Iranian Rehabilitation Journal The official Journal of the University of Social Welfare and Rehabilitation Sciences
Editor-in-Chief Asghar Dadkhah, PhD., Professor University of Social Welfare and Rehabilitation sciences Tehran, Iran [email protected]
Executive Manager Maryam Ranjbar [email protected]
EDITORIAL BOARD Harizuka Susumu, PhD., Professor Kyushu University, Fukuoka, Japan Helander Einar, PhD., President Community Based Rehabilitation Organization, Lisbon, Portugal Hosseiny Seyed Ali, PhD., Assistant professor University of Social Welfare and Rehabilitation sciences, Iran Kamali Mohammad, PhD., Associate professor Iran University of Medical Sciences, Iran Kumar Surender, PhD. Professor Chikushi Jogakuen University, Japan Lotfi Gharahbagh Yunos, PhD., Assistant professor University of Social Welfare and Rehabilitation sciences, Iran McConkey Roy, PhD., Professor University of Ulster, Northern Ireland Mirzamani Syd Mahmood, PhD., Associate professor Baqiyatallah University of Medical Science, Tehran, Iran Nillipour Reza, PhD., Professor University of Social Welfare and Rehabilitation sciences, Iran Reife Carol, PhD., Associate professor Leiden University, Leiden, The Netherlands
Iranian Rehabilitation Journal is an international forum for the publication of peer-reviewed novel papers on the rehabilitation, with two issues published per year. The journal strives to provide its readers with a variety of topics, including: investigations of clinical and basic research in various special needs groups; original articles; hypothesis formation; literature reviews; case reports; short communications, special reports; letters to the editor; discussions of public policy issues and book reviews, methodology in physical and mental rehabilitation, epidemiological studies on disabling conditions and reports on vocational and socio-medical aspects of rehabilitation. Contributions from all parts of the world and from different professions in rehabilitation are welcomed. Please read the "Author Guidelines" carefully for details on the submission of manuscripts, the journal's requirements and standards.
Journal Citation Reports®: ISC(Islamic world Science Citation); IMEMR(Index Medicus for WHO); Magiran; Iran Medex; DOAJ (Directory of Open Access Journals)
Editorial Contact Iranian Rehabilitation Journal (IRJ) University of social welfare and rehabilitation sciences [email protected] Evin, Kudakyar Ave., Tehran - 1985713831, Iran http://www.rehabj.ir Tel/Fax: +98-21-2218-0082
EDITOR’S NOTE
IRJ (Iranian Rehabilitation Journal) is now included in the Directory of Open Access Journals.
Iranian Rehabilitation Journal is the only English journal in Rehabilitation and research in Middle East. Number fourteen of this journal is going to be published with variety of articles in rehabilitation issues. We welcome original articles, reviews and case reports. Open Access Journal is a journal that uses a funding model that does not charge readers or their institutions for access. DOAJ - Directory of Open Access Journals is one of them and it is our pleasure to announce that IRJ has been added to the directory of DOAJ. You can reach to Journals and articles from http://www.doaj.org/. University of social welfare and Rehabilitation sciences is supporting IRJ to facilitate researches and scholars by updating articles online. Please do visit IRJ website regularly www.rehabj.ir.
Asghar Dadkhah, PhD. Editor-in-Chief
CONTENTS
Original Articles A comparison between three methods of language sampling: Freeplay, narrative speech and conversation 4 Yasser Rezapour Mirsaleh, Kianoosh Abdi, Hossein Rezai, Parisa Aboutorabi Kashani
The state of Deterministic Thinking among mothers of autistic children 10 Mehrnoush Esbati
Expressive language development in 45 cochlear implanted children following 2 years of implantation 14 Seyed Basir Hashemi,; Leile Monshizadeh
Physical Appearance Concern Questionnaire (PACQ) in Iranian population 18 Katayoun Khadem, Asghar Dadkhah, Vahid Kazemi
Gender difference in TEOAEs and contralateral suppression of TEOAEs in normal hearing adults 22 Farzaneh Zamiri Abdollahi; Yones Lotfi
The impact of coping strategies on burden of care in chronic schizophrenic patients and caregivers 26 of chronic bipolar patients. Morteza Khajavi, Mansoureh Ardeshirzadeh, Susan Afghah, Behrooz Dolatshahi
Effect of Time Constraind Induced Therapy on Function, Coordination and Movements of Upper 32 Limb on Hemiplegic adults Masoud Gharib, Hooman Ghorbani, Mehdi Abdolvahab, Nader Fallahi, Masoud Kasechi
Challenge of Private Rehabilitation Centers and Welfare Organization (Behzisti) 37 Roghiye Akbari, Mohammad Kamali, Hasan Ashayeri, Narges Shafaroodi
Identification of Genetic Polymorphism Interactions in Sporadic Alzheimer’s disease Using Logic 45 Regression Najimeh Tarkesh Esfehani, Mahdi Rahgozar, Akbar Biglarian, Hamidreza Khorram Khorshid
Dental status and DMFT index in 12 year old children of public care Centers in Tehran 51 Nasim Shafiezadeh; Farin Soleimani; Nahid Askarizadeh; Saeedeh Mokhtari; Reza Fatehi
Effects of Task Related Training and Hand Dominance on Upper Limb Motor Function in Subjects 55 with Stroke Mohammed Azam Khan; Fuzail Ahmad; Jamal Ali Moiz, Majumi M.Noohu
Reviews/Short communication Spasticity: a review of methods for assessment and treatment 60 Mohammad Amouzadeh Khalili ; Masoumeh Rasulzadeh
Patient Centered Model of Care - A Positive Impact on Treatment Outcome in a Rehabilitation 65 Hospital in Saudi Arabia Rana Siddiqui ; Rober A. Asirvatham; Irfan Shaiza
Case Report Efficacy of Mindfulness-Based Cognitive Therapy on Depressed Mothers with Cerebral Palsy Children 69 Zahra Sedaghati Barogh; Jalal Younesi, Fateme Shoaei, Siyamak Tahmasebi Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Original Article
A comparison between three methods of language sampling: Freeplay, narrative speech and conversation
Yasser Rezapour Mirsaleh Allameh Tabatabaee University, Tehran. Iran Kianoosh Abdi University of social welfare and rehabilitation sciences, Tehran. Iran Hossein Rezai* Semnan University of Medical Sciences,.Samnan, Iran Parisa Aboutorabi Kashani Azad University Central Tehran Branch,.Tehran, Iran
Objectives: The spontaneous language sample analysis is an important part of the language assessment protocol. Language samples give us useful information about how children use language in the natural situations of daily life. The purpose of this study was to compare Conversation, Freeplay, and narrative speech in aspects of Mean Length of Utterance (MLU), Type-token ratio (TTR), and the number of utterances. Method and Materials: By cluster sampling method, a total of 30 Semnanian five-year-old boys with normal speech and language development were selected from the active kindergartens in Semnan city. Conversation, Freeplay, and narrative speech were three applied language sample elicitation methods to obtain 15 minutes of children’s spontaneous language samples. Means for MLU, TTR, and the number of utterances are analyzed by dependent ANOVA. Results: The result showed no significant difference in number of elicited utterances among these three language sampling methods. Narrative speech elicited longer MLU than freeplay and conversation, and compared to freeplay and narrative speech, conversation elicited higher TTR. Conclusion: Results suggest that in the clinical assessment of the Persian-language children, it is better to use narrative speech to elicit longer MLU and to use conversation to elicit higher TTR. Keywords: Conversation, Freeplay, narrative speech, Language sampling.
Submitted: 10 Apr 2011 Accepted: 12 Sep 2011
Introduction collect language samples, cannot be ensured by The spontaneous language sample collection and applying standardized language tests as the only analysis has an important role in evaluation of method of language assessment. That is because children's language skills (1-4). Because of the representativeness can only be achieved by engaging limitations of standardized language tests and the the child and the conversational partner in a real lack and unavailability of these tests in Persian conversation on topics of interest to the child (5). language, the necessity for application of the Standardized language tests are highly structured spontaneous language sample analysis in the and cannot ensure obtaining a representative sample assessment of language skills of Persian children is of child’s language. There are several common obvious. Since language sampling embraces both the methods of language sample elicitation. Among content and context of language use, it can present these methods, Conversation, freeplay, and more detailed information for planning intervention. storytelling are the prominent ones (6).These Also, representativeness and effect of conversational methods elicit language samples containing different context that are of special importance when trying to linguistic items.
* All correspondences to:Hossein Rezai; Email:
Iranian Rehabilitation Journal 5 language children. Due to the effect of age, gender, Language samples of the 30 children were elicited culture and language on features of language using three methods of language sample elicitation samples elicited by the studied methods, we limited including conversation, freeplay, and storytelling. the participants to five year old Persian language The language samples, lasting 15 minutes, were children of Semnan city. Concerning the obvious obtained by collecting five minutes of spontaneous importance of obtaining spontaneous language language samples elicited using each three samples in the assessment of children with language mentioned methods of language sampling. disorders and due to the lack and unavailability of standardized language tests in Persian language, Methods of language elicitation Present study aimed to set the stage for the future Methods of eliciting language samples which used in development of better assessment protocols in the present study are described below. Persian language. According to the electronic search of the authors of the present study, in no study in Conversation: Iran, comparing of conversation, freeplay and 1. The researcher asked the child several questions narrative speech was done on the aspects of about his family, his friends, school activities, language elicited. Comparing of the language and favorite television programs. samples obtained by these three methods of 2. The researcher gave verbal imperatives to the language sampling in Persian, can guide our child such as “please tell me about toys or clinicians to select the best method of eliciting a puppets you like to play with. special linguistic feature. The following questions 3. The researcher encouraged the child to explain were considered in the present study: how to play a game. 1. Among conversation, freeplay, and narrative 4. The researcher requested the child to describe speech which one can elicit more number of one picture from a set of pictures and then utterances? researcher guessed which picture has been 2. Among conversation, freeplay, and narrative described (10, 11,20). speech which one can elicit longer MLU? 3. Among one can elicit more MLU which one Freeplay: can elicit more TTR? In this study, language samples elicited during researcher-child interactions when the child played Method with age-appropriate toys or puppets (2, 7, 21).To Participants decrease the influence of nonlinguistic context on Statistical population of the present study included children’s language output, same toys or puppets all the five-year-old Persian language boys resident were used for all the participants. in Semnan City in 2007. By cluster sampling Narrative speech: method, a total of 30 Semnanian five-year-old boys 1. The researcher requested the child to tell a story with normal speech and language development were about a particular topic. selected from Semnan kindergartens. To this aim, 2. The researcher requested the child to tell a folk we first listed all the active kindergartens of the city story (for example, Bozboz-e-Ghandi story in and then randomly selected 6 of them. Finally, Iran. among the five-year-old boys enrolling each of these 3. The researcher gave a prompt to the child such six kindergartens, five boys were randomly selected. as picture series and then requested him to tell a The boys between the ages of four years and six story about it. month and five years and six month were selected as 4. The researcher told a story and then requested five-years-old boys. Before the children enrollment the child to retelling it (10, 11,20). in the kindergartens, they had their mothers as their To keep the situations similar for all participants, we primary caregivers. Written consent for the used the same tasks and materials in administering children’s participation in the study was acquired each method. In conversation, we asked the same from their mothers. Identification of children with questions for interacting with the participants. In normal hearing, speech, and language development freeplay, we used the same toys, and in narrative were accomplished by interviewing the mothers and speech, we used the same picture series and the kindergarten staff. requested all participants to tell us about the same folk story.
6 Vol. 9, No. 14, Oct. 2011 Criteria and data analysis c) Type-Token ratio (TTR): Type-Token ratio was Language samples elicited by each method were calculated by dividing the number of different audiotape recorded and were transcribed by the first words (types) by the total number of words author. Language samples elicited by conversation, (tokens) (22). freeplay, and narrative speech were compared in To evaluate the reliability of language samples aspects of three language evaluation criteria): analysis, third author of the present study randomly Number of utterances, b) Mean length of utterances, analyzed 20 language samples again. Internal and c) Type-Token ratio. validity for number of utterance was 100%, for a) Number of utterances: number of utterance is MLU was 100% and for TTR was 98%. the sum of single words, single phrases and dependent clauses. Results b) Mean length of utterances (MLU): This The mean and standard deviation of the number of criterion was acquired from dividing the utterances, MLU, and TTR of language samples number of morphemes used in each language elicited by conversation, freeplay, and narrative sample by the total number of utterances speech are presented in table 1. elicited.
Table 1. Mean and Standard Deviation of Number of utterances, MLU, and TTR of language samples elicited by conversation, freeplay, and narrative speech Methods N Number of utterances MLU TTR Mean SD Mean SD Mean SD Conversation 30 67.07 23.26 3.32 0.68 0.63 0.13 Freeplay 30 54.5 24.48 3.28 0.99 0.53 0.12 Narrative Speech 30 57.4 20.05 4.02 1.26 0.49 0.12
The results of repeated-measures one-way analysis conversation, freeplay, and narrative speech in of variance (ANOVA) to compare mean of number of utterances, presented in table 2.
Table 2. Results of ANOVA for comparing number of utterances of language samples elicited by conversation, freeplay, and narrative speech SS df MS F P value Treatment (tre) 2599.22 2 1299.6 3.01 0.056 Between Subjects (BS) 18844.2 29 649.8 Within Subjects (WS) 27724.82 60 426.08 Residual (R) 25125.6 58 433.2 Total (T) 74293.85 89
There was no significant difference among three Compared by elicited MLU, a significant difference methods of language sample elicitation in the among three methods of language sample elicitation number of elicited utterance F (2, 58)=3.01, was observed (F (2, 58)=5.41, P=0.07) (table 3). (P=0.56).
Table 3. Results of ANOVA for comparing MLU of language samples elicited by conversation, freeplay, and narrative speech SS df MS F P value Treatment (tre) 10.4 2 5.2 Between Subjects (BS) 38.28 29 1.32 Within Subjects (WS) 66.08 60 1.1 5.41 0.007 Residual (R) 55.68 58 0.96 Total (T) 170.45 89
The Tukey HSD test was used to pairwise 3.68, P>0.5), and narrative speech and freeplay comparison between the methods. There was a (HSD (3, 60) = 3.89, P<0.5). MLU elicited by significant difference between MLU elicited by narrative speech method was significantly longer narrative speech and conversation (HSD (3, 60) = than MLU elicited by conversation and freeplay.
Iranian Rehabilitation Journal 7 There was no significant difference between MLU and freeplay (HSD (3, 60) = 3.44, P<0.5) and elicited by conversation and freeplay (HSD (3, 60) conversation and narrative speech (HSD =0.44, P>0.5). (3,60)=4.28, P<0.1).TTR elicited by conversation The data of Table 4 show that there was a significant method was significantly more than TTR elicited by difference among TTR elicited by three language freeplay and narrative speech. The results of Tukey sampling methods (F (2,58)= 6.73, P=0.01). HSD test showed that no significant difference Pairwise comparisons showed a significant between TTR elicited by freeplay and narrative difference between TTR elicited by conversation speech (HSD (3, 60) =1.37, P>0.5).
Table 4.Results of ANOVA for comparing TTR of language samples elicited by conversation, freeplay, and narrative speech SS df MS F P value Treatment (tre) 0.31 2 0.15 Between Subjects (BS) 0.81 29 0.028 Within Subjects (WS) 1.59 60 0.026 6.73 0.001 Residual (R) 1.28 58 0.022 Total (T) 3.99 89
Conclusion For language sampling, from 50 to 100 utterances The results of the present study indicated that there are considered as sufficient to have a representative was no significant difference among number of sample (1, 25). In this study more than 60 utterances utterances elicited by conversation, freeplay, and provided by the three elicitation methods. Hence, all narrative speech. This finding is not consistent with three methods provided sufficient utterances for those of a similar study indicative of higher number clinical use. Results showed that compared to of utterances elicited by freeplay than by conversation and freeplay, narrative speech yelled conversation (11). However, similar to the present longer utterances. This finding is consistent with study, the results of the mentioned study (11) those of other recent studies (11, 26). Therefore, to showed that there was no significant difference have a language sample with longer utterances, it is between number of utterances elicited by suggested to use narrative speech which according to conversation and narrative speech. Inconsistency the result of this study, elicites more complex between the results of present study and previous language. In the other hand, compared to narrative studies may be caused by individual differences speech andfreeplay, language samples provided by between participants. Some children are extravert conversation resulted in more TTR. This finding is and talkative, and therefore have high number of in agreement with a smillar study (27). Hence, to utterances, but other children may be introvert and have a language sample with more TTR it is better laconic and therefore have low number of to use conversation for language sampling. utterances. Concerning the evident influence of The results of the present study suggest an child’s conversational partner on his communication implication for clinical practice. Apart from the aspects (23), difference between the investigators of observed differences in freeplay, conversation, and this and the previous studies could be another reason narrative speech methods, it is suggested to apply all for the reported inconsistency. Results of a study these three methods when trying to collect their showed that a difference up to four words in language sample to elicit more language abilities of utterance length in homogenous populations can be children. This study sets the stage for future observed by changing the researcher eliciting the investigations on spontaneous language analysis of child’s language sample (24). Also, change in the Persian children. It is suggested to include children topic of conversation results in difference in the with language impairments in the future studies, number and the length of utterances elicited during because the participants of the present study were language sampling. So, difference in the topic of selected among typically developing children who conversations and stories could be another reason for expected to have higher language proficiencies when the inconsistent results. To reduce the influence of compared to language impaired children. To change in topic of conversation and stories, in the increase the extent to which the results of the present present study the applied conversational topics and study can be generalized, inclusion of children from questions for language sampling kept constant different ages and inclusion of girls in the similar among all the participants. future studies are suggested.
