The aim of the piece of work is to define sexuality first. It will then appraise the different models of sexuality. The Ex PLISSIT model will be used in a case study of Lynda. And finally the discussion will focus on the advantages and the limitations of using the model.
Sexuality is a dynamic process and is the right of all individual (Sakellariou & Algado, 2006). Sexuality is not just about “having sex” but includes making relationships, self esteem (persons’ view of their body image), tactile expressions and need for intimacy and closeness which are not only important in the life of disabled but also for the general population (Wells 2002 and Barnes & Ward 2005). Sexuality as a part of holistic care has been advocated by several authors (Wells 2002 for palliative care patients, Sakellariou & Algado 2006, Summerville and McKenna 1998, Couldick 1998 &1999, Northcodd and Chard 2000, Kingsley and Molineux 2000 for the Occupational Therapists and Davis & Taylor 2006). The therapy and the nursing professions are still ambiguous about the issue of addressing client sexuality (Watson 1991 and Couldrick 1998). Hence sex and sexuality is the most ignored and least discussed of disability issues, Barnes et al (2005). However the intervention models which can be used in sexuality were discussed by few authors (Annon 1976, Davis & Taylor 2006 and Taylor & Davis 2006). The PLISSIT model was being suggested as a model of sexuality first (Annon 1976). Irwin (1997) described the PLISSIT model as meta- model due to its informative- educative emphasis. The acronym PLISSIT signifies:
Stage 1: “P”- Permission giving.
Stage 2: “LI”- Limited Information.
Stage 3: “SS”- Specific Suggestions.
Stage 4: “IT”- Intensive Therapy.
The model gave a framework for intervention to healthcare professionals to address sexuality (Davis & Taylor 2006). The model asks for sequential application of the stages which can be viewed as its limitation. Also the other limitations of the model can be argued as the lack of research using the model and its individualistic nature (Irwin, 1997). Davis & Taylor (2006) argued against such a linear format and discussed the “permission giving” process in the model to be very ambiguous and implicit. Davis & Taylor (2006) critiqued further by arguing PLISSIT as a one way interaction model which gives ample scope for assumption for the healthcare professionals. Considering the limitations of PLISSIT model the alternate the Extended PLISSIT (Ex PLISSIT) model was proposed by Davis & Taylor (2006). It addresses some of the limitations of the PLISSIT model as “Permission giving” is more explicit and also the model does not follow a linear format. The model emphasises the need to reflect and review at all stages. Ex PLISSIT model was proposed by Davis & Taylor (2006) as an interactive and dynamic model to address concerns of client sexuality. The use of model can be understood by an example.
Lynda was referred to the Occupational Therapy department (Appendix). The Occupational Therapist (OT) saw Lynda in the Outpatient Clinic. In the first appointment, the OT completed the physical assessment which also included hand assessment. The appointment also included educating Lynda about Rheumatoid Arthritis and also how the condition affects sexuality of clients, i.e... The OT discussed sexuality in context (Davis & Taylor, 2006). The context can be seen as during the educational session. The OT also included in the discussion the affect of Disease Modifying Anti Rheumatoid Drug (i.e. Methotraxate) on sexuality. The educational session can be seen as “Permission giving” Lynda to talk about her sexuality and relationships. At first Lynda was in tears and she said to the OT that she fears her relationship with her partner (John) may break-up, due to her condition. The OT at this stage provided Lynda “Limited Information” by issuing leaflets on Sexuality and Arthritis. This was done in order to reinforce the discussion and also to help Lynda to empower John. The clinic room was an isolated single room which provided Lynda the privacy for the discussion. Davis & Taylor (2006) discussed the need of privacy while discussing sexuality with clients.
Lynda was back for her follow up appointment in two weeks. The OT “reviewed” by asking Lynda if the leaflets had all the information and if there were further issues in her relationship that she would like to discuss. This can be seen as further “Permission Giving” Lynda to discuss her sexuality issues. At this point, Lynda mentioned some of the positions to be particularly painful during sexual activity. The OT explained Lynda that experiencing pain during sexual activity is not unusual for the condition. This can be viewed as “Normalising patient experience” by the OT (Davis & Taylor 2006).The OT than provided “Specific Suggestion” by discussing alternative positions during sexual activity. On “reflection” the OT felt a referral to General Practitioner (GP) may be appropriate. After getting Lynda’s consent a letter was sent to GP for review of pain medications.
When Lynda came to see her OT for her fourth week appointment, the OT “reviewed” by asking if she has seen her GP prior to this appointment. The OT explained the aim of GP referral was to give her adequate pain relief which in turn would help during sexual activity. This can also be seen as further “Permission Giving” Lynda to talk about sexual issues. Lynda then reported that the GP saw her and asked her to take pain medications not more than three times in a day. She also reported that the GP changed some of the pain medications she was taking. Lynda confirms further that with the change of medications her pain and stiffness is better controlled yet the sexual activity not completely pain free. On “reflection” the OT thought Lynda might benefit from continued suggestions. The OT contacted the GP and on her advice, provided Lynda with “specific suggestion” further. The OT advised Lynda to take one of her pain medication dose at night, two hours before going to bed.
