National Health Insurance interprofessional practice implementation in hand rehabilitation service delivery in South Africa.

South Africa's current healthcare system is unequal and inefficient, with 71% of the population accessing underfunded public healthcare facilities. The imminent National Health Insurance (NHI) aims to balance the inequality between private and public health services by providing universal healthcare. The high levels of road accidents, violence and injuries in South Africa, being one of the quadruple burdens of diseases frequently causing hand injuries with resultant devastating economic and functional implications without rehabilitation services, are concerning. The plea is that for specialised injuries, such as hand injuries, the NHI implementation requires innovative interprofessional health education and practice when managing individuals who sustained hand injuries optimally to return to preinjury functioning. When considering the devastating burden of mismanaged hand injuries on all levels of the International Classification of Functioning, Disability and Health (ICF) framework, all South Africans deserve rehabilitation by physiotherapists and occupational therapists based on each occupation's unique strengths. Anecdotally, a lack of interprofessional undergraduate and postgraduate hand rehabilitation education and hand-injured patient management exists in South Africa, highlighting the need for urgent change towards future practice and NHI. This commentary aims to apply the ICF core sets to inform interprofessional hand rehabilitation delivery by physiotherapists and occupational therapists. Clinical implication: Interprofessional rehabilitation framed in the ICF Core Set, accompanied by inclusive interprofessional education opportunities according to the Health Professions Council of South Africa (HPCSAs) scope of practice, will benefit South Africans who sustained hand injuries to fully recover and maximise their functional performance considering the type of injuries sustained.

Hand therapy: Inclusive care by South African physiotherapists.

Hand therapy for individuals who sustained hand injuries is included in the Health Professions Council of South Africa (HPCSA) physiotherapy scope of practice. The training that physiotherapists receive at the undergraduate level lays the foundation for them to deliver hand therapy or hand rehabilitation according to the International Classification of Functioning, Disability and Health domains in a uniquely South African health service context. Further structured formal and informal postgraduate continued education opportunities may put physiotherapists in the ideal position in a multidisciplinary team to deliver optimal hand therapy. The problem is that the physiotherapist's role in the multidisciplinary team delivering hand therapy in the past two decades has decreased, leaving room for a lack of health professional services in South Africa's private sector where physiotherapists are often the first consultation in, for example, sports teams, but more pertinently, in the public and rural areas. The International Federation of Societies for Hand Therapy (IFSHT) practice profile and physiotherapy scope of practice, curriculum and education information assist in achieving the aim of this commentary to position physiotherapists in South Africa as primary health practitioners in delivering hand therapy. Clinical implication: The effective management of individuals with hand-related conditions and injuries is pertinent to ensure optimal hand function and quality of life. Equal continued formal education opportunities should thus be created for all multidisciplinary team professions at a postgraduate level.

Physiotherapy practice in lymphoedema in South Africa: A survey.

Background: Lymphoedema is a chronic condition that is increasing in prevalence and requires specialised management to avoid possible life-threatening complications. Objectives: To describe the perceived knowledge of physiotherapists about lymphoedema and its management, the lymphoedema patient load seen by physiotherapists, and the current treatment approaches of physiotherapists in South Africa when managing lymphoedema. Method: A quantitative study using self-administered, online questionnaires were distributed among physiotherapists. Results: Knowledge of lymphoedema management is perceived to be lacking among physiotherapists. Physiotherapists are getting limited referrals and spending little time managing patients with lymphoedema. Only a few physiotherapists have post-graduate education in lymphoedema management, thus international treatment standards still need to be met. Conclusion: In order to meet international standards and patient needs, future research investigating the physiotherapy perspective is needed in lymphoedema management. Clinical implications: Educational bodies and policymakers may use this data to facilitate improvement in physiotherapy management of the condition and provision of care.

Physiotherapy students' knowledge and attitudes about their role in mental health.

