Bridging the chasm between patients' needs and current rehabilitation care: perceptions of adults presenting for primary care in the Eastern Cape.

BACKGROUND: The need for rehabilitation in low-to-middle income countries (LMICs) is rapidly increasing as more people are living longer with chronic diseases. Primary health care (PHC) is ideally placed to provide the spectrum of care required to meet most of the complex and evolving population's health needs locally. This study aimed to describe the patient journeys of adults attending primary care in the Eastern Cape province of South Africa to understand the factors that affected their access to primary care rehabilitation services (or the lack thereof) and obtain suggestions on how rehabilitation may be enhanced at primary care. METHODS: A maximum variation sampling approach was used to purposefully select persons with varied chronic health conditions and demographic characteristics to gain diverse perspectives regarding their rehabilitation needs and ways in which the current rehabilitation services at primary care may be enhanced. Data were collected via face-to-face semi-structured interviews between March and June 2022 which were electronically recorded. Inductive thematic analysis of transcribed data was done and coded in Atlas.ti.22®. RESULTS: Twenty-five adult patients participated in the study. The patients had different experiences at their local PHC facilities that affected their access to rehabilitation at primary care. The study found that most patients were not able to access rehabilitation at primary care. There were several personal and contextual factors that resulted in the patients having a low perceived need to receive rehabilitation that potentially lowered patients' demand for and utilization of rehabilitation at primary care. Patients suggested increasing rehabilitation workforce at primary care, improving availability of assistive devices, increasing their knowledge regarding rehabilitation, and facilitating socio-economic integration into their communities. CONCLUSIONS: Patients attending primary care are not guaranteed access to rehabilitation by virtue of having entered the PHC system. It is important to consider the patient perspectives regarding their health needs and suggestions for enhancing care.

Primary school learners' movement during class time: perceptions of educators in the Western Cape, South Africa.

BACKGROUND: Over the last decade, the efficacy of in-classroom movement to reduce sedentary behaviour has been mainly conducted in high-income, developed countries. To date, there have been no published reports on the perceptions of principals and teachers regarding learners' movement during class time to inform the implementation of classroom-based movement strategies to reduce sedentariness in South Africa. METHODS: A sample of primary school principals and grades 5 and 6 teachers from a range of socio-economic categories participated in this exploratory, descriptive qualitative study in the metro central district of the Western Cape Education Department in South Africa. Transcripts of individual depth interviews (IDIs) with principals and focus group discussions (FGDs) with teachers were coded using Atlast ti 9* software for qualitative analysis. RESULTS: Thirteen principals (13 IDIs) and 24 teachers (6 FGDs) participated in the study. Two main factors influencing in-classroom movement, namely teacher-related and structural factors, were identified. The teacher-related factors pertained to their classroom management practice, knowledge and beliefs about sitting, and management style influenced their role in delivering the curriculum and creating a classroom environment conducive for learning. Classroom factors pertained to classroom size, the number of learners in the class and the ergonomic utility of traditional classroom desks. Institutional expectations and acceptance of learners' behaviour, and teachers' practice were also notable contributing factors that influenced learners' movement during class time. CONCLUSION: Emerging evidence about the efficacy of in-classroom movement on sedentary behaviour and learning outcomes challenges traditional teacher practice that sitting is essential for the delivery of the curriculum and for creating an optimal learning environment. Teacher training about the behaviour control utility of in-classroom movement, and school management and policy supportive of in-classroom movement may encourage fidelity to in-classroom movement strategies.

Preliminary findings from the early phases of the Music and Movement for Health study: the feasibility of an arts-based health programme for older adults.

Introduction (including aim): There is a lack of community-based programmes for older adults in Ireland. Such activities are vital to enable older people to (re)connect after COVID-19 measures, which had a detrimental effect on physical function, mental health and socialisation. The aims of the preliminary phases of the Music and Movement for Health study were to refine stakeholder informed eligibility criteria, recruitment pathways and obtain preliminary measures for feasibility of the study design and programme, which incorporates research evidence, practice expertise and participant involvement. METHODS: Two Transparent Expert Consultations (TECs) (EHSREC No: 2021_09_12_EHS), and Patient and Public Involvement (PPI) meetings were conducted to refine eligibility criteria and recruitment pathways. Participants from three geographical regions in the mid-west of Ireland will be recruited and randomised by cluster to participate in either a 12-week Music and Movement for Health programme or control. We will assess the feasibility and success of these recruitment strategies by reporting recruitment rates, retention rates and participation in the programme. RESULTS: Both the TECs and PPIs provided stakeholder-informed specification on inclusion/ exclusion criteria and recruitment pathways. This feedback was vital in strengthening our community-based approach as well as effecting change at the local level. The success of these strategies from phase 1 (March-June) are pending. DISCUSSION: Through engaging with relevant stakeholders, this research aims to strengthen community systems by embedding feasible, enjoyable, sustainable and cost-effective programmes for older adults to support community connection and enhance health and wellbeing. This will, in turn, reduce demands on the healthcare system.Note: We would like to thank and acknowledge those who participated in the PPIs for their time and invaluable feedback.