Lynda then came with John, for her eight week therapy appointment. The OT “reviewed” Lynda’s progress by asking if having her pain medication at night is helping her. This can also be seen as OT giving further permission to both Lynda and John. Lynda report she feels better yet anxious that the pain and stiffness will come back. John too sounded anxious about Lynda’s pain. The OT on “reflection” thought anxiety to be the issue for Lynda and John. Hence felt at the stage that Lynda will benefit from “Intensive Therapy”. The OT identified that probably for Lynda and John, Lynda’s altered “body image” in future was the concern. Hence discussed with them how they would feel if a referral is sent to a Clinical Psychologist. This can also be viewed as a part of “strategy development” by the OT to help Lynda, for future. Lynda and John agreed to it. In the end, Lynda felt without the help of the team she would have been in lot of pain and discomfort, which could even have affected her relationship with John.
It is noteworthy to recognise that there could have been a situation when Lynda might have refused to discuss her sexuality concerns with the OT. The key than would have been to leave all “channels of communication open” (Davis & Taylor, 2006). The OT in that situation could have said that I am providing you with some of the information on the affect of arthritis on sexuality. In future if you change your mind you can come back and discuss any issues of concern (in sexuality) with me. By doing so the OT not only ensured that the intervention was client centred but also left all channels of communication open, for future.
-In my opinion, the advantages of the Ex PLISSIT model can be seen as its non prescriptive nature, highly flexible to use and being holistic in sexual care. Reflections and reviews at each of the stages helps and permission giving being paramount.
-However the limitations of the model can be seen as its application could be too repetitive and time consuming. The model puts high expectation on individual practitioner and also it needs further research to be established.
Conclusion
This article has critically discussed the need to address clients’ sexual needs by the healthcare professionals. The PLISSIT and Ex PLISSIT models can be used to address concern areas in sexuality. The essay used the Ex PLISSIT model in a case of Lynda. The sexuality models although discussed in relation to Occupational Therapy can however be used by other healthcare professionals in practice. The discussion ended by considering the advantages and limitations of using the model.
References:
-Annon J (1976): The PLISSIT model: a proposed conceptual scheme for the behavioural treatment of sexual problems. Journal of Sex Education Therapy 2, 1-15.
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-Davis S and Taylor B (2006): From PLISSIT to ExPLISSIT, In: Davis S (Ed.). Rehabilitation: The use of Theories and Models in Practice, Edinburgh: Churchill Livingstone, Chapter6.
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Appendix: A case of Lynda
Lynda, 35 years female, was referred to Outpatient Rheumatology OT following recent diagnosis of Rheumatoid Arthritis, by the Rheumatology registrar. Her problems included pain during her daily activities and early morning joint stiffness. She was started on Disease Modifying Anti Rheumatoid Drugs (DMARD) and pain killers. She recently has been living with her new partner (John) after she had a relationship of 5 years with her ex boyfriend. Coincidently the diagnosis of her disease was following her split. She was anxious that due to her condition she might have another unsuccessful relationship and wanted help from healthcare professionals.
“Preventive measures are less expensive than the restorative measures” (Clark 1992, Friedland et al 2001, Hajnal 1997, Sheiham 1992).
Introduction
The article will define health promotion first and than will look into upstream thinking. The importance of health education in health promotion, along with different types of health promotions will be discussed. Health promotion on a wider perspective will be explored and will be related to rehabilitation. Finally the article will discuss change of health behaviour using health promotion model. The aim is to gain understanding of health promotion for the rehabilitation professional in order to incorporate them into rehabilitation practice.
An analogy of upstream thinking.
McKinlay(1979) analogy of a man standing by a fast flowing river who spent his time jumping in and pulling out people who were drowning. The task of jumping in, pulling them to the shore and applying artificial respiration was so demanding of his resources that he had no time to go upstream to prevent them falling (or being pushed in the river). The story introduced the notion of refocusing upstream and of upstream planning and action.
Defining Health Promotion
Health promotion can be described as the process of enabling people to increase control over and to improve their health (WHO, Ottawa Charter 1986).Ennis et al (2006) describe health promotion activities as behavioural, cognitive and emotional endeavour to promote health and well being of people. It is a multidisciplinary endeavour taken up in diverse setting (Scriven et al, 2004).
Education in Health Promotion: Primary Health Promotion activity
Enabling people by empowerment was emphasised as being a part of health promotion process (Gottwald, 2006). In a systematic review, McDonald et al (2004) found in nine studies involving 782 participants from a pool of 17 potentially eligible studies, the evidence that preoperative education prior to hip and knee replacements, reduces anxiety. The review included only randomised studies which could be seen as its limitation, as inclusion of other rigorously completed studies could have increased the sample size. But empowering people by education is not just health promotion (Davis, 1995 and Gottwald, 2006). In a randomised controlled trial Ennis et al (2006), found health promotion education for multiple sclerosis to be effective in increasing level of health promotion activity undertaken by patients, confidence and belief in ability to undertake health promotion activity as well as certain domains of quality of life. Although the limitation of the study can be seen in its sample size, as it was completed on sixty two adult multiple sclerosis patients. In another randomised controlled trial, Almomani et al (2006) found in a treatment group of twenty patients that dental hygiene instructions along with dental education and a mechanical toothbrush, had a positive effect. The control group was provided with mechanical toothbrushes, in a cohort of fifty mentally ill patients which included schizophrenics, bipolar disorders and other mentally ill clients. The generalisation of the result however can be argued as patients were only followed up once in four weeks and that the study was completed with fifty patients. However the two studies highlight the importance of education in health promotion. But health promotion is not just empowering people by education (Davis 1995 and Gottwald 2006). It is a much broader concept.
