3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item A report to inform the development of a clinical practice guideline for rehabilitation post total knee arthroplasty in a South African public hospital(2011-10-24) Wood, Wendy-AnnThere is no published research available that evaluates the outcome of TKA in South African public hospitals. Prior to this project, there was no South African published research on the role of physiotherapy in patients post TKA. There are also no clinical practice guidelines in South Africa for rehabilitation post TKA. International guidelines may not be appropriate within a South African public hospital context. One of the issues raised in the literature pertaining to CPG development is that they lack practical detail and clarity of how decisions are made. In the current context, these problems may be compounded due to the lack of published research in the field in South Africa. The report that is presented is an attempt to combat these issues when a CPG for physiotherapy post TKA in a South African public hospital is developed. The aim of this study was to draft a report that could inform a comprehensive physiotherapy intervention (in the form of a clinical practice guideline) for patients undergoing a TKA in a tertiary care public hospital in urban South Africa. This was achieved through a series of four studies. The first study involved translating and establishing reliability of the Oxford Knee Score. The second study was a survey of current physiotherapy practice in the management of patients post TKA in South Africa. The third study was a prospective cohort study to establish the effect of an in-patient treatment protocol for use in the final study. The final study was an observational study to explore the outcome of patients post TKA and identify those who may be at risk for poor outcome. The English and translated versions of the Oxford Knee Score was shown to be reliable in this sample. This provided an outcome measure that can be used in the validation and evaluation phases of CPG development. The survey of current practice highlighted the high rate of staff turnover and the relative inexperience of physiotherapists working with patients post TKA in the public sector. It identifies the junior physiotherapists as potential stakeholders in the CPG. The trial of the in-patient physiotherapy protocol rendered similar findings to other similar studies in that a specific physiotherapy intervention did not have any effect on short term outcomes. It puts forward clear clinical questions to facilitate the development of the CPG, particularly relating to scheduling and delivery of weekend and out-patient therapy. The final study provided a demographic profile of the patients within the study context, who are potential stakeholders in the CPG development process. In addition it revealed that level of education, the presence of a caregiver at home, marital status and lack of previous exposure to physiotherapy form part of the profile of an ‘at risk’ patient. When the contribution that this thesis has made thus far to the CPG development process, is appraised using the AGREE tool, it shows that the thesis has contributed to 11 out of 23 of the criteria on the AGREE tool. It has therefore resulted in a report that informs the development of a clinical practice guideline for the physiotherapy management of patients post total knee arthroplasty in a tertiary care public hospital in Gauteng, South Africa.Item The factors affecting physiotherapy rehabilitation in patients following an open rotar cuff repair(2011-02-10) Chivers, Tamarin ClaireIntroduction 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.Item Impact of caregiver education on stroke survivors and their caregivers(2010-09-20) Mudzi, WitnessDespite 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.Item Socio-economic and clinical factors predictive of paediatric quality of life post burn injury(2010-06-28T08:10:11Z) Weedon, MerrynTrauma is the leading cause of death in children. Burns represent the second most common cause of accidental death in children under the age of five. Burns are amongst the most traumatic injuries and may impose significant psychological, educational, social and future occupational impairments to the young child. Quality of life post discharge from a South African hospital is poorly researched. It is also not known whether poor socio-economic factors contribute to the high incidence of children with burn injuries who are admitted to the Paediatric Burns Unit. This crosssectional study aims to determine the socio-economic and clinical factors which predict quality of life in children with burn injuries in a burns unit in South Africa. The Paediatric Quality of Life Inventory (PedsQL) and the Household Economic and Social Status Index (HESSI) questionnaires were administered to children and their caregivers one week post discharge and three months post discharge from the Johnson and Johnson Paediatric Burns Unit, Chris Hani Baragwanath Hospital, Soweto. The findings of this study show that children three month post discharge from a burn injury have a minimally lower score in quality of life than the expected normal score. The improvement in the PedsQL overall scores suggests that the quality of life for children is good despite being burnt. The severity of the burn (partial thickness and full thickness) was found to be a significant clinical predictor of quality of life (p=0.00). The poor socioeconomic status was clearly evident in demographic data of the subjects. A marginally significant socio-economic predictor of quality of life was family problems reported by some of the mothers (p=0.07). To some extent this highlights the increased risk of burn injury where there are poor socio-economic circumstances.Item 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, NeetaIntroduction 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.Item Management of rehabilitation personnel within the context of the National Rehabilitation Policy(2009-10-19T11:06:56Z) Dayal, HarshaThe provision of rehabilitation services has received little attention within the context of health sector reforms in South Africa. This study explores the human resource (HR) management component of