Rehabilitation and primary care treatment guidelines, South Africa.

The World Health Organization recognizes rehabilitation as an essential component of universal health coverage (UHC). In many countries, UHC builds on a standard benefits package of services that is informed by the country's essential medicines list, standard treatment guidelines and primary health care essential laboratory list. In South Africa, primary health care is largely provided and managed by primary health-care nurses and medical officers in accordance with primary health care standard treatment guidelines. However, rehabilitation is mostly excluded from these guidelines. This paper describes the 10-year process that led to rehabilitation referral recommendations being considered for inclusion in South Africa's primary health care standard treatment guidelines. There were five key events: (i) a breakthrough moment; (ii) producing a scientific evidence synthesis and formulating recommendations; (iii) presenting recommendations to the national essential medicines list committee; (iv) mapping rehabilitation recommendations onto relevant treatment guideline sections; and (v) submitting revised recommendations to the committee for final consideration. The main lesson learnt is that, by working together, rehabilitation professionals can be of sufficient number to make a difference, improve service delivery and increase referrals to rehabilitation from primary health care. A remaining challenge is the lack of a rehabilitation representative on the national essential medicines list committee, which could hamper understanding of rehabilitation and of the complexities of the supporting evidence.

L'Organisation mondiale de la Santé considère la réadaptation comme un élément indispensable de la couverture sanitaire universelle (CSU). Dans de nombreux pays, la CSU repose sur un modèle de prestations de services qui tient compte de la liste nationale de médicaments essentiels, des directives thérapeutiques normalisées et d'une liste des analyses en laboratoire essentielles dans le cadre des soins primaires. En Afrique du Sud, les soins primaires sont majoritairement assurés et gérés par du personnel infirmier et médical, conformément aux directives thérapeutiques normalisées en la matière. En revanche, la réadaptation n'y figure généralement pas. Le présent document décrit les dix années de processus qui ont permis d'émettre des recommandations de référence relatives à la réadaptation, que l'Afrique du Sud envisage d'inscrire dans ses directives thérapeutiques normalisées de soins primaires. Cinq événements clés ont été retenus: (i) un moment charnière; (ii) la réalisation d'une synthèse des preuves scientifiques et la formulation de recommandations; (iii) la présentation de ces recommandations au comité responsable de la liste nationale de médicaments essentiels; (iv) l'intégration des recommandations en matière de réadaptation dans les rubriques correspondantes des directives thérapeutiques; et enfin, (v) la soumission des recommandations révisées au comité pour examen final. Le principal enseignement tiré est qu'en collaborant, les professionnels de la réadaptation peuvent être suffisamment nombreux pour faire la différence, améliorer la qualité des services et augmenter les transferts depuis les soins primaires vers les structures de réadaptation. Un défi subsiste: l'absence de représentants du secteur au sein du comité responsable de la liste nationale de médicaments essentiels, ce qui pourrait nuire à la compréhension de la réadaptation et du degré de complexité des faits qui l'étayent.

