3. Electronic Theses and Dissertations (ETDs) - All submissions

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The factors affecting physiotherapy rehabilitation in patients following an open rotar cuff repair
(2011-02-10) Chivers, Tamarin Claire
Introduction Rotator cuff tears can cause great impairment of the shoulder joint with debilitating pain and dysfunction. The surgical repair of rotator cuff tears result in an extensive rehabilitation being required. This process can be affected by various demographic, surgical and rehabilitative factors. There appear to be no studies relating these factors to the rehabilitation process. The aim of this study was to determine the prevalence of partial and full thickness tears seen in one physiotherapy practice over the period of four and a half years. It also was to identify and analyse the factors affecting the amount of physiotherapy following a rotator cuff repair. Methods This was a retrospective record review. It was also a cross sectional correlational study. Results The prevalence of partial and full thickness rotator cuff tears seen over a period of four and a half years in one physiotherapy practice is very similar. Partial thickness tears constituted 46% of the entire sample and full thickness made up 54% of the sample. Four out of eleven factors were found to be associated with the amount of physiotherapy received after a rotator cuff repair. These factors included the age of the patient, whether the patient was injured on duty, iv preoperative physiotherapy and additional procedures after surgery such as a revision of the repair or a manipulation of the shoulder. Conclusion There are only a few factors shown to be associated with the rehabilitation process after a rotator cuff repair. These factors would need to be correlated against outcome in future studies.
Impact of caregiver education on stroke survivors and their caregivers
(2010-09-20) Mudzi, Witness
Despite the improvements that have been made in health care over the years, stroke remains a serious public health problem in low, middle and high-income countries. Post-stroke, there are many consequences that manifest and these include mortality, morbidity and socioeconomic, affecting not only the stroke survivor but also the caregiver. These consequences are felt hardest in low and middleincome countries because they are the least able to deal with health related setbacks to development. Pressure for beds and the need to reduce hospitalisation related costs have resulted in early discharge home of patients culminating in caregivers playing a more significant role post-stroke. The role played by caregivers has of late received much attention and is well documented in highincome regions. Informal caregivers are particularly important in low resourced settings. Caregivers play an important role in the rehabilitation process of the stroke survivor. The discharge home of patients with stroke to unprepared caregivers is associated with burden or strain, which negatively affects the quality of life of not only the caregiver but the stroke survivor as well. The effect of a structured, individualised caregiver training programme on patients with stroke and their carers has not been established in sub-Saharan Africa in general and South Africa in particular. With this in mind, the aim of the study was to establish the impact of caregiver education on the morbidity of the stroke survivors and on the quality of life of the stroke survivors and their carers. The specific objectives of the study were to establish the: physiotherapy caregiver education programmes and associated content in use for managing patients with stroke at Chris Hani Baragwanath hospital, effect of caregiver education on the mobility of the stroke survivors, effect of caregiver education on the health related quality of life of the stroke survivor and the caregivers, effect of caregiver education on the ability of the stroke survivor to socialise and participate in community issues and also the patient and caregiver characteristics associated with caregiver strain post-stroke. To achieve the first objective, a self designed questionnaire was used to establish the physiotherapy caregiver education programmes and associated content in use for managing patients with stroke at Chris Hani Baragwanath hospital from the physiotherapists at the hospital. For the rest of the objectives, a stratified randomised controlled trial using concealed allocation with a broad entry and blinded outcome assessment at baseline, three, six and 12 months was used for data collection. The participants for the study were first time ischaemic patients with stroke admitted to Chris Hani Baragwanath hospital, Soweto, Johannesburg, South Africa. A total of 200 patients and their caregivers participated in the study. These were randomly assigned to either the control group or the experimental group. The caregivers in the experimental group were subjected to an individualised training programme just prior to discharge of the patient with stroke and at the three month follow up. The assessor was blinded to the group allocation of the patients and caregivers until after completion of the study. From the study, the one-year case fatality was 38%. The mean hospital length of stay for patients with stroke was six days and the average number of physiotherapy contacts for the stroke survivors was one. The content of