Higher Levels of Caregiver Strain Perceived by Indian Mothers of Children and Young Adults with Cerebral Palsy Who have Limited Self-Mobility.

AIM: Describe and compare the caregiver strain experienced among Indian mothers of children and young adults with cerebral palsy (CP) living in low resource settings. METHODS: 62 consecutive children and young adults with spastic CP (mean age 6.0 ± 4.5, range 2-21) and their parents were recruited from an outpatient physiotherapy department for this cross-sectional study. Ability to walk was classified using the Gross Motor Function Classification System and mother's caregiver strain was measured using caregiver strain index (CSI). RESULTS: Mothers of children and young adults who have limited self-mobility perceived higher caregiver strain (mean CSI score 12.0 ± 1.3, p < 0.05) than mothers of children who can walk (mean CSI score 4.5 ± 3.0, p < 0.05). All 46 mothers of children and youth in GMFCS levels IV and V reported high levels of caregiver stress compared with only three of 16 mothers of children and youth who walk (levels I and II). CONCLUSIONS: Physiotherapists and occupational therapists serving children and youth with CP are encouraged to partner with families to identify goals for ease of caregiving, activity, and participation at home and in the community.

Do Commonly Used Functional Outcome Measures Capture Activities that Are Relevant for People with Stroke in India?

OBJECTIVES: In India, post-stroke outcomes are determined using functional outcome measures (FOMs), the contents of which have not been validated for their relevance to the Indian population. In this study, we aimed to evaluate the cultural validity of five frequently used stroke-specific FOMs by comparing their contents with the problems reported by patients with stroke in India. METHODS: Face-to-face structured interviews were conducted with 152 patients diagnosed with stroke in India. Problems and goals identified by the patients were compared to each item included in the FOMs used in stroke rehabilitation. RESULTS: The Stroke Impact Scale (SIS) and the Frenchay Activities Index (FAI) include items related to the most frequently identified problems. However, neither covers problems related to the need for squatting and sitting on the floor. Use of public transport and community walking are not included in the SIS. Leisure and recreational activities (e.g. gardening, reading books), cognitive and speech functions (e.g. memory, thinking) and bowel and bladder dysfunctions were the common items identified as "not a problem" or "not relevant" by the patients. DISCUSSION: Our findings suggest that the SIS and FAI are the most appropriate FOMs for patients with stroke in India as they include items related to the majority of problems identified by study participants. Many items on both measures, however, were identified as not a problem or not relevant. There is a need for developing culture-specific FOMs that incorporate all major concerns expressed by patients with stroke in India.

Description of interventions is under-reported in physical therapy clinical trials.

BACKGROUND: Amongst several barriers to the application of quality clinical evidence and clinical guidelines into routine daily practice, poor description of interventions reported in clinical trials has received less attention. Although some studies have investigated the completeness of descriptions of non-pharmacological interventions in randomized trials, studies that exclusively analyzed physical therapy interventions reported in published trials are scarce. OBJECTIVES: To evaluate the quality of descriptions of interventions in both experimental and control groups in randomized controlled trials published in four core physical therapy journals. METHODS: We included all randomized controlled trials published from the Physical Therapy Journal, Journal of Physiotherapy, Clinical Rehabilitation, and Archives of Physical Medicine and Rehabilitation between June 2012 and December 2013. Each randomized controlled trial (RCT) was analyzed and coded for description of interventions using the checklist developed by Schroter et al. RESULTS: Out of 100 RCTs selected, only 35 RCTs (35%) fully described the interventions in both the intervention and control groups. Control group interventions were poorly described in the remaining RCTs (65%). CONCLUSIONS: Interventions, especially in the control group, are poorly described in the clinical trials published in leading physical therapy journals. A complete description of the intervention in a published report is crucial for physical therapists to be able to use the intervention in clinical practice.

Family's presence associated with increased physical activity in patients with acute stroke: an observational study.

BACKGROUND: Inherent differences in organization of stroke care and rehabilitation practices in various settings influence the activity levels of patients in the hospital. The majority of published studies have been carried out in developed countries such as the United States, United Kingdom, Australia, Switzerland and Belgium; however, data from developing countries are scarce. OBJECTIVE: To measure the amount and nature of physical activity of patients admitted to medical wards of Indian hospitals and to assess the association between family presence and the patient and between the patient's functional status and their physical activity level. METHOD: This is an observational behavioral mapping study. A trained physical therapist recorded the patients' (N=47) physical activity level through direct observation in the ward using a predetermined observation scheme. RESULTS: Participants were found inactive and alone for 19% (inter quartile range [IQR] 12-36%) and 15% (IQR 10-19%) of the time during the day, respectively. They spent 46% (IQR 31-55%) of the time in therapeutic activities and 31% (IQR 22-34%) of the time in non-therapeutic activities. The family was present with patients 50% of the time during the day. Family presence with the patient and the patient's moderate dependence in daily activities are positively associated with their activity levels. CONCLUSION: Patients with stroke admitted to Indian hospitals spent less time being inactive and alone and more time with family participating in therapeutic activities. The presence of family members with the patients during hospital stay may be a significant resource for encouraging patients to be more active.