Scriven et al (2004) described “Primary health promotion activities” as upstream activities that target the well population. The goal is to prevent illness and disability by health education (targeting lifestyle and behavioural change) and/ legislation (Such as the smoking policies).
Health Promotion: A wider perspective
Davis (1995) in a qualitative study identified that nurses use health promotion and health education in neuro rehabilitation. The research resulted in the development of a model in which policy making, social and physical environment were all considered as health promotion activities. Empowering patients and working with them to make them independent (clients being the co manager of their conditions) was considered as health education. The study was completed rigorously although the ethical considerations and the data analysis could have been more explicit.
Health promotion includes wider perspective like consideration of social environment, preventive health service, community based work, public health policies, environmental health policies, organisation development, economic and regulatory activities (Gottwald , 2006). Scriven et al (2004) described “Secondary health promotion” is directed at individuals or groups in order to change health damaging habits and/ or to prevent ill health moving to a chronic or irreversible stage and where possible to restore people to their former state of health and/ or community development approaches that encourage structural and environmental changes. The “Tertiary health promotion” takes place with individuals who have chronic conditions and /or are disabled and is concerned with making the most of the potential for healthy living (Scriven et al 2004). These might include client centred approaches, such as those used in rehabilitation, or the management of chronic disease programmes. The therapists currently in United Kingdom (UK) work as the secondary or the tertiary health promoters and hence the emphasis is to work as the primary health promoter, yet that would need a paradigm shift altogether (Scriven et al, 2004).
Health promotion in Orthopaedic or surgical Occupational Therapy Practice
Occupational Therapists see patients in the pre-admission clinics or do pre-operative home visits, before they come in for total hip replacement surgeries. These activities can be seen as “Primary Health Promotion” as the aim is to prevent post operative complications (Most common of which is the hip dislocation). The assessment and intervention includes discussing/ assessing home situations, assessing baseline functioning, providing equipment to assist in ADLs, problem solving patient issues (addressing anxiety of the surgery), addressing sexuality issues for the post operative period and also referring to the other multidisciplinary team members. These activities can be clustered as primary health promotion activities as the aim is to prevent illness or disability.
Therapists see amputee patients immediately post operatively. The empowering process post operatively can be viewed as primary health promotion as it helps patients’ to be better compliant for the forthcoming therapy and helps them to accept their disability, although this can be argued as tertiary health promotion as interventions are following disability caused.
The Occupational Therapists see patients following hip/ knee replacements in hospital wards. They address their home situation, discuss precautions with the operation, assess home environment, check mobility and transfers following the surgery and refer patients to the community team for follow up. These activities can be clustered as “secondary health promotion”, as the aim is early detection of problems and to address them in order to prevent future disability. However therapists in hospitals/ community who work with patients with recurrent hip dislocations can be viewed as “tertiary health promotion”, in the area of practice. Hence Occupational Therapists in order to promote upstream thinking should assess patients pre-operatively. This does not necessarily rule out the need of Occupational Therapists in the wards, but Physiotherapists can contribute to secondary health promotion, in the area of practice. However the roles of Occupational Therapists and the Physiotherapists are indispensable in order to manage trauma patients (admitted following dislocations) for tertiary health promotion.
When rehabilitating the amputees, adapting the home environment and prosthetic rehabilitation can all be viewed as tertiary level health promotion (as the patient is permanently disabled following amputation). Empowering amputees from time and regularly following them up in outpatient/ community can also be seen as secondary health promotion activities. Hence for amputees the process of empowering, environmental adaptations, prosthetic rehabilitation and regular follow up, contributes to health promotion.
Understanding Health Promotion in Rehabilitation: An Overview.
Apart from education, other examples of preventive health service or community based work which can be viewed as upstream working by therapists, can be extrapolated from the rehabilitation of elderly patients in the General Practitioners’ surgery. Time up and Go test (TUG) is an outcome tool for falls assessment in rehabilitation. In a pilot study, Dinan et al (2006) found of the two hundred and forty two patients referred for exercise classes at the GPs surgery, one hundred seventy eight completed cycles of classes. The TUG scores were obtained at the baseline and at follow up. TUG values showed reduced risk of fall for these individuals in the community implicating beneficial effect of the exercises although the sample had more females than male adults. In a randomised controlled trial, Rosendahl et al (2006) found similar positive long term effect of high intensity functional exercise programme in balance, gait ability and lower limb strength for older people dependent in activities of daily living (ADL). Another example of community based work and health promotion is the motivation to volunteer. Black et al (2004) found volunteering to have beneficial effect in mental wellbeing of the elderly population. In an Adult Health Development Program (AHDP), when students from various disciplines (including nursing students) were being paired up with adults to engage in several health promotional activities, it was found to have beneficial effect (bi directional). The activities included health education hour, low impact exercise group, swimming and water aerobics, weight training, trampolining, billiards, Tai chi, walking, three wheel biking, dancing, parties, celebrations and socialising with friends. This was termed as Transgenerational Health Promotion by Watson et al (2000), as students learnt about the ageing process and the program helped to improve health and wellbeing of the adults. This can be viewed as another form of community working in order to promote health and wellbeing. Health promotion in rehabilitation can also be understood by group work called “Problem based rehabilitation”. It is an active group work where the group members discusses and facilitates by problem solving and by providing psychosocial support for each other. Medin et al (2004) in a case study with disabled people on long term sick leave from work found problem based rehabilitation to have positive effect to help people return to work and also to improve self esteem, without making any generalisation of the finding.