8 Vol. 9, No. 14, Oct. 2011
References: 15. Miller JF. Assessing Language Production in Children: 1. Evans JL, Craig HK. Language sample collection and Experimental Procedures. Allyn & Bacon; 1991. analysis: interview compared to freeplay assessment 16. Agha Rasuli Z. [syntactic and morphological features of 3- contexts. J Speech Hear Res. 1992;35 (2):343-53. 5 year old Persian language children in Tehran (Persian)]. 2. Dunn M, Flax J, Sliwinski M, Aram D. The use of Iran University of Medical Sciences; 1996. spontaneous language measures as criteria for identifying 17. Oriadi Zanjani MM, Ghorbani R. [Speech quality indices in children with specific language impairment: an attempt to 4-5 year old typically developing Persian language children reconcile clinical and research incongruence. J Speech Hear in Semnan, Birjand, and Tonekabon cities(Persian)]. Res. 1996; 39 (3):643-54. Journal of Mazandaran University of Medical Sciences 3. Price LH,HendricksS, Cook C. Incorporating computer- (JMUMS). 2004; 15(50):90-6. aided language sample analysis into clinical practice. Lang 18. Maryam AB. [Mean length of utterance in typically Speech Hear Serv Sch. 2010; 41 (2):206-22. . developing children in Shahre Babak. Tehran 4. Evans JL, Miller J. Language sample analysis in the 21st (Persian)].Thesis for bachelor in Linguistics. Iran century. Semin Speech Lang. 1999; 20 (2):101-15; quiz 16. University of Medical Sciences 2000. 5. Owens RE. Language Disorders: A Functional Approach to 19. Khoddam A. [Mean length of utterance in 4-5 year old Assessment and Intervention. 5th edition: Allyn & Bacon; typically developing children in region 3 of Tehran 2009. (Persian)]. Thesis for bachelor in Linguistics. Tehran. Iran 6. Longhurst T,GrubbS& L. A Comparison of Language University of Medical Sciences; 2001. Samples Collected in Four Situations. Lang Speech Hear 20. Atkins CP,CartwrightLR. An investigation of the Serv Sch. 1974;5:71-8. effectiveness of three language elicitation procedures on 7. Crystal D, Fletcher P, German R. Grammatical Analysis of Head Start children. Lang Speech Hear Serv Sch. 1982;13 Language Disability. New York: Elsevier; 1976. (1):33-6. 8. Brinton B, Fujiki M. setting the context for conversational 21. Craig HK, Washington JA. An assessment battery for language sampling. In: SchreinerE. The Best Practices in identifying language impairment in African American School Speech Language Pathology: an Antonio, TX: children. J Speech Lang Hear Res. 2000; 43 (2):366-79. Psychological Corp. p. 9-19. 22. Nilipour R. [objective indices for assessing speech quality 9. Bacchini S,Kuiken F, Schoonen R. Generalizability of (Persian)]. J linguistics. 2002;1:40-50. spontaneous speech data: the effect of occasion and place 23. Nippold MA. Language development during adolescent on the speech production of children. First Lang. 1995; 15 years: Aspects of pragmatics, syntax, and semantics. Topics (44):131-50. Lang Disord. 2000;20 (2):15-28. 10. Wren C. Collecting language sample from children with 24. Cowan PA, Weber J, Hoddinott BA, Klein J. Mean length syntax problems. Lang Speech Hear Serv Sch. 1985; 16:83- of spoken response as a function of stimulus, experimenter, 102. and object. Child Dev. 1967;51 (1):78-9. 11. Southwood F, Russell AF. Comparison of conversation, 25. Kemp K. Clinical language sampling practices: results of a freeplay, and story generation as methods of language survey of speech-language pathologists in the United sample elicitation. J Speech Lang Hear Res. 2004; 47 States. Child Lang Teach Ther. 1997; 13 (2):161-76 (2):366-76. 26. Wagner CR, Nettelbladt U, Sahlen B, Nilholm C. 12. Hegde MN. Treatment Protocols for Stuttering. Plural Conversation versus narration in pre-school children with Publishing Inc; 2006. language impairment. Int J Lang Commun Disord. 2000; 35 13. Gibbons J, Anderson DR, Smith R, Field DE, Fischer C. (1):83-93. Young children's recall and reconstruction of audio and 27. Zanjani MMO, Ghorbani R, Keykhah F. [Standardization audiovisual narratives. Child Dev. 1986; 57 (4):1014-23. of speech quality indices in 2-5 year old typically 14. Wellen C, Broen P. The interruption of young children's developing Persian children in Semnan city (Persian)]. responses by older siblings. J Speech Hear Disord. 1982;47 Semnan. Semnan University of Medical Sciences; 2005; 7 (2):204-10. (3-4): 177-182
Iranian Rehabilitation Journal 9 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Original Article
The state of Deterministic Thinking among mothers of autistic children
Mehrnoush Esbati, Msc* University of social welfare and Rehabilitation sciences, Tehran, Iran
Objectives: The purpose of the present study was to investigate the effectiveness of cognitive-behavior education on decreasing deterministic thinking in mothers of children with autism spectrum disorders. Method and Materials: Participants were 24 mothers of autistic children who were referred to counseling centers of Tehran and their children’s disorder had been diagnosed at least by a psychiatrist and a counselor. They were randomly selected and assigned into control and experimental groups. Measurement tool was Deterministic Thinking Questionnaire and both groups answered it before and after education and the answers were analyzed by analysis of covariance. Results: The results indicated that cognitive-behavior education decreased deterministic thinking among mothers of autistic children, it decreased four sub scale of deterministic thinking: interaction with others, absolute thinking, prediction of future, and negative events (P<0.05) as well. Discussions: By learning cognitive and behavioral techniques, parents of children with autism can reach higher level of psychological well-being and it is likely that these cognitive-behavioral skills would have a positive impact on general life satisfaction of mothers of children with autism. Key words: Cognitive-Behavior Education, mothers of autistic children, Deterministic Thinking
Submitted: 10 Feb 2011 Accepted: 22 Jul 2011
Introduction wives for creating this condition in their children Raising a child is stressful for all parents; however especially if the child is male (5). parents of children with disabilities may have Parents are always at the centre of treatment. Their additional sources of stress (1). Autism is one of the session is central to the cure. All attempts at disorders that make parents lives more difficult. planning intervention and treatments should involve Gray and Holden (2) found that mothers of autistic a close working relationship between the children reported more parent and family problems professional and the family, always keep in mind the and perceived negative child characteristics than the need of filling the gap between science, culture, mothers of children with Down syndrome or no beliefs and the individual needs of children and their disability. Also Olsson and Hwang cited in Baker- families (6). Ericzen(1) reported that mothers of children with The rehabilitation and education of children with autism showed higher depressive level than mothers autism is the focus of the arrangements in the special of children with no disability. It was also stated that education centers; however, the other family parents of children with autism had higher members, especially the mothers who are the prime depression than parents of children with mental caregivers need to be informed and supported for retardation, Down syndrome and no disability (3). both the well-being of the family and the child. When the mothers and fathers of children with As in our society mothers are the primary caregivers autism were the focus of the study, mothers of of the children, they have more difficulties in raising children with autism were found to have more stress and daily care of the child than fathers. Also mothers than fathers (4). Spousal blaming may be another have responsibilities related to other family member factor that causes stress in mothers of children. needs and their own personal needs which may Fathers of children with autism may blame their cause greater stress and problems for them. All of * All correspondence to: Mehrnoosh Esbati, E-mail:
Table 1. K-S test for normality of demographic variables distribution Demographic Variables Experimental Group Control Group K-S test P value K-S test P value Age 0.859 0.452 1.24 0.091 Level of education 0.956 0.320 0.815 0.520 Marriage duration 0.774 0.587 0.815 0.520
Iranian Rehabilitation Journal 11 Level of education in experimental and control scores, F score of absolute thinking, negative events, groups compared by Chi-square test and there was future prediction, interaction with others and no significant difference between two groups. Also deterministic thinking is significant and shows that age and marriage duration were compared by using cognitive-behavioral education has decreased independent T-test and there was no significant deterministic thinking and four sub scale of it among difference regarding age and marriage duration mothers of autistic children with significance values between two groups. of P<0.05. Considering the outcome of analysis of covariance which are shown in Table 2; after controlling pre test
Table 2. Analysis of covariance for effectiveness of cognitive-behavioral education Source Sum of squares df Mean squares F P value Pre test 64.37 1 64.37 53.45 0.001 Absolute thinking Intervention 164.23 1 164.23 136.37 0.001 Pre test 82.65 1 82.65 44.58 0.001 Negative events Intervention 228.63 1 228.63 123.33 0.001 Pre test 58.91 1 58.91 28.28 0.001 Prediction of future Intervention 105.94 1 105.94 50.85 0.001 Pre test 55.35 1 55.35 28.71 0.001 Interaction with others Intervention 92.37 1 92.37 47.91 0.001 Pre test 83.08 1 83.08 49.14 0.001 Deterministic thinking Intervention 153.95 1 153.95 91.06 0.001 * P<0.05
Discussion learn how to manage their anger (14). The purpose of this study was to investigate the Since mothers of children with autism often spend effectiveness of cognitive-behavioral education on all of their time to do parenting or work obligations, decreasing deterministic thinking among mothers of they have little time to do things that they enjoy, so autistic children. by doing pleasant activities they probably reached In cognitive intervention phase, education was more positive feelings about themselves and life. focused on revision of incorrect beliefs and Johnston & Goldberg also indicated the positive cognitions. It seems that cognitive revisions caused effect of doing pleasurable activities on mothers.(15) reduction of annoyance and anger, increased Finally, mothers of disabled children are required to attention to positive aspects of child behaviors, be assertive in discipline situations with their decreased cognitive distortions such as mind children, in advocating for their children’s reading, foretelling, negative labeling, and educational needs, and in responding to critical deterministic thinking. To decrease deterministic family members. So assertiveness training is useful thinking specifically Test of Reality technique was for them. educated and it seems this technique helped The parents of children with autism often feel mothers’ perceive their lives realities and thus hopeless and blame themselves for the situation (16) absoluteness and equalities in their mind were and may have stress, depression, and anxiety. So by decreased. Also the cognitive restructuring module learning cognitive and behavioral techniques they was helpful in changing negative expectations and can reach higher level of psychological well-being attributions related to child behavior that may and it is likely that these cognitive-behavioral skills influence parenting as treatment response. would have a positive impact on general life Behavioral education phase consists of relaxation satisfaction of mothers of children with autism, training, increasing pleasurable activities, and regardless of their current levels of depressive assertiveness training. The relaxation techniques symptoms or anxiety. helped mothers be relaxed during punishment Besides the interventions in cognitive-behavioral situations and ignore mildly inappropriate behaviors. education, mothers stated that concepts and Also mothers expressed that they could control their techniques were clear and easy to understand. Also anger better. Sevin also showed that the most they appreciated the trainers’ communication and mentioned issue by mothers of children with autism were satisfied to speak with the other mothers with was related to anger management and they need to the same problems.
12 Vol. 9, No. 14, Oct. 2011 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
References 9. Younesi J. The role of cognitive distortion (Deterministic 1. Baker-Ericzn MJ, Brookman-Frazee L, Stahmer A. Stress thinking) on Psychological pathology. J. Iranian Psychol. Levels and Adaptability in Parents of Toddlers With and Assoc. 2004;3(12):73–86. Without Autism Spectrum Disorders. Research and Practice 10. Honarian M, Younesi J, Shafiabadi A, Nafissi G. “The for Persons with Severe Disabilities. 2005;30(4):194–204. impact of couple therapy based on attachment” in 2. Gray DE, Holden WJ. Psycho-social well-being among the deterministic thinking and marital satisfaction among parents of children with autism.Journal of Intellectual and couples. International Journal of Psychology and Developmental Disability. 1992 Jan;18(2):83–93. Counselling. 2010;2(6):91–9. 3. Yirmiya N, Shaked M. Psychiatric disorders in parents of 11. Chronis AM, Gamble SA, Roberts JE, Pelham WE. children with autism: a meta-analysis. Journal of Child Cognitive-behavioral depression treatment for mothers of Psychology and Psychiatry. 2005;46(1):69–83. children with attention-deficit/hyperactivity 4. Moes D, Koegel RL, Schreibman L, Loos LM. Stress disorder.Behavior therapy. 2006;37(2):143–158. Profiles For Mothers And Fathers Of Children With 12. Baron J. Thinking and deciding [Internet].Cambridge Autism. Psychological Reports. 1992 Dec;71(3f):1272–4. University Press; 2000. 5. Trigonaki N. Parents of children with autism and the five 13. Younesi J, Mirafzal A. Development of deterministic basic needs. International Journal of Reality Therapy. thinking questionnaire. th European congress of 2002;21(2):13–4. psychology. Prague Czech Republic. 2007. 6. Schulman C, Zimin R, Mishori E. Concluding Comments 14. Sevim B. The effects of stress management program for Chapter 16 inSchopler E, Yirmiya N, Shulman C, Marcus mothers of children with autism [Internet]. Middle East LM, editors. The Research Basis for Autism Technical University; 2007 [cited 2013 Feb 11]. Available Intervention.1st ed. Springer; 2001. from: http://etd.lib.metu.edu.tr/upload/12608638/index.pdf 7. Sommers-Flanagan J, Sommers-Flanagan R. Counseling 15. Johnston E, Goldberg S, Morris S, Livenson J. Stress in UK and psychotherapy theories in context and practice: Skills, families conducting intensive home-based behavioral strategies, and techniques [Internet]. Wiley; 2012 [cited intervention for their young children with autism and Down 2013 Feb 11]. Available from: syndrome. Journal of Autism and Developmental Disorder. http://books.google.com/books?hl=en&lr=&id=Qt0DK0Ps 2001;31:327–36. mHgC&oi=fnd&pg=PR11&dq=Counseling+and+psychoth 16. Fleischmann A. Narratives Published on the Internet by erapy+Theories+in+context+and+practice+Sommers- Parents of Children With Autism What Do They Reveal Flanagan&ots=fRcM2kv9Rf&sig=Gi9uQGrVDlLGr7G_V and Why Is It Important? Focus Autism Other DevDisabl. R-1zCvLmTw 2004 Feb 1;19(1):35–43. 8. Warner R. Environment of Schizophrenia: Innovations in Practice, Policy and Communications. Brunner-Routledge; 2000.
Iranian Rehabilitation Journal 13 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Original Article
Expressive language development in 45 cochlear implanted children following 2 years of implantation
Seyed Basir Hashemi, MD; Leile Monshizadeh*, MSc; Shiraz University of medical sciences,Shiraz, Iran
Introduction: Profound hearing loss encounters children with delay in speech and language. As it is known language acquisition in young deaf children is a lengthy process, but cochlear implanted children have better spoken language skills than if they had not received the device. According to the importance of cochlear implant in deaf child's language development, this study evaluates the effect of different variables on child's language performance. Method and Material: 45 cochlear implanted children were tested, all of whom had used the device for at least 2 years. In order to evaluate the children, the NEWSHA test which is fitted for Persian speaking children was performed and language development of the children was compared through stepwise discriminative analysis. Results: After evaluation of the effect of different variables like child's age of implantation, participating in rehabilitation classes, parent's cooperation and their level of education, we came to a conclusion that the child's age of implantation and rehabilitation program significantly develop the child's language performance. Discussion: The value of cochlear implant in improvement of deaf children in speech language perception , production and comprehension is confirmed by different studies which have been done on cochlear implanted children. Also, the present study indicates that language development in cochlear implanted children is highly related to their age of implantation and rehabilitation program. Key words: Language development, Expressive language, Cochlear implant, Age, Rehabilitation
Submitted: 04 Dec 2010 Accepted: 11 Apr 2011
Introduction variables seem to have critical effects on linguistic Children with significant congenital or prelingual performance after implantation. deafness shown to have noticeable delays in their For some, a cochlear implant allows the full mastery of all aspects of the spoken language (1,2). development of linguistic competence and provide When hearing aids provide little or no benefit, marked benefits in a wide range of psychological cochlear implants seem to provide oral access to and social abilities, whereas others remain language language. As the acquisition of spoken language by delayed or develop a functional but imperfect young deaf children is a lengthy process, measuring command of language(5). This may depend on outcomes in those with implant requires time. various factors like child's age of implantation,… . Preliminary data suggest that the cochlear implanted So, this study is done with the aim of the evaluation children have better spoken language skills than if of the impact of child's age of implantation, they had not received implants (3, 4). It is because of participating in rehabilitation classes, parent's the fact that cochlear implants apparently restitute cooperation and their educational level on language the inner ear functions and increase consciousness of development of 6 years old cochlear implanted pre- and post lingual deaf children (5). However, not children, who received the device at least 2 years all deaf cases make equal benefits from the before. implantation of this electronic device and several
* All correspondences to: Leile Monshizadeh; Email:
Table 1. The effect of different variables on child's expressive language Wilks' Lambda Exact F Step Entered Statistic df1 df2 df3 Statistic df1 df2 Sig. 1 class .443 1 1 43.000 54.156 1 43.000 .001 2 age1 .405 2 1 43.000 30.895 2 42.000 .001
Table 2. Analysis of the variables Step Tolerance F to Remove Wilks' Lambda 1 class 1.000 54.156 class .998 46.750 .855 2 age1 .998 3.937 .443
According to the above tables, the child's In addition, the standardized canonical discriminant improvement in expressive language was highly function coefficient was -0.380 with age and 0.942 related to the age of implantation and his with participation in classes. Based on the participation in rehabilitation classes. Also, the discriminant function which included child's age of Eigen value=1.47, Wilks' lambda=0.405 and implantation and participation in classes, 93.3% of p<0.001 confirmed this finding. the predictions in discriminant analysis were correct predictions.