Importance of squatting and sitting on the floor: perspectives and priorities of rural Indian patients with stroke.

BACKGROUND: Identifying activities that are preferred and valued by patients' is essential to optimize rehabilitation outcomes and quality of care in stroke rehabilitation. Deep knee flexion (DKF) activities like squatting and sitting on the floor are regularly performed and preferred daily activities in many cultures. Yet few studies have investigated its importance as perceived by patients with stroke. OBJECTIVES: To identify the magnitude of importance of squatting and sitting on the floor in carrying out daily activities in adults diagnosed with stroke. METHODS: We conducted a survey among patients with stroke using a questionnaire. A sample of convenience of 123 patients diagnosed with stroke who were receiving physiotherapy in rural rehabilitation setting in Gujarat, India participated. All patients were asked to rate the importance of DKF activities in performing various daily activities related to self care, mobility, domestic life, work and community participation. RESULTS: Sixty-eight percent of participants rated DKF activities as very important for carrying out their daily activities. Toileting (78%), bathing (68%), eating (68%), praying (54%) and work (51%) were the activities for which DKF activities were rated as very important by both men and women. However, higher proportion of women compared to men rated domestic life activities such as cooking, washing cloths and cleaning house as very important. CONCLUSIONS: Because a substantial proportion of patients with stroke identified DKF activities as very important for performing major daily activities, independent performance of squatting and sitting on the floor should be considered as one of the important rehabilitation goals for patients with stroke.

Quantity and quality of randomized controlled trials published by Indian physiotherapists.

BACKGROUND AND OBJECTIVES: Randomized controlled trials (RCTs) are considered as the gold standard evidence for determining efficacy of interventions. Physiotherapeutic interventions are essential in the management of various conditions. However, information on the quantity and quality of RCTs published by Indian physiotherapists is largely unknown. Therefore, the primary objective of this study was to review the RCTs published by Indian physiotherapists for analyzing publication trend and its quality. MATERIALS AND METHODS: Medline database was searched for eligible RCTs published by Indian physiotherapists between the years 2000 and 2013. We performed quantitative analysis of RCTs including type of participants, area of focus in physiotherapy, clinical condition and geographical location of first author's affiliation and analyzed the methodological quality and reporting of RCTs using Physiotherapy Evidence Database (PEDro) scale and consolidated standards of reporting trials (CONSORTs) key criterion statement, respectively. RESULTS: A total of 45 RCTs have been published by Indian physiotherapists. The common conditions investigated in the trials were low back pain (16.3%), followed by diabetes (6.7%) and chronic obstructive pulmonary disease (6.7%). The mean score of PEDro is 5.5 (standard deviation: 1.2). Trial registration (3 [7%]) and sample size calculation (28.9%) are the most common CONSORT items not reported in the trials. INTERPRETATION AND CONCLUSIONS: RCTs published by Indian physiotherapists is gradually increasing in numbers and the methodological qualities of studies are fair. However, there is substantial scope for improvement in conducting and reporting trials. In the future, Indian physiotherapists should focus more on conditions such as stroke, asthma, and others, which have a larger burden of illness among Indian population.

Deep flexion activity training in a patient with stroke using task-oriented exercise: a case report.

BACKGROUND AND PURPOSE: Many individuals with stroke express desires to resume activities involving deep knee flexion, such as daily living, work-related, and sports activities. However, training methods for improving deep flexion activities have not commonly been reported in the stroke rehabilitation literature. The purpose of this case report is to describe the development of a task-oriented training program and demonstrate its use in improving deep flexion activities in an individual with sub-acute hemiplegia. CASE DESCRIPTION: The patient was a 55-year-old shoe salesman diagnosed with ischemic stroke 6 weeks before physical therapy evaluation. His primary concerns were functional activities that required deep flexion, such as the inability to squat and to maintain a squatting position in the Eastern toilet and difficulty in performing work-related activities (e.g. fitting shoes for customers while sitting on a low stool). INTERVENTION: We developed a task-oriented training program that specifically targeted deep flexion activities. The first phase of training consisted primarily of practicing sit-to-stand on a low stool and the second phase consisted of practicing squatting. OUTCOMES: After 6 weeks of intervention, the patient achieved more than the expected outcome on the Goal Attainment Scale (score = +2) for both primary goals and reported positive changes in social participation, such as visiting his friends and relatives and praying at the temple. DISCUSSION: The task-oriented deep flexion activity intervention was associated with positive changes in functional activity and social participation in a patient recovering from stroke.

