The impact of COVID-19 on professional development for physiotherapists in Lagos, Nigeria.

Background: Continuous professional development is important to maintain standards of care in the healthcare sector. However, in Lagos, Nigeria, the additional burden of COVID-19 and limited resources may provide separate challenges for physiotherapists' continuous professional development (CPD). Objectives: To examine the availability and perceived quality of continuous professional development opportunities for physiotherapists working before and during the pandemic in Lagos, Nigeria. Method: A qualitative study was conducted with 10 conveniently sampled physiotherapists, recruited via email. Interviews took place via Zoom, and the video function was utilised. Data were collected via semi-structured interviews using a pilot tested interview, and was transcribed and analysed thematically. Results: The main method of workplace teaching pre-COVID-19 and during COVID-19 was bedside teaching (BT), which most participants received. Pre-COVID-19, the main barrier to receiving teaching was a lack of national guidelines providing specific details on CPD. During COVID-19, the main barrier was the difficulty of increased online teaching instead of teaching on real life patients. The main barriers for non-workplace CPD pre-COVID-19 were a lack of availability of learning opportunities and monetary cost of conferences. This was partially combatted by the increasing trend of online learning events during the pandemic, which increased access to non-workplace learning opportunities. Conclusion: Because of COVID-19, most CPD learning opportunities for physiotherapists in Lagos, Nigeria, were online, increasing overall accessibility. Adequate training to improve utilising online learning resources as well as specific guidelines for workplace physiotherapists CPD in Nigeria should be implemented and promoted to improve confidence and quality of care. Clinical implications: Key insight into the CPD experiences of physiotherapists currently working in Lagos, Nigeria, which can guide policies and improve clinical outcomes.

Physiotherapy in Madagascar: current challenges and opportunities for development.

PURPOSE: World Health Organisation's data show that low and middle-income countries have a higher prevalence of disabilities. Madagascar is the ninth poorest country in the world. This report aims to analyse the current difficulties faced by physiotherapists and physicians working in the hospital setting, and offer recommendations for how healthcare services can develop in the future. MATERIALS AND METHODS: Data were collected over the course of 3 months in the form of observational logs, interviews, and questionnaires. Interpreters were used in all interviews, and written questionnaires were translated from English to Malagasy. RESULTS: Thematic analysis of all data collected was completed with key themes emerging: difficult working conditions, including high patient volume and limited staff capacity or treatment space; limited recognition of physiotherapy as a profession, with no autonomy for physiotherapy staff; the low standard of clinical reasoning skills being used in practice; and variable levels of clinical competence, with little evidence of active continuing professional development or appropriate training specific to the needs of clinicians. CONCLUSIONS: The current practice of physiotherapy in Madagascar mirrors the challenge in low-income settings. This study highlights the ongoing needs of the profession, including increasing clinical reasoning skills, updating the physiotherapy curriculum, and further development of multidisciplinary teamwork.IMPLICATIONS FOR REHABILITATIONThere are approximately 300 physiotherapists in Madagascar serving 25.5 million people in a low-income country with a high prevalence of disability.Developing the core training skills of physiotherapists in areas such as clinical reasoning skills, improved multidisciplinary team working, and access to research will allow physiotherapists to deliver a higher level of patient-centred care focused on rehabilitation.Upskilling physiotherapists and improving rehabilitation standards will result in improved functioning and quality of life for people with disabilities.Developments in multidisciplinary team communication and working will lead to interprofessional respect, improved quality of work, and a focus on patient-centred care.

Trauma rehabilitation in a teaching hospital in Antananarivo, Madagascar: current provision and patients' perspectives.

