Qatar Foundation Annual Research Conference Proceedings Volume 2016 Issue 1

Nonspecific low back pain (NSLBP) is defined as low back pain not attributed to recognizable, known specific pathology (van Tulder 2006). The global prevalence of activity-limiting LBP was recently estimated to be approximately 39% for lifetime prevalence and 18% for point-prevalence (Hoy et al. 2012). In spite of an enormous increase in the health resources spent on LBP disorders, the disability relating to them continues to increase. (Deyo et al. 2009) NSLBP remains a common and exorbitant problem among the nursing profession with a lifetime prevalence extending between 73% and 90% (Maul et al., 2003), a major cause of suffering, disability, and days of work lost. The frequency of reported disability from back injuries in nurses is among the highest of all worker groups (Jensen 1987). It accounts for 16·2% of all sick leave for nurses (Stubbs et al. 1983) and impairs performance. Myofascial release (MFR) is a form of manual therapy which involves the application of a low load, long duration stretch to the myofascial complex, intended to restore optimal length, decrease pain, and improve function (Barnes, 1990). It has been hypothesized that fascial restrictions in one part of the body cause undue tension in other parts of the body due to fascial continuity. This may result in stress on any structures that are enveloped, divided, or supported by fascia (Schleip, 2003). Self MFR involves the application of MFR by themselves with the help of fingers, hands or hand held devices. A recent study by Ajimsha et al (2015) found that MFR was more effective than a control intervention in the back pain management of nursing professionals. The main objective of this study was to investigate whether Self Myofascial Release (SMFR) technique can reduces pain and disability in non-specific low back pain (NSLBP) in comparison with a control group receiving a sham Myofascial release (Sham-MFR) in nursing professionals.

Methods

This study was designed as a Randomized, controlled, single blinded trial and carried out in the clinical wing of Myofascial Therapy and Research Foundation, Kerala, India. Inclusion criteria for this study was nursing professionals aged 30–50 years with a diagnosis of NSLBP of 3 or more month's duration. Patients were excluded if they displayed: 1) osteoporosis of the spine; 2) primary joint disease such as active rheumatoid arthritis; 3) metabolic bone disease; 4) malignant bone disease; 5) fracture; 6) hyper mobility of the lumbar/sacral spine; 7) cardiovascular or other medical disorder preventing the person from engaging in strenuous exercise; 8) evidence of radiculopathy, or primary complaint of radiating pain; 9) pregnancy; or 10) severe psychiatric disturbance. Use of oral/systemic steroids, use of analgesics on more than 10 days a month and any other treatment for LBP during the previous 6 months were also excluded from the study. The Research Ethics Committee of the Myofascial Therapy and Research Foundation and Medical Research wing of Mahatma Gandhi University, Kerala, India, reviewed the study and raised no objections from an ethical point of view. Between May 2013 and October 2014, 73 nursing professionals were referred to the Myofascial Therapy and Research Foundation with a diagnosis of NSLBP. Of these, 57 individuals who met the inclusion criteria and provided written informed consent were randomized to the Self MFR (SMFR) or to the control arm of the study. Participants were asked to maintain a pain and medication diary in which any medication or change in pain pattern during the treatment period was to be recorded with date and time. The SMFR were administered by the nurses themselves whereas the sham-MFR was applied by physical therapists in a predetermined dosage (12 sessions in 4 weeks).

Main outcome measure

The McGill Pain Questionnaire (MPQ) for subjective pain experience and Quebec Back Pain Disability Scale (QBPDS) to assess the disability associated with NSLBP. The primary outcome measure was the difference in MPQ and QBPDS scores between week 1 (pretest score), week 4 (posttest score), and follow-up at week 12 after randomization. Two evaluators blinded to the group to which the participants belonged analyzed scores from the MPQ and QBPDS. Procedure Subjects in each group received either SMFR, or a sham MFR program. The 2 interventions were provided for 3 times per week for 4 weeks (weeks 1–4), with a minimum of a 1 day gap between the 2 sessions; the duration of each treatment session was set as 45 min. A recorded audio which gives step wise instruction for the SMFR was given to the SMFR group with fixed daily timing for the release. A research assistant calls and confirms the SMFR adherence in a daily basis. MFR procedure We used the following treatment protocol for all the patients in the SMFR group derived from the protocol used by Ajimsha et al (2015) in his study. A normal tennis ball and a Rumble Roller® (RR 316, blue, original density) were the items given to the clients in the SMFR group. The clients in the SMFR group were given one hour training for the SMFR and were asked to demonstrate it on the very next day to a therapist who was not the instructor of the SMFR. Control intervention Patients in the control group received sham MFR over the same areas as the application of SMFR (in the other group) for same time and duration. Sham MFR were applied by gently placing the hand over the areas treated in the SMFR group just enough to maintain contact for the desired time. All study participants were advised to take medications only when there were any exacerbations, but were required to record them in their patient diaries, which were analyzed at weeks 4 and 12 after randomization SMFR protocol. a) MFR of the Gluteus Maximus and piriformis Client's Position: Supine with hips and knees bend Technique: By using a tennis ball at the area of release (between the posterior superior iliac spine and the greater trochanter, the client will be asked to slowly press the body against the ball in a way that it elicits an aching pain the region. The body has to be adjusted by using the weight transferred through the feet to roll the ball between the above positions. The client has to stop the rolling for 30 seconds at any point where he/she feels more pain. (Duration: 5 min ×  2 sides =  10 min) b) Back work lower Client's Position: Supine with hips and knees flexed The client places themselves over a Rumble Roller so that the foam roller will be positioned at the lower back in the lumbosacral region. The client is trained in moving the lower back over the roller and releasing the muscles and fascia of the lower back by using the feet. (Duration: 4 minutes release, 2 minutes rest, 4 minutes release =  10 min). b) Back work upper Client's Position: Supine with hips and knees flexed. The Rumble Roller was positioned at the upper back in the thoracic region. The client is trained in moving the upper back over the roller and releasing the muscles and fascia of the lower back by using the feet. (Duration: 4 minutes release, 2 minutes rest, 4 minutes release =  10 min). c) The Trunk sides Client's Position: Side lying, head supported by a pillow. Hips in 450 of flexion, knees in 350 of flexion. The client places themselves over a Rumble Roller in a side line position so that the area between greater trochanter and lower ribs can be released. The client stabilizes himself over the form roller with the help of the upper and lower extremities opposite to the lying side. The feet will be used to move the lateral trunk over the roller. (Duration: 5 minutes ×  2 sides =  10 minutes) d) Seated focused release Client's Position: Seated in a rolling stool with hips higher than the knees feet slightly forward of the knees and well connected to the ground. The client supports their back via their feet and legs. The client will use a tennis ball between the lower back and a wall and by moving the back against the ball by means of counter pressure, releases the deeper muscles of the back. The clients were encouraged to isolate the specific segments on which the pressure was applied. (Duration 5 minutes) Statistics Participants in both groups were comparable at baseline. The primary outcome measure was the difference in MPQ and QBPDS scores between baseline (pretest score), week 4 (posttest score), and follow-up at week 12 after randomization. Statistical analysis of the data was done by using a 2 ×  3 (group ×  time) analysis of variance (ANOVA) and 2 ×  2 (group ×  time) and 2 ×  3 (group ×  time) repeated-measures ANOVA. The between groups (group), within-groups (time), and mixed-groups (group ×  time) interactions were examined; then, in accordance with the primary objective of the study, we compared the MPQ and QBPDS scores of the SMFR and control groups at different time intervals. A P <  0.05 was accepted as statistically significant.