Thus health promotion and rehabilitation are linked very intricately. Change of models of health promotion.
Health behaviour change using health promotion model.
Health behaviour change was defined as “the shift from risky behaviors to the initiation and maintenance of healthy behaviors and functional activities and the self management of chronic health conditions” (Nieuwenhuijsen et al 2006). Health promotion can be achieved by understanding individual “locus of control”. The Locus of control affects a person’s behaviour which could be internal or external (McPherson, 2001). People with internal locus of control usually are self motivated and are capable of making independent decisions. However people with external locus of control are reliant on others to take decisions on their behalf. They are easily influenced by other people. Gottwald (2006), reports people with internal locus of control usually are motivated hence their behaviour change happens early. They are less likely to come out of the cycle when undergoing change of behaviour in the stages of change (Prochaska and DiClemente, 1982) model. The stages include PreContemplation (No intention to change)?Contemplation (Thinks about changing) ?Commitment (Determined to change behaviour) ? Action/ Maintenance (Person finds it difficult but changes behaviour)? Relapse (Person goes back to previous behaviour).This is considered healthcare professionals responsibility to help get them back in the cycle by working as a team with patients’ and their family. Gottwald (2006) reports a person may come out of the cycle few times before being able to complete the cycle. Nieuwenhuijsen et al 2006, report an understanding of a person’s environment (social environment or the work place environment), health models and personal factors are all essential to bring about health behaviour change. Five themes were being identified in relation to health promotion from the literature. The themes were: 1) Preventive aspect of health behaviour (Prevention against primary disease), 2) Early detection behaviour (includes early detection of a condition), 3) Self management of condition. Usually applies for chronic conditions, 4) Treatment adherence or being compliant to treatment, 5) Behaviour of health care providers. Nieuwenhuijsen et al 2006 and Beattie’s 1991, emphasised the need for client centred practice/ or client led practice and argues that a bottom up approach (Negotiation mode of intervention) is preferred to a top down approach (Authoritive mode of intervention), as the former is patient lead. The bottom up approach in health promotion is hence called “client led or client centred approach”.
Nieuwenhuijsen et al 2006, argues that the health promotion models however lacks adequate address of disability issues and also for its more uniform application needs to be based on comprehensive framework like the International Classification Of Functions (ICF).
Conclusion
The article has discussed the different types of health promotion used in rehabilitation. The aims of health promotion were then related to an area of practice. Health promotion and change of behaviour was discussed using the Stages of Change Model (Prochaska & DiClemente, 1982).It can be said that health promotion and rehabilitation have similar aims, as the emphasis of both is to give clients the control to decide for their own health. Healthcare professionals are the facilitators in the process and that the change of behaviour is only achieved better, if a client centred approach is used in interventions. The shift of emphasis is now recognised from professional directed to client led.
Reference:
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Your intervention has been exercise based. Now at 6 weeks following initial presentation, Allex has attended only 3 of 8 scheduled visits (the first, third and seventh) and he is often late when he arrives, which causes disruption to your schedule and waits for your following clients. When he does attend, he often repeats the same information to you about the changes he has had to make in his lifestyle since his original injury, and the activities he has had to give up. He continues to complain that he is experiencing pain though he did recently attempt some running again as the weather was nice and he wanted to be outside, but this increased his pain significantly. He feels that his headaches may be slightly less frequent, though wonders if this is more related to a decreased work load stress rather than your intervention. He reports that the exercises you have prescribed are difficult to do at the suggested frequency due to his busy schedule. The referring physician has asked that you contact her to discuss Allex's progress and your recommendations at this point.
Considering the above information, what factors do you feel are influencing Allex’s engagement in the programme? How would you progress in your approach to Allex?
Within the case study the problems Allex demonstrates following the road traffic accident will be explored as well as strategies that could help him to cope with his chronic disability will be identified. Prior to the accident Allex was a very active man. The study will briefly look at his attitude towards the therapy sessions and the possible reasons influencing his engagement in those sessions. A multidisciplinary approach will be examined that could possibly help to improve Allex’s engagement in the therapy sessions.