Purpose: This study aims to describe the current provision of trauma rehabilitation in Antananarivo, Madagascar and explore the experiences and perspectives of users of this service in order to inform future research and service development.Material and methods: A qualitative study supplemented by a descriptive service review were applied in the central government hospital in Antananarivo. Registers in the rehabilitation department were analyzed for a 3 month period. Semi-structured interviews were conducted with a convenience sample of users of the rehabilitation service and were subject to thematic analysis.Results: One in six patients treated in the rehabilitation department has survived a traumatic injury, with limb injuries comprising the majority. Analysis of interviews with 10 adult patients, following traumatic injuries to the lower limbs (6), upper limbs (3) or polytrauma (1) generated seven broad themes: health seeking behavior, organization of services, clinical management, costs and financial impact, effect on function and role, psychological impact and societal attitudes.Conclusions: Financial constraints and impact on personal finances pervade the overall picture. The perspectives and experiences elucidated will inform future research into the development of context-specific models of care for people with trauma-related disabilities in Madagascar.Implications for rehabilitationPotentially treatable traumatic injury can have a profound effect on function and societal participation in Madagascar.Interventions to increase access to timely acute trauma care and rehabilitation are needed, and may include different models of financing and innovations to reduce materials costs and length of stay.A structured rehabilitation pathway must be integrated to the earliest stages of trauma care, including scrutinizing the use of prolonged immobilization.Consideration should be given to models of care which are financially and geographically accessible to the population.

Evaluating a global health partnership rehabilitation training programme in Madagascar.

OBJECTIVE: Rehabilitation services play an important role in optimizing functional ability and societal integration for people with disabilities. The Madagascar Rehabilitation Programme (2011-2013) resulted from a global training partnership and led to 8 doctors achieving a university diploma in rehabilitation medicine. This paper describes a 2014 evaluation of the programme methods, results and learning points. METHODS: A combination of qualitative methods was used for the evaluation, based on a Theory of Change model, with informants from Madagascar and the UK. RESULTS: Malagasy trainees and UK volunteers gained new theoretical knowledge and practical skills. For Madagascar, it led to changes in working practice and the formation of a national rehabilitation association. Key to its success was the strong collaboration between Malagasy and UK professionals, with support from the University and Ministry of Health in Madagascar, and the UK partners. Having a clear common vision ensured the programme met the needs of the Malagasy clinicians. CONCLUSION: Rehabilitation is increasingly recognized as an important focus for international development. Successful rehabilitation training programmes can be achieved at modest costs with global health partnerships. The combination of factors that enabled this programme to be a success is reproducible in other contexts.

Developing a spinal cord injury rehabilitation service in Madagascar.

Rehabilitation for people with spinal cord injury in many low- and middle-income countries is not avail-able or is in the early stages of development. However, rehabilitation is recognized as crucial in order to optimize functional recovery and outcomes for patients with spinal cord injury. With an increasing incidence of spinal cord injury, the unmet need for rehabilitation is huge. This report describes the early development of a specialist rehabilitation service for spinal cord injury in Madagascar, one of the poorest countries in the world. The sustained input to an expanding rehabilitation team has led to reductions in avoidable complications. The input of the rehabilitation team has been welcomed by the neurosurgery department, which has recognized fewer delays in patients undergoing surgical treatments. Cost, lack of resources and trained staff, and poor understanding of disability continue to provide challenges. However, the development of the rehabilitation service using low technology, but with a high level of knowledge and systematic management, is a source of considerable pride. This development in Madagascar can be regarded as a model for spinal cord injury rehabilitation in other low-resource settings.

Problems encountered by parents of infants with clubfoot treated by the Ponseti method in Madagascar: A study to inform better practice.

OBJECTIVE: Ponseti treatment for clubfoot is effective and inexpensive, improving children's social participation. Two rehabilitation centres in Madagascar piloted Ponseti treatment; however, at one centre 46% of infants failed to complete treatment. The aim of this study was to determine the causes of defaulting in order to facilitate subsequent improvements nationwide when treatment is rolled out to all centres. METHODS: Questionnaire-based interviews. PATIENTS: Twenty mothers of infants younger than 1 year were interviewed after 3 months of treatment in relation to difficulties they experienced with continuing treatment. RESULTS: Fifteen families of these had financial problems: 7 incurred debt, 2 sold possessions, 4 parents stopped work an 2 did not give any further details. All mothers experienced distress; 9 hid their child's foot, and 8 were accused of wrong-doing during pregnancy. Three families travelled more than 500 km to the treatment centre and journeys were costly and difficult. Ponseti splints were acceptable, but aftercare of the splints proved problematic. CONCLUSION: Repeated travel to the clinic resulted in financial and social burden on the families, which reduced their ability to engage in treatment. The findings of this study are similar to work from other countries, but publications on rehabilitation from Madagascar are few. Improved support for parents, information, splinting with better materials and provision of treatment more locally are needed. Financial support for parents is key to enhancing children's life chances.

A rehabilitation training partnership in Madagascar.