the National Rehabilitation Policy (NRP), formulated to improve access to rehabilitation services within the public health sector. Qualitative methodology was used to understand the alignment of policy to practice, with data derived from both the deductive approach (document reviews); and inductive approach (key informant interviews and focus group discussions). The findings reveal that there is a gap between policy and practice. Resistance to integration, problems with professional identity and capacity constraints at national, provincial and local levels hindered the implementation of an integrated rehabilitation service. In addition, polices and norms and standards that aim to guide HR in public health are not coherent. These directly influence HR performance, and have served to highlight the social and institutional phenomena impacting on service delivery.Item Parental perceptions and experience of rehabilitation services for children with cerebral palsy in poorly-resourced areas(2008-09-18T13:11:30Z) Saloojee, Gillian MargaretBackground No data exist about caregivers’ beliefs surrounding a diagnosis of cerebral palsy (CP), its causes and how this influences caregivers’ perceptions of therapy in poorly-resourced South African settings. Neither is there any information about how rehabilitation therapy influences the life of the child or the caregiver. The appropriateness, the outcomes and the effectiveness of therapy for children with CP in a South African setting have not been studied. Numerous tools and scales for measuring outcomes of rehabilitation relating to both the child and the caregiver are available internationally but none have been validated for use in South Africa. Caregiver-related outcomes were the focus of this study and included maternal well-being and mental health, personal quality of life, availability of support and interaction with the child. These are factors known to potentially be influenced through contact with rehabilitation services. Aims The aims of this study were firstly to ascertain whether caregiver-related outcome measures developed in high-income settings were appropriate for a poorly-resourced South African setting; and secondly, to describe parental perceptions and experiences of rehabilitation therapy received in public service hospitals in disadvantaged areas. Methodology The study was undertaken in two phases. Phase One was a quantitative cross-sectional, analytical study and addressed the first aim. Five scales were identified from the literature as being suitable for measuring the caregiver-related outcomes of interest in this study: the Caregiver-Child Scale, the Family Support Scale, the Personal Quality of Life Scale, the Mental Health Subscale of the Medical Outcomes Study (MOS) Short-form 20 Health Survey, and the Measure of Processes of Care (MPOC) Scale. The first four scales measure aspects of maternal well-being and interaction with the child whilst the MPOC assesses caregivers’ reported experiences of family-centred behaviours of rehabilitation service providers. These scales were modified and adapted to make them relevant to a South African setting through a process that included focus groups with caregivers and experienced therapists. After the modified scales had been translated into six local languages and then back-translated into English, the translators, researcher and interviewers met to discuss discrepancies between the two versions (the original modified English version and the back-translation) and to reach consensus on the final translation. The scales were further refined during a pilot study where two trained interviewers administered the modified scales to 24 caregivers of children attending public service hospitals for therapy. Items in the scales which were confusing for caregivers or which they found difficult to understand were clarified. In addition, where necessary, concrete examples were given of the type of behaviour or action being asked about in the scale. Following the pilot study, two trained interviewers administered the modified scales to a convenience sample of caregivers attending rehabilitation therapy in public service hospitals in Gauteng and Limpopo. The reliability and validity of each scale was assessed using multi-trait scaling and factor analysis. Phase Two employed qualitative methodology to address the second aim of the study. A purposive sample of 24 information-rich caregivers attending therapy in public service hospitals in Gauteng and Limpopo participated in one of five focus groups. The discussions were conducted in local languages. Taped recordings were transcribed and translated into English before being analysed using a grounded theory approach. Results Two hundred and sixty three caregivers from 31 hospitals in Gauteng and Limpopo provinces were interviewed during the first phase of the study. The mean age of their children was 3.3 years (± 2.6).Two-thirds of the children (66%) had severe limitations in motor function and few (15%) could communicate verbally. Only one of the five scales, the Mental Health Subscale, proved to be both reliable and valid in South African settings. A second scale - the MPOC - was potentially useful if reduced to an eight item scale (from the original 20 items). The Family Support Scale was reliable but not valid whilst the Caregiver-Child and Personal Quality of Life Scales were neither reliable nor valid. The process of administering the scales combined with the qualitative data helped to explain why the scales did not perform as well as expected in a South African setting. Reasons for these findings included the caregivers’ inexperience in completing these kinds of questionnaires; their difficulty with the concept of grading their responses which meant that Likert-type scales were difficult for them to complete; and thirdly language and cross-cultural applicability. This was because the scales were developed for very different cultural groups. It was not the questions or scale items that were the problem; it was rather finding the language and words that caregivers themselves would use to express the underlying concepts. The study found that caregivers living in disadvantaged South African settings live very differently from their counterparts in