Results

The mean differences between groups vary by time. This indicates the possible existence of their interaction effect. The simple main effects analysis showed that the SMFR group performed better than the control group in weeks 4 and 12 (P <  0.005). The patients in the SMFR group reported a 62.6% reduction in their pain and 36.3% reduction in functional disability as shown in the MPQ and QBPDS scores in week 4, which persisted as a 43.8% reduction of pain and 29.2% reduction of functional disability in the follow-up at week 12 in the SMFR group compared to the baseline. The patients in the control group reported a 9.5% and 3.6% reduction in their MPQ and QBPDS scores in week 4. The proportion of responders, defined as participants who had at least a 50% reduction in pain between weeks 1 and 4, was 63% in the SMFR group and 0 in the control group. The test's between subject effects showed a significant interaction between the effects of group and time on value (F2,189 Z 522.418, P <  0.001). The simple main effects analysis (Table 3) showed that the SMFR group significantly performed better than the control group in weeks 4 and 12 (P <  0.001), but there were no differences between the groups at baseline (P > 0.001). We observed that the interactions between time and group were significant based on univariate and multivariate methods for all 3 repeated-measures ANOVAs. Significant pairs of SMFR and control groups vary at weeks 4 and 12 due to the interaction effect between group type and time. Study limitations One limitation of this trial was that practitioners could not be blinded. Second, long-term outcomes were not assessed, and it is not known whether the differences observed at post-treatment can be maintained over a long time. We also did not examine other important treatment outcomes such as pain beliefs, mood, and quality of life.

Conclusions

This study provides evidence that SMFR can be a useful tool in the management of NSLBP in nursing professionals than a control. A cost and time benefit analysis can be undertaken in the future studies. A major section of nursing professionals with NSLBP might benefit from the use of SMFR and can be taught as a LBP prevention strategy for nursing professionals.

Keywords

Myofascial release; Non specific low back pain, Nursing professionals

Background

Patients with type 2 diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of CVD. Multiple clinical trials have demonstrated significant effects of pharmacological (primarily statin) therapy on CVD outcomes in individual subjects with CHD and for primary CVD prevention. Our aim is to improve documentation of cardiovascular disease risk in medical records of diabetic patients attending non communicable disease clinics at west bay health center from 13% to 70% using world health organization cardiovascular disease risk Prediction Charts from September 2014 to January 2015.

Methods

Baseline audit to determine the percentage of cardiovascular disease risk documentation, Brain storming session was done to identify the causes of such problem including fish bone analysis, Survey questionnaire was designated to assess the main causes of the problem and distributed to all nurses working in non communicable disease clinics, The results demonstrated in paretto chart, We discover the main causes of the problem lies on two main causes (nurses were not oriented to new non communicable disease format and some of them were not trained to calculate risk).Intervention in form of: Education session for nurses working in these clinics were done particularly on: Orientation about new format and cardiovascular disease riskdocumentation, Orientation sessions for clinic running physicians, Putting reminder posters in clinics and staff nurse stations. Several audits done retrospectively for two weeks (3 days each week) to show average percentage of documentation in pre-intervention stage from 15th September to 13th November 2014, Several audits done for three weeks (3 days each week) and then weekly for 5 weeks to show average percentage in post-intervention stage ending at 15th January 2015, All data was demonstrated using run chart.

Results

The intervention began in November 2014 to January 2015 reveals that: Percentage of complete cardiovascular risk documentation for diabetic patients average was 7% in pre-intervention stage and increased to average of 59% after the intervention

Conclusions

Intervention in the form of nurse education and physician orientation improved Documentation of cardiovascular disease risk by 52%. Raising the average of documentation from 7% to 59%. Sustainability is very important for success in such improvement processes.

The occurrence of disinfection by-products (DBPs) of chlorine dioxide (ClO2) in drinking water, namely: chlorite, chlorate, and THMs as well as the concentration of ClO2 were investigated. Two hundred ninety four drinking water samples were collected during the time period from March to August 2014. The water samples were collected from seven desalination plants (DPs), four reservoirs and eight mosques distributed in South and North Qatar. The ClO2 level was ranged from 0.38 to less than 0.02 mg/L, with mean value of 0.17, 0.12, and 0.04 mg/L in the desalination plants (DPs), the reservoirs (R), and the mosques (M), respectively. The chlorite level was varied from 12.78 – 436.36 ppb with median values varied from 12.78 to 230.76, from 77.43 to 325.25, and from 84.73 to 436.36 ppb in the DPs, the reservoirs, and the mosques, respectively. While chlorate was varied from 10.66 ppb to 282.71 ppb with mean values varied from 35.58 to 282.72 ppb, from 11.02 to 200.69, and from 10.66 to 150.38 ppb in the DPs, R, and M respectively. However, the average value of THMs was 4.90 ppb, while maximum value reached 76.97. Lower disinfectant residual was observed in few samples, however this could be attributed to the normal decomposition reaction of ClO2 with organic and inorganic compounds, including biofilms, pipe materials, corrosion products, formation of slime or may due to the fact the water in distribution system experience water aging problem. Significant differences were observed in the concentration level of chlorite, chlorate and THMs between DPs, reservoirs and the mosques. However, the concentrations of all DBPs fell within the range of the regulatory limit set by GSO 149/2009, WHO and KAHRAMAA (KM). It is recommended to slightly increase the average ClO2 dosage at the DPs. Such slight increase would provide safer margin at the customer point of use in case of any microbial activities. Consideration must be given to the overall demand and should account for seasonal variations, temperature, and application points. As well as a monitoring approach is recommended for the drinking water safety assessment. Re-conducting the study to include other DPs of ClO2 is recommended.