We describe here the development of a mid-level training programme for doctors in Madagascar to direct regional and national rehabilitation services. Eight doctors enrolled and all gained their diplomas and have gone on to form the Association of Physical and Rehabilitation Medicine of Madagascar, which is leading further training and service developments. The course was specific to Madagascar's needs, and was devised according to the vision of the senior rehabilitation specialist in the Ministry of Health in Madagascar with support from the University of Antananarivo. The syllabus was developed with a senior Rehabilitation Medicine consultant responsible for setting up a comprehensive range of services and teaching in a University teaching hospital in the UK. Major barriers to success include the economic and political situation in Madagascar, which worsened steadily over the period of the training, the lack of resources for health, rehabilitation and rehabilitation workshops, and the withdrawal of aid. The sustainability of the training and the improved services that have been initiated will be evaluated, but these will be influenced by the situation of the country. It is hoped that this description of a highly practical training using modern teaching methods will be of use in other low-resource countries. Much of the teaching input was given by clinicians from a UK teaching hospital, and this resource will continue to be needed.

What reductions in dependency costs result from treatment in an inpatient neurological rehabilitation unit for people with stroke?

This paper examines the reductions in care costs that result from inpatient multidisciplinary rehabilitation for younger people with acquired brain injury. Thirty-five consecutive patients admitted following a stroke over one year were recruited to this observational study. Physical ability, dependency and potential community care costs were measured on admission and discharge. Fifty-one community-dwelling patients were transferred to rehabilitation from acute medical wards in a large teaching hospital; 35 met the inclusion criteria. After a median of 59 days of rehabilitation, 29 patients were discharged home and six to nursing homes. Patients made highly significant gains in physical ability (median Barthel index 50 to 64; p < 0.001). Dependency decreased; median calculated costs for care were reduced from pounds 1900 to pounds 1100 per week, a saving of pounds 868 per week. Total annualised care costs reduced from pounds 3,358,056 to pounds 1,807,208, a potential saving of pounds 1,550,848. The median time to repay rehabilitation costs was 21 weeks. Savings occurred in those with moderate and severe disability and they have the potential to continue to accrue for over 12 years. Similar results will probably be found for rehabilitation in other forms of acquired brain injury.

Vocational rehabilitation: an educational review.

The aim of this review is to describe aspects of vocational rehabilitation relevant for a physician aiming to become a specialist in physical and rehabilitation medicine (PRM). The review discusses the epidemiology of incapacity for work, the major patient groups in vocational rehabilitation (musculoskeletal and psychiatric diagnoses comprise approximately 50-70% of the patients), the influence of different kinds of environmental and individual risk factors on work resumption (such as the legal framework, application of the law, resources for rehabilitation and its effectiveness, the degree of co-operation between vocational rehabilitation agencies, economic factors/labour market situation, medical and personal factors). The review describes different models of vocational rehabilitation, the effectiveness of various vocational rehabilitation programmes on work resumption or sick leave (where strong evidence is reported for multi-modal rehabilitation programmes for patients with long-lasting musculoskeletal pain). Finally, there are sections about the PRM physician's history-taking in vocational rehabilitation (using the International Classification of Functioning, Disability and Health (ICF)), and report writing with a structure where ICF body functions and activity limitations are reported separately.

Adult outcomes and lifespan issues for people with childhood-onset physical disability.

This paper aimed to discuss functioning, quality of life, (QoL) and lifespan care issues of adolescents and young adults with childhood-onset physical disability from a clinical, scientific, and personal perspective. We present a résumé of results of recently performed studies in rehabilitation-based samples of (young) adults with childhood-onset conditions such as cerebral palsy (CP) and spina bifida (SB), and different models of transition and lifespan care. The studies showed that many young adults with a childhood-onset disability experience health-related problems such as functional deterioration, pain or fatigue, and an inactive lifestyle. A significant number are restricted in participation in work, housing, and intimate relationships. They perceive a lower health-related and global QoL compared with a reference group. In some centres in the UK and the Netherlands specialized outpatient services are available or being developed. In conclusion, transition to adulthood is a critical phase for reaching autonomous participation in adult life. There is an international challenge to incorporate a lifespan perspective in paediatric, transition, and adult health care services for persons with a childhood-onset disability.

Work, disability and rehabilitation: making the best job of it.