La Organización Mundial de la Salud reconoce que la rehabilitación es un componente esencial de la cobertura sanitaria universal (CSU). En muchos países, la cobertura sanitaria universal depende de un paquete estándar de servicios que se basa en la lista de medicamentos esenciales del país, las directrices de tratamiento estándar y la lista de laboratorios esenciales de atención primaria. En Sudáfrica, la atención primaria la prestan y gestionan en gran medida el personal de enfermería y los médicos de atención primaria, de conformidad con las directrices de tratamiento estándar de la atención primaria. Sin embargo, la rehabilitación queda excluida en su mayor parte de estas directrices. Este artículo describe el proceso de 10 años que llevó a que se contemplara la posibilidad de incluir las recomendaciones de derivación a rehabilitación en las directrices de tratamiento estándar de la atención primaria en Sudáfrica. Hubo cinco acontecimientos clave: (i) un momento decisivo; (ii) la elaboración de una síntesis de datos científicos y la formulación de recomendaciones; (iii) la presentación de las recomendaciones al comité de la lista nacional de medicamentos esenciales; (iv) la adaptación de las recomendaciones de rehabilitación a las secciones pertinentes de las directrices de tratamiento; y (v) la presentación de las recomendaciones revisadas al comité para su estudio final. La principal lección aprendida es que, trabajando juntos, los profesionales de la rehabilitación pueden ser lo bastante numerosos como para marcar la diferencia, mejorar la prestación de servicios y aumentar las derivaciones a la rehabilitación desde la atención primaria. Un desafío que aún persiste es que no hay un representante de la rehabilitación en el comité de la lista nacional de medicamentos esenciales, lo que podría dificultar la comprensión de la rehabilitación y de las complejidades de las pruebas que la sustentan.

Rehabilitation workforce descriptors: a scoping review.

BACKGROUND: A comprehensive, accurate description of workforce capacity is important for health service planning, to ensure that health services meet local needs. In many low- to middle-income countries, the government's service planning ability is barred by the lack of accurate and/or comprehensively-described workforce data. In these low-resource settings, lack of appropriate planning leads to limited or no access to rehabilitation services. Variability in the definitions and scope of rehabilitation professionals further complicates the understanding of rehabilitation services and how it should be planned and delivered. Another challenge to describing the primary rehabilitation workforce capacity, is the lack of standardised and agreed-upon global metrics. These inconsistencies highlight the need for a comprehensive understanding of current practices, which can offer guidance to countries wishing to describe their rehabilitation workforce. This study aimed to scope the range of descriptors and metrics used to describe the rehabilitation workforce and to compare the workforce across countries that used similar descriptors in published reports. METHODS: A scoping review was conducted according to the five-step framework first developed by Arksey and O'Malley. The review included a broad search of literature regarding the rehabilitation workforce and how countries quantify and describe the rehabilitation workforce. RESULTS: Nineteen studies on rehabilitation workforce capacity were identified. All but one (a cross-sectional study) were database reviews. The main descriptors and indicators used to describe the rehabilitation workforce capacity were profession type, age, gender, distributions between urban/rural, level of care, and private/public sectors, absolute count totals, and population-adjusted ratios. CONCLUSION: This scoping review provided an overview of descriptors and indicators used to describe the rehabilitation workforce capacity internationally. The study is a first step towards developing standardised descriptors and metrics to quantify the rehabilitation workforce capacity, that will allow for comparison between different settings. TRIAL REGISTRATION: This scoping review protocol has been registered with the Open Science Framework (http://osf.10/7h6xz).

Stance leg and surface stability modulate cortical activity during human single leg stance.

Mobile Electroencephalography (EEG) provides insights into cortical contributions to postural control. Although changes in theta (4-8 Hz) and alpha frequency power (8-12 Hz) were shown to reflect attentional and sensorimotor processing during balance tasks, information about the effect of stance leg on cortical processing related to postural control is lacking. Therefore, the aim was to examine patterns of cortical activity during single-leg stance with varying surface stability. EEG and force plate data from 21 healthy males (22.43 ± 2.23 years) was recorded during unipedal stance (left/right) on a stable and unstable surface. Using source-space analysis, power spectral density was analyzed in the theta, alpha-1 (8-10 Hz) and alpha-2 (10-12 Hz) frequency bands. Repeated measures ANOVA with the factors leg and surface stability revealed significant interaction effects in the left (p = 0.045, ηp2 = 0.13) and right motor clusters (F = 16.156; p = 0.001, ηp2 = 0.41). Furthermore, significant main effects for surface stability were observed for the fronto-central cluster (theta), left and right motor (alpha-1), as well as for the right parieto-occipital cluster (alpha-1/alpha-2). Leg dependent changes in alpha-2 power may indicate lateralized patterns of cortical processing in motor areas during single-leg stance. Future studies may therefore consider lateralized patterns of cortical activity for the interpretation of postural deficiencies in unilateral lower limb injuries.

Physiotherapists' awareness of risk of bone demineralisation and falls in people living with HIV: a qualitative study.