Barriers in implementing evidence-informed health decisions in rural rehabilitation settings: a mixed methods pilot study.

OBJECTIVES: Literature on the barriers to implementing research findings into physiotherapy practice are often urban centric, using self report based on the hypothetical patient scenario. The objective of this study was to investigate the occurrence of barriers, encountered by evidence informed practice-trained physiotherapists in the management of "real world" patients in rural rehabilitation settings. METHODS: A mixed-methods research design was used. Physiotherapists working in rural outpatient rehabilitation settings participated in the study. In the first phase, we asked all participants (N = 5) to maintain a log book for a 4-week period to record questions that arose during their routine clinical encounters and asked them also to follow first four of the five steps of evidence-informed practice (ask, access, appraise and apply). In the second phase (after 4 weeks), we conducted a semistructured, direct interviews with the participants exploring their experiences involved in the process of implementing evidence-informed clinical decisions made during the study period. RESULTS: At the end of 4 weeks, 30 questions were recorded. For 17 questions, the participants found evidence but applied that evidence into their practice only in 9 instances. Being generalist practitioners, lack of outcomes specific to the patients were reported as barriers more so than time constraints in implementing evidence-informed practice. CONCLUSIONS: Practice setting, lack of patient-centered research and evidence-informed practice competency of physiotherapists can be significant barriers to implementing evidence-informed health decisions in rural rehabilitation setting.

Functional training in the management of chronic facial paralysis.

BACKGROUND AND PURPOSE: Disability in patients with facial paralysis is the result of impairment or loss of complex and multidimensional functions of the face, including expression of emotions, facial identity, and communication. However, the majority of interventions for facial paralysis are unidimensional and impairment oriented. Thus, a functional training program intended to address various dimensions of disability caused by facial paralysis was devised. This patient-centered, multidimensional approach to the rehabilitation of people with facial paralysis consists of patient education, functional training, and complementary exercises. This approach is focused on various dimensions of disability, including the physical, emotional, and social dimensions, by encouraging context-specific facial functions, positive coping strategies, and social interaction skills. CASE DESCRIPTION: The patient was a 25-year-old woman with chronic complete right facial paralysis caused by a postoperative complication of ear surgery. The patient's problems were evaluated with the Facial Disability Index (physical function subscale score=45/100, social/well-being function subscale score=28/100) and an informal interview exploring her experiences and priorities. OUTCOMES: After 8 weeks of functional training, the patient showed considerable improvement in facial functions (physical function subscale score=95/100, social/well-being function subscale score=100/100) and reported positive changes in social interactions and interpersonal relationships. DISCUSSION: The use of a functional training program was associated with positive changes in emotional expression, psychosocial function, and social integration, thus contributing to reduced disability of a person with chronic facial paralysis.

Family's presence associated with increased physical activity in patients with acute stroke: an observational study

ABSTRACT Background: Inherent differences in organization of stroke care and rehabilitation practices in various settings influence the activity levels of patients in the hospital. The majority of published studies have been carried out in developed countries such as the United States, United Kingdom, Australia, Switzerland and Belgium; however, data from developing countries are scarce. Objective: To measure the amount and nature of physical activity of patients admitted to medical wards of Indian hospitals and to assess the association between family presence and the patient and between the patient’s functional status and their physical activity level. Method: This is an observational behavioral mapping study. A trained physical therapist recorded the patients’ (N=47) physical activity level through direct observation in the ward using a predetermined observation scheme. Results: Participants were found inactive and alone for 19% (inter quartile range [IQR] 12-36%) and 15% (IQR 10-19%) of the time during the day, respectively. They spent 46% (IQR 31-55%) of the time in therapeutic activities and 31% (IQR 22-34%) of the time in non-therapeutic activities. The family was present with patients 50% of the time during the day. Family presence with the patient and the patient’s moderate dependence in daily activities are positively associated with their activity levels. Conclusion: Patients with stroke admitted to Indian hospitals spent less time being inactive and alone and more time with family participating in therapeutic activities. The presence of family members with the patients during hospital stay may be a significant resource for encouraging patients to be more active.