Background: As the prevalence of mental health disorders (MHD) increases, physiotherapy students will be increasingly exposed to patients with MHD in their undergraduate studies. International research has shown that students who have mental health included in their curriculum have more knowledge and positive attitudes towards patients with MHD. In South Africa, little is known about physiotherapy students' attitudes towards and knowledge of mental health. Objectives: To establish the knowledge of and attitudes towards the role of physiotherapy in determining the mental health attitudes. Method: In our cross-sectional, descriptive study, third- and fourth-year physiotherapy students at the University of the Witwatersrand were purposefully sampled. Online questionnaires, based on the Mental Health Knowledge Schedule (MAKS) and Mental Illness Clinicians' Attitudes (MICA) scales were completed. Results: Thirty-four students participated in our study. Overall, all students indicated a moderate level of knowledge and a positive attitude towards mental health with mean MAKS score: 26.94 (standard deviation [s.d.]: 3.57) and MICA-4 score: 39.12 (s.d.: 16.12). Fourth-year students had more knowledge and a better attitude towards mental health when compared to the third-year students. Conclusion: Third- and fourth-year University of the Witwatersrand physiotherapy students have moderate knowledge and a positive attitude towards the role of physiotherapy in mental health. Clinical implications: The inclusion of mental health in the physiotherapy curriculum may improve students' knowledge and attitudes towards mental health and prepare them for managing these complex patients in the future.

Same-day discharge after early mobilisation and increased frequency of physiotherapy following hip and knee arthroplasty.

Background: Advanced rehabilitation pathway (ARP) after hip and knee arthroplasties is popular globally and is gaining ground in South Africa (SA). A multidisciplinary team in Rustenburg, SA, has implemented an ARP with the first same-day discharge (SDD) from hospital. The lack of evidence of physiotherapy protocols within an ARP determined our study. Objectives: Determine and compare hospital length of stay (LOS) (hours), patient satisfaction (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), patient safety (30-day re-admission) and cost between the two cohorts. Method: A quantitative prospective patient (treatment) group receiving early mobilisation with increased frequency of physiotherapy on post-operative day zero (POD0) was compared to a conservatively managed retrospective historical (control) group following post-operative elective hip and knee arthroplasties. Results: Results for the prospective group which were significantly improved relative to the retrospective group included decreased LOS (median 7.650, p < 0.001), less pain at 6 weeks (mean 16.20, standard deviation [SD] = 2.673, p < 0.001), less stiffness (mean 5.82, SD = 1.214, p = 0.007), higher function (mean 54.87, SD = 8.544, p < 0.001), lower hospital cost (mean R43 340, p < 0.001) and physiotherapy cost (mean R1069, p < 0.001), and total costs compared to the retrospective group (mean R117 062, p < 0.001). Conclusion: Safe and cost-effective SDD is possible in an ARP with earlier mobilisation and increased frequency of physiotherapy on POD0. Clinical implications: Achieving safe SDD after hip and knee arthroplasty surgeries saved costs and improved patient satisfaction, with a decrease in LOS being beneficial for medical funders and stakeholders including government aiming to implement National Health Insurance (NHI) in the future.

Traumatic hand injury management and outcomes: A case report.

Acute hand injuries are routinely managed by family medicine and primary care physicians. An appropriate initial assessment and treatment, early referral to a hand surgeon when indicated, and timeous referral to a hand therapist are imperative. A patient case report is presented reporting on the initial and subsequent assessment, treatment and outcomes at 3, 6, 7 and 9 months for a patient who sustained an acute finger injury. Finger range of motion (ROM), sensation, pain, time of wound closure, hand function measured with the standardised disability of the shoulder, arm and hand (DASH) questionnaire were the outcomes used. Pain, crepitus, decreased sensation, decreased ROM right index finger proximal interphalangeal joint (PIPJ) and dense scarring was measured at 9 months. Missed injuries or lack of recognition of injury severity leads to delayed referral to specialist hand surgeons and therapists, which lengthens recovery time and leads to sub-optimal outcomes. This article aims to provide the primary care practitioner with the initial management of a patient who sustained a traumatic hand injury whilst using a power tool.

Physiotherapy in an advanced rehabilitation pathway for patients after hip and knee arthroplasty: A proposal.