BACKGROUND: Recent research has indicated a seemingly increased propensity for both falls and accelerated bone loss in people living with HIV (PLWH). Physiotherapists play a crucial role in optimising function and quality of life of PLWH through prevention of falls and reducing the harm that results. AIM: This study aimed to explore physiotherapists' awareness of falls risk and accelerated bone demineralisation in PLWH and their perceptions of current falls prevention strategies in the care of PLWH in selected regions of sub-Saharan Africa. METHOD: An exploratory descriptive qualitative research method was employed to explore physiotherapists' perceptions and experiences regarding bone health and falls in PLWH. In-depth semi-structured telephonic interviews were used to collect data from 21 physiotherapists working in primary HIV care. Transcribed interview data were coded in Atlas.ti.8® and analysed using inductive thematic analysis. RESULTS: The primary study revealed a lack of awareness by physiotherapists of falls risk and bone demineralisation in PLWH. As such, physiotherapists did not link falls or fractures to HIV or antiretroviral therapy (ART) when they did observe such events during their general patient assessments. However, in retrospect, some physiotherapists were able to recognise risk factors linked to falls in those with HIV. Current services for falls prevention, as perceived by the physiotherapists, were sub-optimal. CONCLUSION: Physiotherapists may need to be more aware of the potential risk of falls and bone demineralisation in PLWH and routinely assess for these phenomena in both older and younger PLWH.

Nurses back pain beliefs, coping strategies and factors associated with participant activation for self-management of back pain.

AIMS: To determine the back pain beliefs, coping strategies and factors associated with participant activation for self-management of back pain amongst nurses working in peri-urban district healthcare centres. DESIGN: A descriptive cross-sectional study design. METHODS: Data were collected between February and March 2020 using a self-administered questionnaire. Descriptive data analysis was done in Stata version 20.0. Back pain beliefs, participant activation and coping strategies were presented using relative frequencies and percentages. Odds ratios at 5% significance level were used to test association of factors for participant activation for self-management of back pain. RESULTS: Majority of the participants had experienced back pain which lasted 3 days for half of the participants. Further, pain medication was commonly used to cope with back pain. In addition, age, gender and work-setting were significantly associated with participant activation for self-management of back pain. CONCLUSION: Participants' coping strategies for back pain were linked to the conveyed back pain beliefs which demonstrate that participants believed in rest and lengthy periods of time off work for back pain. However, participants acknowledged that taking an active role in determining one's health and function is vital. This highlights the importance of self-management support for health behaviour change amongst nurses. IMPACT: The study addressed back pain beliefs, coping strategies and participant activation for self-management of back pain amongst nurses in peri-urban healthcare centres. Majority of the participants experienced back pain which lasted 3 days. Pain medication was commonly used to cope with back pain. Age, gender and work-setting were significantly associated with participant activation for self-management of back pain. Although this study was conducted in Zambia, outcomes from this study may be of benefit to nurses in similar settings. Further, the research provides insight to the international body of knowledge on the process and appropriateness of international research in resource-constrained settings.

Hop Performance After Return to Sport in Anterior Cruciate Ligament-Reconstructed Gaelic Football and Hurling Athletes.

PURPOSE: Anterior cruciate ligament (ACL) injuries are among the most severe injuries in the Gaelic Athletic Association. Hop tests measure functional performance after ACL reconstruction as they replicate the key requirements for a match situation. However, research examining functional recovery of ACL-reconstructed Gaelic athletes is lacking. The objective of this study is to determine if athletes restore normal hop symmetry after ACL reconstruction and to examine if bilateral deficiencies persist in hop performance following return to sport. METHODS: A cross-sectional design was used to evaluate hop performance of 30 ACL-reconstructed Gaelic athletes who had returned to competition and 30 uninjured controls in a battery of hop tests including a single, 6-m, triple, and triple-crossover hop test. RESULTS: In each test, the mean symmetry score of the ACL reconstruction group was above the cutoff for normal performance of 90% adopted by this study (98%, 99%, 97%, and 99% for the single, 6-m, triple, and triple-crossover hop, respectively). No significant differences in absolute hop scores emerged between involved and control limbs, with the exception of the single-hop test where healthy dominant limbs hopped significantly further than ACL-reconstructed dominant limbs (P = .02). No significant deficits were identified on the noninvolved side. CONCLUSIONS: The majority of ACL-reconstructed Gaelic athletes demonstrate normal levels of hop symmetry after returning to competition. Suboptimal hop performance can persist on the involved side compared with control limbs. Targeted rehabilitation may be warranted after returning to competition to restore performance to levels of healthy uninjured athletes.