The relationship between a person's health and their work was recognised as central to the good practice of medicine by Charles Turner Thackrah (1795-1833) in his seminal work, The effects of arts, trades and professions on health and longevity (1823). The connection is largely forgotten in current clinical practice; the UK has a high level of dependence on benefits mainly in those with non-severe disabilities. Recognition of the value of preventing this by access to early, usually multidisciplinary, rehabilitation and prevocational rehabilitation via a general practitioner and in hospital practice is needed as a priority. This requires that all NHS staff adopt a biopsychosocial approach to illness and are taught about the workplace needs of patients and the value of early rehabilitation. Communications within the NHS and with other agencies have to be improved by the development of better pathways with dedicated staff time for this activity. The creation of the Director of Health and Work position and the refocusing of occupational medicine present an unrivalled opportunity to improve our practice.

Violence to and maltreatment of people with disabilities: a short review.

OBJECTIVE: Violence to disabled persons constitutes a major ethical problem. The European Academy of Rehabilitation Medicine has debated the matter; it presents this short report to alert a wider audience to the problem, with the aim of provoking debate and facilitating prevention. DESIGN: The Academy has produced a full report on the literature. The present short report summarizes the essential features of this and significant references to violence. This is defined, types described, and risk factors and signs identified with the aim of informing rehabilitation practitioners. CONCLUSION: Violence may take many forms, often being subtle, insidious and difficult to recognize. However, the members of the rehabilitation team may be able to provide significant help and act preventively as they work towards the better social integration of the disabled individual helping them gain more control of their lives. European legislation may help us in this task; we are reminded that our roles are set within the context of our civic duties of respect for and tolerance of all.

Development of the BD-QoL: a quality of life measure specific to Behçet's disease.

OBJECTIVE: Current outcome measures for patients with Behçet's disease (BD) are impairment-focused and do not necessarily take account of the wider impact of the condition on the individual's lifestyle. Our aim was to develop a disease-specific measure of quality of life (QoL) for BD. METHODS: The content of the BD-QoL was derived from qualitative interviews with patients using a "needs-based" approach to identify items. A postal survey was used to test the scaling properties, reliability, internal consistency, and validity of the new questionnaire using Rasch analysis. A second postal survey was used to assess test-retest reliability and internal consistency and to provide further evidence of the validity of the questionnaire. RESULTS: Main themes emerging from the qualitative interviews included relationships, emotions, limitations in day to day activities, and self-image. From these themes 71 statements were chosen as potential items for the BD-QoL. After analysis, 30 items of the BD-QoL emerged free of item bias for age and sex. Fit to the Rasch model was excellent. In the second postal survey test-retest reliability of the 30 item BD-QoL was 0.84. CONCLUSION: The BD-QoL provides the clinician with a simple, reliable, and valid tool for assessing the influence of interventions for BD and for evaluating models of service delivery. It is well accepted by patients, and has excellent scaling and psychometric properties. The BD-QoL complements information obtained through BD-specific disease activity scales.

Development of a work instability scale for rheumatoid arthritis.

OBJECTIVES: To explore the concept of work instability (WI), a state in which the consequences of a mismatch between an individual's functional abilities and the demands of his or her job could threaten continuing employment if not resolved, in people with rheumatoid arthritis (RA). To develop the Work Instability Scale (WIS). METHODS: WI in people with RA was explored through qualitative interviews, which were then used to generate items for the WIS. RESULTS: Through Rasch analysis and validation against a gold standard of expert vocational assessment, a short 23-item, self administered, RA WIS was developed. CONCLUSION: The WIS can be scored in 3 bands indicating low, medium, and high risk of work disability.

A randomised controlled trial to determine the effect of intensity of therapy upon length of stay in a neurological rehabilitation setting.

A randomised single-blind controlled trial was designed to determine whether intensity of therapy (physiotherapy and occupational therapy) shortened length of stay for patients in a rehabilitation unit. Patients were under 65, primarily with stroke, but also with other conditions such as traumatic brain injury, and multiple sclerosis. The experimental group were timetabled to receive 67% more therapy in any given week, than the control group. After controlling for confounders and case mix (as expressed by type of therapy required) patients in the experimental group showed a significant 14-day reduction in length of stay (<0.01). Concurrently average length of stay was increased for both groups by 16 days due to delays in discharge.