual practice versus multidisciplinary advice

Purpose.?To compare the volume of occupational therapy (OT), physical therapy (PT) and speech therapy (ST) as currently received by patients with neuromuscular diseases with the volume of OT, PT and ST recommended by a multidisciplinary team.

Method.?The use of OT, PT and ST was studied retrospectively and prospectively in a reference group (n = 106) receiving usual care and in an intervention group (n = 102) receiving advice based on multidisciplinary assessments. A cost analysis was made and the implementation of the advice was evaluated at 6 months.

Intervention.?Multidisciplinary assessments consisted of a single consultation by OT, PT and ST each, followed by a multidisciplinary meeting and integrated advice.

Outcome variables.?Volume (frequency times duration) of therapy, relative over- and underuse of therapy and costs of therapy and intervention.

Results.?Compared to the multidisciplinary advice, there was 40% underuse of OT among patients with neuromuscular disease. For PT, there was 32% overuse and 22% underuse; for ST, there was neither over- nor underuse. Some 40% of patients received once-only advice regarding ST compared to 27% regarding OT and 19% regarding PT. The costs of the multidisciplinary advice were estimated at €245 per patient. If fully implemented, our multidisciplinary approach would result in a mean cost savings of €85.20 per patient. The recommended therapy had, however, been implemented only partially at 6 months follow-up.

Conclusions.?Some patients with a neuromuscular disease do not receive any form of allied healthcare, whereas they should. Among patients with neuromuscular disease who do receive some form of allied healthcare, quite a few receive these treatments for too long periods of time. Ways need to be developed to improve implementation of the multidisciplinary advice and to obtain a more favourable balance between its costs and benefits.     

The role of occupational therapy in vision rehabilitation of individuals with glaucoma

Abstract

Purpose: Specific to individuals with glaucoma: (1) provide an overview of the role of occupational therapists (OTs) as part of the vision rehabilitation team, (2) outline evaluation and intervention approaches provided by OTs, and (3) summarize the evidence to support those intervention approaches. Methods: Literature on vision rehabilitation and the typical practice patterns of OTs working with individuals with glaucoma are reviewed and the occupational therapy process is applied to evaluation and intervention approaches. The evidence which supports intervention approaches for individuals with glaucoma is presented. Results: The strength of the evidence to support common intervention approaches employed by OTs is weak or inconclusive; many studies lack quality methodological rigor. Moderate evidence supports patient education programs and strong evidence supports problem-solving and self-management strategies; this evidence is based on a limited number of studies. Conclusion: The prevalence of eye diseases is increasing; knowledge of how visual impairment affects disability will inform resource allocation and development of rehabilitation programs that address the unique needs of individuals with glaucoma. Rehabilitation specialists are key members of the healthcare team aligned to proactively recognize and develop comprehensive rehabilitation programs to maximize individuals’ function, quality of life and independence in everyday living.

• Implications for Rehabilitation:

• Glaucoma is one of the four major eye diseases that may result in visual impairment leading to disability.

• Research supports intervention approaches and vision rehabilitation techniques used by occupational therapists to optimize the health and well-being of individuals with glaucoma.

• Rehabilitation specialists are key members of the healthcare team who need to be alert to subtle behaviors that may be indicative of visual impairment versus attributed to other client factors.

     

Using the ICF to clarify team roles and demonstrate clinical reasoning in stroke rehabilitation

Purpose.?The International Classification of Functioning, Disability and Health (ICF) is advocated as a tool to structure rehabilitation and a universal language to aid communication, within the multi-disciplinary team (MDT). The ICF may also facilitate clarification of team roles and clinical reasoning for intervention. This article aims to explore both factors in stroke rehabilitation.

Method.?Following a review of the literature, a summary was presented and discussed with clinicians working within stroke rehabilitation, to gather expert opinions. The discussions were informal, being part of service development and on-going education. The clinicians summarised key themes for the potential use of the ICF within clinical practice.