Kinematics and temporospatial parameters during gait from inertial motion capture in adults with and without HIV: a validity and reliability study.

BACKGROUND: Inertial measurement unit (IMU)-based motion capture systems are gaining popularity for gait analysis outside laboratories. It is important to determine the performance of such systems in specific patient populations. We aimed to validate and determine within-day reliability of an IMU system for measuring lower limb gait kinematics and temporal-spatial parameters (TSP) in people with and without HIV. METHODS: Gait was recorded in eight adults with HIV (PLHIV) and eight HIV-seronegative participants (SNP), using IMUs and optical motion capture (OMC) simultaneously. Participants performed six gait trials. Fifteen TSP and 28 kinematic angles were extracted. Intraclass correlations (ICC), root-mean-square error (RMSE), mean absolute percentage error and Bland-Altman analyses were used to assess concurrent validity of the IMU system (relative to OMC) separately in PLHIV and SNP. IMU reliability was assessed during within-session retest of trials. ICCs were used to assess relative reliability. Standard error of measurement (SEM) and percentage SEM were used to assess absolute reliability. RESULTS: Between-system TSP differences demonstrated acceptable-to-excellent ICCs (0.71-0.99), except for double support time and temporophasic parameters (< 0.60). All TSP demonstrated good mean absolute percentage errors (≤7.40%). For kinematics, ICCs were acceptable to excellent (0.75-1.00) for all but three range of motion (ROM) and four discrete angles. RMSE and bias were 0.0°-4.7° for all but two ROM and 10 discrete angles. In both groups, TSP reliability was acceptable to excellent for relative (ICC 0.75-0.99) (except for one temporal and two temporophasic parameters) and absolute (%SEM 1.58-15.23) values. Reliability trends of IMU-measured kinematics were similar between groups and demonstrated acceptable-to-excellent relative reliability (ICC 0.76-0.99) and clinically acceptable absolute reliability (SEM 0.7°-4.4°) for all but two and three discrete angles, respectively. Both systems demonstrated similar magnitude and directional trends for differences when comparing the gait of PLHIV with that of SNP. CONCLUSIONS: IMU-based gait analysis is valid and reliable when applied in PLHIV; demonstrating a sufficiently low precision error to be used for clinical interpretation (< 5° for most kinematics; < 20% for TSP). IMU-based gait analysis is sensitive to subtle gait deviations that may occur in PLHIV.

What low back pain is and why we need to pay attention.

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause-eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

Correlation of the self-reported Leeds assessment of neuropathic symptoms and signs score, clinical neurological examination and MR imaging in patients with lumbo-sacral radiculopathy.

BACKGROUND: Lumbo-sacral radiculopathy (LSR) is a common musculoskeletal disorder for which patients seek medical care and referrals for advanced imaging. However, accurate diagnosis remains challenging. Neuropathic pain screening questionnaires, clinical neurological examination and magnetic resonance imaging (MRI) are used in the initial diagnosis. The utility of these tools in diagnosing LSR varies and their correlation has not been reported. METHODS: A cross-sectional, multicentre, blinded design was used in six physiotherapy departments in Kenya. Each participant was blindly examined by three independent clinicians using the Self-Reported Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) score, clinical neurological examination (CNE) and MRI. Spearman's rank coefficient (r) was used to examine the correlation between the three tests. Linear regression and odds ratios were used to establish correlations between socio-demographic, clinical and diagnostic parameters. The diagnostic accuracy of individual or combined sets of CNE tests in diagnosing LSR, with reference to MRI, was determined using Receiver Operating Characteristics (ROC) curves. RESULTS: We enrolled 102 participants (44 males, 58 females; mean age: 44.7 years). Results indicated a significant positive correlation (r = 0.36, P = 0.01) between S-LANSS, CNE and MRI among patients with low back and radiating leg symptoms. Positive agreement existed between combined neuro-conduction tests (sensory, motor and reflex) and neuro-dynamic tests (NDT). The NDT component of CNE (Straight Leg Raise Test [SLRT] and Femoral Nerve Stretch Test [FNST]) was significantly associated (P = 0.05) with MRI: patients who had positive NDT results had higher odds (8.3) for positive nerve root compromise on MRI versus those who had negative NDT results. CONCLUSION: This was the first study to investigate the correlation between S-LANSS, CNE and MRI in patients presenting with low back and radiating leg symptoms. Results indicated a significant positive correlation. The strongest correlations to MRI findings of LSR were firstly, NDT (SLRT and FNST); secondly, the S-LANSS score; and thirdly, the CNE components of motor power and deep tendon reflex. The clinical implication is that clinicians can confidently use the S-LANSS score and CNE to diagnose and make therapeutic decisions in LSR, when MRI is medically contra-indicated, unaffordable or unavailable.

