A study to investigate the functional rehabilitation outcomes of patients undergoing physical rehabilitation at Gugulethu Community Health Centre

Pegram, Elizabeth Anne (2016-03)

Thesis (MSc)--Stellenbosch University, 2016.

Thesis

ENGLISH ABSTRACT: There has been a significant shift in the focus of evidence-based health care internationally and within government in South Africa, specifically the Western Cape (The Lancet, 2009:1793; Cieza, et al. 205-207: 2002; Western Cape Government, xv: 2014). A need for improved evidence based information for disability and rehabilitation services has been identified at international level (WHA, 1-2; 2005). There is hence an opportunity to strengthen the development of rehabilitation services and with that concurrently, an evidence approach to this part of the public sector health services. Aim: The aim of this study was to describe the functional rehabilitation outcomes of patients undergoing physical rehabilitation at the Gugulethu Community Health Centre. Methodology: This study employed a descriptive study design with pre-and post-rehabilitation test measuring changes in functional ability of clients. Quantitative methodology was followed. The study population included all patients who attended the Gugulethu Community Health Centre and who were referred to rehabilitation. The study sample included all patients who were admitted to the physiotherapy service at GCHC during the period February 2012 to September 2012. Patients with the five most prevalent conditions were included in the sample. Self-developed outcome measures that used the ICF and CBR guidelines as conceptual models were used to determine what the participants’ socio-economic and environmental facilitators and barriers were. Six, standardised outcome measures were applied, namely the EQ5D for the whole cohort; and the Barthel Index, DASH, AIMS, Clinical Mobility Scale and the Oswestry respectively to do determine the level of functioning at the onset of rehabilitation and again either at discharge or three months post cessation of rehabilitation for each of the five most prevalent conditions. Results: By applying a t-test for dependent samples (Pre-VAS: N = 58; Post-VAS: N =52) to the whole cohort a statistically significant difference (p=0.03) in the participants’ self-assessment of their health status (VAS) is noted. No statistical difference was reported in the activity related domains as well as the impairment related domains. Results for sub-sets of the cohort however indicated different results: Participants with Lower Limb Injuries (N=40) showed an overall significant improvement in pre- and post-testing in the activity domain; walking (p=0.02), Gait (p<0.3), Stair Climbing (p=0.01), Hand-held appliances (p=0.03). There was no improvement in the participation domain. Participants with Upper Limb Injuries (N=16) reported improvement in all three domains, namely impairment, activity limitations and participation restrictions. In terms of activity related elements, the following results indicated a significant improvement: Pushing a heavy door (p=0.04); Garden/yard work and making a bed (p=0.03) as well as pulling over a sweater (p=0.04). Impairment related element “tingling of the arm, shoulder or hand” showed a significant improvement (p=0.02). Participation related elements where participants indicated significant improvement includes recreational activities with “little effort” (p=0.01) and where the “arm can move freely” (p<0.01); “managing transportation needs” (p=0.01) and “sexual activities” (p=0.01). Participants with Lower Back Pain (N=11) reported a statistically significant difference in pre- and post-test results for the participation restriction domain: Socialising and Travel (p=0.04). No statistically significant difference was reported in the activity and impairment domains in this sub-set. Participants with Arthritis and Stokes reported no statistically significant difference between pre- and post-tests. This can be contributed to the low numbers of re-test that was present in these sub-sets. Conclusion The results indicate significant changes in patients attending physical rehabilitation as far as mobility is concerned for people with lower leg injuries and lower back pain. Positive shifts were noted in the activity levels for patients with upper limb injuries as well as those with mobility problems. Significant improvements were noted in pain levels as well as patients’ mental health. Participation in life roles were improved. More in-depth studies regarding the rehabilitation process would be beneficial to establish which interventions yield the most positive outcomes. Recommendations The mainstreaming of outcome measures at primary health-care level for rehabilitation services is strongly recommended. This will strengthen the development and delivery of rehabilitation services at primary health-care level. Furthermore, recommendations will be used to inform management and policy makers to move towards a firm outcome-based approach. Other recommendations include areas of strengthening further research, based on limitations identified in this study. KEY TERMS: Disability, Rehabilitation, functional outcomes, standardised outcome