Table 3. Child's age of implantation and rehabilitation class Predicted Group Membership group Total 0 1 0 27 2 29 Count 1 1 15 16 Original 0 93.1 6.9 100.0 % 1 6.2 93.8 100.0
Iranian Rehabilitation Journal 15 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Discussion children, with no great changes in performance after Cochlear implants enable different degree of 6 months of experience; the largest performance improvement for deaf patients in the areas of speech occurred one year after operation and rehabilitation, and language perception, production and followed by steady improvement. comprehension depending upon the extent of their In another study,100% of phoneme detection was hearing loss and other variables (5). According to achieved 3 months after implantation in children the present study, two important factors that have with prelingual deafness, whereas both identification significant impact on child's performance after of closed-set word and sentence and open-set cochlear implantation are the child's age of recognition increased gradually, reaching 100% and implantation and his participation in rehabilitation 80% respectively, by 48 months of implantation and classes. In other word, rehabilitation(12). the younger children who completely participated in The primary role of cochlear implant is to enable rehabilitation program developed in expressive speech perception. One of the secondary important language acquisition significantly. Over the past roles is to let the speech production and help patients several years , the lower age limit for implantation acquire and produce consonants and vowel features has decreased, with the current age limit of 24 which are difficult for individuals with profound months. At birth, the cochlea has already reached hearing loss. Language development in implanted adult size and the related structures are appropriately pre lingually deaf children may be significantly developed by the age of two (6). However, faster than predictions based only on maturation of considering the critical periods for auditory system unimplanted peers would suggest. At the 12 months and language acquisition(7) and the negative post operative interval, expressive language scores correlation between age at onset of deafness and the have been shown to be higher than the predicted development of speech perception, speech corresponding scores based on non-operated peers- production and language competence following an this effect was not seen at the 6 months interval. implantation, it is clear that younger children can Although, implanted children were delayed derive significant benefits from an implantation (6). compared to normal hearing children at each interval Implantation may also result in better speech tested, their rate of language growth matched that of perception and overall linguistic performance in hearing controls. What implanted children have children as young as 16 months (8), probably gained in expressive language were similar to those because it reduces the language development delay. expected from hearing children and more than those A study in 1997 indicated that gains in receptive and expected from unimplanted deaf children at each expressive language are highly related to children's testing interval from 6 months to 2.5years after use of the device and participation in rehabilitation implantation. There is however, significant program. The two discussed variables will help the interpersonal variability in linguistic abilities cochlear implanted children in language following the operation, with some patients reaching development similar to that is observed in normal near normal language level, whereas others remain hearing children (9). delayed and show a wide gap between linguistic age The patients response therefore progress from a and chronological age(3). Support from home and phase of sound detection to speech discrimination to school, (re) habilitation, and education are essential the ability to repeat fragments of speech and finally factors that determine linguistic improvement (7, 9) to true understanding of speech (10). and permit the achievement of adequate phonetic Cochlear implants may also make it possible to have and phonological competencies. An implantation access to auditory perceptual information otherwise should be done in case that the cochlear implant unavailable. Speech perception is enhanced by center can offer multidisciplinary team support increasing the auditory signals. Research results of before the operation, as well as immediate and speech perception tests, one year following intensive speech rehabilitation in which both parents implantation were significantly higher than pre- and teachers must cooperate (10). implantation observations in a majority of The rehabilitation program may take months and prelingually deaf children, even when preoperative lasts longer for prelingually than postlingually deaf levels suggested a limited verbal ability(5). patients (13).To develop hearing and speech Miyamoto et al (11), also showed a pattern of word abilities, patients must receive adequate stimulation. identification development in their implanted The habilitations should focus on the use of audition
16 Vol. 9, No. 14, Oct. 2011 to optimize language development and production Acknowledgment: skills. Parents are encouraged to preferentially use We thank parents and children who cooperated to do audition in their interactions with children (14) the test. and guide them into auditory-verbal education and linguistic interactions on a daily basis (15). Finally, Conflict of interests: The authors declare that they either oral (speech, listening) or total (sign plus have no conflict of interests. speech and listening) modes of communication may be applied to help the child being improved in learning language.
References 10. Waltzman SB, Cohen NL, Spivasl L, Ying E, Brachett 1. Geers A,Moog J. Spoken language results: vocabulary, D,Shapiro W, Hoffman R.Improvements in speech syntax, and communication. Volta Rev.1994;96:131-148. perception and production abilities in children using a 2. Kretschmer R,Kretschmer L.Discourse and hearing multichannel cochlear implant. J laryngoscope. 1990; impairment. In: eds. School discourse problem. San Diego 100:240-3. Calif: Singular publishing Group.1994;pp:263-296. 11. Miyamoto RT, Osberger MJ, Robbins AM, Myres WA, 3. Miyamoto Rt, Svirsky MA. Robbins AM. Enhancement of Kessler K, Pope ML. Longitudinal evaluation of expressive language in prelingually deaf children with communication skills of children with single or cochlear implants. Acta otolaryngol.1997; 117:154-157. multichannel cochlear implants. American j otology. 1992; 4. Svirsky MA. Robbins AM , Krik KI, Pisoni DB, Miyamoto 13:215-22. RT. Language development in profoundly deaf children 12. Mondain M, Sillon M, Vieu A, Lanvin M, Rewilland- with cochlear implants. Psychol sci .2000;11:153-158. Artieres F, Tobey E, et al .Speech reception skills and 5. Ouellet C, Cohen H.Speech and language development speech production intelligibility in Frenchchildren with following cochlear implantation. J prelinguall deafness and cochlear implants. J otology head Neurolinguistics.1999;12:271-288. and neck surgery.1997;123:181-4. 6. Miyamoto RT, Osberger MJ, Kessler K. Cochlear implant 13. Fry auf-Bertschy H, Tyler RS, Kelsay DM,Gantz BJ. in aural re (habilitation)of adults and children. J Performance over time of congenitally deaf and post ling otolaryngology head and neck surgery.1996;116:1142-52. ally deafened children using multichannel cochlear implant. 7. Lenarz T, Hartrampf R, Battmer RD, Bertram B, Lesinski J speech and hearing research .1992;35:913-20. A. Cochlear implant management of young children. J 14. Dawson PW, Blamey pj, Dettman SJ, Barker EJ, Clark laryngorhinootologie .1996;75:719-26. GM.A clinical report on receptive vocabulary skills in 8. Parisier SC, Chute PM, Popp AL, Hanson MB.Surgical cochlear implant users. J ear and hearing.1995;16:287-94. techniques for cochlear implantation in the very young 15. Bertram B, Pad D. Importance of auditory verbal education child. J otolaryngology- head and neck and parents' participation after cochlear implant of very surgery.1997;117:248-54. young children. Annals of otology, rhino logy and 9. Robbins AM,Suvirsky M,Krik KI.Children with implants laryngology.1995;166:97-100. can speak but can they communicate? J otolaryngology head and neck surgery. 1997;177:155-60.
Iranian Rehabilitation Journal 17 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Original Article
Physical Appearance Concern Questionnaire (PACQ) in Iranian population
Katayoun Khademi* University of PayameNoor, Tehran, Iran Asghar Dadkhah, PhD. University of Social Welfare and Rehabilitation Sciences, Tehran, Iran Vahid Kazemi, MD. Islamic Azad University (Tehran Medical branch)
Objectives: The purpose of this study is to make questionnaire for screening body dysmorphic disorder sufferers in cosmetic clinics. Method and Materials: A sample of 150 female patients with age average 29.4 years completed Physical Appearance Concern Questionnaire. It has been used as screening tool for screening patients with body dysmorphic disorder symptoms in cosmetic clinics. Results: Result of reliability analysis (α=0.908) and validity have shown the effectiveness of this questionnaire for recognizing individuals with BDD symptoms. Conclusion: Physical appearance concern questionnaire can be used in cosmetic clinics for identifying BDD sufferers among clients, with score for the severity of symptoms. Keywords: Physical appearance; Iranian; Physical appearance concern questionnaire
Submitted: 11 Jul 2011 Accepted: 02 Sep 2011
Introduction disorder causes excessively distress or impairment in Body dysmorphic disorder (BDD) is a partly social functioning (5-7). common and sometimes serious psychiatric illness Body dysmorphic disorder with an onset in that is probably undetectable and also it is classified adolescence (4) influences 1-2% of the general as a somatoform disorder in DSM-IV-TR. Actually population (8-11). there is no assurance that body dysmorphic disorder Range of prevalence for BDD patients in both has been belonged to somatoform category and inpatients and outpatients are 13%-15% and for the beside that we can’t completely consider it in community is0.7%-2.4% (5). obsessive-compulsive disorder, it can be supposed to In a study in plastic surgery settings, the rate of 7% be in a spectrum (1). has been reported (12) and 12% patients screened Maybe activity front striate systems and visual positive for this disorder in dermatology setting (13) cortex involve in severity of BDD (2,3) and related and It is 3 to 16% in dermatological and cosmetic with symptoms of obsessive thoughts and surgery patients (14,4). compulsive behaviors (2, 4). It seems to be essential for dermatologists to ask One of the most striking characteristic of this some questions for checking the existence of BDD disorder is a preoccupation with an imagined defect like how much time they spend thinking about their in appearance or inappropriate concern with a slight perceived flaws each day or whose concerns cause physical flaw. Their main focus areas are usually the clinically significant distress (15). face, head, skin, hair, nose and etc. Although any Often sufferers from BDD tend to have cosmetic body part can be involved in sufferer’s surgery for body part related to source of distress preoccupations. By definition, body dysmorphic and with considering the high rate of this type of * All correspondence to: Katayoun Khademi, E-mail:
Table 1. Mean, variance and Cronbach's Alpha for each item deleted Scale Mean if Item Scale Variance if Corrected Item-Total Cronbach's Alpha if Item Deleted Item Deleted Correlation Item Deleted 1 21.4131 68.687 0.683 0.899 2 21.7933 67.360 0.709 0.897 3 21.4200 64.608 0.631 0.902 4 21.1200 65.757 0.659 0.899 5 22.2867 69.602 0.713 0.899 6 22.0400 65.247 0.765 0.894 7 22.4667 70.452 0.683 0.900 8 22.2733 71.220 0.565 0.904 9 21.5400 66.639 0.541 0.907 10 21.5267 66.640 0.578 0.904 11 22.2933 68.168 0.667 0.899 12 21.8467 66.600 0.645 0.900
Iranian Rehabilitation Journal 19
The PACQ was found to be a reliable and valid Third, previous study samples have differed in instrument for screening individuals with symptoms various ways like gender distribution which may of body dysmorphic disorder in cosmetic clinics. have influenced the results and we just worked on female patients. Discussion There is another inventory in Iran for detecting To our knowledge, this is the first study in Iran to patients for seeking rhino-plasty surgery named prepare screening tool (PACQ) for body dysmorphic Body Image Concern Inventory (BICI); however it disorder in cosmetic clinic (dermatology setting and has been studying just for rhinoplasty and has shown cosmetic surgery). 12.2% prevalence in subjects seeking rhino-plasty All questionnaires have been filled by various (17). dimensions of marital status, occupation and type of Unfortunately there are few researches for BDD in procedure sought. We recommend that patients with cosmetic clinics in Tehran, Iran. There is another score 36 or more should be referred for further study in Tehran, Iran that has shown 31.5% assessment. prevalence for body dysmorphic disorder among 130 Scores between 12 to 36 needs psychological consult patients (mean=26.43, SD=6.29 years)seeking rhino- for assessing traits of BDD presence. There is no plasty in ENT clinics by using Body Dysmorphic clue of BDD presence for patients with scores under Questionnaire (24).In another study in 2003 has 12. found 20.7% for BDD in patients requesting rhino- According to the filled questionnaires, most BDD plasty (18). patients have responded to questions 1, 3, 4, 10 and With considering of developmental research on body 9, which mean most concerns are in order as dysmorphic disorder in the world in recent years, follows: checking appearance, time spending in a Iran has received little empirical attention in this day, seeking reassurance from others, requests for area. Thus, further study is required. surgery, being perfectionist. Unfortunately questionnaires such as the Body Other items in questionnaire like excessive Dysmorphic Disorder Questionnaire (BDDQ) (19) preoccupation, comparing with models, distress, have been validated in a dermatology setting (15) keep or making relationship, avoiding (places, they have not been studied in a cosmetic surgery and people, and activities), critical view about one’s also there is no score for the severity of symptoms. appearance and social impairment are placed in Another questionnaire like BDDQ to develop the lower priority. Body Image Disturbance Questionnaire (BIDQ) that Based on filled questionnaires among patients for have been made by Cash and colleagues (20,21) has cosmetic surgery, 54% have diagnosed for mild, 9% not been validated in people seeking cosmetic moderate, 3% severe BDD. It seems that BDD surgery and also it is hard to be accessed. prevalence among cosmetic clinic patients are more In study of 17 BDD sufferers, BDD was diagnosed than rhino-plasty patients in ENT clinics in Tehran, in 5 out of 17 (2).This under recognized is due to the Iran. Fortunately, among BDD patients 81.82% have lately being contained in DSM IV, thus, practitioner mild and 5.05% have severe disorder. Actually knowledge is not extensive (19). Subjects were evaluated with Clinical Interview In another study has been shown that 76% of BDD after filling questionnaires for checking co morbid patients were dissatisfied of their surgery outcomes disorders. (22). Obviously, for a final diagnosis, the clinical Therefore, it is not predictable how patients will interview is required and should be done by respond to cosmetic surgery outcome, apparently qualified therapist with experience in treating body these treatment are unlikely to be sufficient, it is image concerns like BDD. critical that both dermatologist and surgeons screen The results supported the use of the questionnaire as patients for BDD and refer them for psychiatric specific screening instrument for BDD in cosmetic treatments (23). clinics. With considering poor global insight and it’s There are several possible explanations why we correlation with symptom severity in BDD (24), found an apparently higher rate of BDD. First, we More research is needed in the development of a haven't studied on specific procedure. Second, we screening questionnaire for recognizing patients with selected patients from last season of the year that BDD in cosmetic clinics (18). clinics have had high load of cosmetic surgery.
20 Vol. 9, No. 14, Oct. 2011 Eventually, by improving people awareness of BDD Almost all of the researches have been studying in presence, sufferers can receive social support by cosmetic clinics or dermatology settings and there is friends and significant persons in their life, that is no investigation for people with special needs, thus related with less severe body dysmorphic disorder further research is required in the development of a symptoms in both gender (Marques, et al., 2011). screening questionnaire or interview for identifying patients with BDD with special needs.
References 15. Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A 1. Castle DJ, Rossell SL. An update on body dysmorphic Screening Questionnaire for Body Dysmorphic Disorder in disorder.CurrOpin Psychiatry. 2006;19(1):74-78. a Cosmetic Dermatologic Surgery Practice.Dermatologic 2. Feusner JD, Moody T, Hembacher E, Townsend J, Surgery. 2001;27(5):457–62. McKinley M, Moller H, et al. Abnormalities of visual 16. Sarwer DB, Crerand CE, Magee L. (2010)Bodydysmorphic processing and frontostriatal systems in body dysmorphic disorder in patients who seek appearance-enhancing disorder. Archives of general psychiatry. 2010;67(2):197. medical treatments. Oral MaxillofacilSurgClin North 3. Feusner JD, Moller H, Altstein L, Sugar C, Bookheimer S, Am,22(4):445-53. Yoon J, et al. Inverted face processing in body dysmorphic 17. Ghadakzadeh S, Ghazipour A, Khajeddin N, Karimian N, disorder. Journal of Psychiatric Research. 2010 Borhani M. Body Image Concern Inventory (BICI) for Nov;44(15):1088–94. Identifying Patients with BDD Seeking Rhinoplasty: Using 4. Conrado LA. Body dysmorphic disorder in dermatology: a Persian (Farsi) Version. AesthPlast Surg. 2011 Dec diagnosis, epidemiology and clinical aspects. 1;35(6):989–94. AnaisBrasileiros de Dermatologia. 2009 Dec;84(6):569–81. 18. Veale D, De Haro L, Lambrou C. Cosmetic rhinoplasty in 5. Phillips KA, Menard W, Fay C, Pagano ME. Psychosocial body dysmorphic disorder. British journal of plastic functioning and quality of life in body dysmorphic surgery. 2003;56(6):546–51. disorder.Comprehensive Psychiatry. 2005 Jul;46(4):254– 19. Phillips KA. The Broken Mirror: Understanding and 60. Treating Body Dysmorphic Disorder. Oxford University 6. Ishigooka J, Iwao M, Suzuki M, Fukuyama Y, Murasaki M, Press; 1996 Miura S. Demographic features of patients seeking 20. Cash TF, Phillips KA, Santos MT, Hrabosky JI. Measuring cosmetic surgery. Psychiatry and Clinical Neurosciences. “negative body image”: validation of the Body Image 1998;52(3):283–7. Disturbance Questionnaire in a nonclinical population.Body 7. Bowe WP, Leyden JJ, Crerand CE, Sarwer DB, Margolis Image. 2004 Dec;1(4):363–72. DJ. Body dysmorphic disorder symptoms among patients 21. Hrabosky JI, Cash TF, Veale D, Neziroglu F, Soll EA, with acne vulgaris.Journal of the American Academy of Garner DM, et al. Multidimensional body image Dermatology. 2007;57(2):222–30. comparisons among patients with eating disorders, body 8. Otto MW, Wilhelm S, Cohen LS, Harlow BL. Prevalence dysmorphic disorder, and clinical controls: A multisite of Body Dysmorphic Disorder in a Community Sample of study. Body Image. 2009;6(3):155–63. Women. Am J Psychiatry. 2001 Dec 1;158(12):2061–3. 22. Phillips KA, Hollander E, Rasmussen SA, Aronowitz BR. 9. Rief W, Buhlmann U, Wilhelm S, Borkenhagen ADA, A severity rating scale for body dysmorphic disorder: Brahler E. The prevalence of body dysmorphic disorder: a Development, reliability, and validity of a modified version population-based survey. Psychological medicine. of the Yale-Brown Obsessive Compulsive Scale. 2006;36(6):877–86. Psychopharmacology Bulletin. 1997;33(1):17–22. 10. Koran LM, Aboujaoude E, Large MD, Serpe RT. The 23. Phillips K.A., Dufresne R.G. Body Dysmorphic Disorder: prevalence of body dysmorphic disorder in the United A Guide for Dermatologists and Cosmetic Surgeons. States adult population.CNS spectrums. 2008;13(4):316. American Journal of Clinical Dermatology. 2000;1(4):235– 11. Haas CF, Champion A, Secor D. Motivating factors for 43. seeking cosmetic surgery: a synthesis of the literature. 24. Eisen JL, Phillips KA, Coles ME, Rasmussen SA. Insight in Plastic Surgical Nursing. 2008;28(4):177-182. obsessive compulsive disorder and body dysmorphic 12. Sarwer DB, Crerand CE, Magee L. Body dysmorphic disorder.Comprehensive Psychiatry. 2004 Jan;45(1):10–5. disorder in patients who seek appearance-enhancing 25. Kazemi V. [Association of body dysmorphic syndrome and medical treatments. Oral MaxillofacSurgClin North Am. rhinoplasty request ENT clinics in Tehran(Persian)]. Thesis 2010 Nov;22(4):445–53. for doctorate of medicine. Islamic Azad University college 13. Phillips KA. The Broken Mirror: Understanding and of Medicine; 2010: No 4607. Treating Body Dysmorphic Disorder. Oxford University 26. Marques L, Weingarden HM, LeBlanc NJ, Siev J, Wilhelm Press; 2005. S. The relationship between perceived social support and 14. Conrado LA. (2009). Body dysmorphic disorder in severity of body dysmorphic disorder symptoms: the role of dermatology: diagnosis, epidemiology and clinical aspects. gender. RevistaBrasileira de Psiquiatria. 2011 An Bras Dermatol, 84(6):569-81. Sep;33(3):238–44.