Integrating strain sensors into textiles opens new applications. For example when attaching the sensors in the knee or elbow region, the bending angle of the joints can be measured. Such a measurement can be used in sports (e.g. to measure the number of steps and the speed while jogging) or in rehabilitation to give the patient an online feedback whether he practices the injured joint in the appropriate range. Measurement of fabric strain flexion of human joints caused an elongation of the affixed skin up to 45% in the region of the knee and 30% in the region of the lower back. Consequently, strain sensitive materials that react to elongation were integrated into tight fitting garments for a reconstruction of the joint angle. One could even think of a whole body posture measurement which enables a quality and quantity measurement of exercise conduction in fitness training and rehabilitation.

Keywords

Medical textiles; Conductive yarns; Flexible strain sensors; knitted structures; Rehabilitation

Introduction

The fabrication of electronic systems onto substrates represents a breakthrough in many areas of application, such as virtual reality, tele-operation, tele-presence, ergonomics and rehabilitation engineering. The need of the hour is to develop such an integrated effective system for medical textile applications which is not only flexible but also conformable to the human body, for such type of flexible strain sensors, one should focus on some crucial parameters like development of optimized composite conductive yarns used for the substrate and flexible strain gauges based on composite conductive yarns. Measuring strain in textile is a problem addressed by different research groups. One of the first groups who mentioned this problem was Tognetti et al. They built a knitted strain sensor which was integrated into a jacket and was used to measure upper body movements [1]. Gibbs et al. designed a textile potential divider to measure joint movements. In a thin layer of poly-pyrrole (using chemical vapor deposition) was applied on the fabric substrate at low temperature. With this configuration, a measurement range of up to 50% strain and a strain sensitivity of 80 was achieved [2]. Mattmann et al. investigated ethylene-vinyl acetate (EVA) and ethylene-propylenediene rubber (EPDM) composites for sensor applications. Such carbon composite materials show high relaxation behavior and creep which means that the change in resistivity is influenced by the strain rate [3]. An elastomer/carbon black-composite (CE) was used by Tognetti et al. to measure arm and finger movements. This sensor showed high relaxation behavior too. Carbon black/elastomer- and rubber-composites need to be cured after compounding and shaping [4]. In contrast, when using thermoplastic elastomer (TPE) based composites, curing is not necessary and simple thermoplastic processing technology can be used for shaping. Therefore, such polymers are interesting when developing strain sensors with large strain. Yamada et al. presented a sensor of a thermoplastic elastomer and filled with carbon black (27.6 by %vol.). They focused on noncyclic strain sensing and looked at influences of temperature and humidity on the resistance. The sensor showed a dependence of the resistance on the humidity but not on the temperature [5]. In this paper we use a similar composition (50wt–%/32vol–% carbon black) but focus on the characterization of the sensor's dynamic behavior, as sensors integrated into textiles are exposed to repeated strain cycles. The conductive fibers can be incorporated into the yarn (Figure1) and then subsequently incorporated into fabric. Integrating strain sensors into textiles opens new applications in medical textiles, for example, when attaching the sensors in the knee or elbow region, the bending angle of the joints can be measured. Such a measurement can be used in rehabilitation to give the patients an online feedback whether they practiced the injured joint in the appropriate range or not. One could even think of a whole body posture measurement which enables a quality and quantity measurement of exercise conduction in fitness training and rehabilitation. Measuring the posture using strain sensors enables an unobtrusive integration into textile currently not possible with other sensors (e.g. accelerometer, gyroscope, and magnetometer). This calls for a combined effort on one hand from the materials side in terms of developing functionalized fabrics and tackling integration issues, and also from the computer applications side to provide user-friendly interfaces. Through characterization of their response and assess functionality for specific applications. These are not only valuable to the athlete who wish get the most from their training regime and assess their progress but also for different patient who need rehabilitation. This project will focus on the development of optimized composite conductive yarns and strain sensors which measures strain in textiles. Furthermore, these strain sensors will be integrated in to braces which could be used for many applications such as patient rehabilitation and monitoring and controlling of athlete movements. The scope of this work is to develop a device capable of measuring strain, based on conductive textile yarns and using them as strain sensors. Furthermore, these sensors can also be incorporated into intelligent braces which can be used for endless medical textile applications.

Material

The conductive yarns will be prepared by TPE (thermoplastic elastomer) based composites and for shaping simple thermoplastic processing technology will be used. The TPE material such as SEBS-Block copolymer (THERMOLAST Kr (FD-Series)), Compound No. TF7- ATL produced by KRAIBURG TPE GmbH, Germany may be used. Thermoplastic elastomers (TPE), sometimes referred to as thermoplastic rubbers, are a class of copolymers or a physical mix of polymers (usually a plastic and a rubber) which consist of materials with both thermoplastic and elastomeric properties. While most elastomers are thermosets, thermoplastics are in contrast relatively easy to use in manufacturing. The carbon black powder (ENSACO 250 produced by TIMCAL, Belgium) may be used and will be added in TPE during fiber manufacturing.

Method for producing filament

For the fibre manufacturing we will use extrusion and drawing method. The TPE pellets will be filled in an electrically heated torque rheometer with roller blade configuration. After melting the thermoplastic part of the TPE, carbon black powder will be added and subsequently homogenized and dispersed into the polymer. The rotation speed may be constant (10 rpm) during the whole procedure. After compounding, the fibre will be produced by using a capillary rheometer, and an extrusion die. The composite material will be preheated and compacted in the cylinder of the rheometer. By using the furnace (proposed) furnace we can produce activated carbon through stabilization and carbonization of different materials like polyamide and PAN (Polyacrylonitrile) in the presence of inert atmosphere. Then through ball milling machine (proposed) we can create nano particles of this activated carbon. The coating of these nano particles will give us good results regarding electrical and thermal conductivity. Strain sensor Preparation: Textile Stretch Sensor will be manufactured by Flat Hand Knitting through incorporate conductive yarns into fabric. With the help of weft knitted machine this sensor will be prepared. For the effectiveness of sensors, we may change different parameters such as Loose knitted with and without lycra yarn Tight knitted with and without lycra yarn Single Plied knitting Double plied knitting Testing: The Strain sensors will be characterized in terms of quasi-static and dynamic electromechanical transduction properties. Thermal and aging properties of the sensing fabrics will also be determined through cyclic loading on UTM machine. Conductive properties of the Textile Stretch Sensor (TSS) will be tested on ohm meter in BUITEMS Textile lab. All measurements will be performed on Electronic Extensometer (proposed). The resistance will be measured in parallel with a multi meter. These strain measurements will be done at a speed of 200 mm/min which corresponds to a strain rate of 16% = sec (sensor length 2 cm) which is achieved in typical body movements. Brace Performance Testing Following is the picture of the preliminary developed sensor. The target will be the improvement of reproducibility for the accurate results. We may also miniature the circuits involved to make it easy to wear.