A South African experience in applying the Adopt-Contextualise-Adapt framework to stroke rehabilitation clinical practice guidelines.

BACKGROUND: Clinical practice guideline (CPG) activity has escalated internationally in the last 20 years, leading to increasingly sophisticated methods for CPG developers and implementers. Despite this, there remains a lack of practical support for end-users in terms of effectively and efficiently implementing CPG recommendations into local practice. This paper describes South African experiences in implementing international CPG recommendations for best practice stroke rehabilitation into local contexts, using a purpose-build approach. METHODS: Composite recommendations were synthesised from 16 international CPGs to address end-user questions about best practice rehabilitation for South African stroke survivors. End-user representatives on the project team included methodologists, policy-makers, clinicians, managers, educators, researchers and stroke survivors. The Adopt-Contextualise-Adapt model was applied as a decision-guide to streamline discussions on endorsement and development of implementation strategies. Where recommendations required contextualisation to address local barriers before they could be effectively implemented, prompts were provided to identify barriers and possible solutions. Where recommendations could not be implemented without additional local evidence (adaptation), options were identified to establish new evidence. FINDINGS: The structured implementation process was efficient in terms of time, effort, resources and problem solving. The process empowered the project team to make practical decisions about local uptake of international recommendations, develop local implementation strategies, and determine who was responsible, for what and when. Different implementation strategies for the same recommendation were identified for different settings, to address different barriers. CONCLUSION: The South African evidence translation experience could be useful for evidence implementers in other countries, when translating CPG recommendations developed elsewhere, into local practice.

The effect of an individualised functional retraining intervention on pain, function and biomechanics in participants with patellofemoral pain: a series of n of 1 trial.

[Purpose] To determine the effect of an individualised functional retraining intervention on pain, function, kinematics and self-reported recovery in participants with PFP. [Participants and Methods] Thirty-one participants with unilateral PFP between the ages of 14-40 were included. Data collection and treatment sessions were conducted at the Tygerberg 3D Motion Analysis Laboratory and Physiotherapy Clinic at the University of Stellenbosch Medical School in Cape Town, South Africa. Participants underwent motion analysis testing pre- and post-intervention and attended physiotherapy weekly for a 6-week individualised intervention. [Results] Thirty of the thirty-one participants (96.8%) demonstrated improved pain levels (NPRS) post intervention. Participants demonstrated a statistically significant improvement in function (AKPS) immediately post intervention and continued to improve with greater functional scores at 6-month follow up. Fifteen participants (48.4%) rated themselves as fully recovered on a 7-point Likert scale at 6-month follow up. Nineteen of the 31 participants (61.3%) demonstrated a clinically significant improvement in their priority kinematic outcome post intervention. [Conclusion] Individualised functional retraining may improve pain, function, kinematics and long-term recovery in participants with PFP presenting with kinematic contributing factors. Clinicians need to be educated on common biomechanical contributing factors and how to tailor treatment accordingly.

An update on the prevalence of low back pain in Africa: a systematic review and meta-analyses.

BACKGROUND: Low back pain (LBP) remains a common health problem and one of the most prevalent musculoskeletal conditions found among developed and developing nations. The following paper reports on an updated search of the current literature into the prevalence of LBP among African nations and highlights the specific challenges faced in retrieving epidemiological information in Africa. METHODS: A comprehensive search of all accessible bibliographic databases was conducted. Population-based studies into the prevalence of LBP among children/adolescents and adults living in Africa were included. Methodological quality of included studies was appraised using an adapted tool. Meta-analyses, subgroup analyses, sensitivity analyses and publication bias were also conducted. RESULTS: Sixty-five studies were included in this review. The majority of the studies were conducted in Nigeria (n = 31;47%) and South Africa (n = 16;25%). Forty-three included studies (66.2%) were found to be of higher methodological quality. The pooled lifetime, annual and point prevalence of LBP in Africa was 47% (95% CI 37;58); 57% (95% CI 51;63) and 39% (95% CI 30;47), respectively. CONCLUSION: This review found that the lifetime, annual and point prevalence of LBP among African nations was considerably higher than or comparable to global LBP prevalence estimates reported. Due to the poor methodological quality found among many of the included studies, the over-representation of affluent countries and the difficulty in sourcing and retrieving potential African studies, it is recommended that future African LBP researchers conduct methodologically robust studies and report their findings in accessible resources. TRIAL REGISTRATION: The original protocol of this systematic review was initially registered on PROSPERO with registration number CRD42014010417 on 09 July 2014.