BACKGROUND: Accelerated rehabilitation pathway (ARP) decrease patients' hospital length of stay (LOS). A lack of evidence exists on physiotherapy management and outcome as part of ARP in South Africa (SA). Our study will aim to determine whether early mobilisation and increased frequency of physiotherapy treatments for participants after hip or knee arthroplasty surgery on post-operative day 0 (POD 0) affect outcome. METHODS/DESIGN: A quantitative prospective cohort study incorporating ARP on (n = 60) non-randomised elective hip and knee arthroplasty participants will be compared with a more conservatively managed historical control group (n = 60). The physiotherapy protocol includes early mobilisation and exercises 1-3 h post-operatively on POD 0 and a second mobilisation and exercise session, 1-2 h later. Outcomes measures are as follows: hours for LOS, the WOMAC measured pre-operatively, 6 weeks and 3 months post-operatively, 30-day readmission for safety and cost comparison between the prospective and historical cohorts. Descriptive statistics will be undertaken. A paired t-test will be used to analyse each of the outcome measures across the time periods if data are normally distributed. Length of stay, WOMAC score and cost data will be compared between the groups, using a Mann-Whitney U test. The occurrence of adverse events will be compared between the groups using Pearson's chi-square tests. The confidence interval will be set at 95% and p = 0.05 will be considered statistically significant. DISCUSSION: Globally, ARP's are successfully implemented to manage patients presenting with hip and knee osteoarthritis (OA). Research investigating physiotherapy protocols in an ARP is lacking in the literature. CONCLUSION: Achieving the same-day discharge after hip and knee arthroplasty surgeries may help elective surgery backlogs and waiting lists in a more cost-effective manner. CLINICAL IMPLICATIONS: The same day discharge after arthroplasty may be a cost-effective management option in the future. PROTOCOL IDENTIFICATION: Pan African Clinical Trial Registry, PACTR202103637993156.

Experiences and effects of telerehabilitation services for physiotherapy outpatients in a resource-constrained public health set-up in the backdrop of the COVID-19 pandemic: A proposal.

BACKGROUND: The announcement of a national lockdown in South Africa had country-wide impact on the delivery of health services. Strategies included prioritisation of patients and protecting patients who were considered at risk, resulting in the need for cancellation and temporary termination of many outpatient therapy services. This necessitated the urgent need to come up with a way of delivering physiotherapy rehabilitation services to patients in a more non-traditional format. Telerehabilitation allows for the provision of services by using electronic communication, thus ensuring that patients are still able to access necessary rehabilitation services. METHODS/DESIGN: This is a prospective, mixed method study with participants recruited from the outpatient physiotherapy department of Chris Hani Baragwanath Academic Hospital (CHBAH). Telerehabilitation services will be provided via the patients' preferred method of communication. On discharge, participants and therapists will be asked about their experiences of telerehabilitation. DISCUSSION: Because of the current coronavirus disease 2019 (COVID-19) pandemic, patients are unable to receive traditional face-to-face physiotherapy services. Telerehabilitation offers a suitable alternative to treatment, but the feasibility, outcome and experiences of offering these services in the public health system have not been studied. CONCLUSION: This study will determine whether telerehabilitation is a feasible service that can be offered in the COVID-19 pandemic, as well as post-pandemic, to enable physiotherapists to access those patients who are often unable to attend physiotherapy because of transport costs and various other reasons for non-attendance. CLINICAL IMPLICATIONS: The results of this study may indicate a way of managing patients in situations where face to face therapy cannot be undertaken. PROTOCOL IDENTIFICATION: Pan African Clinical Trial Registry, PACTR202103637993156.

Hand rehabilitation programmes for second to fifth metacarpal fractures: A systematic literature review.