Reverse addition-fragmentation atom transfer (RAFT) living polymerization, a popular means of preparing coplymers of methacrylate and methyl methacrylate with narrowly defined size distributions and architectures, can readily be performed in sub-mililiter quantities in the absence of stirring, yielding biocompatible materials with excellent yields and low PDI values, and a linear molecular weight response curve extending to above 180,000 g·mol^–1. When multiple studies were done involving the variation on the RAFT/monomer ratio under a variety of concentrations, the corresponding molecular weights of the materials exhibited a linear response. Furthermore, in comparing the resulting material to polymers prepared using more classical free-radical polymerization techniques, the miniaturized RAFT-mediated batches showed similar biocompatibility. These facile reaction conditions offer the prospect of preparing well defined polymeric systems in parallel with minimal equipment investment, without compromising the quality of the final product. The resulting polymers were then inkjet printed onto an agarose-coated glass slide, and then tested for bioactivity.

Objective

To determine the causing association of the cigarettes smoking (measured by cotinine level in the seminal plasma) on the immunologic inflammatory markers (PMN-elastase, pro-inflammatory cytokines, and leukocytospermia) in seminal fluid (SF) of unexplained infertile men.

Materials and Methods

Tow hundred-thirty six unexplained infertile men, one hundred fourteen smoking and ninety six non-smokers were included in the study. They were being found without evident cause for infertility after initial workups. Other ninety fertile healthy non-smokers men were enrolled in the study as a control group. Seminal immunologic inflammatory markers (PMN-elastase, pro-inflammatory cytokines IL-8 and IL-6, and leukocytospermia) were measured in seminal plasma (SP) of all participants. Cotinine level in SP was measured as well, and correlated with inflammatory markers in all three hundred- twenty six specimens.

Results

The differences of seminal plasma inflammatory markers and cotinine level were significant between the three groups of the study, and significantly correlated with inflammatory markers.

Conclusion

The resulted substantial negative impact on sperm motility and morphology, and the correlation of cotinine level with immunologic inflammatory markers in SP, strongly indicate the presence of immunologic reaction in genital tract of the smokers. That may lead to silent genital tract inflammation. Which is, may be, the main cause for their unexplained infertility, and so, it would be sensible to advise infertile men to abstain from smoking cigarettes.

Introduction

Culture has been defined as: “a tradition of knowledge and practice that is shared, albeit imperfectly, across the members of a society and across its generations” [Zou et al 2009]. It shapes people's experiences and their emotional reactions [Gard et al 2005], including their understandings of what it means to be healthy, the meanings of symptoms, attitudes towards disability and treatment, and coping strategies [Dean et al 2006; Gallaher et al 2001]. The study suggested here may offer new insights by exploring how culture shapes the experience of stroke care through the perceptions of Physical therapists working in the state of Qatar. Qatar is one of the wealthiest countries in the world. The culture reveals the modernising influences associated with oil exploration and technological advances whilst preserving collective traditions. The state provides extensive financial support for its own citizens including generous pensions and access to health care. However, in common with other Gulf states, the majority of the population are migrant or expatriate workers [Gallahar et al 2001], The Islamic faith plays a central role in government legislation and everyday life. This is a unique culture, as in Qatar, strong commitment to the Muslim religion, collective values, and generous financial support to purchase physical therapy services abroad, may result in an experience of care that is different from that reported in other areas of the world. Physiotherapists require not only cultural sensitivity but cultural competency, which is “the ability to honor, understand, and respect the beliefs, lifestyles, attitudes and behaviors demonstrated by diverse groups of people, and to diligently act on that understanding” [Omu et al 2012; Dean et al 2006]. Culturally competent care invites maximal cooperation with patients and their family members with the aim of promoting better outcomes [Niemeier et al 2007; Balcazar et al 2010].

Purpose

The aim of this study was to investigate the perceptions of Physical therapy professionals who treat stroke patients regarding cultural influences on the experience of stroke rehabilitation in the state of Qatar. Physical therapy professionals interviewed were from a variety of cultural backgrounds thus providing an opportunity to investigate how they perceived the influence of culture on stroke recovery and Physical therapy in Qatar.

Method

A descriptive qualitative exploratory research approach was used for the study. Semi-structured interviews were carried out with 23 Physical therapy professionals with current/recent stroke Physical therapy experience meeting the inclusion criteria from the department of Physical therapy, Rumailah hospital, Hamad Medical Corporation, Doha, Qatar, followed by thematic analysis of the verbatim transcripts.

Inclusion Criteria: Physical therapy professionals with current experience of working in stroke rehabilitation in the Department of Physical therapy, Hamad Medical Corporation, Doha, Qatar, those who are able and willing to participate in a 45-minute face-to-face interview which will be audio recorded, those who are having clinical experience of 5 years or more in the field of stroke rehabilitation and those who are having more than 2 year's experience working in stroke rehabilitation in the state of Qatar.

Exclusion crieteria: Other Health Care professionals and Physiotherapists poor in English language Data Collection: Primary data was collected through semi-structured face-to-face interviews. The interview consist of structured open ended questions. Trained researchers conducted all the informant interviews at the department. All interviews were conducted in English, and once the interview were completed, the researcher immediately transcribed it into an MS Word document. A second researcher who had not transcribed the interviews reviewed each of the audio recordings and subsequent transcriptions in order to ensure that the qualitative data is accurately transcribed and translated.

Procedure

The interviews were taken place in a quiet room at the Physiotherapy department, Rumailah Hospital. Interviews were conducted in English and were of 45 minutes duration which were audio recorded. The main questions/topic were as follows: In your experience, what are the Most significant challenges faced by stroke patients in the state of Qatar? How have you addressed psychological social issues during stroke rehabilitation? In your experience, does culture have any influence on the stroke experience and rehabilitation process in the state of Qatar (if so, why and how?)? What is your opinion regarding willingness of the patients for home exercise programs and their motivation level for doing so, does the culture is having any impact over this?