Targeted Functional Movement Retraining to Improve Pain, Function, and Biomechanics in Subjects With Anterior Knee Pain: A Case Series.

CONTEXT: Anterior knee pain (AKP) is a common condition, especially in a young active population. The clinical presentations of this condition vary considerably, and therefore, an individualized approach to treatment is needed. OBJECTIVE: The primary objective of this study was to assess the effect of a novel targeted biomechanical intervention on subjects with AKP. DESIGN: A case series was conducted on 8 participants with AKP. SETTING: The study was conducted at the Tygerberg Motion Analysis Laboratory and Tygerberg Physiotherapy Clinic in Cape Town, South Africa. PARTICIPANTS: Eight subjects (5 females and 3 males) diagnosed with AKP were included in this case series. INTERVENTION: Participants received a 6-week subject-specific functional movement retraining intervention. MAIN OUTCOME MEASURES: Three-dimensional hip, knee, and ankle kinematics were used for analysis for each participant preintervention and postintervention. Pain was measured weekly using the Numeric Pain Rating Scale. Two functional scales (Lower-Extremity Functional Scale and Anterior Knee Pain Scale) were used to assess pain and function the preintervention and postintervention. RESULTS: All 8 subjects demonstrated improved pain levels (Numeric Pain Rating Scale) and functional outcomes (Anterior Knee Pain Scale and Lower-Extremity Functional Scale). Seven of the 8 participants (87.7%) demonstrated improvements in their main biomechanical outcome. CONCLUSION: A subject-specific functional movement retraining intervention may be successful in the treatment of subjects with AKP presenting with biomechanical risk factors. Research on a larger sample is required to further investigate this approach.

Primary care clinical practice guidelines in South Africa: qualitative study exploring perspectives of national stakeholders.

BACKGROUND: Clinical practice guidelines (CPGs) are common tools in policy and clinical practice informing clinical decisions at the bedside, governance of health facilities, health insurer and government spending, and patient choices. South Africa's health sector is transitioning to a national health insurance system, aiming to build on other primary health care initiatives to transform the previously segregated, inequitable services. Within these plans CPGs are an integral tool for delivering standardised and cost effective care. Currently, there is no accepted standard approach to developing, adapting or implementing CPGs efficiently or effectively in South Africa. We explored the current players; drivers; and the context and processes of primary care CPG development from the perspective of stakeholders operating at national level. METHODS: We used a qualitative approach. Sampling was initially purposeful, followed by snowballing and further sampling to reach representivity of primary care service providers. Individual in-depth interviews were recorded and transcribed verbatim. We used thematic content analysis to analyse the data. RESULTS: We conducted 37 in-depth interviews from June 2014-July 2015. We found CPG development and implementation were hampered by lack of human and funding resources for technical and methodological work; fragmentation between groups, and between national and provincial health sectors; and lack of agreed systems for CPG development and implementation. Some CPG contributors steadfastly work to improve processes aiming to enhance communication, use of evidence, and transparency to ensure credible guidance is produced. Many interviewed had shared values, and were driven to address inequity, however, resource gaps were perceived to create an enabling environment for commercial interests or personal agendas to drive the CPG development process. CONCLUSIONS: Our findings identified strengths and gaps in CPG development processes, and a need for national standards to guide CPG development and implementation. Based on our findings and suggestions from participants, a possible way forward would be for South Africa to have a centrally coordinated CPG unit to address these needs and aspects of fragmentation by devising processes that support collaboration, transparency and credibility across sectors and disciplines. Such an initiative will require adequate resourcing to build capacity and ensure support for the delivery of high quality CPGs for South African primary care.

Objective impairments of gait and balance in adults living with HIV-1 infection: a systematic review and meta-analysis of observational studies.