Iranian Rehabilitation Journal 21 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Original Article
Gender difference in TEOAEs and contralateral suppression of TEOAEs in normal hearing adults Farzaneh Zamiri Abdollahi*; Yones Lotfi, MD. University of Social Welfare and Rehabilitation sciences, Tehran, Iran
Introduction: Otoacoustic emissions (OAEs) are sounds that originate in cochlea and are measured in external auditory canal and provide a simple, efficient and non-invasive objective indicator of healthy cochlear function. Olivo cochlear bundle (OCB) or auditory efferent system is a neural feedback pathway which originated from brain stem and terminated in the inner ear and can be evaluated non-invasively by applying a contralateral acoustic stimulus and simultaneously measuring reduction of OAEs amplitude. In this study gender differences in TEOAE amplitude and suppression of TEOAE were investigated. Method and Materials: This study was performed at Akhavan rehabilitation centre belonging to the University of Social welfare and rehabilitation sciences, Tehran, Iran in 2011. 60 young adults (30 female and 30 male) between 21 and 27 years old (mean= 24 years old, SD=1.661) with normal hearing criteria were selected. Right ear of all cases were tested to neutralize side effect if there is any. Results: According to Independent T-test, TEOAE amplitude was significantly greater in females with mean value of 24.98 dB (p-value <0.001) and TEOAE suppression was significantly greater in males with mean value of 2.07 dB (p-value <0.001). Conclusion: This study shows that there is a significant gender difference in adult’s TEOAE (cochlear mechanisms) and TEOAE suppression (auditory efferent system). The exact reason for these results is not clear. According to this study different norms for males and females might be necessary. Key words: TEOAEs, Contralateral suppression of TEOAEs, Efferent system, Androgen
Submitted: 17 May 2011 Accepted: 012 Sep 2011
Introduction hearing aids and surgical options. As a research tool, Otoacoustic emissions (OAEs) are sound waves that OAEs are non invasive tools for intra cochlear originate from cochlea and emit back into the processes and have brought a new understanding external ear canal. These sounds can be recorded in about the nature of sensory hearing impairments (2). ear canal using a sensitive microphone (1). They are OAEs can be classified into two main responses: produced by active motions of the sensory hair cells First, spontaneous otoacoustic emissions (SOAEs) - of cochlea in response to auditory stimuli (2). OAEs if response is being recorded in the external acoustic are generated in the outer hair cells (OHCs) which meatus without any auditory stimulation; Second, have motility function. Active contractions of the Evoked Otoacoustic Emissions (EOAEs) - when ear actin and myosin in these cells produce a mechanism energy is being recorded in response to a kind of of frequency specific cochlear amplifier (3). sound stimulus. Evoked otoacoustic emissions are There is consensus that OAEs are simple, efficient also divided (based on stimulus type) into three and non-invasive objective indicators of healthy emissions: Transient (TEOAE) - evoked by a brief cochlear function especially OHCs and OAE sound stimulus, usually a click that has a wide range screening are widely used as a part of universal new- of frequencies; Distortion product (DPOAE) - born hearing screening programs. OAEs, as part of evoked by two pure and simultaneous tones (f1 and the audio logical diagnostic test, can help for f2) to produce a response based on intermodulation differential diagnosis among some hearing distortion in cochlea (for example 2f1- f2); pathologies, can be used to monitor the effects of ear Stimulus-frequency (SFEOAE) - evoked by a disease treatments and are useful in the selection of continuous and low intensity tone (4).
* All correspondence to: Farzaneh Zamiri Abdollahi ; Email:
22 Vol. 9, No. 14, Oct. 2011 Auditory system consists of afferent and efferent previous ear disease or ear surgery and they were systems that operate in together (5). Olivocochlear volunteers. The inclusion criteria were as follow: bundle (OCB) or auditory efferent system is a neural Normal otoscopy (by using Riester otoscope), hearing feedback loop which is originated from brain stem threshold ≤ 15 dBHL between 250 and 8000 HZ (by nuclei and terminated in the inner ear hair cells. This using Clinical Audiometer AC 33 and headphone system has two subsystems: Medial olivocochlear TDH-39p of Telephonics), tympanogram type An and bundle (MOCB) and Lateral olivocochlear bundle existence of acoustic reflex threshold between 500 and (LOCB). MOCBs originate in medial portion of 4000 HZ (by using Zodiac 901 of Madsen). superior olivary complex (SOC) and LOCBs Right ear of all cases were selected for TEOAE and originate from lateral part of SOC. Both of these TEOAE suppression tests to neutralize side effect if subsystems have crossed (mainly MOCB) and there is any. Cases were instructed to lie down uncrossed (mostly LOCB) projections (6). without movement on examination table. OAE and Stimulation of auditory efferent has been shown to OAE suppression was tested (by using ILO292 of have a suppressive effect on cochlear responses like Otodynamics with ILO v6 software in an acoustic OAEs and suppression of OAE has been used room). Probe was calibrated before examinations on frequently in clinical and research settings because it daily bases with probe test cavity of Otodynamics. assesses efferent pathways quickly and non- Nonlinear click with 80μs electrical pulse at a rate of invasively (5). Activation of MOCS can be 50/s, mean intensity of 84 dBpeak and 20 ms time performed by delivering a contralateral acoustic window after stimulation was used. Rejection level stimulation and simultaneously measuring OAEs was 6 percent. TEOAE stimuli were presented amplitude in test ear. Contralateral acoustic through probe 1 of ILO292 of Otodynamics. The stimulation leads to attenuation of the OAE (7). contralateral acoustic stimulation (CAS) was a 70 Efferent auditory pathway modulates OHCs of dBSPL white noise delivered by probe 2 of device. cochlea, reduces action potentials of auditory nerve Contralateral noise was linear and intermittent fibers, and involves in locating sources of sound and (every 3 seconds was turned on/off automatically). improving sound detection in noisy context (5). TEOAE test in right ear was done while intermittent Auditory efferent system involves in anti-masking, white noise was simultaneously presented in protection from damage due to loud noise, auditory contralateral ear. Device shows TEOAE amplitude and visual attention and auditory development (6). without and with contralateral noise in two separate Stimulation of MOCS provides protection against windows on screen at once. The difference between moderate levels of noise, encoding noise signals as TEOAE amplitude with and without contralateral well as selecting hearing attention (7). stimulation is suppression magnitude and it is due to In this study gender difference in TEOAE amplitude efferent system activation. and suppression of TEOAE was investigated. SPSS software ver. 13 was used for analyzing the data. Independent T-test was selected for analyzing Materials and Methods data. The significance level for the statistic tests was This study was performed at Akhavan rehabilitation set at 5% (p<0.05). centre belonging to the university of Social welfare and rehabilitation sciences, Tehran, Iran in 2011. 60 young Results adults (30 female and 30 male) between 21 and 27 Table 1 and 2 respectively show summary of years old (mean age of both groups 24 years old with TEOAE amplitude and TEOAE suppression in 1.66 standard deviation and 0.30 standard error of males and females. mean) from students and staff of Akhavan rehabilitation centre were selected. They had not any
Table 1: TEOAE amplitude in males and females TEOAE amplitude (dB) Males Females Mean 20.96 24.98 Standard error of mean 0.34 0.42 Median 20.99 25.03 Standard Deviation (SD) 1.87 2.30 Lower 20.26 24.11 95% confidence interval for mean Upper 21.66 25.84 Total number 30 30
Iranian Rehabilitation Journal 23
Table 2: TEOAE suppression in males and females TEOAE suppression (dB) Males Females Mean 2.07 1.54 Standard error of mean 0.05 0.03 Median 2.04 1.54 Standard Deviation (SD) 0.27 0.16 Lower 1.97 1.48 95% confidence interval for mean Upper 2.18 1.60 Total number 30 30
One sample Kolmogorov-Smirnov test was used to McFadden D. (1993) proposed that the amount of determine if distribution of variables is normal. efferent inhibition is relatively less in females than According to this test all variables were within in males. So OAE amplitude is greater in females normal distribution (p-value> 0.05): TEOAE and contralateral suppression of OAE is greater in amplitude p-value in males was 0.96 and in females males (11). was 0.98, TEOAE suppression p-value in males was McFadden D. Et al (2006) continued study of gender 0.52 and in females was 0.97. So parametric effects on OAE and indicated that in human beings Independent t-test was used to compare TEOAE and Rhesus monkeys, Click-Evoked Otoacoustic amplitude and TEOAE suppression between men emissions (CEOAEs) are more powerful in females and women. Leven's test for equality of variances than males, and this gender difference is the result of was not significant with p-value of 0.22 (p-value> greater exposure to androgens prenatally in males 0.05) so variances of two groups were equal. (12). Other works showed that this gender difference The Independent T-test results show that there is a in OAE amplitude fluctuated seasonally and is significant difference between males and females in related to the annual fluctuations of testosterone TEOAE amplitude and TEOAE suppression. TEOAE levels in male Rhesus. The CEOAEs of male Rhesus amplitude was significantly greater in females with monkeys were weaker in the breeding season (when mean value of 24.98 dB (p-value <0.001) and male androgen levels are high) than in the birthing TEOAE suppression was significantly greater in season (when male androgen levels fall) (13). males with mean value of 2.07 dB (p-value <0.001). Al-Mana D. et al (2008) stated that it is possible that hormones contribute to pathophysiology of some Discussion auditory dysfunctions, including hyper acusis, Several studies have shown gender influence on tinnitus, Menière's disease and pre-menstrual OAEs and contralateral suppression of OAEs. auditory dysfunction and play role in modulating the Cassidy and Ditty (2001) showed that in female auditory functions (14). newborns TEOAE is more powerful than male McFadden D. et al (2009a,b) showed that in humans, newborns. They suggested that OHCs in females OAEs have significant differences between males respond more sensitive than in males (8). and females. From early studies on OAEs in Durante and Carvallo (2006) found that gender has humans, ear (right ear versus left ear) and gender significant effect on TEOAE and contralateral differences were apparent. These effects have been suppression of TEOAE in neonates. They have shown in newborns and adults. In general, human shown that TEOAE was larger in female infants and females have stronger and more prevalent SOAEs suppression of TEOAE was larger in male infants. and more powerful CEOAEs than males (15, 16). They explained this finding with differences in McFadden D. et al (2009) insisted that one obvious prevalence of SOAEs (SOAEs are more prevalent in explanation for the gender difference in newborns is female) and cochlear length (cochlea is longer in the differential prenatal exposure to androgens in males) (9). Miller JD. (2007) examined cochlea two sexes (15, 16). All male mammals early in the length in males and females and found that gender course of prenatal development develop embryonic difference in cochlea length was 3.36% (corresponds testes that begin producing the androgens that are to 1.11 mm difference in length with 0.49 SD) (10). responsible for masculinizing the prenatal body and The shorter cochlea in females could lead to the brain (16). higher amplitude of females' TEOAE response (9). OHCs are the most important part in the production of OAEs. Thus, OHCs might have some differences
24 Vol. 9, No. 14, Oct. 2011 between males and females. The electro motility of older age than males. Further, postmenopausal OHCs is dependent to the prestin molecules in the women who are on estrogen-based hormone walls of the OHCs, so any differences in prestin replacement therapy (HRT) have better hearing than could be a major contributor to the OAE differences. those who are not, while progestin-based HRT can Perhaps, for some reasons, women have, on average, diminish hearing ability. These sex and female more prestin molecules per OHC than men, or ovarian cycle variations in hearing are attributed to perhaps the prestin molecules in women OHCs are the protective effects of estrogen and may be better aligned along the cell’s contraction axis. In partially related to estrogen receptor (ER) expression either case, female OHCs would be capable of in the cochlea (17). greater electro motility than male OHCs (16). Maruska K. and Fernald R. (2010) stated that Conclusion gonadal and stress-related steroid hormones have This study among others shows that there is a influences on auditory function across vertebrates significant gender difference in TEOAE (which is by but the cellular and molecular mechanisms of product of cochlear mechanisms) and TEOAE steroid-mediated auditory plasticity at the level of suppression (which is due to effects of auditory the inner ear remain unknown. The peripheral and efferent system on cochlea). The exact reason for these central auditory system of vertebrates is sensitive to results is not clear but there are some hormonal and sex- and stress-related steroid hormones, which can structural explanations. According to this study and have strong effects on how an animal perceives other results, it might be necessary to have different acoustic information and behaves during social norms for males and females, especially in newborn interactions. The steroid receptors have been found OAE testing to avoid any wrong interpretation. in the inner ear which suggests there might be a direct pathway for hormones to act on the peripheral Acknowledgement: auditory system. The expression levels of steroid The authors wish to acknowledge the assistance of the receptors differ between the genders. In mammals, students and staff of Akhavan rehabilitation centre of females often have "better" hearing (e.g., better high the University of Social Welfare and Rehabilitation frequency hearing; shorter auditory brainstem Sciences, Tehran, Iran, in collecting data. response wave latencies) and presbycusis begins in
References Pró-Fono Revista de Atualização Científica. 2006 Jan; 1. McFadden D, Pasanen EG, Raper J, Lange HS, Wallen K. 18(1):49–56. Sex differences in otoacoustic emissions measured in rhesus 10. Miller JD. Sex differences in the length of the organ of Corti monkeys (Macaca mulatta). Hormones and Behavior. 2006 in humans. The Journal of the Acoustical Society of Aug;50(2):274–284. America. 2007;121(4):EL151–EL155. 2. Kemp DT. Otoacoustic emissions, their origin in cochlear 11. McFadden D. A speculation about the parallel ear asymmetries function, and use. Br Med Bull. 2002 Oct 1;63(1):223–241. and sex differences in hearing sensitivity and otoacoustic 3. A L-D. [Otoacoustic emissions]. HNO. 1992 Nov; 40(11): emissions. Hearing Research. 1993 Aug;68(2):143–151. 415–421. 12. McFadden D, Pasanen EG, Weldele ML, Glickman SE, 4. Vasconcelos RM, Serra LSM, Aragão VM de F. Transient Place NJ. Masculinized otoacoustic emissions in female evoked otoacustic emissions and distortion product in school spotted hyenas (< i> Crocuta crocuta). Hormones and children. Revista Brasileira de Otorrinolaringologia. 2008 behavior. 2006;50(2):285–292. Aug;74(4):503–507. 13. McFadden D, Pasanen EG, Raper J, Lange HS, Wallen K. 5. Fronza AB, Barreto DCM, Tochetto TM, Cruz IBM da, Sex differences in otoacoustic emissions measured in rhesus Silveira AF da. Association between auditory pathway monkeys (Macaca mulatta). Hormones and Behavior. 2006 efferent functions and genotoxicity in young adults. Brazilian Aug;50(2):274–284. Journal of Otorhinolaryngology. 2011 Feb; 77(1): 107–114. 14. Al-Mana D, Ceranic B, Djahanbakhch O, Luxon LM. 6. Zeng F-G, Martino KM, Linthicum FH, Soli SD. Auditory Hormones and the auditory system: A review of physiology perception in vestibular neurectomy subjects. Hearing and pathophysiology. Neuroscience. 2008 Jun 2; 153(4): research. 2000;142(1):102–112. 881–900. 7. Komazec Z, Filipović D, Milo\vsević D. Contralateral 15. McFadden D, Martin GK, Stagner BB, Maloney MM. Sex acoustic suppression of transient evoked otoacoustic differences in distortion-product and transient-evoked emissions: Activation of the medial olivocochlear system. otoacoustic emissions compared. J Acoust Soc Am. 2009 Medicinski pregled. 2003;56(3-4):124–130. Jan;125(1):239–246. 8. Cassidy JW, Ditty KM. Gender differences among 16. McFadden D. Masculinization of the Mammalian Cochlea. newborns on a transient otoacoustic emissions test for Hear Res. 2009 Jun;252(1-2):37–48. hearing. Journal of Music Therapy. 2001;38(1):28–35. 17. Maruska KP, Fernald RD. Steroid receptor expression in the 9. Durante AS, Carvallo RMM. Changes in transient evoked fish inner ear varies with sex, social status, and reproductive otoacoustic emissions contralateral suppression in infants. state. BMC Neuroscience. 2010 Apr 30;11(1):58.
Iranian Rehabilitation Journal 25 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Original Article
The impact of coping strategies on burden of care in chronic schizophrenic patients and caregivers of chronic bipolar patients
Morteza Khajavi, MD; Mansoureh Ardeshirzadeh, MD; Susan Afghah*, MD; Behrooz Dolatshahi, PhD. University of Social Welfare and Rehabilitation sciences, Tehran, Iran
Objective: One of the principles of mental health programs is burden and coping of caregivers of chronically mental disorders patients. In this regard, the aim of present study was to measure the amount of burden and relationship between burden and their coping strategies of caregivers. Method and Materials: One hundred of main caregivers of patients (50 schizophrenic patients, 50 bipolar patients) from both Razi psychiatric hospital and clinic were enrolled to the study. The instruments were FBIS (Family Burden Interview Schedule) as well as Weintraub coping strategies check list (COPE). Chi-square, Pearson correlation coefficient and t-test were used for data analysis. Results: The study showed that the mean of burden in caregivers of chronic schizophrenic patients was significantly (P<0.05) higher than that of bipolar patients (35.5 vs. 28.9). There was inverse correlation (but not statistically meaningful) between burden and problem focused coping strategy. Conclusion: There was also a direct correlation between burden and emotional-oriented and less benefit and not effective coping strategies, but was not meaningful. Regarding the higher burden in caregivers of chronic schizophrenic patients, social support and offering health services to them seems to be necessary. Training of caregivers for problem-focused copings can also reduce the burden. Keywords: Caregiver, Schizophrenia, Bipolar disorder, Burden, Coping Strategy.
