Dawn Verna Ernstzen

Clinical practice guidelines for the management of chronic musculoskeletal pain in primary healthcare: a systematic review

BackgroundUp-to-date, high quality, evidence-based clinical practice guidelines (CPGs) that are applicable for primary healthcare are vital to optimize services for the population with chronic musculoskeletal pain (CMSP). The study aimed to systematically identify and appraise the available evidence-based CPGs for the management of CMSP in adults presenting in primary healthcare settings.MethodsA systematic review was conducted. Twelve guideline clearinghouses and six electronic databases were searched for eligible CPGs published between the years 2000 and May 2015. CPGs meeting the inclusion criteria were appraised by three reviewers using the Appraisal of Guidelines Research and Evaluation (AGREE) II.ResultsOf the 1082 records identified, 34 were eligible, and 12 CPGs were included based on the inclusion and exclusion criteria. The methodological rigor of CPG development was highly variable, and the median domain score was 66%. The median score for stakeholder involvement was 64%. The lowest median score was obtained for the domain applicability (48%). There was inconsistent use of frameworks to aggregate the level of evidence and the strength of the recommendation in the included CPGs. The scope and content of the included CPGs focussed on opioid prescription.ConclusionNumerous CPGs that are applicable for the primary healthcare of CMSP exists, varying in their scope and methodological quality. This study highlights specific elements to enhance the development and reporting of CPGs, which may play a role in the uptake of guidelines into clinical practice. These elements include enhanced reporting of methodological aspects, the use of frameworks to enhance decision making processes, the inclusion of patient preferences and values, and the consideration of factors influencing applicability of recommendations.Trial registrationPROSPERO CRD42015022098.

The effectiveness of low-level laser therapy on pain, self-reported hand function, and grip strength compared to placebo or “sham” treatment for adults with carpal tunnel syndrome: A systematic review

ABSTRACT Background: Carpal tunnel syndrome (CTS) is one of the most common peripheral neuropathies in the upper extremity. Objective: The aim of this review was to systematically and critically appraise the available literature for the effectiveness of Low-Level Laser Therapy (LLLT) on pain, self-reported hand function, and grip strength compared to placebo treatment in adults with CTS. Methodology: Seven databases were searched from 2000 to March 2015 namely: Cinahl, Cochrane Library, EBSCOhost, PEDro, PubMed, Science Direct, and Scopus. Key search terms were: CTS, LLLT, and physiotherapy. Specific inclusion and exclusion criteria were applied. The methodological quality was appraised with the PEDro scale. Data were extracted and captured on an Excel spreadsheet. Results: The nine included randomized control trials (RCTs) had an average score of 8.2/11 according to the PEDro scale. The heterogeneity of the LLLT regimes used made statistical pooling inappropriate for this review and results were described narratively. Conclusion: No strong evidence exists concerning the effects of LLLT on CTS in adults. Studies that used 780–860 nm Lasers and energy dosages of 9–11 J/cm2 or 10.8 J reported a more favorable outcome for pain, symptom severity, and functional ability as well as grip strength at the end of treatment and short-term follow up.

Building capacity in primary care rehabilitation clinical practice guidelines: a South African initiative

BackgroundThe large number of South Africans with disability who cannot access good quality rehabilitation presents a public health and human rights challenge. A cost-effective, efficient approach is required to address this. Implementation of high-quality, contextually relevant clinical practice guidelines (CPGs) could be a solution; however, this requires significant investment in innovative capacity-building.MethodsA qualitative descriptive national study was conducted to explore the perspectives of South African stakeholders in rehabilitation, regarding CPG capacity-building. Twenty rehabilitation professionals (physiotherapists, occupational therapists, speech language therapists, podiatrists, rehabilitation managers or directors) were interviewed. Transcribed interview data were analysed using a deductive content analysis approach, mapping findings to an international capacity-building framework to produce new knowledge.ResultsCapacity-building is required in content, purpose and construction of locally relevant CPGs, as well as personal, workforce and systems capacity. Principles and strategies were derived to underpin implementation of CPGs that are user friendly, context specific, relevant to the needs of end-users, and achievable within available resources. Collaboration, networks and communication are required at national, provincial and regional level, within and between sectors. A central agency for CPG methods, writing, implementation and evaluation is indicated.ConclusionSouth African rehabilitation can benefit from a multi-level CPG capacity-building focusing on performance, personal, workforce and systems issues.