the rehabilitation programme of patients post-stroke was well structured and appropriate at Chris Hani Baragwanath. However, there was no caregiver involvement or training during in-patient rehabilitation. The barriers to caregiver involvement included perceived high workload by therapists, short hospital length of stay, poor referral systems between clinicians and therapists of patients post-stroke and caregivers being unavailable during working hours for training purposes. Using the Barthel Index (BI) scores, 78% of the patients were functionally dependent at 12 months post discharge. None of the patients were fully independent in mobility and stair climbing. The experimental group had better mean BI scores at the three and 12 month follow up periods (p = 0.01 and p = 0.05 respectively) when compared to the control group. Caregiver education had the effect of improving the BI scores by one and 0.7 at the three and 12 months follow ups respectively. However, the functional abilities of the patients from both groups were still low at 12 months with averages of 13.3 and 12.6 for the experimental and control groups respectively (out of a possible 20). The overall patient mobility scores as measured on the Rivermead Mobility Index were low over the study period with averages of 9.1 and 8.5 for the experimental and control group respectively (out of a possible 15). However, the experimental group had slightly better Rivermead Mobility Index (RMI) scores, which were not statistically significant. Caregiver education had the effect of reducing the risk of death by 27% relative to that occurring among the control group patients. The health related quality of life of the stroke survivors was generally poor over the study period. The baseline means from their EQ-5D scores (for health related quality of life) were 42.4 and 43.7 for the control and experimental groups respectively, which rose to 67 and 68.8 at 12 months respectively post discharge. Caregiver education had the effect of improving patients’ EQ-5D scores by a factor of three and this was only at 12 months. The caregivers’ quality of life generally declined over the 12 months of the study period (more in the control group than the experimental group) from averages of 92 and 93 at three months (for the control and experimental groups respectively) to 83 and 86 (respectively) at 12 months. However, the experimental group had better mean EQ-5D scores (health related quality of life) than the control group (p = 0.001). Caregiver education had the effect of improving EQ-5D scores by factors of 3.4 and 3.6 at the six and twelve month follow up period. The ability to socialise and participate in community issues was poor. None of the participants could carry out single and multiple tasks without assistance at 12 months post discharge. More than 87% of the patients had mild to moderate difficulty with walking at 12 months post discharge and they were all unable to lift and carry objects, have fine hand use and move around with equipment without assistance. None of the patients was able to carry out domestic activities without any difficulty and consequently they could not prepare meals and do housework without assistance from helpers. All of the participants had mild to moderate and severe to complete difficulty in basic interpersonal interactions, complex interpersonal interactions and formal relationships. They all had mild to moderate difficulty engaging in recreation and leisure activities while 27% of the control group and 25% of the experimental group had severe to complete difficulty with community life at 12 months post discharge. The design, construction and building products and technology for both public and private use were cited as barriers to community participation. More than 50% of the patients also cited friends as being barriers to community participation but acquaintances, colleagues, neighbours and community members were cited as being facilitators together with personal care providers (caregivers). Transport services, systems and policies were also cited as barriers by more than 80% of the participants. Caregiver education did not seem to influence patients’ ability to participate in community issues given the similarities in percentages between the control and experimental groups. At three months post discharge, 89% of the caregivers in the control group and 92% of those in the experimental group were strained from caregiving duties. However, these percentages declined to 78% and 43% respectively at 12 months, showing the effectiveness of caregiver education. Caregiver education had the effect of reducing strain by a factor of 2.6 at 12 months. The patient characteristics that were associated with caregiver strain were the dependency levels in transfers, mobility, dressing, bathing, poor activities of daily living scores, patient anxiety/depression, pain and poor perceived health state. The only caregiver characteristic that influenced caregiver strain was the level of education. The reduced hospital length of stay, pressure for beds and possibly inadequate rehabilitation personnel levels means that its possible that some caregivers are not adequately trained to meet patient needs, although this needs to be confirmed with further controlled research. The current pressure on in-patient services at Chris Hani Baragwanath hospital is resulting in suboptimal exposure to rehabilitation of