Data Analysis

Transcribed interview data were entered into a qualitative data analysis software package (NVivo 2.0) for systematic coding. A content analysis was performed to identify themes that emerged from the interviews. Content analysis, or qualitative description, has been reported as useful when the description of phenomena is desired (Pope et al. 2000). The identified themes were based on informants' collective perceptions and experiences relevant to the issues being explored in the study. Once transcripts were coded, reports weer generated which the research team analyzed according to the research objectives. The team met regularly to share impressions, develop main themes and discuss alternate interpretations.

Results

The Physical therapy professionals identified several features of the Qatari culture that they believed affected the experiences of stroke patients. These were religious views, family participation, lack of awareness regarding expected outcomes and use of Physical therapy, inadequate education and public information about stroke, prevailing negative attitudes toward stroke, depression and loss of hope, social stigma and the public invisibility of disabled people, difficulties in identifying meaningful goals for Physical therapy, lack of patient and family centeredness and an reception of reliance linked with the extensive help of maids or helpers in Qatari homes. Community reintegration of the stroke victims need to be addressed in a vider perspective Lack of ‘self help groups’ with expert back up is not yet established to satisfy the demand. Lack of recreational and group activity scenarios for the stroke survivors in association with community groups Perodic councelling and antidepression measues at the social level has to be addressed. The key features identified for non-Qatari populations are insecurity, financial burden, social and emotional isolation. The anxiety of the future, lack of family support, fear of unemployment and repatriation worsens the scenario for those staying in group accommodations. Majority of the non-Qatari population wants a complete recovery and participates heavily in Physical therapy practice in order to resume back to their jobs as early as possible.

Conclusion

To offer culturally delicate care, these issues should be taken into account during the provision of Physical therapy or rehabilitation for stroke survivors in a culturally compatable way. There should be more emphasis on ongoing education, community out reach programs and environmental modifications for an ulitilame rehabilitation of such patients Insinuations for Rehabilitation Physical therapy professionals need to mold therapy to the patient's and family's model of care, reflecting their cultural background. Physical therapy professional can suggest, develop and actively participate stroke awareness sessions and community out reach programs, deliverable at home and community levels addressing the nation. Physical therapy professionals may need to be attentive that the presence of house maids and privately hired nursing staff may decrease the motivation of people to engage in Physical therapy after stroke. A care giver education and training should be considered as an important adjunct to the stroke physical therapy care. Cultural variations in degree of family involvement, prevailing negative attitudes towards stroke, and acceptance of dependency should be taken into consideration by stroke Physical therapy professionals. Physical therapy professionals should participate actively in the community based rehabilitation of stroke survivors. As patients spent more time with Physical Therapy professionals than any other health care professionals, physical therapists can act as counselors and/or motivators for the survivors. Physical therapist can be deployed as captains of self help groups which can be designed in the national level. There should be community out reach programs for the stroke survivors where Physical therapy potentials can be tapped further Physical therapist can facilitate the ongoing rehabilitation process of non Qatari expatriate survivors with the help of concerned employers and embassies once they are discharged from the active care, if it is acceptable.

Limitation

The main limitation was the sample size and difference in the percentage of national and expatriate Physical therapists interviewed, which any way will have a strong influence on the result. This was a reporting own perceptions about the stroke physical therapy care and familial and cultural back ground of the patients which will be different from the patient perspectives. Conclusions Physical Therapy professionals need to deliver therapy which is culturally molded and acceptable to the patient, family and the community. Care giver training need special emphasize in Qatari culture. Qatari and non-Qatari patients are facing dissimilar psychosocial issues which needs to be analyzed and managed as different topics. Cultural sensitivity entails Physical therapy professionals to engross with the family of the stroke survivors and to escalate their confidence and hue their perception own their disability, as well as offering more education about the principles behind therapeutic strategies.

Declaration of interest

The authors report no conflicts of interest.

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Balcazar F, Suarez-Balcazar Y, Taylor-Ritzler T, Keys, C. Race, culture, and disability: Rehabilitation science and practice. Boston, MA, US: Jones and Bartlett; 2010.

Aims

Duchenne Muscular Dystrophy (DMD) is a disease that mainly affects young mans. It is characterized by striated muscle disorder. DMD is associated with depressed heart pump function resulting from a down regulation of the left ventricular (LV) contractility. However, its effects on myofilament structure and function are poorly understood. A healthy heart is characterized by gradient of contractility spanning throughout its left ventricular (LV) wall thickness. The inner layer of the wall is known as the sub-endocardium layer (ENDO) and the outer layer is known as the sub-epicardium (EPI). The gradient of contractility is established due to the significantly high contractility of the ENDO compared to EPI. During heart failure, the contractile heterogeneity between ENDO and EPI is suppressed eliminating, thus, the gradient of contractility. Interestingly, this effect of pathology is mainly due to ENDO contractile dysfunction. These observations have maid ENDO layer to be an ideal target for heart failure treatment. Golden Retriever Muscular Dystrophy (GRMD) is a dog model of DMD observed in human. In the present study, we employed this animal model to evaluate the impact of DMD on the myofilament structure-function relationship. Accordingly, we isolated cardiac multicellular and single cells samples on which we evaluated myofilament lattice spacing, myofilament calcium sensitivity and contraction kinetics. It is to note that the force developed by cardiac single cell and multicellular preparations depends on their stretch status. For instance, at long length tension developed by an isolated single cardiac cell is higher than when it is maintained at slack length. During heart failure, this stretch effect on the contractility is significantly reduced particularly in the ENDO layer. Sarcomere length (SL) is the unit commonly used by investigators to evaluate muscle length. Accordingly, in the present study, we conducted our experiment on samples isolated from EPI and ENDO layers of GRMD animals at both short and long SL.