Physiotherapy students’ perceptions of the dual role of the clinical educator as mentor and assessor: Influence on the teaching–learning relationship

Background Clinical education is widely considered to be the cornerstone of health care professionals’ education. Clinical educators (CEs) fulfil many roles and act as both mentors and assessors in the learning process of students’ undergraduate health care professions education. However, changing from being a mentor to being an assessor may present particular challenges for both the CE and the students. Objective To explore students’ perceptions of how the dual role of a CE as mentor and assessor influenced the teaching–learning (T-L) relationship. Method A qualitative descriptive study, involving seven individual semi-structured interviews and two focus group discussions, was conducted with students in the Division of Physiotherapy, Stellenbosch University. A contextualised interpretive content analysis was used to analyse the data. By following an iterative process, themes were identified and categories were reviewed and refined. Results Challenges were experienced when CEs had to act and change as both mentors and assessors to the needs of the students. This influenced the T-L relationship and consequently impacted the learning of students. The expectations of students and CEs were often not fulfilled. Contradictions were disclosed regarding the dual role of CEs. Conclusion The findings of the study, grounded in the perceptions and experiences of students on the dual role of the CE, are highlighted. It is important to consider the challenges that the students face in order to minimise any negative effects these challenges could have on students’ learning processes.

Patient perspectives about the healthcare of chronic musculoskeletal pain : three patient cases

Background Consideration of the patient’s perspective in healthcare is important because it may inform holistic and contextually relevant management strategies. Objectives The purpose of this study was to explore patients’ experiences and perspectives about their chronic musculoskeletal (CMSK) pain and its management in the private healthcare sector in South Africa. This work was done as a pilot study to test, adapt and finalize an interview schedule. Methods A descriptive, qualitative study was conducted. The sampling was purposive. Three patients with CMSK pain were recruited to participate in in-depth individual interviews. The interviews were recorded and transcribed ensuring confidentiality. Inductive, thematic content analyses of the transcripts were undertaken. Initial codes were assigned and a code book developed, which was applied to the transcripts to develop categories and themes. Results Four themes emerged from the data: (1) the participants sought understanding about the pain’s origin and the reason for pain persistence; (2) pain impacted their lives in multiple ways; (3) the participants depended on healthcare providers (HCP) for guidance and support; and (4) they had the option of acceptance of chronic pain. Conclusion The participants’ knowledge about their health condition had important implications as it influenced their perspectives on pain and its management. The pain presented the participants with several challenges, which included developing an understanding about pain and coping with the impact of pain in their lives. HCPs were perceived to play an important role in empowering or disempowering the participants.

Physiotherapy students' perceptions about the learning opportunities included in an introductory clinical module : supplement 1 - research

Background. Clinical education forms a core component of physiotherapy training. However, the transition from the classroom to clinical learning environments can be challenging. An introductory clinical placement with appropriate learning opportunities is therefore important to ensure that learning outcomes are reached. Objectives. To determine second-year physiotherapy students’ perceptions about the learning opportunities provided in an introductory clinical module and to determine their perception about the attainment of the learning outcomes. Methods. A descriptive case study was undertaken, using mixed methodology. All 39 second-year physiotherapy students were invited to participate. Data were collected using a self-developed questionnaire which focused on the outcomes of the module and the perceived value of the learning opportunities. A focus group discussion was conducted with a random subset (n=15) of the population. Results. The response rate to the questionnaire was 79% (n=31). Peer learning by observing senior students, demonstrations by clinical lecturers and the assessment of specific skills were perceived by students to be particularly useful. However, several learning opportunities did not contribute effectively to learning. Participants highlighted a transitional process between classroom and clinical environments during which they became aware and could respond mentally to the demands of a clinical placement. Conclusions. The clinical education introductory module provided valuable opportunities, where students learnt productively in a non-threatening learning environment. Junior students linked theoretical and practical concepts to clinical implementation. Peer mentoring and progressive mastering were valuable learning strategies. Reflection and students’ emotional adjustment to clinical practice are topics for further investigation.