Results.?Two key themes emerged from the literature and expert opinion for the potential use of the ICF in stroke rehabilitation: (i) to aid communication and structure service provision, (ii) to clarify team roles and aid clinical reasoning. Expert opinion was that clarification of team roles needs to occur at a local level due to the skill mix, particular interests, setting and staffing levels within individual teams. The ICF has the potential to demonstrate/facilitate clinical reasoning, especially when different MDT members are working on the same intervention.

Conclusion.?There is potential for the ICF to be used to clarify team roles and demonstrate clinical reasoning within stroke rehabilitation. Further experiential research is required to substantiate this view.     

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.     

Access and perceived need for physical and occupational therapy in chronic arthritis

Purpose.?Physical and occupational therapy are beneficial for persons with chronic arthritis; however, access is problematic. The goal was to examine issues related to access to these services for patients with chronic arthritis.

Methods.?We used two data sources: 1) questionnaires sent to a random sample of 600 family physicians and to all 85 rheumatologists in the province of Quebec; and 2) interviews of 211 patients with physician-confirmed chronic arthritis recruited from 34 primary care settings in Quebec.

Results.?Only 11.5% of family physicians and 31.7% of rheumatologists referred patients with rheumatoid arthritis (RA) to rehabilitation, whereas 60.4% of family doctors referred patients with osteoarthritis. Only 26.1% of patients felt that they required rehabilitation and this was associated with lower self-efficacy (OR: 0.84, 95% CI: 0.72, 0.99) and higher educational level (OR: 2.10, 95% CI: 1.01, 4.36).

Conclusion.?Family physicians are less likely to refer patients with RA to therapy. Only about a quarter of patients with chronic arthritis treated in primary care perceived the need for these services. Efforts to improve arthritis care should address education of physicians and patients regarding the benefits of rehabilitation and there should be efforts to increase therapy resources in order to enhance access.     

Effect and process evaluation of implementing standardized tests to monitor patients in spinal cord injury rehabilitation

Purpose.?To evaluate the implementation of standardized physical and functional tests to monitor patients with a spinal cord injury (SCI) in eight rehabilitation centers and to analyze the enablers and the barriers of the implementation process.

Method.?The method involved prospective effect and process evaluation. Team members responded to mailed questionnaires at the start (n?=?115) and end (n?=?82) of the 1-year implementation period. Furthermore, a questionnaire was administered to managers (n?=?8), coordinators (n?=?8), and 32 persons with SCI in four centers. Outcome of the effect evaluation was the phase of implementation of standardized testing in each center. The process evaluation analyzed enablers and barriers of the implementation process.

Results.?After a year of implementation, half of the centers shifted to higher implementation phases. None of the centers was classified in the highest phase. Enablers were the positive attitude of the team members regarding standardized testing and an encouraging local coordinator. Most important barrier was lack of time to implement the standardized testing.

Conclusion.?There is a large support for implementing standardized tests to monitor patients with SCI. During the 1-year, a positive shift was visible in the extent of implementation. Successful implementation of patient monitoring requires substantial amounts of time and effort of the rehabilitation centers involved.     

‘Bringing them back on the right track’: Perceptions of medical staff on the rehabilitation of individuals with violently acquired spinal cord injuries

Purpose.?To explore the perceptions of medical staff on the rehabilitation of spinal cord injured individuals, who became disabled from street violence.

Method.?A total of 16 medical staff members from two rehabilitation hospitals were interviewed, using a semi-structured interview. The interview recorded demographic information about the staff and probed at differences in clinical goals and practices with violently and non-violently injured individuals with spinal cord injuries. In all, 34 interviews were conducted from staff. Responses were tabulated and interpreted using a grounded theory approach.