Submitted: 19 Apr 2011 Accepted: 22 Sep 2011
Introduction Some factors in psychiatric patients may affect Caregivers of mental disorders patients such as taking care of the patient (4, 5). Such factors may schizophrenia and bipolar disorders often tolerate high include caregivers’ cognition estimation, coping burden against compatibility with signs of their patients. approaches and social supports. Also upon Increase of burden has various subsequences for assessment of the relation between such factors with caregivers such as decrease in taking care of patients, mental burden and health of caregivers, it is family isolation, elusion of other relatives from them, specified that high level of mental burden may be decrease in social and mental supports of the patient related to: more repetition of negative and positive and consequently to reject the patient and aggravation symptom behaviors, tending to application of coping of disease which may be resulted in their approaches based on resolving the problem in facing homelessness (1). High burden in caregivers with a with negative behaviors, not tending to application high expressed emotion may increase the probability of coping approaches based on resolving the of exacerbations and re-hospitalization (2). problem in facing with positive symptom behaviors. A study conducted in Japan indicated that educating Falloon et al. (6) found that the caregivers who coping strategies to the schizophrenic patients apply problem-centered approaches may show lower caregivers is useful for all caregivers particularly burden and better compatibility. caregivers with high expressed emotion (3). A lower level of caregivers’ awareness may cause to more application of negative coping approaches by * All correspondences to: Susan Afghah; Email: < [email protected]>
26 Vol. 9, No. 14, Oct. 2011 them which may be resulted in a high level of (COPE). By use of T test and chi-square and Pierson mental burden (7, 8). correlation coefficient of findings were analytically The relatives of psychiatric patients may experience analyzed. an expanded extent of emotional and practical All samples are psychiatric patients’ caregivers tension (9). whose patients were considered as schizophrenic or The impact of caregivers’ mental burden such as any bipolar patients according to psychiatrist interview other stress relates to recognition assessment of the and according to DSM-IV diagnostic criteria and problem by them and available resources for coping recourse to Razi psychiatric hospital or were (10). Vulnerability of individuals against mental hospitalized there. burden may be affected by coping strategies and Studies were conducted on caregivers of such available social supports (11). There is no direct patients who have conditions for selection. relation between tension, mental burden feeling and their negative consequences, so that Lazarous and Selection conditions Folkman (12) believed that coping approaches by 1. To meet DSM-IV criteria (in order to diagnose individuals may have intermediary role in the extent schizophrenic and bipolar disease), of mental burden feeling and their negative 2. The caregiver must be between 20-75 years old. subsequences, so that application of problem- 3. At least two years have passed from disease. centered coping approaches may decrease extent of 4. The caregiver must be in sound physical burden and emotional-centered and ineffective conditions. coping approaches may increase burden or may have 5. The caregiver must not be dependent to any no significant effect on compatibility. psychedelic drugs. Therefore, by taking the listed cases into account the 6. Each caregiver shall care only one patient. burden tolerated by caregivers of chronic mental Taking samples was performed by use of convenient disorders patients (Schizophrenia and bipolar disorders) group sampling method. All caregivers declared may differ proportional to applied coping strategies. their consent concerning filling questionnaire. The study conducted by Lazarous and Folkman as 100 people were selected. 50 schizophrenic patients’ stated by Hins and Co. indicated that application of caregivers and 50 bipolar patients’ caregivers were coping strategies emphasizing on problem solving selected and then assessed. approaches is more compatible than emotional- centered coping approaches (12). Measurement Tools A number of papers were also conducted in Iran on The following tools were applied for evaluating application of coping strategies while facing with extent of burden and assessment of coping stress and these studies showed that particular approaches applied by 50 schizophrenic and bipolar coping approaches more compatible in specific patients’ caregivers in this study: conditions. By assessing the relevant texts, it seems - Questionnaire concerning individual particulars that in circumstances that the available problem may (patient-caregiver), be solved problem-centered coping approaches are - Family burden interview schedule (FBIS) more compatible but in some cases that the problem - Weinteraub coping strategies check list (COPE). may not be solved the emotional-centered approaches may also be compatible. Caregiver Burden Schedule As mental burden tolerated by caregivers of This questionnaire was prepared by Pais and Kapur schizophrenic patients have been pointed out in papers (17) which may be filled in form of a semi- mental burden tolerated by caregivers of bipolar constructed interview. This questionnaire may patients have also been considered (13, 14, 15, 16). analyze caregivers’ burden in two objective or subjective dimensions. Each includes 24 clauses and Method 6 classes in total that each includes 3 options which 100 caregivers (50 schizophrenic patients’ caregivers evaluate the said dimensions in 0-2 scale in each and 50 bipolar patients’ caregivers) referred to clause. The maximum point in this scale is 48 and psychiatric clinic or Razi hospital was selected through the minimum point is 0. The greater point indicates convenient sample group method. The tools and the higher extent of burden. instruments include a questionnaire on caregivers’ This scale has a high static coefficient (72%) which was burden and Weinteraub coping strategies check list translated and applied in Iran by Malakouti and et. al
Iranian Rehabilitation Journal 27 (18). According to the points gained in this scale, three Wishful Thinking; D) Negative Thinking; and E) categories including low burden (0-16), mean burden Using medicine and substances. (17-32) and high burden (32-48) are achieved. Validity and Stability Coping Strategies Check List Carver and et al. (19) assessed the validity and stability This questionnaire is a multi-dimensional tool which of these tools through three separate studies on a group analyzes various types of responding people to stress of students. The results of stability assessment through which was prepared by Carver, Schier and Weinteraub re-evaluation method indicated that the stability (19) and translated by Zolfaghari, Mohammadkhani coefficient was between r=0.42 and r=0.76 for various and Ebrahimi Mohammadkhani (20) and revised by scales. The results of the study conducted by taking Iranian culture into account and by use of other Mohammadkhani (20) showed that this scale is a valid available coping schedules. Since, the list does not tool for evaluation of coping strategies. Also the contain all coping behaviors, the schedules analyzed in stability of all its scales was assessed on a sample the study conducted by Epstein and Majer (21). This including 20 students through re-evaluation with a two- check list includes 72 clauses and 18 categories in total week interval. The highest stability coefficient was that each includes 4 options. Besides, according to tending to religion i.e. r=0.95 and the lowest but the theoretical scheme of the test, this list includes 4 most meaningful stability coefficient relates to general subjects including: behavioral non-engagement i.e. r=0.63. The stability coefficient for the whole scale was reported as 0.93. Problem-Centered Coping 5 conceptual scales were allocated to problem- Results centered coping evaluation including the following The studies indicated that there is an inverse relation categories: A) Active coping; B) Scheduled coping; between extent of burden and problem-centered C) Ceasing semi-ordinate activities; D) Avoiding coping approaches, but it was not statically impatient facing with problem or patience; and E) meaningful and there is a direct relation between Seeking for operative social support. extent of burden and emotional-centered, low- effective and ineffective coping approaches. Emotional-Centered Coping Demographical study relating to the patients and 5 scales were allocated to emotional-centered coping caregivers of both groups indicated that evaluation including the following categories: notwithstanding the equal number of patients in both A) Coping based on deny; B) Coping through groups but the average age of schizophrenic patient seeking emotional social support; C) Coping through is higher and that the number of employed bipolar tending to religion; D) Coping based on acceptance; patients is four times more than employed and E) Coping through positive re-interpretation. schizophrenic patients. Of course both groups were analyzed based on age category. Their caregivers Low-Effective Coping and Ineffective Coping were often illiterate. As to schizophrenic patients the 3 scales were allocated to low-operative coping father played role of caregiver (28%) more than responses including the following categories: mother (22%). A) Centralizing on emotion and its express; B) The table 1 indicates that chronic schizophrenic mental non-engagement; C) behavioral non- patients’ caregivers meaningfully tolerate higher engagement. 5 scales were allocated to inoperative burden (p < 0.050) than chronic bipolar disorders coping responses including the following categories: patients’ caregivers (averagely 35.5 versus 28.9). A) Impulsiveness; B) Superstitious Thinking; C)
Table 1- Comparison of Burden Average of Schizophrenic and Bipolar Disorders Patients Caregivers Standard Freedom Meaningfulness Group Number Average Extent Deviation degree level Chronic Schizophrenic 50 35.54 8.6 Patients Caregivers 3.14 49 0.003 Chronic Bipolar Patients 50 28.94 11.5 Caregivers
28 Vol. 9, No. 14, Oct. 2011 Tables 2 and 3 indicate that although applying centered, low-effective and ineffective coping problem-centered coping approaches has an invert approaches applied by caregivers of both groups is relation with the burden extent but it is not direct but not meaningful. meaningful, and that the relation between emotional-
Table 2-Relationship between Extent of Burden and Coping Approaches Applied by Schizophrenic Disorders Patients Caregivers Coping Approaches of Chronic Schizophrenic Disorders Correlation Reasonability Number Patients Caregivers coefficient level Problem-centered coping approaches 50 -0.066 0.65 Emotional-centered coping approaches 50 0.082 0.57 Low-effective and ineffective coping approaches 50 0.045 0.75
Table 3- Relationship between Extent of Burden and Coping Approaches Applied by Bipolar Disorders Patients Caregivers Coping Approaches of Chronic Bipolar Patients Caregivers Number Correlation coefficient Reasonability level Problem-centered coping approaches 50 -0.164 0.254 Emotional-centered coping approaches 50 0.005 0.972 Low-effective and ineffective coping approaches 50 0.189 0.188
Discussion short-term hospitalization services or permanent care The study indicated that burden tolerated by of the patient also the impact of presence of a mental schizophrenic patients’ caregivers is meaningfully patient on family's income and caregiver's gender. higher than chronic bipolar patients’ caregivers, so These findings conform to demand of schizophrenic that burden average is 35.5 in schizophrenic patient caregivers who have severed symptoms and patients’ caregivers and 28.9 in chronic bipolar their caregivers must tolerate higher burden. patients’ caregivers. Since most human disorders are A study conducted in Chili indicated that the extent related to stress in some aspects (22) and the higher of mental burden arises by lacking social stress (23) and longer (24, 25) has more negative rehabilitation schedules for mental disorders patient psychiatric and physiologic effects. Malakouti et al. caregivers (27). (18) discovered in their studies that the extent of The major hypotheses of the study was assessment burden tolerated by chronic schizophrenic patients’ of relationship between extent of burden with coping caregivers is higher than burden tolerated by other approaches that an invert but non-meaningful chronic mental disorder patients caregivers. A study relation was recognized between problem-centered conducted in India indicated that although in most coping approaches and caregivers burden of both studies the quality of chronic sever diseases such as schizophrenic and bipolar patients groups in this schizophrenia and characteristics of caregivers in research. Similarly there was a direct relation coping with mental disorder were pointed out but between emotional-centered, low-operative and similar disorder like bipolar mood disorder are rather inoperative coping approaches and extent of burden ignored (26). that was not statically meaningful. This result In a study conducted by Webb et al. (4) on the applies to both groups of schizophrenic and bipolar relationship between mental burden and mental patients caregivers. health of chronic mental disorder patients caregivers A study conducted in India indicated that problem- and its relation to social support and coping centered coping approaches were rather applied by approaches, they founded that mental burden along bipolar patients’ caregivers and emotional-centered with higher frequency of positive and negative coping approaches were rather applied by symptoms and mental health is related to lower schizophrenic patients’ caregivers (28). frequency of positive symptoms and social support Non-meaningfulness of these findings may be due to than coping approach applied by the caregiver. In the low mass of sample in this study (100 samples), this study the burden source in caregivers of both on the other part, the current sampling method was groups was more objective rather to be subjective convenient group method from two centers, that may be resulted from poor social supports such psychiatric hospital and Razi clinic that individuals as out-patients, rehabilitation and long-term and who refer to this clinics due to their special
Iranian Rehabilitation Journal 29 geographic location, are of a lower social – selected for sampling that may be considered as a economic level as well as literature level. As factor for bias of choosing cases. indicated in tables relating to demographic 2- The sampling place is located at southern side of specifications of samples, caregivers (whether male the city and the referees are generally chronic or female) are often illiterate that may be a factor patients with multiple history of hospitalization. A influencing applied coping strategy and extent of great number of families refer to these centers for burden. permanent care; also the geographical situation of Of course, caregivers of such patients by referring to Razi Psychiatric Hospital is an effective factor for the said centers indeed applied problem-centered selection of referees. coping approach, but the domain of low or high application of this approach is limited among them Conclusion that may be considered as another factor of non- By use of the impact of type of coping strategies on meaningfulness of this relation. extent of burden sustained to chronic schizophrenic Vulnerability of individuals against mental burden and bipolar caregivers, training problem-centered may be affected by their coping strategies and coping strategies to caregivers may be considered as available social supports (11). Thus the extent of an approach for reducing burden tolerated by burden arising from caring chronic mental patients caregivers. may be different depending on coping approaches Chronic mental disorder caregivers are a specific applied (29). In a study conducted in Japan indicated group in the society who has specific demands that in order to provide effective support for which must be recognized. As the starting point, reducing caregiver burden the necessity of nursing development of supports such as training families, and social support must be emphasized (30). In other short-term hospitalization, psychiatric and words, a number of factors such as gender, race, professional rehabilitation and rendering services to social supports, level of literature, education and patients at home may be pointed out. Also, the social class as well as characteristics of individuals burden sustained to them may be reduced by and disease nature may all affect the type of applied planning medical sessions based on increasing use of approach that we could not control them due to problem-centered coping approaches, particularly restrictions of study. concerning schizophrenic caregivers who tolerate higher burden. Restrictions of study 1- Disability in selecting cases randomly which Acknowledgements: require a national and comprehensive plan. Two I hereby appreciate all personnel of Razi Psychiatric centers i.e. Razi hospital and Razi clinic were Clinic and Razi Hospital who extended their sincere cooperation towards this study.
References pathology. Journal of Family Therapy. 1986;8(4):339–350. 1. Biegel D, Milligan S, Putnam P, Song L. Predictors of 7. Lim YM, Ahn Y-H. Burden of family caregivers with burden among lower socioeconomic status caregivers of schizophrenic patients in Korea. Applied Nursing Research. persons with chronic mental illness. Community Ment 2003 May;16(2):110–117. Health J. 1994 Oct 1;30(5):473–494. 8. Baldassano C. Reducing the Burden of Bipolar Disorder for 2. Scazufca M, Kuipers E. Links between expressed emotion Patient and Caregiver. Medscape Psychiatry & Mental and burden of care in relatives of patients with Health [Internet]. 2004;9(2). schizophrenia. BJP. 1996 May 1;168(5):580–587. 9. Tsang HWH, Tam PKC, Chan F, Chang WM. Sources of 3. Yamaguchi H, Takahashi A, Takano A, Kojima T. Direct burdens on families of individuals with mental illness. Int J. effects of short-term psychoeducational intervention for Rehabil Res 2003, 26: PP 123-130. relatives of patients with schizophrenia in Japan. Psychiatry 10. Eticson R, Eticson, Richard Hilgard, E. Field of and Clinical Neurosciences. 2006;60(5):590–597. Psychology. Barahani MT,et al. (Persian translators) 4. Webb C, Pfeiffer M, T K, Gladis M, Mensch E, DeGirolamo Tehran: Roshd publications;1989 J, et al. Burden and well-being of caregivers for the severely 11. Sarason AJ, Sarason BA. Pathologic Psychology. Najarian mentally ill: The role of coping style and social support. B, Asgharimoghadam MA, Dehghani M. (Persian Schizophrenia Research. 1998;34(3):169–180. translator). Tehran: Roshd publications;1992 5. Lloyd H, Singh P, Merritt R, Shetty A, Yiend J, Singh S, et 12. Lazarus R, Follkman S. Stress, Appraisal, and Coping. al. A Comparison of Levels of Burden in Indian and White Springer Publishing Company; 1984. Parents With a Son or Daughter With Schizophrenia. Int J 13. Jungbauer J, Angermeyer MC. Living with a Schizophrenic Soc Psychiatry. 2011 May 1;57(3):300–311. Patient: A Comparative Study of Burden as It Affects 6. Falloon IRH, Pederson J, Al-Khayyal M. Enhancement of Parents and Spouses. Psychiatry: Interpersonal and health-giving family support versus treatment of family Biological Processes. 2002 Jun;65(2):110–123.
30 Vol. 9, No. 14, Oct. 2011 14. Jungbauer J, Mory C, Angermeyer MC. Does caring for a and Social Psychology. 1989;57(2):332–350. schizophrenic family member increase the risk of becoming 22. Shamloo, Saeed (2009) metal health, Tehran, Roshd ill: psychological and psychosomatic troubles in care givers publications of schizophrenia patients Fortschr. Neurol. Psychiatr. 2002 23. Sarason IG. Social support personality and health. In Oct;70(10):548–554. Ganise, M.P. (Ed). Individual Differences. Stress and health 15. Schmid R, Huttel G-U, Cording C, Spiessl H. Burden of psychology. New York springer – verlag.1998; caregivers of inpatients with bipolar affective disorder. 24. Taylor SE. Health psychology (4th ed.). New York, NY, Psychiatrische Praxis. 2006;33(1):155–156. US: McGraw-Hill; 1999. 16. Reinares M, Vieta E, Colom F, Martinez-Aran A, Torrent 25. Fwuerstein, M. Labbe, E. and Kuczemexzyk, A. R. (1987) C, Comes M, et al. What really matters to bipolar patients’ health psych. (2nd printing). Plenum press, New York and caregivers : Sources of family burden. Journal of affective London. disorders. 94(1-3):157–163. 26. Nehra R, Chakrabarti S, Kulhara P, Sharma R. Caregiver- 17. Pai S, Kapur RL. Impact of treatment intervention on the coping in bipolar disorder and schizophrenia. Soc Psychiat relationship between dimensions of clinical Epidemiol. 2005 Apr 1;40(4):329–336. psychopathology, social dysfunction and burden on the 27. Caqueo-Urízar A, Gutiérrez-Maldonado J. Burden of Care family of psychiatric patients. Psychological Medicine. in Families of Patients with Schizophrenia. Qual Life Res. 1982;12(03):651–658. 2006 May 1;15(4):719–724. 18. Malakouti. Seyed Kazem and Co., Burden of caregivers of 28. Chakrabarti S, Gill S. Coping and its correlates among chronic mental disorders patients and their need to care and caregivers of patients with bipolar disorder: a preliminary medical services, 1997, Hakim Journal, Summer 2003, 6th study. Bipolar Disorders. 2002;4(1):50–60. print, No. 2, p 8. 29. Hanzawa S, Bae J-K, Tanaka H, Bae YJ, Tanaka G, 19. Carver CS, Scheier MF, Weintraub JK. Assessing coping Inadomi H, et al. Caregiver burden and coping strategies for strategies: a theoretically based approach. Journal of patients with schizophrenia: Comparison between Japan personality and social psychology. 1989;56(2):267. and Korea. Psychiatry and Clinical Neurosciences. 20. Mohammadkhani, Parvaneh (1992), Assessing strategies 2010;64(4):377–386. for coping stress and symptoms in obsessive – compulsive 30. Hanzawa S, Tanaka G, Inadomi H, Urata M, Ohta Y. patients (Thesis of MSc. in clinical psychology). Burden and coping strategies in mothers of patients with 21. Epstein S, Meier P. Constructive thinking: A broad coping schizophrenia in Japan. Psychiatry and clinical variable with specific components. Journal of Personality neurosciences. 2008;62(3):256–263.
Iranian Rehabilitation Journal 31 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Original Article
Effect of Time Constraind Induced Therapy on Function, Coordination and Movements of Upper Limb on Hemiplegic adults
Masoud Gharib, MSc; University of Social Welfare and Rehabilitation Sciences, Neurorehabilitation Research Center, Tehran, Iran. Hooman Ghorbani, MSc; Mehdi Abdolvahab, MSc; Nader Fallahian*, MSc; Masoud Kasechi University of Social Welfare and Rehabilitation Sciences,Tehran, Iran.