Methods and results

To evaluate the effect of muscular dystrophy on the myofilament structure, we have employed synchrotron x-rays diffraction approach to measure myofilament lattice spacing at various sarcomere lengths (SL) on permeabilized LV myocardium. Moreover, to evaluate transmural contractile heterogeneity in normal dog heart, myocardium samples were isolated from both EPI and ENDO left ventricular layers. Here we tested whether the lattice spacing responds differently to stretch in ENDO and EPI tissues. We obtained clear X-ray patterns from our tissue sample showing sharp equatorial reflections. As expected, spacing between thin and thick filament was reduced upon stretching. We found that d1,0 decreased linearly with SL over the SL range from 2.1 to 2.5 μm in ENDO and EPI, and that the slope of the SL–d1,0 relationship was similar in both myocardial tissue layers (Fig. 1). Despite the lack of regional lattice spacing heterogeneity, we investigated sarcomere function in isolated myocytes from the same hearts to measure myofilament calcium sensitivity. Force-pCa relationship was fitted with a modified Hill equation and EC50 ([Ca²⁺] generating 50% of maximal active force) was estimated. Both ENDO and EPI cardiomyocytes showed a decreased EC50 at long SL indicating increased calcium sensitivity (Fig. 2, A). To estimate myofilament length dependent activation (LDA), we computed the difference between [Ca²⁺] generating half of the maximal force at short (1.9 mm) and long (2.3 mm) sarcomere length (DEC50). This parameter is commonly employed to evaluate LDA. We found LDA to be higher in ENDO cardiomyocytes (Fig. 2, B) as indexed by a significantly higher DEC50 in this region. These results indicate that in dog myocardium, the higher length sensitivity of activation in the inner layer of the ventricle cannot be explained by differential interfilament lattice spacing. We evaluated myofilament Ca²⁺ sensitivity and LDA on permeabilized cardiomyocytes isolated from both CTRL and GRMD dogs. Myofilament calcium sensitivity was higher at short SL in ENDO GRMD myocytes compared with control dogs as indexed by a significant lower EC50 (Fig. 4, A). Differences of myofilament calcium sensitivity between CTRL and GRMD ENDO myocytes disappeared following stretch. As a result, LDA indexed by the DEC50 was lower in GRMD myocytes (Fig. 4, B). We did not find any significant difference in EPI cardiomyocytes contractile parameters. To determine whether the changes in myofilament calcium sensitivity in myocytes from failing hearts were associated with myofilament structure alteration, we performed X-ray diffraction experiments on permeabilized normal and GRMD dog ENDO myocardium at short (∼1.9 mm) and long (∼2.3 mm) sarcomere length (Fig. 4). Next, we used small -angle X-ray diffraction to assess changes in myofilament lattice structure with increasing sarcomere length in GRMD and normal dog myocardium to see if structural changes correlate with LDA. Figure 4 Panel A shows a typical CCD image of X-ray diffraction pattern. Pixel intensity was plotted and the 1,0 equatorial reflection estimated (Fig. 3, B). As observed with the first experiments (Fig. 1), the lattice spacing is reduced with stretch on CTRL myocardium (Fig. 3, C). Interestingly, the interfilament spacing was significantly higher on GRMD ENDO myocardium compared with the normal myocardium. Stretch reduced the interfilament spacing of ENDO GRMD myocardium that matches the spacing obtained on CTRL dog myocardium. The myopathy induced a myofilament lattice expansion that exceeded the physiological range. In order to test that the expansion in interfilament spacing was not due to the lack of dystrophin we also analyzed the myocardium dissected from the sub-epicardium. The higher lattice spacing in ENDO GRMD myocardium may impact myofilament calcium sensitivity and/or cross-bridge cycling kinetics. At the permeabilized single cardiomyocytes level, kinetic of tension redevelopment (ktr) was measured by mechanically disrupting force-generating cross-bridges at either sub-maximal activating solution ([Ca²⁺] = 1.3 μM) or at maximal calcium activation ([Ca²⁺] = 32 μM). Cross-bridge disruption was induced by rapid release/restretch protocol. Cardiomyocytes were perfused with activating solution, when developed force reached steady state, a rapid (2 ms) release/restretch of 20% original cell length was applied. The cell was shortly kept (20 ms) at the unload shortening prior to 100% restretch. Following the release step, force dropped to zero indicating a complete cross-bridge detachment. The restretch step, in the other hand, was characterized by an apparent monoexponential raise of force up to initial maximal force with rate constant ktr. This experimental protocol has been applied on both CTRL and GRMD permeabilized ENDO cardiomyocytes (Fig. 5). Ktr is usually used to estimate the rate of transition from weakly bound (non-force-generating) to strongly bound (force-generating) cross-bridges. Therefore, an estimation of cross-bridge cycling performance can be obtained. In ENDO cardiomyocytes from healthy dogs, ktr obtained at sub-maximal calcium activation tended to increase after stretch but it did not reach significance (Fig. 5, B). Interestingly, ktr was significantly accelerated in ENDO GRMD myocytes only at short SL (Fig. 5, A and B). Collectively, our results suggest that in myocytes from GRMD dog with heart failure there are structural changes that affect the myofilament contractile properties.

Conclusions

At short SL myopathy induces an excessive expansion of the myofilament lattice spacing that may affect myosin heads orientation. This myofilament restructuration improves weak to strong cross-bridge transition as indicated by ktr acceleration. The positive cooperative activation of thin filament through strongly bound cross-bridges improves myofilament Ca²⁺ sensitivity and overall cardiomyocyte active tension. Additional experiment need to be conducted to better understand the interconnection between myofilament lattice spacing and performance in myopathy induced heart failure of large animal model.

Background

Anemia is the most common hematologic abnormality that a pediatrician encounters in clinical practice. Alpha-Thalassemia (a-thal) is widely reported in the Arabian Peninsula as one of the main causes ofasymptomatic microcytic hypochromic red blood cells with or without anemia in the pediatric population. The most common cause of anemia is either iron deficiency or thalassemia trait. Majority of the carriers for beta-thalassemia and some forms of alpha-thalassemia are clinically asymptomatic and although their hematologic phenotypes (i.e. microcytic hypochromic red blood cells) with or without anemia are predictive markers, they are not specific and overlap with conditions such as iron deficiency. Precise diagnosis of alpha-thalassemia is particularly important in the Gulf region where certain forms of alpha-thalassemia (especially non-deletional) are found, resulting in more severe phenotypes. Geographical prevalence's in the region are also variable as seen in a recent large survey of cord blood from Oman at the Sultan Qaboos University Hospital revealing a minimal frequency of approximately 50% of alpha-thalassemia of which hematologically relevant form is expected to represent a significant proportion. Unlike beta-thalassemia for which differential diagnosis can be made by measuring HbA2 levels, it is difficult to distinguish between alpha-thalassemia and iron deficiency, and DNA based diagnosis is essential. Furthermore, DNA diagnostics can provide insight into the commonly observed discrepancies between phenotypes and genotypes, especially in cases of sickle cell disease and beta-thalassemia, where alphathalassemia is known to act as a genetic modifier. To date neither diagnosis of alpha-thalassemia (trait) nor its molecular spectrum had been accurately performed and described in Qatar. This is despite the fact that in Qatar, both beta and alpha-thalassemias (Hb Barts at birth) are not uncommon and nutritional anemia can rarely be expected as cause of such microcytic hypochromic red cells because of therelatively high socioeconomic status of the country. The only published work on alpha-thalassemia in Qatar is a hospital based study in which 1,702 Qatari nationals (905 females, 797 males) were investigated for hemoglobinopathies and of which 8.05% of the patients were suspected to be alpha-thalassemia trait. Preliminary hematology results from the first year of the national premarital program in Qatar further support these results (unpublished data). Our study is the first of its kind in attempting to characterize the molecular spectrum of alpha-thalassemia in Qatar. For this purpose the study population were selected from Qatari school children. According to Qatar's national preschool assessmentprogram, all students are required to undergo routine physical checkup and blood analysis for anemia, prior to the start of their school. Results are then forwarded to the school where the school nurse will review and refer students with low Hb leveland/or low normal Hb along with low MCV values, to the Consultant Pediatrician at Qatar's Pediatric Clinic at the School Objectives:

● Determine the mutation spectrum of alpha-thalassemia in Qatari school children population.

● Making a preliminary assessment of the prevalence of inherited alpha-thalassemia in Qatari school children with hypochromic microcytic red cell with or without anemia.

● Establish molecular diagnostic protocols for diagnosis of alpha-thalassemia in Qatar, more specifically in HMC.

● Improving the healthcare management (treatment options) of individuals with hypochromic microcytic red cell with or without anemia.

● Depending upon the spectrum obtained, making recommendations regarding expansion of the current premarital and genetic counseling services in Hamad Medical Corporation.

Methodology

This was a prospective study that began in May 2012 for duration of two years and extended for an extra year searching for further mutations and analysis. Random samples were selected through the pre-school health assessment program at Qatari public schools. It is mandatory for all students to submit a full blood work-up on admission, to be held on record at their respective schools. The designated health professionals at these schools evaluate the complete blood count (CBC), and identify students with hypochromic mycrocytic red cells with or without anemia. Those with definite clinical and laboratory determination of iron-deficiency anemia are treated first for nutritional anemia. For this study, children that continued to have microcytosis (low MCV) were randomly selected. Hemoglobin (Hb) electrophoresis was performed to rule out other causes of microcytic anemia, including beta-thal. The group was ultimately narrowed down to a pool of 127 individuals with findings highly suggestive of alpha-thal, although not yet molecularly diagnosed. The samples were screened for the presence of the –alpha3.7 deletion and the alpha–5 nt, alphapoly A1 (alphaT-Saudi) and alphapolyA2 nondeletional mutations. A second group of 110 children who attended the pediatric clinic for reasons other than anemia were randomly selected. and included in this study in order to determine the alleles and genotype frequencies of the –alpha3.7 deletion in the Qatari population.

Results

Among the samples of 127 individuals, a total of 50 samples exhibited the 3.7 kb deletion; 38 (30.0%) subjects were heterozygous for the mutation, while 12 (9.4%) subjects were homozygous for the mutation. Only one subject (0.8%) was found to be heterozygous for the alpha–5 nt mutation. Three samples were positive for the alphapolyA1 (alphaT-Saudi) mutation, two (1.6%) of the three were heterozygotes and one was a compound heterozygote with the –alpha3.7 deletion. None of the subjects carried the apolyA2 mutation. Fifteen (11.8%) subjectswith mild indices who tested negative for the presence of the–alpha3.7 deletion were considered normal for alpha-thal, while 58 (45.6%) subjects were negative for all four alpha-thal mutations. These subjects were characterized by severe hypochromic microcytic anemia necessitating the extension of the screening for other alpha-thal mutations by sequencing both alpha-globingenes for nondeletional mutations or by multiplex ligand dependent probe amplification (MLPA) (P140 HBA kit; MRC-Holland, Amsterdam, The Netherlands) (http://www.mlpa.com) analysis of the a locus for large deletions. The 110 individuals who constituted the random sample were subsequently screened for the presence of the –alpha3.7deletion that was the most common alpha-thal mutation in the 127 individuals with hypochromic microcytic anemia. Twenty nine (26.4%) out of 110 samples were found to be heterozygous, while five (4.5%) samples were homozygous for the–alpha3.7 deletion. The –alpha3.7 allele frequency in the Qatari population was calculated from these data as 17.7%. Using this frequency, the expected carrier frequencies in the Qatari population were calculated as 3.13% for homozygotes and 29.13% for heterozygotes.

Conclusion

were found positive for one of the three mutations, the ? α3.7 deletion, αpolyA1 and the α?5 nt mutations. In this pool of individuals, the ? α3.7 deletion was the most common with 9.4% homozygotes, 30.0% heterozygotes and an allele frequency of 19.7%. 57.2% of children failed to exhibit any mutation despite their clinical presentations highly suggest alpha-thalassemia. This suggests the possibility of other existing mutations in Qatari populations that are yet to be elicited. The mutations found in this study are ground breaking for the Qatari medical community, and have provided a solid explanation for patients with findings suggestive of alpha-thal. This study has paved the way for diagnostic testing for alpha-thal in the Qatari pediatric population. This data will be shared in order to establish an algorithm for prevention, treatment and counseling related to alpha-thal in the Qatari pediatric population. This study has provided important clinical diagnostic insight for physicians treating patients suspected of alpha-thalassemia in Qatari pediatric population and also molecular diagnostic tools for laboratories to test such patients.