Results.?Staff set goals of ‘increasing independence’ that are informed by their professional backgrounds. The ‘differences’ in persons with violently acquired disabilities were noted, both in terms of needs, resources and attitudes. Depending on the professional and racial background of the staff, there was an indication of different degrees of tolerance toward patients' non-compliance with rehabilitation goals. Staff members are largely welcoming of the perceived impact of peer mentoring as it increases the cultural competence of the hospital in dealing with individuals who were violently disabled.

Conclusions.?Findings, although exploratory, emphasise the dynamics of perception development, through the tensions in the goal of independent functioning and perceived differences in persons who became disabled from street violence.     

‘Beyond the cushion’: a study of occupational therapists' perceptions of their role and clinical decisions in pressure care

Purpose.?Occupational therapists are frequently involved in pressure care management in rehabilitation and community settings. The purpose of this study was to investigate the perceptions of occupational therapists about their role within pressure care and the influences on clinical decisions in this area.

Methods.?A grounded theory approach was used and semi-structured interviews were conducted with nine occupational therapists who had provided pressure care to clients within the Hunter Region of Australia. Data were analysed using the constant comparative method.

Results.?The occupational therapy (OT) role in pressure care is diverse and shaped by contextual factors in the workplace. Informants perceived uncertainty surrounding some aspects of their role in pressure care, and with perceptions of other health professionals about their role. OT clinical decisions in pressure care are influenced by intrinsic and extrinsic factors including OT knowledge and experience, client centred approaches and the availability of resources. Relationships between study themes were summarised in a diagram to articulate the factors contributing to the perceptions of OT's about their role in pressure care.

Conclusions.?There is a need for further investigation into the role and clinical decision making of therapists involved in pressure care. Occupational therapists need to promote their role in pressure care to other health professionals.     

Adaptations to pain rehabilitation programmes for non-native patients with chronic pain

Purpose.?(i) To determine whether adaptations for non-native patients have been implemented in pain rehabilitation programmes; (ii) to determine whether characteristics of the rehabilitation institute are related to having adaptations for non-native patients in place.

Subjects.?Rehabilitation institutes and rehabilitation departments of general hospitals in The Netherlands who offer a pain rehabilitation programme.

Method.?A questionnaire was handed over in person or by e-mail to the rehabilitation physicians of the participating institutes. Twenty-seven (90%%) questionnaires were returned. The questionnaire concerned programme adaptations and institute characteristics. The data were analysed by χ² tests or Fischer's exact tests and logistic regression analysis.

Results.?Twelve institutes (44.4%%) reported having adaptations in place for non-native patients in their pain rehabilitation programme. The most common adaptations were as follows: increased number of consultations (25.9%% of the institutes); longer consultations (25.9%%) and education for employees regarding cultural competency (11.1%%). Institutes which treated a high percentage (≥11%%) of non-native patients had implemented significantly more frequently adaptations to their rehabilitation programme (p == 0.04). The number of adaptations was neither associated with the proportion of non-native citizens in the local population nor with the number of the institutes' employees.

Conclusion.?Less than half of the institutes had implemented one or more programme adaptations for non-native patients. Institutes which had made adaptations to their rehabilitation programme treated more non-native patients.     

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.     

Increasing medical students’ understanding of the role of occupational therapists

Abstract

Understanding the roles and responsibilities of different healthcare professionals allows for collaborative care to occur. This article describes the evaluation of a student-designed, case-based educational module about the roles and responsibilities of occupational therapists (OTs) designed to increase the knowledge of occupational therapy among medical students. The study used a quasi-experimental, pre-/post-test design. Independent paired t-tests showed medical students’ mean score on the OT Awareness Education Module at post-test was significantly greater than their mean score at pre-test. Results demonstrated how using an evidence-based approach to design an educational strategy can increase the knowledge of one member of the healthcare team about the role of another within a short period. This study documented an effective approach for educating future physicians about the roles and responsibilities of occupational therapy as they prepare to make decisions affecting patient care outcomes.     