well-resourced areas. They lived in poverty; were beset by financial concerns; often abandoned and rejected by their partners; and endured gossip and ignorant attitudes from their neighbours and the community. The burden of daily care-giving was high as most of the children were severely disabled. This was compounded by concern about the child’s health and the future. Despite this, the study found that they were happy, healthy and generally well satisfied with their lives. Support from informal support structures such as relatives and close family members, together with formal support structures, was an important dimension in helping caregivers cope. Qualitative data from the focus groups yielded information regarding caregivers’ beliefs surrounding the perceived cause of the child’s disability. These ranged from traditional and cultural beliefs to medical explanations, and to frank confusion between the two. This was accompanied by misconceptions about therapy and the outcome thereof. Parental perceptions and experiences of rehabilitation were positive although many caregivers initially expected therapy to provide a cure. Respectful and caring attitudes, “hands on” therapy, practical help and assistance with assistive devices and school placements were aspects of service most valued by caregivers. The study helped define the components of an “ideal” therapy service in disadvantaged South African settings. They would include the availability of parent support groups; greater involvement of fathers, close family members and traditional healers in the rehabilitation process as well as the implementation of innovative strategies to ensure clearer communication and understanding between therapists and caregivers operating in a cross-cultural setting. Elements of care not traditionally perceived as part of therapy such as promoting supportive networks and taking on advocacy role for children with disabilities may offer additional advantages. Conclusion The study confirms the view that scales developed in high-income settings are not necessarily immediately applicable to less well-resourced settings and often require extensive modifications to ensure reliability and validity. Whilst the Mental Health Scale is a reliable and valid tool for caregivers attending public service hospitals in South Africa, other scales, such as the MPOC, a popular scale in North American and Europe, require substantial modification for a South African setting. In addition to highlighting the challenges involved in finding suitable outcome measures of therapy intervention for this population, this study has objectively documented the lives and experiences of caregivers of children with CP in South Africa for the first time together with their experiences and perceptions of rehabilitation therapy. Using this information, the components of an “ideal” rehabilitation service in a disadvantaged South African setting have been identified and described. This may facilitate the establishment of a more effective and appropriate therapy service for caregivers and children with CP living in poor areas.Item The extent of delay of language,motor and cognitive development in HIV positive infants(2006-11-10T12:10:28Z) Baillieu, NicoleIn South Africa, a total number of 5.7 – 6.2 million individuals had acquired HIV infection by 2004 (Department of Health, 2004). It is estimated that 3.3 million females, 2.8 million males, and 104 963 babies had been infected with HIV in South Africa by 2004 (Department of Health, 2004). It has been found that HIV-positive children have significantly greater neurological dysfunction in eight domains (activity, language, cranial nerve, fine motor, gross motor, cerebellar, sensory and primitive reflexes) than their HIV negative counterparts (Belman et al, 1996). There has been very little research conducted in Africa regarding the extent of delay of language, motor, and cognitive development in HIV positive infants. The main aim of this study is to determine the extent of delay in acquisition of language, cognitive and motor skills of HIV positive children The Bayley Scales of Infant Development II (BSID II) were used to determine performance in each section of the child’s age group. These results were transferred to the facet scoring section, which analyse in greater detail, with respect to cognitive, language and motor development. Baseline BSID II assessments of HIV infected children currently enrolled in a longitudinal study of neurodevelopmental delay were analysed to determine which facets of development are most delayed. The Mental and Psychomotor Developmental Indices (MDI and PDI) of the BSID II were used to determine the extent of mental and motor delays in this sample. Mean cognitive development was 7.63 months delayed, which was statistically significant (p<0.01) and 97.5% of the sample were functioning below the expected cognitive age. Mean motor development was 9.65 months delayed (p<0.01), and 97.5% of the sample were functioning below expected motor age. Gross motor skills were more affected than fine motor skills, and 85% of the sample demonstrated gross motor delays on descriptive analysis. Language was descriptively analysed, revealing language delays in 82.5% of the sample. The infants in this study demonstrated significant mental and motor delays, as well as delays in language. It is postulated that motor delays may be attributed to decreased strength, as the most adversely affected skill in this sample was gross motor development. The cognitive delays noted may be due to disease progression and structural damage to the brain, as well as socio-economic factors. The language delays noted could be due to neurological impairment, cognitive delay or environmental deprivation. Children with HIV have significant delays in mental and motor development, and language is delayed in most children with HIV. The results of this study are similar to findings in other parts of the world, which indicates a global trend in HIV and neurodevelopmental delay. The results of this study are important, particularly for those involved in motor and language rehabilitation, as an awareness of potential problems in these infants is needed in order to provide them with the best management and care possible.