patients post-stroke. There is insufficient organised caregiver education at present. Structured individualised caregiver training has the effect of positively influencing the health related quality of life of the patients especially at six and 12 months post discharge. Caregivers for patients with stroke suffer from physical, financial and psychological problems, which negatively affect their health related quality of life. Currently, high levels of caregiver strain persist poststroke. Caregiver education however has the effect of reducing the decline in caregiver health related quality of life over time. Caregiver training did not positively influence patient mobility and this is most probably because the patients had very low or poor functional ability levels at discharge from hospital. However, structured and individualised caregiver training has the effect of improving patients’ quality of life and can help reduce deaths among stroke survivors. The patient ability to socialise and participate in community issues post-stroke is currently poor. This mainly stems from the poor functional ability levels, which necessitate dependency on caregivers. Compounding the low functional ability levels are the transport systems, services and policies, attitudes of friends and the design, construction and building products and technology for both public and private use, which are barriers to community participation. The high patient dependency levels result in caregivers being highly strained. The patient characteristics that influence caregiver strain are dependence in transfers, grooming, mobility, dressing, poor activities of daily living, patient anxiety/depression, pain and poor perceived health state (health related quality of life). The only caregiver characteristic that was associated with caregiver strain is the level of education. The early discharge home with little caregiver training calls for provision of community rehabilitation services preferably through domiciliary visits. Caregivers of patients with stroke should be assessed and treated for depression given its high prevalence among this cohort. The referral system between the local community health centres and the discharging hospital need to be strengthened to ensure access to rehabilitation by all patients post discharge from hospital. The referral to social workers during in-patient and out-patient rehabilitation also need to be strengthened to ensure processing of social grants to alleviate financial strain as is appropriate. Caregiver strain is a complex and multifaceted problem with no single causation or solution. As a result, further research is needed to establish the reasons for poor rehabilitation service provision post-stroke for patients and caregivers and find solutions to these. It is important to explore different methods of caregiver education programmes so that the method that yields the best results for both patients and caregivers can be established in our setting and internationally.
The postoperative status of total knee arthroplasty (TKA) patients on discharge from an acute setting in Johannesburg hospitals, South Africa
(2009-10-28T13:08:29Z) Khandoo, Neeta
Introduction There is little known about the acute status of TKA patients, as many studies have focused on the long-term outcomes (Aarons et al., 1996). Knowing the acute status can aid physiotherapists in planning postoperative treatment protocols and help with discharge planning. This research examines the postoperative status of total knee arthroplasty (TKA) patients on discharge from an acute setting. The objectives of the study were to establish pain, ROM of the operated knee, functional level, socio-demographic factors, clinical data and the relationship between identified factors and postoperative functional status of TKA patients in the acute setting. Materials and Methods This study is classified as a quantitative, cross-sectional design. Sociodemographic and clinical data, pain, range of movement (ROM) and function of TKA patients were collected on day three post operation. A selfdesigned data capture sheet, the goniometer, VAS (Visual Analogue Scale) and ILOA (Iowa Level of Assistance) were used to measure data. Results Forty-four patients were assessed. There were 41% males and 59% females. The average age was 67 years and BMI was 30kg/m2. All patients had decreased ROM and 82% had poor quadriceps strength. Pain on walking was 5.8 on the VAS and correlated with the ILOA score. Pain on rest was 3.3 and when climbing stairs was 2.4. Sixty-one percent of subjects performed supine to sit, 59% performed sit to stand and 43% performed ambulation independently. Men performed better with an ILOA score of 24. Females had an ILOA score of 31. Length of stay (LOS) was 5.7 days. Females, older subjects and those with no medical conditions were more likely to stay in hospital for longer. Conclusion Knowledge of these factors will help to give patients a likely prognosis following a TKA and target future rehabilitation. Patients should receive adequate pain control to improve their functional ability. More attention should be given to female patients as they perform worse than men. Patients in this population should be referred for outpatient physiotherapy post-discharge, as their status on day three post operation reflected poor ROM, quadriceps muscle strength and function which may affect their rehabilitation outcome.