Factors associated with quality of life and caregiver strain amongst frail older adults referred to a community rehabilitation service: implications for service delivery

Purpose.?To identify factors contributing to reduced quality of life and increased caregiver strain in an older population referred to a community rehabilitation team and to recommend service delivery models.

Methods.?Analytical cross-sectional study arising from baseline assessments from 107 subjects drawn from a randomised controlled trial of community rehabilitation service delivery models.

Setting.?A community rehabilitation team based in Brisbane, Queensland, Australia.

Measures.?Primary outcome variables include quality of life (EQ-5D & VAS) and Carer Strain Index. Predictor variables include participation in functional activities, history of falls, number of medications, number of co-morbidities, depression, environmental hazards, physical function and nutrition. Association between variables assessed using linear regression.

Results.?Major factors contributing to reduced quality of life were having reduced participation in daily activities, depression, and having poor vision. Having poor nutrition and no longer driving also contributed to poor quality of life. The major factor contributing to increased caregiver strain was reduced participation in daily activities by the older person.

Conclusions.?Community rehabilitation services working with older populations must adopt models of care that screen for and address a wide range of factors that contribute to poor quality of life and caregiver strain.     

Human rights and rehabilitation outcomes

Purpose.?The aim of this article is to introduce rehabilitation professionals to the rapidly growing literature on human rights particularly as it relates to health and rehabilitation. The article aims to stimulate further discussion and debate concerning the place of human rights in rehabilitation practice.

Method.?Some important milestones in the recent history of the human rights movement are briefly outlined, and some important terms in the rights literature are explained. The Ward and Birgden model of the structure of human rights is then described as an example of a rights perspective that might have particular relevance for health and social services and rehabilitation.

Results.?A rehabilitation case study is presented as an example of how the Ward and Birgden model could have practical relevance when deciding on the most important outcomes for an individual in rehabilitation.

Conclusion.?Human rights are playing an increasing role in the struggle to improve health and healthcare globally. They also have important implications for rehabilitation practitioners and researchers and should form the core of any ethical framework for rehabilitation. It might even be argued that rights and dignity are themselves valued outcomes for rehabilitation.     

An in-depth analysis of ethics teaching in Canadian physiotherapy and occupational therapy programs

Abstract

Purpose: The purpose of this study was to examine current approaches and challenges to teaching ethics in entry-level Canadian physiotherapy (PT) and occupational therapy (OT) programs. Methods: Educators responsible for teaching ethics in the 28 Canadian PT and OT programs (n?=?55) completed an online survey. Results: The quantity of ethics teaching is highly variable, ranging from 5 to 65?h. Diverse obstacles to ethics teaching were reported, relating to the organization and structure of academic programs, student issues and the topic of ethics itself. Specific challenges included time constraints, large class sizes, a lack of pedagogical tools adapted to teaching this complex subject, a perceived lack of student interest for the subject and a preference for topics related to clinical skills. Of note, 65% of ethics educators who participated in the survey did not have any specialized training in ethics. Conclusion: Significant cross-program variation in the number of hours dedicated to ethics and the diversity of pedagogical methods used suggests that there is little consensus about how best to teach ethics. Further research on ethics pedagogy in PT and OT programs (i.e. teaching and evaluation approaches and effectiveness of current ethics teaching) would support the implementation of more evidence-based ethics education.

• Implications for Rehabilitation

• Ethics educators in Canadian PT and OT programs are experimenting with diverse educational approaches to teach ethical reasoning and decision-making to students, including lectures, problem-based learning, directed readings, videos, conceptual maps and clinical elective debriefing, but no particular method has been shown to be more effective for developing ethical decision-making/reasoning. Thus, research on the effectiveness of current methods is needed to support ethics educators and programs to implement evidence-based ethics education training.

• In our survey, 65% of ethics educators did not have any specialized training in ethics. Ensuring that educators are well equipped to support the development of necessary theoretical and applied competencies can be promoted by initiatives including the creation of tailored ethics teaching and evaluation tools, and by establishing communities of practice among ethics educators.