Health care professionals use the interpretive model of clinical reasoning in practice as cause and effect phenomenon are not always appropriate when analysing human behaviour (Higgs et al, 1995). The clinical reasoning process requires the clinician to have a sound knowledge base, cognition, meta-cognition, a better understanding of the patient’s perspective of his/her problem, the complexity of the clinical problem as such and the context of the problem (Higgs et al, 1995).Benner (1984), reports experts do not always follow rules but use their intuition and previous experience when taking complex decisions. In the case study a combination of different Interpretive reasoning i.e.. Procedural, Conditional and Interactive reasoning will be used.
Allex’s poor attendance to his scheduled visits to clinic regularly can be considered as symptomatic of his low motivational level. He does not perceive much incentive in changing his present behaviour, Health Belief Model (see Appendix 1) probably because he feels that there is no solution to his suffering and his resultant disability. He seems to be in the Pre contemplation stage in Transtheoretical stages of change behaviour (consisting of five stages, Prochaska, Diclemente and Norcross cited by Ogden, 2000).Allex lacks self efficacy probably due to his suffering for a long time and hence lacks any positive outcome expectancy from therapy sessions which might explain his low motivation towards attending the therapy sessions. And as he lacks determination and will to change, this affects his action plan and action control towards positive outcome. Allex’s family probably is not very supportive and Allex very frequently feels depressed due his inability to participate in social activities as a result of his disability. This further demotivates Alex in any of his endeavour towards positive behavioural change, Health Action Process Approach (See Appendix 2).
So going back, the challenge is to help Allex progress to the Contemplation stage (Transtheoretical stages of change behaviour) next and to work from there but keeping a ‘client centred approach’ (ethical principle of ‘Autonomy’) and interventions aiming to help Allex (ethical principle of ‘Beneficence’) i.e..to teach him coping strategies for him to be able to self manage his problems. The transition can be made easier for Allex by reassuring him that he has the right to have his problems heard and attended to individually (ethical principle of ‘Confidentiality and Justice’) by the health care professionals.
Bury (2004) described patients with chronic conditions as ‘Expert Patients’. Chronic conditions however result in loss of self identity/partial identity transformation in sufferers (Asbring, 2000). The diagnosis of a chronic condition and subsequently living with the effects causes major disruption in individuals’ lives. Bury (1982), introduced the term “Biographical disruption” which means life transition, in his work with arthritic patients. Similar disruptions were seen in Chronic Fatigue Syndrome (CFS) and Fibromyalgia patients (Asbring, 2000).Allex’s life transition is due to his long standing pain, headache, decreased function and social impairment. He therefore struggled to get into any biographical flow and continuity in his life (Faircloth et al, 2004). ‘His often repetition of the same information about the changes….(See Appendix A)’– are all reflections of Martin’s Biographical disruptions.
Allex lacks motivation towards therapy sessions due to his past experience (as he had physiotherapy following his injury which did not work), his pain, and his anxiety and depression, Schon (1983), describes ‘reflection in action’ which means the critical appraisal process is undertaken by a clinician when doing data collection or treating a patient, but it can be argued that diagnostic reasoning is sometimes following pattern recognition/ illness scripts (Donaghy et al, 2000),Allex’s often repetition of the same information about the changes he has had to make in his lifestyle since his original injury reflects his depressed state of mind (which further contributes to his lowered motivation towards the therapy sessions), Allex’s self perception and his social issues.
To help Allex, health care professionals can use Principles of Motivational Interviewing (Wagner, 2004) by sharing their own understanding with him of how he feels and also create an environment in which Allex will be able to express his thoughts and feelings adequately, which in turn will help to develop that relationship of trust and understanding. Facilitating a calm and supportive discussion even when Allex is defensive will help Allex to feel that he is understood and accepted. Gradual and cautious attempts than to explore differences in behaviour followed by collaborative working will help to set some achievable goals with Allex, e.g.. probably agreeing with Allex to do exercises only once a day to start with. When Allex has reached a point where he can manage the exercises without pain and within his available time, he can make gradual progression to other aspects of his backcare management routines. Spunt et al(1996), even found in their study in spinal patients, that a videodisc program helps when patients are to decide either to go for spinal surgery or to be managed conservatively. This aids in informed decision making keeping a client centred approach. It can however be argued that the study did not individually randomised patients and the results cannot be compared to other form of information i.e.. education by clinicians. But audiovisual cues could be motivating for Allex as he will be able to see how patients with similar conditions benefited from therapy, in the past. This in turn will influence his informed decision making (to attend therapy sessions) in a positive manner.
Due to the multifaceted nature of chronic pain (with its physical and psychological components), its management requires a multi disciplinary approach. However the concept of multidisciplinary team working can be argued as (Cott, 1997) found that teamworking within a ward situation constitutes a hierarchy of teams (multidisciplinary team and a nursing team) with the multidisciplinary team taking decisions and the nursing team implementing those decisions. A multidisciplinary approach will not only help Allex to take more responsibility for himself but also will help him to regain control of his life, and as it is a collaborative approach it will require patience, permission and persistence on all sides (Sofaer, 1998). Contrary to the strict medical model of patient-doctor relationship previously, Bury (2004) discussed partnership in care as a transfer of power in a therapeutic relationship away from the professional and more towards the client, when using a client-centred approach. The client is encouraged to self manage and make decisions relating to their own care. However he argued that there is a lack of evidence for this power transfer when considering the motivation of the client to make their own decisions, and the will of the professional to allow it to happen.