Introduction: Stroke, is one of the major causes of disability in adults .so, the patient may prefer to use the non- involved limb to perfom selfcare & named this phenomen learned non used. Constraint induced therapy is one of the rehabilitative interventions that can be effective in restoration of the function of the involved limb in some hemiparetic post stroke patients. purpose of this study was to investigate effect of time constraind induced therapy on function, coordination and movements of upper limb on hemiplegic adults. Method and Materials: In an interventional design, 15 hemiplegic patients attended in stracture exrcises for 2 hours a day, 5 days a week for 12 weeks in during while for 5 hours a day, 5 days a week for 12 weeks, the sound limb was restricted within an arm sling for movement & dextrity assessment were used Fugl-Meyer & Minnesota Manual Dexterity Test. Results: the results of Fugl-Meyer & Minnesota Manual Dexterity Test were significantly improved in patients, after the intervention(p<0.0 5). Discussion: our study shows that using CIT in involved limb encouraged the patients to use their involved limb and improved function by conquering learned non-use of the limb. more research is necessary to define baselines or golden times for rehabilitation of the patients using CIT method. Key words: Strok,constraint Induced Therapy, Function, Dextrity
Submitted: 1 May 2011 Accepted: 22 Aug 2011
Introduction Variety of methods have been used in rehabilitation Stroke, is one of the major causes of disability in of the stoke patients, such as biofeedback, adults and in most of the times is accompannied by neuromuscular stimulation, and motor learning. considerable motor functional loss(1). It results in These methods may be effective in early functional hemiplegia, and functional impairment in restoration of the upper limb to perform ADL. When performing activities of the daily living(ADL). the function of one side is superior to the Many researcher are interested in finding more contralateral limb, the patient may prefer to use the effective treatment modalities(2). sound limb to perfom selfcare. As the time passes Recovering motor function and integration of after the stroke, patients use their non-involved limb recovered motor skills to improve functional to perform ADL(5). Taub described this independence level in ADL is one of the most phenomenom as “learned non-use” of the upper important responsibilities of the ocupational limb. In other words, as the patient finds the limb therapists. Because of the importance of the upper useless, learns to “non-use” it(6). limb for performing the activities of daily living, Constraint induced therapy is one of the improving the function is one of the most important rehabilitative interventions that can be effective in aspects of retrainning motor control, and has an restoration of the function of the involved limb in important role in rehabilitation programs(3, 4). some hemiparetic post stroke patients(6, 7). “Constraind Induced Therapy”(CIT) and “forced * All correspondence to: Nader Fallahian; Email: < N. Fallahian@uswr. ac. ir>
32 Vol. 9, No. 14, Oct. 2011 use” of the involved limb are new therapeutic intervention group compared to custom treatment intervantions. In these approaches the non-involved and no treatment groups(p<0. 05). limb is restricted to encourage utilization of the In 2005, Bonifer used CIT on 20 patients, 1 year involved limb via performance of functionl post- stroke(11). All subjects had 20 degrees of wrist activities(8). Great amount evidence exists about the extension. the patients were asked to use a mit on application of these methods in order to motor loss non-involved hand and perform CIT exercises for 6 of the involved limb and improving the functional hours a day in 3 weeks. The patients were assessed independence in strok. using the Fugl-Meyer test. The scores improved Also both Induced therapy and forced use of the significantly after the intervention. limb include limitting the non-involved limb and In 2006, Wolf et al used CIT in post stroke patients, performing excercises by the involved limb, These 3 to 9 months post stroke(12). the goal of this study modalities are different from each other in types of was to evaluate the effectiveness of CIT on excercises and time of the restriction. in forced use, functional movements of the upper extremity in two the non -involved limb will be restricted and the week intervals for a period of twelve weeks. the patient has to perform all actions with the involves movements of the non-involved hand of 22 patients limb. in this method the exercises are not structured was restricted with a mit. using the shaping and the severity of excercises depends on the patient technique, each patient was encouraged to use the conditions. but constraind induced therapy is a involved limb. at the end, the results within this structured exercise that includes shaping and group was superrior than the control group in repetitive tasks (7). functional movement tests. CIT was first introduced on behavioral cognitive Tarka et al used CIT in 27 patients with stroke. the basic science researches on monkeys. the results non-involved limb of each patient was restricted showed when the limb has no function, the animal within an arm sling for 2 weeks, 7 hourse a day. the would not use the limb for the activities of daily patients completed CIT exersices for grasp-release living. as non-use of the limb that gradually results and manipulation of small objects. This stuy showed in persistent non-use of the weaker limb(6). that the functional movements of the involved limb In 2002, Page et al used CIT on 14 patients with improved significantly after the intervention(13). stroke in 10 week interval, for 3 days a week; and purpose of this study was to investigate effect of found an improvement in results of the Fugl-Meyer constraind induced therapy on function, coordination test(9). In 2003, similar study was performed by and movements of upper limb on hemiplegic adults. Bonifer et al (10) on 7 patients with stroke after at least 1 year after the stroke. The patients had at least Materials and Methods 10 degrees of wrist extension in involved limb and In an interventional design, 15 hemiplegic patients CIT was used for 3 weeks. The patients were asked (9 males and 6 females)&(9 right,6 left) were to perform particular exercises, that cuased more use radomely selected from the patients referred to of involved limb both in clinic and in home, for 3 occupational therapy clinic of rehabilitation faculty weeks, 5days a week for 6 hours a day. Fugl-Meyer of Tehran university. The average age of the patient test was also used to assess the movements befor and was 60. 8 years, with Standard Deviation(SD) of 10. after the intervention. the results significantly 8 years. Written contestant was acquired from the improved after the intervention. patients before the intervention. Demographic In 2004, another research was carried out with Page characteristics of the subjects are summerized in et al(9) on 17 stroke patient, after 1 year of table 1. involvment. an intervention group of 7 patients were Inclusion criteria were: encouraged to use their involved limb to perform at least 1 year passed from the stroke ADL. 4 patients received common treatments as the no symptoms of frozen shoulder persist at the intervention group and 6 patients had no treatments. onset of the intervention activities including writing, using utensiles, brushing the ability to sit on the edge of the table for 10 teeth and combing own hair, while their non- minutes, to ensure required stability of the trunk involved limb was constrained by splint for 10 the ability to obey the verbal and functional weeks, 5 days a week for 5 hours a day. the scores of commands Fugl-Meyer test was significantly improved in at least 20 degrees of wrist extension preserved in involved limb
Iranian Rehabilitation Journal 33 Exclusion Criteria were: exersises was included of 10 minutes of practice and unwillingness of the patient to continue the 10 minutes of rest. 2 sets of excerrcise, total of two therapeutic sessions hourse were performed with the involved limb while occurance of orthopedic desease the sound limb was restricted within an arm sling. recurrence of stroke or other neurologic conditions Fugl-Meyer Test was used to assess velocity and All patients completed specified routine coordination in movements of shoulder, elbow, wrist occupational therapy exersices 45 minutes a day, 3 and hand joints. Minnesota Manual Dexterity Test times a week meanwhile non-involved limb was was also used to assess dexterity of the upper limb. constrained within an orthopedic sling (9) for 5 Both tests were used before and after the hours a day, 5 days a week for 12 weeks. intervention in two week intervals. Paired t-test was Occupational therapy stays on the principle that used to compare the score before and after the using purposful activities can facilitate intervention. SPSS (version 11. 5) was used for data rehabilitation, so in this study we used aimed analysis. activitites to develope the required motivation for more use of the involved limb. In order to have the Results subjects perform a unique form of exersises, an There are demografic characteristics of the patients educational video demonstration was recorded and in table (1). The results of Fugl-Meyer test are the patients were asked to perfrom their exersises summerized in Fig (1). As it is demonstrated, the based on the media. these exersices include grasp scores of the test were significantly improved in and release of a tennis ball, openning and closing of patients, after the intervention(p<0. 5). the door, and utilizing a glass for drinking. Each
Table 1: Demographic characteristics of the subjects variable Average Standard Deviation Age 60.8 10.8 (years) Weight 67.87 5.05 (kilograms) Height 171.53 5.06 (centimeters) Time passed from storke (years) 2.5 1.2
Score
Average
Perivous Second Fourth Sixth Eighth Tenth Twelfth intervention week week week week week week week Fig 1. Averages for scores of Fugl-Meyer test in involved upper limb during twelve week intervals.
The results for Minnesota Manual Dexterity Test also improved and are summerized in Fig (2).
34 Vol. 9, No. 14, Oct. 2011
Score
Average
Previous Second fourth Sixth eighth Tenth Twelfth intervention week week week week week week week Fig 2. Averages for scores of Minnesota Manual Dexterity test in involved upper limb during twelve week intervals
Discussion enhanced functional skills and has a positive effect The results recommand that repeated and functional on cortical neuroplasty. The results of this study exercises, and implication of CIT approach can show that CIT could be an effective modality to conquer learned non-use and improve utilizing of the overcome the learned non-use of limb after stroke. involved limb, thus result in decreasing the As the results of the Fugl-Meyer test demonstrate, disability. The significant improvements in scores we can suggest that CIT can facilitate functional may be attributed to several factors: improvement in changes. physical abilities of the upper limb, changes in The results of this study were consistent with Page learned non-use behavior, or cortical neuroplasticity study in 2002(9) that used CIT on 14 stroke patients due to limb use. for 10 weeks, 3 days a week. Scores from the Fugl- Also Taub et al(6) stated that any kind of technic Meyer were improved after intervention to more that can encourge the patients to use involved limb than 11 points, while in our study, the average score can be effective in treatment, it seams that constraint improved to 11. 07. In this study, the most induced therapy approach can result in cortex improvment of the results of Fugl-Meyer test were plasticity and functional improvement. repeated found by the eighth week. but the results did not application of the involved limb is one of the improved significantly in 9th to 12th week for primary factors in CIT approach. That may cause shoulder, elbow, wrist and hand velocity, motion cortical neurplacticity that is nessessary for and coordination. some possible causes would be as functional improvement. follows: 1. Fugl-Meyer test items can not assess the Great amount of evidence exist that recommands changes and improvement of the motion in latest different merthods of exercises and repetitive use of weeks of the study, after the patients improved in the involved limb result in cortical neuroplasticity motor abilities. 2. the patients improved faster in the and funcitonal improvement. It seems that stroke first 8 weeks of CIT. in other words the rate of patients grow more motor disability in involved improvment was higher in early weeks of limb, because they prefere to use non- intervention and it went more steady and stabilized involved(sound) limb and not use the involved limb during the latest weeks. Maybe the patients will not for performing the activities of daily living. As the more improve a certain level using CIT. 3. maybe time goes on from stroke, learned non-use results in improvement in function of the upper limb has a less use of the involved limb, and the limb becomes kind of effect on performing activities of daily more and more non-used and weak. living, that can not be assessed using the Fugl-Meyer Short time treatment protocols can make functional test, and other tests that assess the activities of daily improvements or cortical changes, cortical living should be used. neuroplasticity depends on using the limb. In this our results were also consistent with the findings of study, we found added use of the involved limb can Bonifer in 2003(10) and 2005(11). also most of the
Iranian Rehabilitation Journal 35 participants of Bonifer’s study mentioned that after due to extended time of intervention(12 weeks) intervention they used their involvede upper compared to 3 weeks of intervention in mentioned limb(10), it dos not mean that the patients has gained study. the ability to independently use the involved limb, or our study shows that using CIT in involved limb the motor abilities has improved and reach the level encouraged the patients to use their involved limb of the time before the stroke. and improved function by conquering learned non- In Bonifer’s second study(11), the scores improved use of the limb. more research is necessary to define to 5. 6 points after 3 weeks of intervention, while in baselines or golden times for rehabilitation of the our study the scores improved 11. 07 points in 12 patients using CIT method. week. the higher scores found in our study may be
References 8. Andrew M, Gordon M. Methods of constraint –induced 1. Ferrucci L, Bandinelli S, Gurlnik J, Lamponi M, Bertini C, movement therapy with hemiplegic cerebral palsy. Arch Falchini M. Recovery of functional status after stroke: post Phys Med Rehab 2005;86:837-844. rehabilitationfollow-upstudy. stroke1993;24:200-205. 9. Page S, SueAnn S, Johnson M, Levin P. Modified 2. Shumway-Cook A, Woollacott M. Motor Control. USA: Constraint-Induced Therapy after Subacute stroke. J Elsevier 2001. Intensive care Med2002;17:111-119. 3. Ekman L. Neuroscience: Fundamentals for rehabilitation 10. Bonifer N, Anderson KM. Application of constraint-induced USA: WB Saunders; 2002. movement therapy for an individual With Severe chronic 4. Gillen G, Burkhardt A. Stroke rehabilitation: a function- upper-extremity hemiplegia. Physical based approach. USA: Elsevier; 2004. Therapy2003;83(4):384-398. 5. Pamela S, Vegher J, Gilewski M, Bender A, Riggs R. client- 11. Bonifer N, Anderson K, Arciniegas D. constraint-induced centered occupational therapy using constraint-induced therapy for moderate chronic upper extremity impairment therapy. Stroke.2005;14(3):115-121 after stroke. Brain Injury2005 May 2005;19(5):323-330. 6. Taub E, Miller N, Novack T. Technique to improve chronic 12. Wolf S, Winstein C, Miller J, Taub E. Effect of constraint- motor deficit after stroke. Arch Phys Med induced movement therapy on upper extremity function 3 to Rehabil1993;74:347-354. 9 months after stroke. JAMA2006;296(17):104-296. 7. Morris D, Crago J, DeLuca S, Pidikiti R, Taub E. 13. Tarka I, Pitkanen K, Sivenius J. Paretic hand rehabilitation Constraint-induced movement therapy for motor recovery with constraint-induced movement therapy after stroke. Am after stroke. Neurorehabilitation1997;9:29-43. J Phys Med Rehabil2005;84:501-505.
36 Vol. 9, No. 14, Oct. 2011 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Original Article
Challenge of Private Rehabilitation Centers and Welfare Organization (Behzisti)
Roghiye Akbari Ghaemshahr welfare organization, Mazandaran, Iran Mohammad Kamali*, PhD.; Hasan Ashayeri, MD.; Narges Shafaroodi Iran University of Medical Sciences, Rehabilitation Research Center, Tehran, Iran
Studying the situation of providing services for people with disability are very important and in current situation which is dominate on system providing rehabilitation services in Iran, private rehabilitation centers can be the best and the most important focus for this study. This research performed by qualitative method and with phenomenology type, and purposeful sampling did as purposeful and based on similar samples. The samples of this study consisted of 14 managers of private rehabilitation centers who had especial experiences about the theme of research and providing rehabilitation services. The method of executing research was base on deep and open semi-structured interview that use from method focus group discussion which is a type of semi-structure interview for collecting data from samples. Collected data were analyzed by written analyze method and used from suggested Van Manen suggestion method. Managers of private rehabilitation centers meet different problems and confront with different situations in their centers. General problem which appear as a frame of problems related to private politic, especial problems related to private rehabilitation centers activities, and intra/extra communication. The delivery of services to private sector does not mean depriving the responsibility from Welfare Organization and its rehabilitation deputy. The organization should issue establishment license for private rehabilitation centers and administer it. Keywords: Qualitative Research, Phenomenology, Lived Experience, Private Rehabilitation Center, Management.