BACKGROUND: Metacarpal fractures, one of the most prevalent upper limb fractures, account for 10% of all bony injuries. OBJECTIVE: Our systematic review aimed to review, appraise and collate available evidence on hand rehabilitation programmes for the management of second to fifth metacarpal fractures in an adult human population after conservative and surgical management. Since 2008, no review on a similar topic has been performed, thus informing clinical practice for physiotherapists and occupational therapists. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) principles guided the reporting. Experimental, quasi-experimental, cohort and case-control studies between January 2008 and September 2018 were included. Searches were conducted on Medline, Academic Search Ultimate, CINAHL, CAB Abstracts, Health Source - Consumer Edition, Health Source: Nursing/Academic Edition, SPORTDiscus, Africa-Wide Information and MasterFILE Premier, Web-of-Science and Scopus. Screening, selection, appraisal and data extraction were independently performed by two reviewers. No meta-analysis was performed. RESULTS: A total of 1015 sources were identified, 525 duplicates removed and 514 excluded. Three articles were included in the final data extraction: one randomised controlled trial (RCT) and two observational studies. CONCLUSION: Limited evidence is available that a well-designed, well-implemented home-based exercise programme results in statistically significant improved hand function (p ˂ 0.0001) and digital total active motion (TAM) (p = 0.013) compared with traditional physiotherapy (PT) post-surgically. CLINICAL IMPLICATIONS: Our study contributes to the knowledge base of hand rehabilitation after an individual sustained a second to fifth metacarpal fracture. The authors identified a gap where future studies should further investigate the effect of hand rehabilitation after conservative and surgical management.

Blended teaching versus traditional teaching for undergraduate physiotherapy students at the University of the Witwatersrand.

BACKGROUND: Shifting from face-to-face teaching to incorporating technology may prepare students better for future work as health professionals. Evidence of blended teaching's effect on the academic performance of undergraduate physiotherapy students' performance is scarce. OBJECTIVE: The purpose of our study was to determine students' theoretical and clinical performance in a blended teaching module compared to their own performance in two knowledge areas taught face to face, and student perceptions of blended teaching in the third-year physiotherapy curriculum. METHODS: The cross-sectional study design included 47 third-year physiotherapy students. The orthopaedic module was delivered using a blended teaching approach in two consecutive semesters, whilst two other physiotherapy knowledge areas, neuromusculoskeletal and cardiopulmonary, in the same semesters were delivered face to face. Theoretical and clinical performances of students were compared for significance and effect. Students were assessed on their theoretical and clinical knowledge in all areas using the same assessment methods. The students (n = 43) also completed a survey on their blended teaching experience. RESULTS: Significantly higher theoretical marks for orthopaedics were calculated compared to neuromusculoskeletal and cardiopulmonary for both semesters with a large positive effect (average Cohen d = 4.44) for blended teaching on theoretical examination performance; no statistically significant difference for clinical performances. Students felt engaged in the blended teaching process, and 72% preferred blended teaching over face-to-face teaching or online delivery. CONCLUSION: Blended teaching improved the theoretical marks, demonstrating that knowledge acquisition was improved, but not clinical performance. CLINICAL IMPLICATIONS: The study contributes to the knowledge base of blended learning in Health Science Education in South Africa. The authors identified a gap where future studies should investigate the effect of blended learning on clinical performance outcomes as a continuation from this one.

The impact of episporic modification of Lichtheimia corymbifera on virulence and interaction with phagocytes.

Fungal infections caused by the ancient lineage Mucorales are emerging and increasingly reported in humans. Comprehensive surveys on promising attributes from a multitude of possible virulence factors are limited and so far, focused on Mucor and Rhizopus. This study addresses a systematic approach to monitor phagocytosis after physical and enzymatic modification of the outer spore wall of Lichtheimia corymbifera, one of the major causative agents of mucormycosis. Episporic modifications were performed and their consequences on phagocytosis, intracellular survival and virulence by murine alveolar macrophages and in an invertebrate infection model were elucidated. While depletion of lipids did not affect the phagocytosis of both strains, delipidation led to attenuation of LCA strain but appears to be dispensable for infection with LCV strain in the settings used in this study. Combined glucano-proteolytic treatment was necessary to achieve a significant decrease of virulence of the LCV strain in Galleria mellonella during maintenance of the full potential for spore germination as shown by a novel automated germination assay. Proteolytic and glucanolytic treatments largely increased phagocytosis compared to alive resting and swollen spores. Whilst resting spores barely (1-2%) fuse to lysosomes after invagination in to phagosomes, spore trypsinization led to a 10-fold increase of phagolysosomal fusion as measured by intracellular acidification. This is the first report of a polyphasic measurement of the consequences of episporic modification of a mucormycotic pathogen in spore germination, spore surface ultrastructure, phagocytosis, stimulation of Toll-like receptors (TLRs), phagolysosomal fusion and intracellular acidification, apoptosis, generation of reactive oxygen species (ROS) and virulence.