Guzman et al(2001), Van Tulder et al(2000) and Turner (1996) cited by Daykin (2003), found strong evidence that Cognitive Behavioural Therapy (CBT) helps to improve functions in chronic backache patients and moderate evidence that there is an improvement in pain and this impacts overall superior result in back care management. A review of literature by Reneman et al (2006), even identified a biopsychosocial association of backpain in children over and above the biomedical etiology. The review highlighted that carrying backpacks was not the main cause of back pain in the children but other psychosocial factors were involved. These included activities like a) having jobs outside schools, b) watching television, c)playing computer games. Non specific symptoms like tiredness/ abdominal discomforts/ aggressive or violent behaviour and familial history of back pain, all contributed to vulnerability to back pain in children. However it can be argued that as the study was not a Systematic review so the authors were unsure of the methodologies used for the different studies. The chronicity of Allex’s neck pain has made him overly anxious and depressed over a period of time. As a result of his sufferings he developed some negative attitudes and perceptions. Therefore in Allex’s case, an association of psychological issues to physical disability could be argued.
Due to the chronic nature of Allex’s problems, a functional restoration programme using a cognitive behavioural framework might be beneficial instead of relying just on exercise based intervention. The aims and goals of such programmes would be
Goal setting: Siegert et al (2004), reports goal setting in rehabilitation to be a dynamic and collaborative process. Involving Allex and his family in the goal setting process for the therapy sessions might be beneficial. Emmons, added a component of ‘emotion’ to goal setting and as Allex is depressed so setting up initially some pleasurable goals will set the scene for future realistic goals. Allex’s lowered confidence level and impaired social relationship due to his disability affects the goal setting process (Deci and Ryan’s self determination model cited by Siegert et al, 2004). Karniol and Ross emphasised the impact of past experience in present goal setting. Allex’s past physical fitness could be argued as a hurdle for his present realistic goal setting. Barnes and Ward states ideally when doing goal setting, the goals should be SMART (Specific, Measurable, Achievable, Realistic and Time specific) goals. In order to provide objectivity and to be able to measure outcome of interventions, SMART goals with Allex can be agreed upon which could be short term, medium term or long term. Goal setting will eventually increase Allex’s optimal level of activity, will reduce pain behaviour, will help planned gradual increments in activity and reinforcement of achievements’ (Shorland, 1998). However Pain et al (2004), argues that it is not the setting up of short term goals that works effectively all the time, but strategies of anger management as priority sometimes work better, although their work was with a Paratelic motivated athlete. However an association can be seen with young and active individuals who have become recently disabled.Allex’s anger subjectively can be argued due to his pain, his disability and his suffering for a prolonged period which prevents him from doing his job, his leisure activities and probably affects his family life.
Cognitive therapy to identify and modify maladaptive thinking processes and coping strategies (Shorland, 1998). This is achieved by patient education individually or in a group. Goodwin et al(2005), found a positive effect in disabled young people who attended summer camps in a segregated group of disabled youths by: not feeling alone, found new identity of self and also identified new levels of independence although it can be argued that the findings to be applicable to context only as the groups had few non disabled people too (thus was not a segregated group completely). Allex might benefit from attending group sessions with other chronic backpain patients, empowering him with information about his condition and teaching him some of the coping strategies will specifically help him to come out of the stressed situation and to be more compliant with his therapy regimen.
In conclusion,Allex’s inability to engage in therapy sessions can be considered multifactorial when an appropriate clinical reasoning framework is used by healthcare professionals whilst analysing physical and psychosocial issues involving his engagement.Allex’s motivational level affecting his attendance in the therapy sessions is presented with an overview of the biographical disruption/ life transition, he was in. The strategy of motivational interview discussed that could help Allex to be more compliant with his therapy sessions. It is proposed towards the end that a multidisciplinary Cognitive Behavioural Therapy (CBT) approach will not only help Allex to engage in the therapy sessions but also will help him to cope and self manage his problems (especially his chronic pain and functional limitation) better.
References for the case study:
? Asbring P (2000) Chronic illness- a disruption in life: identity –transformation among women with chronic fatigue syndrome and fibromyalgia. Journal of Advanced Nursing. 34 (3), 312-319.
? Becker (1974) cited by Ogden (2000) Health beliefs. Textbook of health Psychology (2nd edition). Open University Press.
? Benner P (1984) From novice to expert.Dreyfus model applied to nursing.28-37.
? Birkholtz M, Aylwin L and Harman RM (2004) Activity Pacing in Chronic Pain Management: One aim, but which method? Part two: National Activity Pacing Survey. British Journal Of Occupational Therapy. 67(11), 481-487.
? Bury M (2004) Researching patient- professional interactions. Journal of Health Services Research & Policy.9 (1), 48-54.
? Cott C (1997) “We decide, you carry it out”. A social network analysis of multidisciplinary long term care teams. Social Sciences Medicine. 45(9), 1411-1421.
? Donaghy ME and Morss K (2000) Guided reflection: A reflection to facilitate and assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and Practice. 16, 3- 14.
? Faircloth CA, Boylstein C, Rittman M, Young ME and Gubrium J (2004) Sudden illness and biographical flow in narratives of stroke recovery. Sociology of health and illness.26(2), 242-261.