Submitted: 17 Sep 2010 Accepted: 29 Sep 2010
Introduction transmission of authority and responsibility from Developing countries faced economic crises in 1980 central offices to semi-independent or autonomous decade. These crises made major hindrances in institutes. “Devolution” is the transmission of governments' capacities for investment in state- authority and responsibility from central offices to owned institutes. Regarding this issue, governments separated management structures which are still in different countries have thought in de- managed by state managers. “Privatization” is the concentration as one of the possible solutions for the transmission of operative responsibilities and the problem and it has been involved in governments' ownership in some cases to the private providers programs since long time ago. Several countries and mostly becomes in a contract style to satisfy the governments are trying to execute this policy. De- reciprocal expectations (1). concentration means the transmission of power, With attention to increase the number of people with authority and responsibility of the government to disabilities and their families who come to receive state organizations, semi-independent institutes and rehabilitation services and regarding the most cooperative or private units, and it's divided to important point in disability especially in first different kinds. “De-concentration” is the power stages, is the rehabilitation and training of transmission from central offices to local ones with rehabilitation person (2). Thus investigating how same executive structure. “Delegation” is the these services are offering would be very important
* All correspondences to: Dr. Mohammad Kamali, Email: [email protected]
Iranian Rehabilitation Journal 37 and incurrent situation and with operative condition part of costs related to the services will be paid by which effect rehabilitation services offering in Iran, government subsidies. Guerriere, et al (5) also private rehabilitation centers would be the important mentioned on partnership of service receivers and focus in this study. the government in paying the costs, in their research It's clear that, in addition to reducing the government on costs and determinant factors in health care with expenses help reaching the development targets and personal finance but great motion of the currently suitable distribution in services, access improvement the daily and 24-hour rehabilitation services and also the increment of quality and efficiency, are procedure for children with corporeal and main targets of the De-concentration policy in intellectual disabilities, indistinct and blind children general and creation of private rehabilitation centers and also seniors and chronic mental patients is being in specific (1). In a research done by Giraldes (3) done according to the welfare organization rules. also quality and efficiency factors with their Now over 1000 rehabilitation services offering descriptions and all points that evaluated in each centers are active in country. Here the manager's factor, have been used for comparing general and "motive" and their "knowledge" about "disability”, private hospitals. "rehabilitation" and "special education" for people The expectation of increasing the quality and with disabilities , and their viewpoints about these efficiency of services offering by private institutes concepts can highly affect their activities can be raised from differences in management and performance (6) . organizing patterns between private and state-owned It's clear that the implementation of private centers institutes, which studied and affirmed in a research establishing policy by welfare organization doesn't done by Roman, Ducharme, and others (4) on relieve its responsibility from welfare organization general and subjective treatment programs for drug in rehabilitation and education services offering to abuse. people with disabilities, and the organization should The cogency of implementation for De- succor the private centers and the managers to abate concentration and privatization policy and on the the problems and difficulties with continued training other hand increasing disability and accordingly programs and constant supervision on their increasing society requirements to receive activities. Thus getting knowledge and information rehabilitation services, are decisive reason for about different insights and viewpoints of managers clarifying the importance of private institutes in pertaining to establish private rehabilitation centers rehabilitation guidelines. Then promotion of quality can help us to realize the problems and difficulties , level in these centers will improve the quality of and find effective and practical solution to abate the rehabilitation services offering to the target society halves and reach the "efficacy and efficiency and finally will lead to reach the target which increasing" target . Then to reach the main target of determined for privatization policy in health care describing the viewpoints and experiences of private services area such as rehabilitation .The evaluation rehabilitation center's managers about establishing scales for efficiency and efficacy in rehabilitation and managing these centers and getting more and education of people with disabilities, (which are knowledge and deeper insight at this background , the basic operations for private rehabilitation we surveyed the viewpoints and experiences of centers), are quality and condition of rehabilitation private rehabilitation centers' managers about services offering in these centers and coincidence of managing a rehabilitation center Through a research their services and activities with standards . to be able to hand over the results and findings to the Then we were able to see the execution of responsible and rehabilitation services renderers and privatization – one of De-concentration methods – in then to become more familiar with difficulties and state welfare organization that transferred the problems of centers' managers and affecting factors responsibility of such services to the private on rehabilitation services offering quality , and find institutes. In fact since 1984 in order to reduce the easier ways of offering rehabilitation services in government's ownership and increasing the their centers (6) . partnership of individuals and private organizations Catalono, Kendall, Vandenberg, and Hunter (7) in rehabilitation services, daily and 24-hourcenters faced equal professional managers' experiences to specialized for people with disability, seniors and investigate the subject of these persons' realization chronic mental patients have been established in and knowledge toward people cooperation with each whole country by individuals and corporations that a other and work together, in their research like any
38 Vol. 9, No. 14, Oct. 2011 other one, in this research, these were the questions In present research because of the qualitative type, to be answered after analyzing the findings. the sampling has been done as intended and based Questions are: on similar samples. According to the research aim 1- Which reason and motivational factors make a the researcher start to choose intended sampling person emprise a private rehabilitation center? regarding the type of experiments (the private 2- What kind of problems, the private rehabilitation rehabilitation center managing). In fact, the centers' managers faced in establishing and participants have the same experience of managing managing their centers. the private rehabilitation center. And the similar 3- Does the welfare organization's policy against the samples in private rehabilitation center managing category of "Private rehabilitation centers" affect experience have been chosen. these centers' activities? The participants were 14 managers from private 4- How much the human force and employees rehabilitation center with education levels bachelors arrangement in private centers can be affected by and master graduated in physiotherapy, psychology, managing styles and how effective can be the exceptional children psychology, occupational methods of management on the center. therapy and management and had special knowledge 5- Is it possible for the private center's manager to and experiences in rehabilitation services. 4 of them impart the partnership of disabled person's family were female and the others were male. With the and parents in directing the center, rehabilitation factor of: having the established authorization for and education offering to this target society? private rehabilitation center, with 3 years old The researcher had to analyze the givens and average of the center and taking the management information by recording and paying accurate position. Considering these factors for participants in attention to participants’ statements and then this research would be possible by asking them and repeating the study of recorded point and deep referring to their center establishment files .the seated investigating of got contents and record of service of the private centers under communicates these contents to the research topic. management of participants in this research were between 4-14 years. There was no necessity for Material and methods identification of whole participants and the exact The present research has been done based on a number of them from the beginning. Repetition and phenomenological method and as a qualitative conformation of last collected data would be the research. The decision to use qualitative number of participants. methodology should be investigated accurately Data collecting started by arranging 2 or 3 group because regarding the nature of qualitative research discussion meetings with different members and is maybe excitingly severe and highly time taking. continued by reach the end stage. After each focus However this type of research gives a collection of group discussion meeting the meeting have been rich information which is not reachable through recorded and classified based on the interview guide statistical sampling techniques. and determined targets, and upon this collection the Strauss & Corbin (8), claim that it's possible to use next meeting has been arranged. qualitative methods in order to realize phenomenon Analyzing started by defining the subjects came out which was not realized well before. Qualitative of data, a process which sometimes we name it methods give us a new scope from things which are coding (10). During coding process the researcher not known well and offer more accurate information should identify conceptive headlines, through them which are difficult to transfer through quantitative the phenomenon have been observed and will be research. categorized, and name them tentatively. The target is In quantitative research the prevailing sampling creating multi dimensional descriptive groups from a strategy is random sampling that depends on primary framework, for analyzing word, phrases and choosing an accident sample from a larger society. events that look similar should become categorized The purpose of random sampling is to generalize the as same group. research findings to the whole society in the next The next stage of analyzing includes reconsidering stage. On the other hand intended sampling is the the known groups to identify relations between most evident strategy in qualitative research. them, a complicated process, sometimes called axial Purposive sampling searches rich samples of coding (10). In present research, data analyzing has information which can be studied in details. (9) been done by written analyzing method using Van
Iranian Rehabilitation Journal 39 Manen suggested style Van Manen (11) offers a Results: primary regular structure for explanatory Findings that will be explained in this section are phenomenological research that is introduced in a part of a vaster study results came out of this model with 6 methodological contents, including research. Interview meeting which were transcribed these stages: and totalizing the participants' statements. In present 1. Having a tendency to a phenomenon which research leaded to creating 50 subthemes and by seriously makes us interested in our world. classification of this subthemes, 11 themes have 2. Considering the experience as we live it not as we been found and in repetitive study and several imaging it. considering of these themes and finally after 3. Thinking of basic and inherent contents that totalizing all themes and subthemes it seemed that define the phenomenon's nature and specifications. it's possible to take all statements of these people 4. Description of the phenomenon through writing into account in 2 general grounds and put declared and rewriting art. themes into these 2 general grounds and investigate 5. Keeping a strong directional training relation to the present research's topic on base of these 2 phenomenon. general grounds including: 6. Balancing the research texture by observing and 1. The condition leads the person through deciding paying attention to details and totalities. for establishing the center and executing this To observe the ethical principles in present research decision. together with providing a testimonial for which 2. Condition the person faces, in managing the given to all participants in several stages and center. different times to any of the focus group members One of the main and basic themes of this research became a assured that all their sayings will stay found around the communication with welfare confidential and in order to record their words in organization that in declared experiences 9 focus group interview nothing will change. subthemes came out from this main theme Shown in below table.
Table 1: The subthemes and related themes Main theme Subthemes 1. CCaopula expert 2. LLaws and bylaws 3. GGradation of centers 4. TThe government subsidize and referrer referring Necessary relationship with Welfare Organization 5. TThe view of organization to the centers (Behzisti) 6. Supervision or interference? (What means supervision?) 7. TThe township welfare chief 8. WWorking place geography and type of the centers activities 9. EExpectation from the welfare organization
Thus we content to point to these theme and valuation of the centers will be done according to subthemes: them. There are some points mentioned by 1. Copula expert participants especially around this topic. As mentioned before the uttermost relations of a "Each year a new bylaw, each year a new circular, I private rehabilitation center is the relation with the feel they didn't reach to the common target even by welfare organization according to participants' themselves, because from the beginning, two statements the most important link for this relations "privatization" and "releasing" topics have been is the copula expert and they believe that his revenue mixed up." "These changes in manuals confuse the and specifications can affect the center's activities. person.” "What their expert say, wouldn’t be as a revelation. I 3. Gradation of the centers also have experts and I'm also an expert and my The result of valuation will appear as a grade given experts are also skilled". to each center and this grade in fact will determine 2. Laws and bylaws the amount of finance and benefits the center Description of each center’s activities is based on receives from welfare organization. elements enacted in laws and bylaws and the
40 Vol. 9, No. 14, Oct. 2011 "They did a subtle action graded in 1, 2 and 3 but it economic partnership of families in payment. The also doesn't work.". costs and fluency or difficulty in absorbing skilled 4. The governmental subsidize and referrer referring. experts will affect the center. Regarding the participants' statements the centers' "They should indicate the tuitions locally and activities are highly depended on subsidizes. describe the services according to the location. For "There are infirmities but it's not a good reason for example don't make equal the services offered in reducing the subsidizes, they should not go Tehran with those in township equal ". immediately to the last step.” "They repeatedly say 9. Expectation from the welfare organization you have to stay quiet because you get subsidize.” Some of participants stated some expectations in a 5. The view of organization (welfare organization) frame of offering some services from welfare. to the centers. Organization to private rehabilitation centers in The participants mentioned that, the act of the order to help them in executing the activities and centers is in fact taking some responsibilities of cooperation with them. welfare organization, and then they are like "Exceptional children in Vardavard pay only 50000 executing arms for the organization. Rials for dentist but children in our centers can't and "They don't care about the service offered and the any other dentist doesn't accept them because they type of services which the center should offer.”. are afraid of unconsciousness , they are afraid "They say we should not pay attention to strong because these children have abnormal movements .". points and should never mention theme. We should only mention the weaknesses.” Discussion and conclusion 6. Supervision or interference? (What means The beginning point for private rehabilitation center supervision?) activities is the decision the one makes to establish Private rehabilitation centers became established the center. Being subject of some conditions leads to under supervision of welfare organization and this this thinking and decision. If exiting condition can supervision will be continued during their working. propel the person to establish a center and he or she In this research some of participants believe that the can actualize the decision to establish the center, the description which the organization has about the managing and directing topic comes up (12). supervision on centers' activities is not a suitable A private rehabilitation center's manager faces description and sometimes has some common point different conditions and problems in the way of his with interference in centers' management. "In my (her) management. General problems related to opinion it's not their business that how much salary I privatization policies and special problems related to pay to my employee, it's related to job private rehabilitation centers activities and their administration.” internal and external relations. As mentioned in 7. The township welfare chief previous sections, before 1984 the welfare We mentioned that there is a relation between organization was the main responsibility for welfare organization and the centers that the rehabilitation services offering to disabled people, managers think as the middle ring for these relations and after that it transferred gradually to the private is copula expert but one who can highly affect this sector. But this transferring doesn't mean depriving middle ring is the township welfare chief and his welfare organization from all responsibilities and viewpoints thinking and acting. this organization was responsible for supervising the "Our organization management is inconstant; it's 8 private rehabilitation centers' activities, and issuing years that I'm working and the welfare chief has all establishing justifications. Therefore all private changed several times.” rehabilitation centers’ activities should be under "The new welfare chief is so much better for us supervision of this organization. because he thinks as we think and we are not against Then regarding this procedure, welfare organization each other he completely understands us it's better takes the greatest volume of external relations of for administrating the center.". private rehabilitation centers. There for utter most 8. Working place geography and type of the center's problems which involve the private rehabilitation activities centers' management are related to these relations Some of participant's statements mention to the with welfare organization. geographic location and the covered area by the The connection between welfare organization and center according to type of disabilities, factors like the private rehabilitation center in each county is
Iranian Rehabilitation Journal 41 "copula expert" who is appointed by rehabilitation experts mentioned there is a missing part in between. deputy of province welfare office and is the To conclude the participants' statements about responsible one for the coordination between private copula expert we get results like the irrefragable rehabilitation center and welfare organizations effect of copula expert and his/her visits and reports which transfers the problems and difficulties to the to the welfare organization – which sometimes organization and help them to find ways to solve the affects by personal opinions caused by scant problems. On the other hand it informs the centers knowledge in related ground – and problems like managers about the laws and bylaws, sanctioned by this which affect the centers' activities . province welfare office and country welfare On of other debatable problems is the gradation and organization to help them to take the opportunity to government subside which is paid by the welfare adjust and execute their activities according to, and organization to the centers. a great part of service coordinated with laws and bylaws. offering quality in the centers depend on financial As we mentioned before all private rehabilitation condition and as most of accepted cases in the center centers' activities are under supervision of welfare become enrolled through subsides , then a great part organization and part of costs will be paid by of financial problems will be considered through government as government subside . And it will be subsides . Then in this condition its irrefragable the different depending on the grade which the center dependence of the centers apostleship to subside can get through the province valuations (1, 2 or 3 paid by welfare organization. grade), and here the report which prepared by copula Then it would be easy to imagine, which problems expert looks very important. the manager will face if he/she doesn't get the According to findings of this research practically subsides in proper time, or be not able to enroll this relation makes problems for the managers to enough cases through subsides. understand and realize the problems and the copula Laws and bylaws and repeatedly changes in them expert become informed about them during his/her after small changes in managers of welfare presence at the center , he/she should have enough organization, and personal styles of managers in knowledge and acquaintance about the activities and province and township level are the other problems responsibilities of a private rehabilitation center and which its minimum effect on the center's operation about the conditions there . will be confusing the manager in implementing the It's highly depended on the copula expert's plans related to determined responsibilities. experience in this ground, as we investigated most of Regarding the experiences of different managers managers present in focus group interview meetings cooperated with us in this research, we found that in were interested in this point and mentioned that determined criteria and scales for identifying the people who are appointed for this position have standards about the centers' activities, there are a lot temporary presence in this position and there is no of margins and offshoots in between which play enough time to get experience and find information down the importance of main targets in a center and and knowledge related to this ground Then of this the importance of target population of center's scant knowledge, will bring the utter most prejudice activities and apostleship of the center or make it to the center and it's manager. Because regarding the equal with the importance of margins. determined responsibility for the copula expert and Referring to the experiences mentioned by the his/her key role in evaluation the results and managers in focus group interview meetings we determining the subsides. If he/she could not prepare found the effect of some other factors like adopted a clear and exact report from the center (either in policies and type of acting of the "township welfare recording the points or showing disadvantages and chief" against private rehabilitation centers and deficiencies) it will definitely affect a majority of the his/her acquaintance and belief about rehabilitation center's activities in addition to working experience , and activities and apostleship of private training and retraining are factors which can reduce rehabilitation centers . the experimenting time and increase the knowledge The township welfare chiefs as the higher levels of of copula expert about the problems in the centers managers should administer different departments and his/her authorities and about how to play his/her and deputies like social, prevention engagement and role in assisting the manager to administer his/her rehabilitation. To manage all these sections' private rehabilitation center. Regarding our activities beside the frame mentioned by the rules investigations as either the managers or the copula for these sections' activities will definitely affect the
42 Vol. 9, No. 14, Oct. 2011 policies he/she adopt from each section and also the mentioned (5 years) . In fact "abettor workshops" operation of personnel in each section – personnel subject – one of the ways to provide treatment and include all staff in rehabilitation department, survey rehabilitation continuance for these people – was team those who work around private rehabilitation that all managers with responsibilities in vocational center activities and the copula expert – the higher training centers mentioned on missing of that (as we level of this acquaintance and dominance will investigated there are 4 active abettor workshops and improve the acting of each section and it's staff. one establishing one in the country) . Regarding the important role of an organization's The geographic region which the center acts, affects manager in creating coordination between his/her the private rehabilitation center's activities with a subordinate units, improving this coordination will view of local culture and people's attitude against help the side long wings of the rehabilitation disability and rehabilitation, and it causes different department – that private rehabilitation centers are of experiences for managers present in focus group these wings – in their operation and activities and it interview meetings In different geographic regions will be easier for the organization and the centers to there are different cultures which definitely causes reach their determined targets . Then it would be differences in attitude against social , political , irrefragable the direct and indirect effects of the economical , therapeutic this also includes township welfare chief on the private rehabilitation rehabilitation and private rehabilitation center topics centers' activities. and this type of attitude will from part of private The type of the center's activities and type of rehabilitation center working and it's manager's disabilities the center undertakes and service experiences . Because regarding type of private offering responsibility are the factors which affect rehabilitation center's activities and human target the operation and activities of private rehabilitation society for its activities, people in each region will centers from one viewpoint we may survey this be outside customers. Another effect which is factor from view of ease or difficulty of caused by this factor is substituting released accommodating families to the policies which the referrers, that based on differences in disabled center's manager contemplates to administer his/her population in different townships and effect of center. economic and cultural texture in the township the For example, about therapeutic feedbacks from list of waiting referrers has been reported different in disabled people present in the center for instance the different townships. The discussable point is not the results would be more touchable and take less time differences in compression to the mentioned list, but in corporal – motional centers in comparison with is the effect of that on administrating and managing mental centers, receiving these feedbacks from the the center. A manager who has no problem in parents will cause them to accept the conditions and substituting released referrers can act easier and accommodate themselves to the terms according to stronger in practicing his/her frames and rules for which the center's manager administrates his/her managing the center and can easily bind the families center – like transportation services costs and to pay all tuitions and partnership payments. undertaking this responsibility by the families – Whereas the private rehabilitation center's activities whereas in comparison to mental centers. These should be done under supervision of welfare payments and partnership will not appear easily and organization the determined confine for this the manager will face problems about them. Another supervision and contemplating a separation viewpoint we can contemplate for this view is the boundary between supervision and interference comparison between vocational training centers and would be another factor which affects the private other centers with a view to difficulties in finding rehabilitation center's activities that has been referrers and substituting released ones and on the mentioned by the managers present in this research. other hand , absorbing the cooperation and As they said, the experts who are responsible for this partnership of the families in different grounds of supervision should act in determined frame and the center's activities . And this difficulty might be through the purpose of helping the private because of missing of engagement and ways to rehabilitation center reach prescribed targets. While complete the treatment and training for disabled some of the managers present in research declared people who are in vocational training centers for that these experts even enter some managing areas treatment and training and have to leave after the which are completely authorized by the manager period of time which welfare laws and bylaws himself/herself, in case of their supervision
Iranian Rehabilitation Journal 43 responsibilities – like determining the economic cause managers to face several problems and partnership of the families – or areas out of the regarding can highly affect the private private rehabilitation center's activities area – like rehabilitations' activities and managers that because type of fruit for feeding program – Regarding the of the extent of this effect it looks necessary to find a likeness between welfare organization and good solution for this problem. exceptional education organization and considering It is sensible the missing of negotiation in a calm more exceptional education organization in side and safe environment without deflecting the private services offering to disabled people covered by them rehabilitation service managers or welfare there will appear some expects from these services organization responsible in province and township offered in welfare organization (private areas. Reducing the intellectual engagements and the rehabilitation center manager) and from receivers of worries caused by them which engage a private these services (disabled people families) that stated rehabilitation center's manager will definitely as suggestions by participants of this research. From provide more comfortable conditions for managing another view, the result comes out of this and administrating the private rehabilitation center comparison, to outside customers of these services, and regarding a better ground to offer the services to will be a basis for the customers to choose the disabled people society (13). As the effect of the exceptional education organization for these services worry level for service offered in private institutes offering because of more services offered in there on quality of service offering to the target population and it will cause the case absorption problem in the has studied by Bilotta (10) on a issue of private centers Some of the suggestions were not result of personal care for disabled seniors and had same mentioned comparison and just propounded as a results. suggestion to help service offering in private rehabilitation centers. Acknowledgments: Finally and based on what the managers present in We would like to take this opportunity to appreciate the research said, interaction with welfare all private rehabilitation center's managers and organization engrosses the uttermost volume of province and township welfare office experts who intellectual engagements of a private rehabilitation were present in our focus group interview meetings center's manager. What we can get from these and helped us to execute this research and reach statements is that this interaction and relation will determined targets.