The effect of physiotherapy in a group on the motor function of children with developmental coordination disorder
(2009-10-20T08:34:02Z) Brenner, Julie
Children with Developmental Coordination Disorder (DCD) are a heterogeneous group who have a marked impairment in the performance of functional motor skills. DCD affects 5-8 % of children in the mainstream educational system, with twice as many boys than girls being affected. DCD often co-occurs with other developmental disorders such as Attention Deficit Hyperactivity Disorder (ADHD), Attention Deficit (ADD), severe learning disabilities and reading disabilities and is often associated with educational, social and emotional problems that often persist beyond adolescence. Current research has shown that children with DCD do not outgrow their motor problems and without intervention they do not improve (Zoia et al, 2006; Barnhart et al, 2003; Peters and Wright, 1999). The aim of this study was to investigate the effect of an eight week group gross motor intervention programme on 26 children with Developmental Coordination Disorder (DCD) at Forest Town School, which is a special-needs school for children with learning disabilities. The intervention programme consisted of gross motor activities commonly used by the physiotherapists at the school for their DCD groups. The children attended a thirty-minute physiotherapy session a week, in groups of up to 6, for eight weeks. The children’s motor performance was assessed using the Bruininks-Oseretsky Test for Motor Proficiency (BOTMP) pre- intervention, post- intervention and then eight weeks after the intervention had ceased. The children were used as their own controls. The results of the statistical analysis revealed that the mean group gross motor and fine motor scores significantly improved after the intervention. It was found that the gross motor scores improved by a larger percentage than the fine motor, which may be because the intervention consisted purely of gross motor activities. The fine motor scores also significantly improved, implying that there was a transfer or generalisation of skills to the fine motor tasks. The improvement in the motor performance was found to be maintained eight weeks after the intervention was stopped. It was concluded in the study that the eight week group physiotherapy programme at Forest Town School improved the motor skills of children with DCD and learning difficulties. Physiotherapy in a small group may therefore be a cost effective solution for the treatment of children with DCD in government-funded schools and hospitals that have a limited number of physiotherapists available to treat these children.
Physiotherapy modalities used in the management of chronic low back pain
(2009-10-15T08:10:39Z) Naidoo, Vaneshveri
Low back pain (LBP) is one of the commonest and most costly medical problems in both the low and high income countries accounting for 75-90% of compensation costs. Compensation costs for LBP in South Africa in the year 2000 were approximately two hundred million rand and about 30 000 people suffer from neck and back problems on a daily basis. Physiotherapy treatment modalities are commonly used in the management of LBP but there is no consensus on the choice of treatment modalities. A cross-sectional survey was used to investigate the treatment modalities used by physiotherapists in Kwazulu-Natal (KZN) for the management of chronic low back pain (CLBP). The objectives of the study were to establish the commonly used physiotherapy modalities in the management of CLBP, the reasons behind the selection of those modalities and the extent to which the physiotherapists in KZN used evidence based modalities when managing CLBP. Self-Administered questionnaires were posted to all registered physiotherapists in KZN, that is, six hundred and eighty-five (685) physiotherapists. A 31% (213) response rate was achieved, of which 20.6% (141) met the inclusion criteria and 10.5% (72) were excluded. The results established that general exercises (30%); spinal mobilisation (28%); myofascial release (18%), education (12%) and training of local stabilisers (12%) were the commonly used treatment modalities in the management of CLBP. The key reasons for the selection of the treatment modalities were the undergraduate education received; own clinical experience and the attendance of postgraduate courses/physiotherapy conferences. Treatment modalities were not selected on the basis of the current available evidence hence evidence-based practice is not employed by physiotherapists in KZN in the management of patients with CLBP.