? Goodwin DL and Staples K (2005) The meaning of summer camp experience to youths with Disabilities. Adapted Physical Activity Quarterly. 22 (2), 160-78.
? Guzman J, Esmail R et al (2001) cited by Daykin A (2003) Literature review. Unpublished work.
? Higgs J and Jones M (1995) Clinical reasoning. Clinical Reasoning in the
Health Professions. Pp 3-23. Oxford Butterworth-Heinemann.
? Louie SWS (2004) The effects of guided imagery relaxation in people with COPD. Occupational Therapy International.11(3), 145-159.
? McCaffery (1983) Pain Therapies Pain Principles, Practice and Patients (3rd edition). Cheltenham: Stanley Thornes (Publishers) Ltd.
? Pain M and Kerr JH (2004) Extreme risk taker who wants to continue taking part in high risk sports after serious injury. British Journal of Sports Medicine 38, 337-339.
? Prochaska, Diclemente and Norcross cited by Ogden (2000) Health beliefs. Textbook of health Psychology (2nd edition). Open University Press.
? Reneman MF, Poels BJJ, Geertzen JHB and Dijkstra PU (2006) Back pain and backpacks in children: Biomedical or biopsychosocial model? Disability and Rehabilitation.28 (20),1293- 1297.
? Schwarzer cited by Ogden (2000) Health beliefs. Textbook of health Psychology (2nd edition). Open University Press.
? Schon cited by Donaghy ME and Morss K (2000) Guided reflection: A reflection to facilitate and assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and Practice. 16, 3- 14.
? Shorland S (1998) Management of Chronic pain following whiplash injuries. Topical Issues in Pain 2 (1st edition). Cornwall: CNS Press Ltd.
? Siegert RJ and Taylor WJ (2003) Theoretical aspects of goal- setting and motivation in rehabilitation. Disability and rehabilitation.26(1), 1-8.
? Sofaer B (1998) Pain Principles, Practice and Patients (3rd edition). Cheltenham:Stanley Thornes (Publishers) Ltd.
? Spunt BS, Deyo RA, Taylor VM, Leek KM, Goldberg HI and Mulley AG (1996) An interactive videodisc program for low back pain patients Health Education Research Theory & Research 11(4), 535-541.
Wagner C (2004) Motivational Interviewing and Rehabilitation Counseling Practice. Rehabilitation Counseling Bulletin 47(3), 152-161
Appendix 1:
Health Belief model:
-Developed initially by Rosenstock (1966) and further by Becker and colleagues throughout 1970s and 1980.
Core beliefs:
• Susceptibility to illness (example: ‘my chances of getting lung cancer are high’).
• The severity of illness (example: ‘lung cancer is a serious illness’).
• The costs involved in carrying out the behaviour (e.g. ‘stopping smoking will make me irritable’).
• The benefits involved in carrying out the behaviour (e.g.. ‘stopping smoking will save me money).
• Cues to action, which may be internal (e.g.. symptoms of breathlessness) or external (e.g. information in the form of health education leaflets).
So risks/ benefits appraisal and cues to action than result in Health Behaviour (I will stop smoking).
Appendix 2: (Health Action Process Approach).
- Social Cognition model of motivation developed by Schwarzer (1992).
- Stages of HAPA:
a) Decision making/ motivational stage.
Components of it:
? Self efficacy: ‘I am confident that I can stop smoking’.
? Outcome expectancies: ‘Stopping smoking will improve my health’. It has a subset of social outcome expectancies (e.g. ‘Other people want me to quit smoking’).
? Threat appraisal: ‘I will get lung cancer if I continue smoking’.
b) Action/ Maintenance stage.
Components of it:
? Cognitive (Volitional): Shows determination/ person’s will.
a) Action plans: ‘If offered a cigarette when I am trying not to smoke I will imagine what the tar would do to my lungs’.
b) Action control: ‘I can survive being offered a cigarette by reminding myself that I am a non- smoker’.
? Situational factor:
a) Social support: The existence of friends who encourage non- smoking.
b) Absence of situational barrier: The financial support to join an exercise club.
- HAPA bridges the gap between intention and behaviour.
- Criticisms of the HAPA:
Less rational factors like emotions are neglected.
What role do social and environmental factors play?
Do the cognitive states really exists or are created by the theorists?
Jackson & Davies (1995) discussed Trans-disciplinary working yet expressed uncertainty of the extent of its use. Kevin R & Feaver S (2006) reports in healthcare there is an increasing emphasis on interprofessional working- this has become a priority and is now extending to the development of interprofessional education for healthcare professionals at every level, both pre and post qualification.
The point though that I fail to understand is:
When formulating the undergraduate curriculum, does this kind of multidisciplinary teamwork happen at any level?
I shall give couple of examples:
Do we have doctors/ physios/ Nurses/P&O/ Social Worker/Speech and Language Therapists etc involved when formulating an undergraduate Occupational Therapy curriculum? Why is that it is only the College of Occupational Therapy that sets up all the standards and beanchmark of any Occupational Therapy curriculum. Do College of OT get all these group of professionals involved in the consultation process at any level?