Background

Development of clinical guidelines in health services is generally considered important for improving and managing the care process (Grimshaw et al., 1995a, Grimshaw et al., 1995b, Grol and Grimshaw 2003, Grol et al., 2004). Clinical guidelines are systematically developed statements designed to help practitioners and patients to make decisions about appropriate health care (Field and Lohr 1992). Higher quality of care and improved cost effectiveness are important goals in guideline development, optimally resulting in improved health (Woolf et al., 1999). Moreover, the process of guideline development addresses the need to decrease variability in professional practice, and practitioners' desire to legitimize their profession in the eyes of external stakeholders (Grimshaw et al., 1995a, Grimshaw et al., 1995b, Grimshaw and Hutchinson 1995, Grol and Grimshaw 2003, Grol et al., 2004). The concept of evidence-based practice, supported by clinical guidelines, is a common aspect of health care today. No reviews have been published which specifically review the effect of strategies to increase the implementation of Physical therapy guidelines. In a study by Rebbeck et al., (2007), the effect of implementation of spinal pain guidelines was reviewed. Although 14 trials were included in the review, only three included Physical therapy interventions Currently there is no formal training or education sessions to unify the Physical therapy practice in the department, which in turn resulting in greater practice variations and results. Grater variability in professional practice directly influences the outcome of patient care. To counteract this, Physical therapy unit, Rumailah hospital, Qatar has developed Physical therapy specific clinical practice guideline called ‘PAAS Guideline’ (Physical Therapy After Acute Stroke) to enhance the effectiveness and efficiency of post acute stroke Physical therapy care. Evidence argues that guideline-adherent care results in better health outcomes, quality of care, shorter treatment period and reduced cost of care. The phase II of the PAAS guideline trail focuses on the adherence of Physical therapists on the implemented guideline through file monitoring to compare its effectiveness before and after the guideline. ‘Physical Therapy After Acute Stroke’ (PAAS) guidelines is a professional Physical therapy guideline for patients with stroke; based on scientific evidence, intended to optimize patient care ‘exclusively’ developed by the Physical therapists of Rumailah hospital. The goal of the PAAS guideline is to improve the quality, transparency, and uniformity of the physical therapy provided to patients whose main diagnosis is a stroke (cerebrovascular accident), throughout the chain of integrated care, by explicitly describing the Physical therapist's management of these patients on the basis of scientific research, adjusted where necessary on the basis of consensus among Physical therapy experts in primary, secondary and tertiary care, as well as associated professions in the field.

Objective

To find out the effectiveness of a structured clinical practice guideline in the quality of care and practice behavior of Physical therapist's practicing in stroke in the Physical therapy department of Rumailah hospital.

Alternative Hypothesis

A PAAS structured clinical practice guideline is an effective way to improve the quality of care and practice behavior of the stroke practicing Physical therapists of Rumailah hospital.

Design

The project was structured in an observational prospective cohort model implemented during the year 2015 in the Physical therapy unit, Rumailah hospital, which will include all the practicing Physical therapists of Physical therapy unit of Rumailah hospital. We have chosen Physical therapists even from other units who are seeing stroke patients at its different stages to maintain the continuum of care and coalesce the practice. We have identified the ‘Health Service Executive (HSE) model of change’ as the suitable model since it is to fit the health care organizations. HSE model of emphasizes 4 major steps: (1) Initiation of change, (2) Planning of the change, (3) implementation stage and (4) Mainstreaming comprises evaluating and learning from the change.

The change process was initiated by January 2015, around 30 Physical therapists from the concerned area were involved in the program. Staff orientation and competency to the guideline were introduced through an in-depth training programs with pre and post-tests, periodical refresher courses and information leaflets.

Method

A subspecialty stroke form was developed as an additional form to be added with the general stroke assessment form from 1 April 2015. The subspecialty stroke form exactly reflects the PAAS guideline in its evaluation and management. It was made mandatory that the sub specialty form has to be attached with the general neurology assessment form when assessing and managing a stroke case with effect from 1 April 2015. A retrospective file monitoring was initiated to understand the practice behaviour before the PAAS guideline implementation by selecting 2 closed files of stroke patients per therapist treated from 1 January to 29 March 2015. Post guideline monitoring was started between 21 June and 30 June 2015 to cover the closed files from 1 April to 29 June 2015. The same monitoring tool was used for both the phases of monitoring. Evaluations or goals where rated as met or not met. Use of at least 80% of the basic neurological and 60% of functional measurement tools were considered as ‘MET’ in the evaluation criteria. At least 5 recommended approaches per domain from any four out of five domains during the whole treatment course as per the assessment or review was decided as ‘MET’ for the Physical therapy management part. In the pre guideline phase total number of outcome measures and total number of approaches were used to reach up the conclusion.

Result

The PASS guideline adherence analysis revealed marked difference in the Physical therapy evaluation and practice of the hemiplegic patients. Since there was no organized systems before the implementation of PAAS guideline, the evaluation and treatment part was in the ‘NOT MET’ status as pre guideline implementation phase the 80 and 60% rule in evaluation phase and 4 out of 5 domain rule in the treatment part couldn't reached. The Guideline Task Force (GTF) decided to go with the direct counting of outcome measures and treatment techniques to compare between the two phases. Comparison of stroke specific outcome measures before and after the guideline implementation revealed that the use of stroke specific outcome measures became 74% post guideline compared to 36% in the pre guideline implementation phase (Fig. 1). Comparison of use of evidence based approaches for stroke care before and after the guideline implementation has shown that 73% post guideline compared to 35% pre guideline implementation (Fig. 2) with an overall 45% gain in evidence based care post guideline implementation (Fig. 3) A paired ‘t’ test was executed to analyses the pre and post file monitoring results. The ‘t’ statistics was observed as, t = 20.003, and p = 0.001; ie, 0.001 probability of this result occurring by chance, under the null hypothesis of no difference (table 1). The null hypothesis was rejected, since p <  0.05.

Conclusion

There is strong evidence (p = 0.001) that the structured guideline improved the practice behavior and quality of care post guideline implementation. In this data set, it improved use of outcome measures and evidence based approaches after the guideline implementation directly reflects the change in practice behavior and quality of care of stroke practicing Physical therapists of Rumailah hospital.

Implication

PAAS guidelines is a professional Physical therapy guideline for patients with stroke; based on scientific evidence, intended to optimize patient care, developed by the guideline task force of Physical therapy unit, Rumailah Hospital. PAAS Guideline offers recommendations for appropriate care. An evaluation of the guideline adherence and practice variations helps to fine tune the Physical therapy care to a highest possible standard of practice. A proper assessment of the relationship between the process of Physical therapy care and outcomes with a comprehensive set of process indicators will be implemented during the year 2016. We strongly believe that by means of systematic approach and implementation we can change the culture of practice so that it can suit and align with the international quality care in evidence based manner there by uplifting the corporation and its vision of becoming an internationally recognized center of excellence in health care. We believe that this ‘small changes will make a big difference in our health care system in the coming years’.

Physical Therapy, Practice behavior, Clinical practice guideline, Adherence

References

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Grimshaw, Jeremy, Martin Eccles, and Ian Russell. “Developing clinically valid practice guidelines.” Journal of evaluation in clinical practice 1.1 (1995): 37–48.

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Grol, Richard, and Jeremy Grimshaw. “From best evidence to best practice: effective implementation of change in patients' care.” The lancet 362.9391 (2003): 1225–1230.

Rebbeck, Timothy R., et al. “A retrospective case-control study of the use of hormone-related supplements and association with breast cancer.” International journal of cancer 120.7 (2007): 1523–1528.

Woolf, Steven H., et al. “Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.” BMJ: British Medical Journal 318.7182 (1999): 527.