• This survey identified heterogeneity in ethics teaching content, format and duration, and location within the curriculum. In order to be able to assess more precisely the place accorded to ethics teaching in PT and OT programs, careful mapping of ethics content inside and across rehabilitation programs is needed – both in Canada and internationally. These initiatives would help advance understanding of ethics teaching practices in rehabilitation.

     

Adult acquired major upper limb amputation in Norway: prevalence,demographic features and amputation specific features. A population-based survey

Purpose.?To estimate the prevalence of adult acquired major upper limb amputation in Norway. To describe this amputee population regarding demographic features and amputation specific features. To compare our data to data collected internationally.

Method.?Population-based cross-sectional study on adult upper limb amputees with acquired limb loss through or proximal to the radio-carpal joint. Patients were found in the databases of the two companies in Norway that make upper limb prostheses and in the medical records of three of the largest Norwegian hospitals. Data were collected by postal questionnaires.

Results.?We estimated a population prevalence of 11.6 per 100,000 adults (n == 416). Our survey was not 100%% comprehensive and the estimate is conservative. The amputees were predominantly men with traumatic, unilateral, distal amputations at a young age. There were significant gender- and amputation level differences in cause. Most amputees had used prostheses. About four in ten were in paid employment.

Conclusions.?Our findings are mainly consistent with earlier studies from other countries. Implications of our findings related to the planning of future health care for these patients are outlined, including suggestion of regional multidisciplinary rehabilitation emphasising occupational rehabilitation and focus on preventive measures. Potential areas of follow-up are suggested.     

Engagement and learning: an exploratory study of situated practice in multi-disciplinary stroke rehabilitation

Purpose.?Active participation is considered to be a key factor in stroke rehabilitation. Patient engagement in learning is an important part of this process. This study sets out to explore how active participation and engagement are ‘produced’ in the course of day-to-day multi-disciplinary stroke rehabilitation.

Method.?Ethnographic observation, analytic concepts drawn from discourse analysis (DA) and the perspective and methods of conversation analysis (CA) were applied to videotaped data from three sessions of rehabilitation therapy each for two patients with communication impairments (dysarthria, aphasia).

Findings.?Engagement was facilitated (and hindered) through the interactional work of patients and healthcare professionals. An institutional ethos of ‘right practice’ was evidenced in the working practices of therapists and aligned with or resisted by patients; therapeutic activity type (impairment, activity or functional focus) impacted on the ways in which patient engagement was developed and sustained.

Conclusions.?This exploration of multi-disciplinary rehabilitation practice adds a new dimension to our understanding of the barriers and facilitators to patient engagement in the learning process and provides scope for further research. Harmonising the rehabilitation process across disciplines through more focused attention to ways in which patient participation is enhanced may help improve the consistency and quality of patient engagement.     

Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: A comparison between four European rehabilitation centres

Purpose. The aim of this study was to compare the time allocated to therapeutic activities (TA) and non-therapeutic activities (NTA) of physiotherapists (PT) and occupational therapists (OT) in stroke rehabilitation units in four European countries.

Method. Therapists documented their activities in 15-min periods for two weeks. They recorded: activity, number of patients, number of stroke patients, involvement of other people, location and frequency of each activity. Kruskal-Wallis tests and negative binomial regression models were used to compare activities between professional groups and between units.

Results. The average proportion of TA per day ranged between 32.9% and 66.1% and was higher for PT than for OT in each unit. For OT, significant differences emerged between the units in the proportion of time allocated to TA compared to NTA with British OTs spending significantly less time in TA. In the Belgian unit, three times less time was spent on patient-related co-ordination activities (e.g., administration, ward rounds) compared to the British and Swiss units.

Conclusions. Time allocation differed between PT and OT and between units, affecting the time available for TA. Further investigation is necessary to study the effect of work organization in stroke rehabilitation units on the efficiency of rehabilitation regimes.