Mainstreaming HIV/AIDS in physiotherapy education and practice
(2009-09-01T11:47:12Z) Myezwa, Hellen
This thesis centres around the issues concerning HIV/AIDS and physiotherapy education, curriculum and practice. In particular, this thesis examines which HIV specific content should be included in a physiotherapy curriculum and ultimately presents a conceptual framework for HIV input into the curriculum. There is a vast body of literature available on HIV. For physiotherapists, however, apart from a brief review given by Nixon and Cott (2000) using the ICIDH, no comprehensive literature is available that places information on HIV into a framework that speaks to physiotherapists as part of the rehabilitation fraternity. The literature on impairments is descriptive and buried in the medical model as symptoms. Section one of the literature review placed the literature in such a framework and provided a comprehensive description using the ICF and related aspects that concern physiotherapists. The ICF captures all the elements of current rehabilitation theory and practice and the literature is presented in an ICF framework. In addition, important background information on prevalence, its determinants, treatment approaches and subsequent impacts were reviewed. As most of the literature available still remains in the medical model, the conditions that manifest and from which patients develop impairments, were reviewed. The effects of HIV on body systems are extensive and pervasive. In each body system HIV has direct effects on mature and maturing cells e.g. progenitor cells and mature muscle cells. In the musculoskeletal system HIV impacts on functional systems and organs resulting in pathophysiological changes that manifest as impairments such as muscle wasting. Conditions manifesting in all body systems were reviewed and outlined. Impairments such as pain, breathlessness and proximal muscle weakness were reported in the literature. In addition to impairments, analysis of the literature revealed studies that had found high levels of functional and activity limitations as well as impacts on Health-related Quality of Life in HIV. The literature also presents the current status of physiotherapy interventions. Many studies have reported that exercises are a safe and effective mode of intervention not-withstanding the limitations encountered. The second part of the literature review focussed on aspects concerned with curriculum. Previous studies have focused on establishing baseline knowledge, attitudes and practices (KAP) to HIV and the impact of training programmes on KAP. What the actual content was for health workers, in particular physiotherapists and the approach to incorporating HIV into curricula is a gap in the literature. To inform the overall aim, with context-appropriate HIV content, this study undertook a number of studies in order to obtain the necessary information on HIV, specific to physiotherapy. Therefore the overall approach was a mixed methods one employing both a quantitative and qualitative study mix. The first and second studies informed the clinical picture and were both cross-sectional and descriptive. In both studies descriptive statistics were used to analyse data, especially in determining the absence or presence of conditions. Study 1 sought to establish the level of referral to physiotherapy by retrospectively examining the patient records of patients admitted with HIVrelated conditions over a period of one year. Of the 732 patient records reviewed, 139 (19%) had diagnoses considered suitable for physiotherapy and 3% were referred to physiotherapy. Study 2 aimed to establish a relevant overview of the functional and participation limitations of people living with HIV. Two groups of patients were studied i.e. an in-patient group and an outpatient group. The out-patient group was from a well resourced mining out-patient setting. The ICF checklist was utilised to collect the data and statistical analysis was performed to indicate the presence or absence of impairments, activity limitations and participation restrictions. A logistic regression was done to determine the odds of activity, limitation or participation restriction given certain levels of domains. Both groups showed high levels of impairment. For the in-patient group loss of muscle power 75%(n=60) energy and drive 75%(n=60), disturbed sleep 71%(n=56), emotional problems 62%(49), mild-severe pain 80%(66), weight maintenance difficulties and diarrhoea were apparent. In the out-patient mining group memory problems, energy and drive functions 36%(n=18), sleep 24% (n=12) and emotional functions 28% (n=14), seeing 32% (n=17), hearing, vestibularproblems 28%(n=14) and pain 55%(n=28), blood pressure and respiratory problems 24%(n=12), weight maintenance 63%(n=32), sexual functions 22%(n=11) and reduced proximal muscular power 24%(n=12) were encountered. The in-patient group had high levels of activity limitations and participation restrictions, while the out-patient mining group did not. There was association between the different domains and in the in-patient group gender (p=0.02) and marital status (p=0.01) were likely to influence the activity and participation levels and the experience of the environment. The remaining three studies involved aspects related to informing the curriculum component of this thesis. Study 3 audited the universities’ curricular documents to establish what the current curriculum included. Seven of the eight universities that offer physiotherapy training were reviewed and their curricula were generally scanty on information regarding HIV/AIDS. When compared to the areas outlined as a result of the literature