BACKGROUND: Gait and balance deficits are reported in adults with HIV infection and are associated with reduced quality of life. Current research suggests an increased fall-incidence in this population, with fall rates among middle-aged adults with HIV approximating that in seronegative elderly populations. Gait and postural balance rely on a complex interaction of the motor system, sensory control, and cognitive function. However, due to disease progression and complications related to ongoing inflammation, these systems may be compromised in people with HIV. Consequently, locomotor impairments may result that can contribute to higher-than-expected fall rates. The aim of this review was to synthesize the evidence regarding objective gait and balance impairments in adults with HIV, and to emphasize those which could contribute to increased fall risk. METHODS: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An electronic search of published observational studies was conducted in March 2016. Methodological quality was assessed using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Narrative synthesis of gait and balance outcomes was performed, and meta-analyses where possible. RESULTS: Seventeen studies were included, with fair to low methodological quality. All studies used clinical tests for gait-assessment. Gait outcomes assessed were speed, initiation-time and cadence. No studies assessed kinetics or kinematics. Balance was assessed using both instrumented and clinical tests. Outcomes were mainly related to center of pressure, postural reflex latencies, and timed clinical tests. There is some agreement that adults with HIV walk slower and have increased center of pressure excursions and -long loop postural reflex latencies, particularly under challenging conditions. CONCLUSIONS: Gait and balance impairments exist in people with HIV, resembling fall-associated parameters in the elderly. Impairments are more pronounced during challenging conditions, might be associated with disease severity, are not influenced by antiretroviral therapy, and might not be associated with peripheral neuropathy. Results should be interpreted cautiously due to overall poor methodological quality and heterogeneity. Locomotor impairments in adults with HIV are currently insufficiently quantified. Future research involving more methodological uniformity is warranted to better understand such impairments and to inform clinical decision-making, including fall-prevention strategies, in this population.

The three-dimensional kinematics and spatiotemporal parameters of gait in 6-10 year old typically developed children in the Cape Metropole of South Africa - a pilot study.

BACKGROUND: Functional gait is an integral part of life, allowing individuals to function within their environment and participate in activities of daily living. Gait assessment forms an essential part of a physical examination and can help screen for physical impairments. No three-dimensional (3D) gait analysis studies of children have been conducted in South Africa. South African gait analysis laboratory protocols and procedures may differ from laboratories in other countries, therefore a South African data base of normative values is required to make a valid assessment of South African children's gait. The primary aim of this study is to describe joint kinematics and spatiotemporal parameters of gait in South African children to constitute a normative database and secondly to assess if there are age related differences in aforementioned gait parameters. METHODS: A descriptive study was conducted. Twenty-eight typically developing children were conveniently sampled from the Cape Metropole in the Western Cape, South Africa. The 3D lower limb kinematics and spatiotemporal parameters of gait were analyzed. The lower limb Plug-in-Gait (PIG) marker placement was used. Participants walked bare foot at self-selected speed. Means and standard deviations (SD) were calculated for all spatiotemporal and kinematic outcomes. Children were sub-divided into two groups (Group A: 6-8 years and Group B: 9-10 years) for comparison. RESULTS: A significant difference between the two sub-groups for the normalized mean hip rotation minimum values (p = 0.036) was found. There was no significant difference between the sub-groups for any other kinematic parameter or when comparing the normalized spatiotemporal parameters. CONCLUSION: The study's findings concluded that normalized spatiotemporal parameters are similar between the two age groups and are consistent with the values of children from other countries. The joint kinematic values showed significant differences for hip rotation, indicating that older children had more external rotation than younger children.

Guide to clinical practice guidelines: the current state of play.

INTRODUCTION: Extensive research has been undertaken over the last 30 years on the methods underpinning clinical practice guidelines (CPGs), including their development, updating, reporting, tailoring for specific purposes, implementation and evaluation. This has resulted in an increasing number of terms, tools and acronyms. Over time, CPGs have shifted from opinion-based to evidence-informed, including increasingly sophisticated methodologies and implementation strategies, and thus keeping abreast of evolution in this field of research can be challenging. METHODS: This article collates findings from an extensive document search, to provide a guide describing standards, methods and systems reported in the current CPG methodology and implementation literature. This guide is targeted at those working in health care quality and safety and responsible for either commissioning, researching or delivering health care. It is presented in a way that can be updated as the field expands. CONCLUSION: CPG development and implementation have attracted the most international interest and activity, whilst CPG updating, adopting (with or without contextualization), adapting and impact evaluation are less well addressed.