Do we have OTs/ doctors/P&O/ Nurses/ Social Worker/ Speech and Language Therapists etc included at any level when finalising a Physiotherapy undergraduate curriculum? Why is that it is only the Chartered Society of Physiotherapists that sets up the standards and benchmark of Physiotherapy curriculum, I meant only Physiotherapists set up a physiotherapy curriculum?
Do we cater for each others expectations when developing our curriculum?
In the end we all are expected to work as a Multidisciplinary team. Do people think setting up our undergraduate curriculum using multidisciplinary approach will have a positive impact in the way we practice? Do professionals think that may raise the profile of our profession.
“Interprofessional Education occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care” (CAIPE 2002).
A Swedish concept well integrated: (Second of its type in UK)
Heard of Interprofessional Wards. Here it is http://www.wandsworth-pct.nhs.uk/about/teachingPCT/projects.asp and than go to “Inter-professional training ward project”. OT students work here with Physios, Nursing and Medical students.
It is the beginning and not the end of the concept of Interprofessional working. I am sure the curriculum's will be looked in a similar way one day.
References:
- Jackson H, Davies M 1995 A transdisciplinary approach to brain injury rehabilitation. British Journal of Therapy and Rehabilitation.
- Kevin R, Sally F 2006 Models- terminology and usefulness. Rehabilitation the use of theories and models in practice, Elsevier Churchill Livingstone, 2006, Pg 49-62.
Subhajit Sengupta.
]]>Neutrotrophic Factors
Neutrotrophic factors regulates the proliferation and differentiation of cells in the Central Nervous System. The Neutrotrophic factors elevated by exercise are- Insulin like Growth Factor (IGF), Fibroblast Growth Factor2 (FGF2) and BDNF. The release and regulation of BDNF is activity dependent whereas release of other neutrotrophic factors like Nerve Growth Factor (NGF), NT3 and NT4 expressions are not activity dependent.
Brain Derieved Neutrotrophic Factor (BDNF)
BDNF secretions are of two types mainly- Regulated (Once synthesised the Neurotrophins are stored in secreatory granules and are released in response to Extracellular cues) and Constitutive (Released spontaneously after being synthesised. So these are continuously available to cells that needs it).
Exercise and BDNF
Exercise induces the expression of BDNF mRNA and protein in cerebral cortex, Cerebellum and Spinal Cord. This is the non invasive paradigm to activate the plastic potential of injured CNS by employing BDNF and similar trophic support factor. Exercise improves cognitive abilities. Animals who learned fastest and had best recall had highest BDNF levels. BDNF improves learning, memory tasks and long term potentiatiation (LTP). BDNF plays role in consolidating Short Term Memory to Long term memory. Other Neutrotrophic factors like NGF/ NT3 doesnot seen to have similar effect. Most of the BDNF researches are on rats or other animals. Chronic delievary of BDNF in human patients is difficult as it is unable to cross the blood brain barrier and also infusing it in human brain will be too invasive. Hence the importance of exercise in Neurorehabilitation Therapy.
BDNF and Protein regulation
BDNF increases the Transcriptional Regulator cAMP response element binding protein (CREB). CREB activates de NOVO transcription and translation of inducible transcription factors such as cFOS and JUN, which results in more persistent expression of target gene. CREB disruption has resulted in memory impairement in Drosophila and mice. Animals with highest BDNF expression had the highest CREB expression and the best memory recall. BDNF regulates syneptic protein called SYNAPSIN I. Inhibiting Synapsin I reduces both the synaptic vesicle reserve pool and Neurotransmitter release . Blocking the action of BDNF produces synaptic fatigue and decreased SYNAPSIN I levels. In epileptics clinical study found genetic mutation in Synapsin I gene to be associated with learning difficulties. Synapsin I functions by: regulating neurite development, formation and maintenance of pre synaptic structures, axonal elongation and new synaptic formation.
Exercise and brain
Exercise has therapeutic effect on injured brain by:
Exercise therapy may be beneficial for people who had sustained TIA and have a high disposition to experience secondary insult. In animal research it is seen that use of exercise immediately following traumatic brain injury can exaggerate the extent of ischaemia/ Traumatic Brain Injury (TBI). It has been seen that post injury cellular ATP availability is low. Exercise increases the energy demand of various brain parts like hippocampus, motor cortex and the striatum, hence the likelihood that physical activity during energetically compromised time may accelerate cellular dysfunction. When exercise is delayed by about 14 days post injury, it enhances BDNF and cognitive function.
BDNF and Synapses
BDNF improves synaptic function and Neurite outgrowth in Spinal Cord and innervated skeletal muscle. BDNF localizes to synaptic vesicles in dorsal horn and modulates sensory input within the spinal cord.
Conclusion
It is seen that repetitive loading of hind limb during running produces increase in BDNF levels. Exercise should be considered as an important tool capable of improving overall neural health and cognitive ability and particularly as a regimen that can sustain cognitive functions throughout one’s lifetime.
Limitation of the studies
Most of the BDNF related studies are on animals and correlations were made to human nervous system.
References:
Subhajit Sengupta MSc(Trainee), PGDDRM, BSc (OT)
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