AFRIKAANSE OPSOMMING: Daar is ‘n merkwaardige verandering in fokus op meer uitkoms-gebasseerde gesondheidssorg op internasionale sowel as plaaslike vlak in Suid-Afrika en ook in die Wes-Kaap.(The Lancet, 2009:1793; Cieza, et al. 205-207: 2002; Western Cape Government, xv: 2014). Die behoefte om verbeterde uitkomste-gebasseede inligting rondom gestremdheid en rehabilitasie te bekom, is reeds op internasionale vlak identifiseer en gedryf. (WHA, 1-2; 2005). Daar is dus ‘n geleentheid om rehabilitasie dienste te verbeter en sodoende die fokus op meer uitkomste-gebasseerde benadering to vestig en te versterk. Doelwit: Die doelwit van hierdie studie was om die funksionele rehabilitasie uitkomste van pasiente wat fisiese rehabilitasie dienste by Gugulethu Gemeenskap Gesondheidssentrum (GGGS) bywoon, te beskryf. Metodologie: Die studie het ‘n beskrywende ontwerp met ‘n voor- en na-rehabilitasie toets gebruik wat verandering in funksionering by kliente meet. ‘n Kwantitatiewe metodologie was gevolg. Die studie populasie het alle pasiënte verwys was na rehabilitasie dienste by die GGGS. Die steekproef het pasiënte wat die vyf hoof diagnostiese groepe gesien by die sentrum ingesluit oor die periode van Februarie 2012 tot September 2012. Pasiënte met die vyf toestande wat die meeste voorgekom het, is ingesluit in die steekproef. Self-ontwikkelde meetinstrumente wat die IKF en GGR riglyne as konseptuele modelle gebuik het, is aangewend. Ses gestandaardiseerde meetinstrumente was ook gebruik, naamlik die EQ5D wat aangewend was vir die hele streekproef; en die Barthel Indeks, DASH, AIMS, Clinical Mobility Scale and the Oswestry was onderskeidelik aangewend ten einde uitkomste te meet in die vyf hoof diagnostiese groepe. Results: Die resultate van die EQ5D dui aan dat daar wel ‘n statisties-beduidende verskil in die self-gerapporteerde gesondheidsevaluasie was. ‘n T-toets is gedoen vir afhanklike steekproewe (Voor-toets: N=58; Na-Toets : N=52) en het ‘n statisties-beduidende resultaat getoon met p=0.03. Die resultate vir die onderskeie sub-groepe van die steekproef het wel ander resultate getoon: Deelnemers met onderste ledemaat beserings (N=40) het ‘n algemene statisties beduidende verbetering in getoon met die voor- en na-toetsing in die aktiwiteite naamlik: loop (p=0.02), Loopgang (p<0.3); Klim van trappe (p=0.01); Hantering van apparate wat met hand vasgehou word (p=0.03). Geen verbertering is gerapporteer in die deelname afdeling nie. Deelnemers met boonste ledemaat beserings (N=16) het verbeteringe in al drie afdelings rapporteer naamlik aktiwiteit, fisiese inkorting en deelname. In terme van aktiwiteite, is die volgende statisties beduidende resulte verkry: Stoot van swaar deur (p=0.04); beide Tuinwerk en “om bed op te maak” (p=0.03) asook om ‘n trui aan te trek (p=0.04). Afdelings wat ‘fisiese inkorting” insluit “tingling of the arm, shoulder or hand” het ‘n statisties beduidende verbetering getoon (p=0.02). Elemente wat “Deelname” behels, sluit in ‘n beduidende verksil in ontspannings aktiwiteite wat min inspanning verlang” (p=0.01); aktiwiteite waar die arm nie meer vrylik kan beweeg (p<0.01); die bestuur van vervoer behoeftes( “managing transportation needs”) (p=0.01) en seksuele aktiwiteite (p=0.01). Deelnemers met Lae Rugpyn (N=11) het ‘n statisties beduidende verskil rapporteer in die voor-en na-toetse vir die deelname afdeling: “Socialising and Travel” (p=0.04). Geen beduinde verskille is in die aktiwiteit en inkorting afdeling. Deelnemers met Artritis en Beroertes het geen beduidende verskille rapporteer nie. Dit mag wel wees as gevolg van die lae aantal deelnemers wie teruggekom het vir die her-toetsing. Terwyl daar was ook ‘n statisties-beduidende verskil en voor-en na toetsing is vir pyn/ongemak sowel as angs/depressie was, was daar geen beduidende verbetering in aktiwiteite nie. Deelname is nie hier getoets nie. Die resultate vir diagnosties-spesifieke instrumente het eerder anders gewys. Daar was ook ‘n statisties beduidende verbetering in belangrike aktiwiteite wat mobiliteit en self-sorg ingesluit het. Deelnemers met boonste ledemaat beserings het ‘n algemene statisties beduidende verbetering getoon. Deelnemers met lae rugpyn het ‘n statisties beduidende verskil in voor-en na toete vir deelname rapporteur. Geen statisties beduidende verandering was rapporteur in die aktiwiteit en liggaamsfunksie en struktuur in hierdie groep nie. Deelnemers met artritis en beroerte het geen statisties beduidende verskille in voor-en na-toetse gerapporteer nie. Dit kan moontlik toegeskryf word aan die beperkte getalle deelnemers wat her-toets is. Afsluiting Die resultate toon beduidende verandering in mobiliteit in pasiënte met onderste ledemaar beserings sowel as lae rugpyn wie fisiese rehabilitasie ondergaan. Positiveiwe veranderinge het gebeur in aktiwiteitsvlakke vir pasiënte met boonste ledemaat beserings sowel as diegene met lower limb injuries. Interessant is die beduidende veranderinge in pasiënte se se pynvlakke en geestesgesondheid. Deelname in hul lewensrolle is verbeter. Meer in-diepte studies word aanbeveel om te bepaal watter behandeling die beste uitkomste bied. Aanbevelings Die algehele gebruik van uitkomste-gebasseerde instrument op primêre gesondheidsvlak word sterk aanbeveel. Dit sal die ontwikkeling en lewering van rehabilitasie dienste versterk. Aanbevelings sal verder gebruik word om bestuur in diegene verantwoordelik vir beleidformuleing in te lig rondom ‘n uitkoms-gebasseerde diens. Die versterking van navorsing soon identifiseer in die beperkinge van die studie word ook aanbeveel.

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