review, the study of the patients and focus groups with clinicians and academic staff, revealed some gaps, in particular; the types of conditionsand the influence of HIV on other body systems which are pertinent to the clinical reasoning process for the physiotherapist: The philosophy of care and approach to management and the physiotherapists’ role in HIV prevention, treatment and care were evident gaps. Study 4 sought to develop a framework of HIV content for a physiotherapy curriculum. This was done by integrating the results found so far and verifying and enriching this data by gaining clinicians’ and academics’ insights and perceptions around HIV, based on their clinical and educational experience. Focus group discussions were conducted and a qualitative approach was undertaken for data analysis. A framework for curricula content emerged from this exercise. In study 5 the framework of HIV content was used to develop a questionnaire that was sent out in the Delphi survey to academic staff with the aim to test the level of consensus. Eighty three components of the curriculum under four outcome areas (Appendix 7.2) were sent to 68 academic staff who were identified. Of the 68 academic staff, 58 were available and 47 responded and consented to participate. All but two topics obtained consensus set at 80% and the remaining two obtained consensus in the second round. The final chapter discusses the results of these studies and illustrates how these results on HIV affect and can be applied to the physiotherapy curriculum, when applied to the UNAIDS mainstreaming criteria. Applying the mainstreaming principles to the process of including HIV content into the curriculum, ensures that the process is not done in a piece meal fashion but encompasses all important facets which were identified. The programme, if systematically implemented, could result in a coordinated outcome accounting for all the important facets. A conceptual framework is drawn from the results of this thesis illustrating the three levels of curriculum taxonomy: At the micro level, through the body systems, the meso level through the role of physiotherapy, dealing with internal and external domains and teaching approaches. The macro level is accounted for by the facilitatory activities such as advocacy among clinicians and academics and forming strategic partnerships at all levels.
A pilot study of extubation from mechanical ventilation and the effect of chest physiotherapy intervention
(2009-05-15T09:55:21Z) Ngubeni, Winnifred Keabecoe
It is a common practice for physiotherapists working in Intensive Care Unit (ICU) to treat patients who are intubated and mechanically ventilated and assist with extubation. The role of chest physiotherapy treatment (CPT) with extubation hasn’t been scientifically proven to be effective. Purpose of the Study The purpose of this pilot study was to determine whether the omission of one CPT prior to extubation influences the outcome of patients four-hours after extubation. Methods A randomized-controlled trial (RCT) was conducted in an academic hospital with 20- cardiothoracic and general ICU beds. Patients consented to participate in the study after ethical clearance was obtained from University of Witwatersrand Committee for Research on Human Subjects. Twenty-two patients were randomly assigned to a control group to receive CPT and suctioning prior to extubation (n=12) or to an experimental group to receive suctioning only prior to extubation (n=10). All patients were then re-assessed four-hours after extubation to assess the difference in outcome measures in arterial blood gases (ABG), breathing pattern, peak expiratory flow rate (PEFR), respiratory rate (RR), cough effectiveness and re-intubation rate. Groups were compared with respect to the categorical parameters using the Fischer’s exact test. A two-sample t-test with unequal variances and a non-parametric Mann-Whitney test were used to compare the ABG and RR results between the groups. Results and Discussion The ABG, breathing pattern, RR, and cough effectiveness were not statistically significant between the groups. PEFR could not be measured due to the inability to follow instruction by the majority of patients. None of the patients required re-intubation within 24-hours. Eight patients in each group received CPT after four-hours due to clinical findings of an ineffective cough, added sounds and abnormal breathing patterns. Conclusion: Patients in the control group had a significant shorter period of mechanical ventilation (MV) than those allocated in the experimental group. However eight patients in both groups required CPT treatment when assessed four hours after extubation.
The relationship between knee integrity and function post total knee replacement
(2008-10-13T10:34:39Z) Lally, Candace
ABSTRACT The purpose of this study was to determine if there is a relationship between knee integrity and function in patients who have had a total knee replacement. Twenty-two patients were selected at the arthroplasty clinics at the Johannesburg Hospital and Chris Hani Baragwaneth Hospital. This occurred at six weeks following a primary total knee replacement. Twenty-two subjects who participated in the study underwent two tests. The first test measured the patients’ functional ability using the Iowa Level of Assistance (ILOA) Scale. Knee integrity was measured using the Knee Society Knee Score. The two examiners were blinded to each other’s results. The results indicate that there is no relationship between knee integrity measured using the Knee Society Knee Score and function measured using the ILOA Scale (p= 0.19).

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