Analysis of a foundational biomedical curriculum: exploring cumulative knowledge-building in the rehabilitative health professions

This study was motivated by the researcher's experience that students in the rehabilitative health professional programmes were finding it difficult to access fundamental knowledge upon which their professional practices and clinical contexts are based. An important focus of the research was the extent to which cumulative knowledge-building was impacted after the foundational biomedical curriculum became an interdisciplinary programme. The study explored whether the organisation of the interdisciplinary foundational curriculum served the fundamental needs of the professions, and whether, as a matter of social justice, students' access to powerful knowledge was enabled by the form that the fundamental curriculum assumed. This curriculum study at a particular Faculty of Health Sciences foregrounds the structuring, organisation and differentiation of disciplinary knowledge, and reflects a twenty year period that included not only transitions in professional education but also extensive transformation in, and a different approach to, health delivery. At the institution, physiology and anatomy, the biomedical sciences basic to the health professions, underwent disciplinary merging and subsequent altered positioning in curricula. Medicine opted for a problem-based learning approach whereas the rehabilitation health sciences did not. Legitimation Code Theory (LCT) provided the means for analysis of the extent to which interdisciplinary organisation in the foundational curriculum for Physiotherapy and Occupational Therapy enabled integrative, cumulative building of knowledge for professional and clinical contexts. Specialisation and Semantics dimensions of Legitimation Code Theory were used to reveal the principles underpinning practices, contexts and dispositions of Anatomy and Physiology at the Faculty of Health Sciences over a twenty year period post democratisation in South Africa (1994 - 2013). Disciplinary positioning in curriculum prior- and post-merger, were compared and contrasted. LCT were used to characterise the distinctiveness of Physiotherapy and Occupational Therapy at the university including the kind of knowledge and the kind of knower that specialises the different professions, and what is valorised and legitimated for each kind of professional. Semantic gravity was used to explore the expected knowledge recontextualisations in diverse and complex clinical settings for each of the professions. Registered professionals who are clinical educators as well as curriculum designers for clinical studies were interviewed. Profession-specific course outlines were further data sources. The biomedical disciplines Anatomy and Physiology were characterised for their measures of distinction and their respective knowledge-knower structures. Analysis traced each discipline from its strongly classified form in autonomous curricula when there were separate learner-cohorts for physiotherapists and occupational therapists, to post-merger when the disciplines were framed as human biology in an integrated foundational curriculum for a joint cohort of students. Curricular documents for the twenty year period were analysed quantitatively and qualitatively to establish the positioning of Physiology and Anatomy before and after the disciplines merged to a single course of Human Biology. Teaching staff were interviewed for their understanding of what specialises the physiological and anatomical components of the Human Biology curriculum, what they considered as powerful knowledge for the professions, and who they envisaged as the ideal student-knower exiting the basic sciences platform to enter more advanced clinical studies. The degree of context-dependence for meaning-making in the different disciplinary domains and the condensation of meanings inherent in the respective practices and contexts, were analysed. The thesis argues that following the merger Anatomy is preferentially legitimated as powerful knowledge at the expense of Physiology; that the ideal of disciplinary integration is not reached, and that the segmental organisation and structuring of the curriculum negatively impacted on cumulative knowledge-building and application of professional knowledge in the clinical arena. After the merger the disciplines lost their shape, and in particular the hierarchical knowledge structure of Physiology collapsed. By not having access to the necessary disciplinary knowledge structures and their associated practices, students' ability for scaffolding and integrating knowledge into the clinical arena was constrained. The organisation of the current Human Biology curriculum does not facilitate cumulative learning, and in so doing may not contribute to the envisaged graduate professional who is required to practice within a complex and demanding healthcare work environment. The significance of this study conveys that interdisciplinary programmes should be carefully considered, and there is an added imperative in the health professions which ultimately realise treatment of patients. If, aside from interdisciplinary teaching, there are also merged cohorts of participant students, then a sound understanding of the epistemic requirements of each profession is required. Those involved in curriculum development in various fields need to take these recommendations into account to enable cumulative learning and enable epistemological access to powerful knowledge for an increasingly diverse student body

BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

The effects of acute hypoxia on metabolic enzymes in skeletal muscle

Thesis (MPhil (Physiological Sciences))--University of Stellenbosch, 2006.The responses of central systems to oxygen deprivation have been well characterised while adaptations in peripheral systems, such as skeletal muscles, have presented confounding variations. Several reasons for these discrepancies are purported, amongst them being the duration of exposure to hypoxia and variations in fibre composition. Moreover, in real-life high altitude situations there may be a combination of factors which have the ability to modify or alter the effect of hypoxia. This study investigates the effect of short duration hypoxia per se on substrate utilisation in different types of skeletal muscles

Effects of three home-based exercise programmes regarding falls, quality of life and exercise-adherence in older adults at risk of falling: protocol for a randomized controlled trial

BACKGROUND Fall prevention interventions with home-based exercise programmes are effective to reduce the number and the rate of falls, by reducing risk factors. They improve balance, strength, function, physical activity, but it is known that older adults' exercise adherence declines over time. However, it is unclear which delivery-modalities of the home-based exercise programmes show the best adherence and the largest effect. We created a new home-based exercise programme, the Test-and-Exercise (T&E) programme, based on the concepts of self-efficacy and empowerment. Patients learn to build their own exercise programme with a mobile application, a brochure and cards, as well as with eight coaching sessions by physiotherapists. The main objective of this study is to compare the T&E programme with the Otago Exercise Programme and the recommendation-booklet and exercise-cards of Helsana regarding incidence of falls. Other outcomes are severity of falls, functional capacities, quality of life and exercise-adherence. METHODS The design of this study is a Swiss multicentre assessor blind randomized controlled trial. A block-randomization, stratified in groups for age and risk of fall categories, will be used to allocate the participants to three groups. The targeted study sample consists of 405 older adults, ≥ 65 years of age, living in the community and evaluated as at "risk of falling". Experimental group will receive the T&E programme (N = 162). Second group will receive the Otago programme (N = 162) and the third group will receive the Helsana programme (N = 81). All interventions last six months. Blinded assessors will assess participants three times: at baseline before the start of the intervention, after six months of intervention and a final assessment after twelve months (six months of follow up). DISCUSSION Although home-based exercises programmes show positive effects in fall prevention in elderly persons, existing programmes do often not include patients in the decision-making process about exercise selection. In our programme the physiotherapist and the older adult work together to select the exercises; this collaboration helps to increase health literacy, pleasure of exercising, and empowers patients to be more autonomy. TRIAL REGISTRATION ClinicalTrials.gov: NCT02926105 , First Posted: October 6, 2016, Last Update: November 11, 2016: Enrolment of the first participant

Effects of three home-based exercise programmes regarding falls, quality of life and exercise-adherence in older adults at risk of falling: protocol for a randomized controlled trial

Abstract Background Fall prevention interventions with home-based exercise programmes are effective to reduce the number and the rate of falls, by reducing risk factors. They improve balance, strength, function, physical activity, but it is known that older adults’ exercise adherence declines over time. However, it is unclear which delivery-modalities of the home-based exercise programmes show the best adherence and the largest effect. We created a new home-based exercise programme, the Test-and-Exercise (T&E) programme, based on the concepts of self-efficacy and empowerment. Patients learn to build their own exercise programme with a mobile application, a brochure and cards, as well as with eight coaching sessions by physiotherapists. The main objective of this study is to compare the T&E programme with the Otago Exercise Programme and the recommendation-booklet and exercise-cards of Helsana regarding incidence of falls. Other outcomes are severity of falls, functional capacities, quality of life and exercise-adherence. Methods The design of this study is a Swiss multicentre assessor blind randomized controlled trial. A block-randomization, stratified in groups for age and risk of fall categories, will be used to allocate the participants to three groups. The targeted study sample consists of 405 older adults, ≥ 65 years of age, living in the community and evaluated as at “risk of falling”. Experimental group will receive the T&E programme (N = 162). Second group will receive the Otago programme (N = 162) and the third group will receive the Helsana programme (N = 81). All interventions last six months. Blinded assessors will assess participants three times: at baseline before the start of the intervention, after six months of intervention and a final assessment after twelve months (six months of follow up). Discussion Although home-based exercises programmes show positive effects in fall prevention in elderly persons, existing programmes do often not include patients in the decision-making process about exercise selection. In our programme the physiotherapist and the older adult work together to select the exercises; this collaboration helps to increase health literacy, pleasure of exercising, and empowers patients to be more autonomy. Trial registration ClinicalTrials.gov: NCT02926105, First Posted: October 6, 2016, Last Update: November 11, 2016: Enrolment of the first participant