MOVING TOWARD AND ACCESSING ADULT-ORIENTED REHABILITATION THERAPY SERVICES FOR ADULTS WITH LIFELONG DISABILITIES: A TALE OF THREE STUDIES

The aim of this dissertation was to explore how adults with a Lifelong Disability (LLD) access and experience rehabilitation therapy services across their lives. Many LLD diagnoses such as cerebral palsy and spina bifida are considered non-progressive; however, there are common challenges that occur as people with LLD become adults, including increased pain, fatigue, and functional loss. Literature addressing the needs of people with LLD to access adult-oriented medical providers has focused primarily on medical transitions, which have described the processes for pediatric patients moving to adult-oriented settings from pediatric settings. Few studies have addressed the rehabilitation therapy needs of patients who were either aging out of pediatric settings, or who needed the services of adult-oriented therapists as they acquired secondary orthopedic concerns. This three-part dissertation examines the perceptions of physical therapists (PTs) and individuals with LLD about therapy services. First, a Delphi Study with pediatric PTs described the needs of patients with LLD as they aged out of pediatric services, and identified concerns best addressed by both pediatric and adult-oriented therapists. The pediatric therapists indicated that people with LLD will likely need orthopedic management by adult-oriented PTs. A second study explored the experiences of adult-oriented PTs as they provided services to adults with LLD. This qualitative study explored the perceptions of adult-oriented PTs in providing care for adult patients with LLD. Themes that emerged were similarities and differences between patients with LLD and other patients, and the differences in the patients’ expectations of therapy. The therapists all agreed that adults with LLD having orthopedic concerns should be referred to adult-oriented outpatient therapy settings. They viewed the orthopedic complaint as the central focus of service. The diagnosis of LLD was seen as part of the person’s co-morbidities, adding more challenges to the patient’s presentation. A final qualitative study described the experiences of adults with LLD with therapy services across their lives. The participants represented a wide range of functional abilities, and all demonstrated the capacity of consent and independence in communication. Four major themes emerged: the influences of changes over time, therapy versus education services, transitions and meeting therapy needs as an adult, and the importance of communication and support. The self-determination concepts of autonomy, competence and relatedness were woven among the four themes. The participants discussed changes over time as seen by changes in themselves, the systems they used, and the demands on their abilities. Most had participated in some form of early intervention services when they were diagnosed. Most had received school-based therapy services that targeted stretching and maintaining mobility. Many felt that schools should have focused more on academics. Some of the participants mentioned the priority of walking in their pediatric PT services, and they felt this could have been discontinued sooner. Despite having feelings that they may not have benefitted from pediatric therapy; participants felt the therapists had good intentions. None of the participants transitioned directly from pediatric services into adult-oriented services. Several people did seek out PT services as adults, but some expressed dissatisfaction with the adult-oriented services. Most participants did not seem to understand the benefit of adult-oriented therapy. This dissertation increases our understanding of the needs of people with LLD across their lives in terms of physical therapy services. In synthesizing these three studies, it is clear that pediatric and adult oriented physical therapists and people with LLD need more education about appropriate physical therapy interventions for this group of people

Goal Development Practices of Physical Therapists Working in Educational Environments

Aims: The aims of this study were to (1) describe the practices that school-based physical therapists use in developing student goals, and (2) identify facilitators and barriers to development of goals that are specific to participation in the context of the school setting. Methods: 46 school-based physical therapists who participated in a previous study on school-based physical therapy practice (PT COUNTS) completed a questionnaire on goal development. Frequencies and cross tabulations were generated for quantitative data. Open-ended questions were analyzed using an iterative qualitative analysis process. Results: A majority of therapists reported that they frequently develop goals collaboratively with other educational team members. Input from teachers, related services personnel, and parents has the most influence on goal development. Qualitative analysis identified five themes that influence development of participation-based goals: (1) school-based philosophy and practice; (2) the educational environment, settings, and routines; (3) student strengths, needs, and personal characteristics; (4) support from and collaboration with members of the educational team; and (5) therapist practice and motivation. Conclusion: Goal development is a complex process that involves multiple members of the educational team and is influenced by many different aspects of practice, the school environment, and student characteristics

Treatment of recurrent rejection in heart transplantation: cytolytic therapy or bolus steroids?

OBJECTIVES: The treatment of recurrent rejection in heart transplant recipients has been a controversial issue for many years. The intent of this retrospective study was to perform a risk-benefit analysis between treatment strategies with bolus steroids only versus anti-thymocyte globulins (RATG; 1.5 mg/kg q 4 days). METHODS: Between 1986 and 1993, 69 of 425 patients (17 male, 52 female; mean age 44 +/- 11 years) who had more than one rejection/patient per month (rej/pt per mo) in the first 3 postoperative months were defined as recurrent rejectors. RESULTS: Repetitive methylprednisolone bolus therapy (70 mg/kg q 3 days) was given in 27 patients (group M; 1.4 +/- 0.2 rej/pt per mo) and RATG therapy for one of the rejection episodes of the 42 remaining patients (group A; 1.5 +/- 0.2 rej/pt per mo). The quality of triple drug immunosuppression in the two study groups was comparable. The rejection-free interval (RFI) following RATG treatment in group A was 21.6 +/- 10 days and 22 +/- 11 in group M. In group M, 3 of 27 patients (11%) had a rejection treatment-related infection (2 bacterial; 1 viral) versus 6 of the 42 patients of group A (14.2%; bacterial 1, viral 5). During postoperative months 3-24, 0.15 +/- 0.12 rej/pat per mo were observed in group M and 0.21 +/- 0.13 rej/pat per mo in group A (n.s.). In this 21-month period cytolytic therapy for rejection was initiated in 8 of the remaining 21 patients of group M (38%) and 15 of the remaining 37 patients of group A (40.5%). The absolute survival and the individual causes of death were not affected by the type of initial treatment of recurrent rejection. The actuarial freedom of graft atherosclerosis is comparable in the two groups with 78% in group A versus 79% in group M free of graft atherosclerosis at 3 years postoperatively. CONCLUSIONS: A comparison of cytolytic therapy versus repeated applications of bolus steroids for treatment of recurrent rejection reveals no significant difference in the long-term patient outcome with respect to the incidence of future rejection episodes and survival

Preventing obsolescence through retraining : contexts, policies, and programs /

Bibliography: p. 57-63.Mode of access: Internet