References Queensland: exploring Health Professional and Peer 1. Litvack J, Seddon J. Decentralization Briefing Notes. World Leaders’ perceptions of working together. Health & Social Bank Institute (WBI) Working Papers, World Bank, Care in the Community. 2009;17(2):105–115. Washington, DC. (1999, p.140) 8. Corbin J, Strauss A. Basics of qualitative research: 2. International Classification of Impairments, Disabilities and Grounded theory procedures and techniques. Basics of Handicaps (ICIDH), World Health Organization, Geneva, qualitative research: Grounded Theory procedures and 1980. techniques. (1990, p. 41). 3. R GM. [Evaluation of the efficiency and quality of hospitals 9. Qualitative research uses the natural setting as the source of publicly owned with private management and hospitals of data. The researcher attempts to observe, describe and the public sector]. Acta Med Port. 2006 Dec;20(5):471–490. interpret settings as they are, maintaining what Patton calls 4. Roman PM, Ducharme LJ, Knudsen HK. Patterns of an "empathic neutrality" (1990, p. 55). organization and management in private and public 10. Bilotta C, Vergani C. Quality of private personal care for substance abuse treatment programs. Journal of Substance elderly people with a disability living at home: correlates Abuse Treatment. 2006;31(3):235–243. and potential outcomes. Health & Social Care in the 5. Guerriere DN, Wong AY, Croxford R, Leong VW, Community. 2008;16(4):354–362. McKeever P, Coyte PC. Costs and determinants of privately 11. Manen M. Researching lived experience: Human science for financed home-based health care in Ontario, Canada. Health an action sensitive pedagogy (1990, p. 174). & social care in the community. 2007;16(2):126–136. 12. Hamidi Practical studies about privatization in Iran. 2007. 6. Nadjafi A. [The study of nongovernmental rehabilitation 13. Khiabani Moghaddam A. Ministerial evolution (rationalize centers cases' capitation cost in Tehran province(Persian)]. of government's extent) . Legal relating office in Mashsad State welfare organization. 2001. University of medical science. 2008. 7. Catalano T, Kendall E, Vandenberg A, Hunter B. The www.mums.ac.ir/shares/btom/btom1/amoozesh/powerpoint/ experiences of leaders of self-management courses in %20tahavol/khiyabani.ppt
44 Vol. 9, No. 14, Oct. 2011 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Original Article
Identification of Genetic Polymorphism Interactions in Sporadic Alzheimer’s disease Using Logic Regression
Najimeh Tarkesh Esfehani, MSc; Mahdi Rahgozar*, PhD; Akbar Biglarian, PhD; University of Social Welfare and Rehabilitation, Tehran, Iran Hamidreza Khorram Khorshid, PhD; University of Social Welfare and Rehabilitation, Genetic Research Center, Tehran, Iran
Objectives: Genetic polymorphism interactions are among the important factors in affliction with complex diseases like Alzheimer’s disease. The important goal of genetic association studies is to identify a combination of polymorphisms and measure their importance in increasing the risk of occurrence of such diseases. In this study, feature selection approach of logic regression was used to identify the interactions among genetic polymorphisms influential in patients affected with Alzheimer’s disease. Method and Materials: 101 Alzheimer’s cases and 109 control subjects from Iranian population were recruited in a case-control study. The evaluation of genes in two groups was performed using molecular technique methods; in particular, the PCR-RFLP technique was used to evaluate the intended polymorphisms in APOE, ABCA1, CALHM, CCR2, GSK3β, SAITOHIN, TAU, TNF-α and VDR genes, and then the feature selection approach was used to detect the significance polymorphisms and interactions between them. Results: Based on feature selection approach, the two-way interaction between the polymorphisms of SAITOHIN and APOE genes were significant on occurrence of Alzheimer’s disease. Conclusion: Logic regression approach is recommended to detect interaction in the genetic association studies. Keywords: Logic regression, Feature selection, Interactions, Genetic Polymorphisms, Alzheimer’s disease
Submitted: 12 Dec 2010 Accepted: 04 Mar 2011
Introduction United States (2), and is one of the most important Single nucleotide polymorphism (SNP) is a minor factors of disability and health endangering in the genetic variation which can occur in DNA sequence. world. In 2006, nearly 26.6 million people in the SNP occurs when a nucleotide is replaced by one of world were suffering from AD. With elevation of the other three nucleotides in nucleotide chain. On life expectancy, it is quite possibly anticipated that the average SNPs in human populations occurs more until 2050, more than 100 million people will suffer than %1 of the times. Individual SNP usually has from AD, which shows that one per 85 people in the small to medium effects in occurrence of diseases, world will be affected with the disease (3). Due to particularly in complex or multi-factorial diseases. the increasing trend in Alzheimer’s disease it is Therefore when dealing with complex diseases, the crucial paying more attention to its early diagnosis purpose of association studies is to specify the and detection. Over 95% of patients suffering from combined effects of SNPs and the interaction among Alzheimer are sporadic and late-onset type, the them on the increase in risk of disease (1). diagnosis of which is based on clinical and Alzheimer’s disease (AD) is one of such diseases. neuropsychological evaluations and is time AD is the most common cause of dementia in consuming and costly. Consequently, the diagnosis middle and old age in western societies; therefore, of disease by a genetic marker could be a good aging increases the risk of affliction with the disease. solution for this problem, so as to be used for quick AD is the fourth important cause of death in the diagnosis of disease in early stages or for treatment * All correspondences to: Mahdi Rahgozar, E-mail:
46 Vol. 9, No. 14, Oct. 2011 Results For fitting the logic regression model and using Present study was conducted on data obtained from feature selection method, the input variables are 210 participants above 65 years of age including 101 changed into binary variables in the following form. afflicted with Alzheimer’s disease in the case group Regarding the APOE gene, the information related and 109 in the control group. The primary to the six genotypes (e2e2, e2e3, e2e4, e3e3, e3e4, information about the APOE genotypes and other e4e4) is at hand and the binary variables of X1 to X6 polymorphisms investigated is given in table 1 and 2. are defined as follows:
Table1: The APOE genotype frequencies were compared between Alzheimer cases and control subjects control case Genotype number (percent) number (percent) e2e2 1 (0.9) 1 (1.0) e2e3 14 (12.8) 5 (5.0) e2e4 1 (0.9) 1 (1.0) e3e3 81 (74.3) 78 (77.2) e3e4 11 (10.1) 15 (14.9) e4e4 1 (0.9) 1 (1.0)
Si2: “Both bases explaining Si are the less frequent variant.” Each SNP Si, is split into two variables as defined in These made variables are used instead of the SNPs below: themselves. Si1: “At least one of the bases explaining Si is the less frequent variant.”
Figure1: VIMSingle (left panel) and VIMMultiple (right panel) of the interactions identified in analysis of Alzheimer data set. Since the SNP names are too long for graphical representation, they are coded.
Consequently, having six genotypes from APOE Logic FS is applied to this data set twice using 10000 gene and eleven SNPs from other genes possibly iterations in each run of simulated annealing and 200 related to Alzheimer, the 28 binary variables as bootstrap samples,—once with a single-tree and a predictors are available as input for the logic maximum of 6 variables contained in this tree and the regression model. Of these variables all observations other time allowing 2 trees to grow with a maximum of showing more than 5 missing values are removed 10 variables in all the 2 trees combined. In the single- from the analysis leading to a total of 22 variable tree case, this leads to the detection of 449 potentially and 210 observations. interesting polymorphisms interactions, whereas in the
Iranian Rehabilitation Journal 47 multiple-tree case, 562 SNPs and SNP interactions are previous studies have shown the relationship identified. however, just one interaction, namely between several single SNPs and Alzheimer (4, 9- !X1&X20 or decoded e2e3&STH (HinfI(A/G))1, 15). Since the interaction between SNPs ore more consisting of 2 polymorphisms from the gene APOE influential than single SNPs in the occurrence of and SAITOHIN seems to be associated with the case– complex disease, it seems necessary to have some control status since in it both indexes VIMsingle and methods to identify these influences. Moreover, in VIMmultiple have high values. If the STH (A/G) is not of order to have a suitable prediction and classification homozygous reference genotype and there is no e2e3 for the intended response, these methods should be genotype in the person, there will be a little higher risk able to quantify the significance of these of developing Alzheimer. interactions. In this article, feature selection which is STH (A/G) itself has the highest value of VIMmultiple a combination of bootstrap and logic regression and third highest VIMsingle. Therefore, the methods was used to determine potential individual SAITOHIN gene may itself influence in Alzheimer and interaction effects between genetic and AG and GG genotypes of this gene are risk polymorphisms influential in affliction with one-late factors for the disease. Alzheimer and then the two indexes of VIMsingle and VIMmultiple were used to quantify the importance of Discussion the specified effects and based on it, one interaction Alzheimer’s disease is one of the complex diseases effect of the polymorphisms of APOE and which lacks specific hereditary pattern and is SAITOHON genes was determined. The results heterogenic and mutations and polymorphisms revealed that if the polymorphism A/G in the existent in several genes along with environmental SAITOHIN gene is not of homozygous reference factors, are influential in it. Since there is no definite type and in case of non-existence of e2e3 genotype treatment for Alzheimer at the time, the in the person, the risk of Alzheimer increases. Based identification of risk factors leading to this disease on the previous studies in non-Iranian populations, and prevention of their occurrence is of high the e2 allele increases the age of onset of the disease significance. Based on the studies conducted, one- and protects from it (16-18). In the studies late Alzheimer occurs under the influence of a conducted in Iran by Vaisi Reygani and et.al (19) number of genetic and environmental factors. and Gozalpour (20), the frequency of ε2 allele and Controlling genetic factors is impossible but it is ε2ε3 genotype in healthy people was reported to be highly possible, through the identification of genetic more than in no significant the patients, but there factors influential in Alzheimer, to identify people at was difference between the two groups. The only risk and trying to control the influential study investigating the SAITOHIN gene in Iranian environmental factors in the occurrence of population was conducted by Veisi (21); in his study Alzheimer such as low level of mental activities, the AA genotype was introduced as having a social-psychological stress, diet, smoking and protective role and the AG genotype as being the drinking, pesticides environmental factors over use risk factor in affliction with Alzheimer. Moreover, in of some medicines,”. Also it is possible to use these the investigation of interaction of this gene in AG genetic markers to detect diseases in elementary polymorphisms and minus APOEε2 subjects a stages and reduce the speed and disabilities resulted significance difference was reported but the from the disease by its early diagnosis of it. interaction of GG genotype and minus APOEε2 One of the important and common goals in genetic subjects was not meaningful. association studies in such diseases is the One of the advantages of this method is that unlike determination of SNPs and their interactions which other regression models, in order to investigate the are related to the occurrence of the disease. The existence of an interaction,
Table2: The SNP frequencies were compared between Alzheimer’s cases and control subjects Control case genotype Gene SNP number (percent) number (percent) GG 41 (37.6) 34 (33.7) R219K ABCA1 GA 50 (45.9) 48 (47.5) (G/A) AA 18 (16.5) 19 (18.8) CALHM1 P86L CC 93 (85.3) 79 (78.2) CT 12 (11.0) 17 (16.8)
48 Vol. 9, No. 14, Oct. 2011 Control case genotype Gene SNP number (percent) number (percent) TT 4 (3.7) 5 (5.0) GG 91 (83.5) 86 (85.1) CCR2- (V64I) CCR2 GA 16 (14.7) 14 (13.9) (G/A) AA 2 (1.8) 1 (1.0) TT 33 (30.3) 27 (26.7) GSK3â AluI(T/C) TC 52 (47.7) 53 (52.5) CC 24 (22.0) 21 (20.8) GG 77 (70.6) 63 (62.4) ALuI(G/A) GA 24 (22.0) 30 (29.7) AA 8 (7.3) 8 (7.9) CC 80 (73.4) 60 (59.4) TAU Alw26I(C/G) CG 21 (19.3) 32 (31.7) GG 8 (7.3) 9 (8.9) AA 77 (70.6) 66 (65.3) SepI(A/G) AG 27 (24.8) 31 (30.7) GG 5 (4.6) 4 (4.0) GG 93 (85.3) 77 (76.2) TNF-α -308(G/A) GA 15 (13.8) 24 (23.8) AA 1 (0.9) 0 (0) AA 89 (81.7) 67 (66.3) SAITOHIN HinfI(A/G) AG 17 (15.6) 34 (33.7) GG 3 (2.8) 0 (0) CC 50 (45.9) 45 (11.9) TaqI(C/T) CT 46 (42.2) 46 (42.2) TT 13 (11.9) 10 (9.9) VDR GG 23 (21.1) 19 (18.8) ApaI(G/T) GT 52 (47.7) 46 (45.5) TT 34 (31.2) 36 (35.6)
Interactions do not need to be known in advance and SAITOHIN genes with a larger sample is used as input variables in the model, but the recommended. detection of important variable interactions is the main aim of logic regression; and this way it is Conclusion possible to concentrate on the most important effects Feature selection approach is a new method for the specified by this approach. Since in case-control detection of interaction in genetic association studies studies, the goal is to make a classification rule with many variables. In the present study, the two- based on the minimum possible number of variables, way interaction between polymorphisms in APOE the identification of the interactions of SNPs and SAITOHIN genes was detected using this influential in predicting the response is the first, and method. the same time a very important, stage. In the next stage, it is possible to, for example, consider K Acknowledgement: number of the most important interactions which are We wish to express our special thanks to all higher than specific level of significance and use the colleagues at the Genetic Research Center - form of binary variables in logic regression or any University of Social Welfare and Rehabilitation other classification and prediction models. Sciences, especially Dr. Koorosh Kamali, for their Therefore, conducting studies based on APOE and helps in the data collection.
References aged 75 years or older. J Neurol Neurosurg Psychiatry 1. Garte S. Metabolic susceptibility genes as cancer risk 2003;74(6):720-4. factors: time for a reassessment? Cancer Epidemiol 3. Hooijmans C, KIliaan A, Fatty acids, lipid metabolism and Biomarkers Prev. 2001;10:1233-7. Alzheimer pathology. Eur J Pharmacol . 2008; 585: 176-96. 2. Rahkonen T, Eloniemi-Sulkava U, Rissanen S, Vatanen A, 4. Shibata N, Kawarai T, Lee JH, Lee H-S, Shibata E, Sato C, Viramo P, Sulkava R. Dementia with Lewy bodies et al. Association studies of cholesterol metabolism genes according to the consensus criteria in a general population (CH25H, ABCA1 and CH24H) in Alzheimer's disease. Neurosci Lett. 2006; 391(3): 142-6.
Iranian Rehabilitation Journal 49 5. Reinshagen VH-, zhou S, Burgess B, Bernier L, Mclsaac S, 14. Zuo L, Dyck C, Luo X, Kranzler H, zhu Yang B, Gelernter Chan J. Deficiency of ABCA1 Impairs Apolipoprotein E J. Variation at APOE and STH loci and Alzheimer's disease. Metabolism in Brain. J Biol Chem. 2004; 279(39): 4119- Behav Brain FUNCT. 2006; 2(1). 207. 15. Poduslo S, Yin X. Chromosome 12 and late onset 6. Puglilli L, Tanzi R, Kovasca D. Alzheimer's disease: Alzheimer's disease. Neurosci Lett. 2001; 88(310): 188-90. Cholestrol connection. Neuroscience. 2003; 6(4): 345-51. 16. Corder EH, Saunders AM, Risch NJ, Strittmatter WJ, 7. Ruczinski I, Kooperberg C, Leblanc M. Logic Regression. J Schmechel DE, Jr PCG, et al. Protective effect of COMPUT GRAPH STAT. 2003; 12(3): 475-511. apolipoprotein E type 2 allele for late onset Alzheimer 8. Schwender H, Ickstadt K. Identification of SNP Interaction disease. Nat Genet. 1994; 35(7): 180-4. Using Logic Regression. Biostatistics. 2008; 9: 187-98. 17. Scott W, Saunders A, Gaskell P, Locke PA, Grow J, Farrer 9. Smith MW, Dean M, Carrington M, Winkler C, Huttley GA, L. Apolipoprptein E e2 does not increase risk of early-onset Lomb DA, et al. Contrasting Genetic Influence of CCR2 and sporadic Alzheimer's Disease. Ann Neurol. 1997; 36(42): CCR5 Variants on HIV-1 Infection and Disease Progression. 376-38. Science. 1997; 277(5328): 959-65. 18. VaisiRaygania A, Zahraia M, VaisiRaygania A, Doostia M, 10. Dreses-Werringloer U, Lambert J-C, Vingtdeux V, Zhao1 H, Javadic E, Rezaeid M. Association between apolipoprotein Vais H, Siebert A, et al. A polymorphism in CALHM1 E polymorphism and Alzheimer disease in Tehran, Iran. influences Ca2+ homostasis, AB levels, and Alzheimer Neurosci Lett. 2005; 58(375): 1-6. Disease risk. Cell. 2008; 133(7): 1149-61. 19. Gozalpour E, Kamali K, Mohammd K, Khorram Khorshid 11. Luo J. Glycogen synthase kinase 3 in tumorigenesis and HR, Ohadi M, Karimloo M, et al. Association between cancer chemotherapy. Cancer Lett. 2009; 273(2): 194-200. Alzheimer’s Disease and Apolipoprotein E Polymorphisms. 12. Ezquerra M, Gaig C, Ascaso C, Muñoz E, Tolosa E. Tau and Iranian J Publ Health. 2010; 39(2): 1-6. saitohin gene expression pattern in progressive supranuclear 20. Veisi K. Association study between MAPT, GSK3b and palsy. Brain Res. 2007; 1145: 168-76. STH genes polymorphisms with sporadic Alzheimer disease 13. Candore G, Balistreri CR, Colonna-Romano G, Lio D, in Iranian population. Tehran: University of social welfare Caruso C. Major histocompatibiblity complex and rehabilitation Sciences; 1388. polymorphisms and sporadic Alzheimer’s disease: a critical reappraisal. Exp Gerontol. 2004; 39(4): 645-52.
50 Vol. 9, No. 14, Oct. 2011 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Original Article
Dental status and DMFT index in 12 year old children of public care Centers in Tehran
Nasim Shafiezadeh; Islamic Azad University, Tehran, Iran Farin Soleimani*; University of Social Welfare and Rehabilitation sciences, Pediatric Neurorehabilitation Research Center, Tehran, Iran. Saeedeh Mokhtari Shahid Beheshti University of Medical sciences, Tehran Nahid Askarizadeh;Reza Fatehi Islamic Azad University, Tehran, Iran
Objectives: Dental caries is a public health problem that affects pre-school and school children throughout the world. Poor oral health profoundly affects a person’s quality of life. Information on caries prevalence and severity represents the basis for caries prevention programs and indicates treatment necessity in the population. The occurrence of permanent teeth caries particularly in non-industrial societies, seems to be high;The aim of this study was to present the prevalence of dental caries inunder supervision 12- years old children living in Tehran and to assess the influence of the factors which are related to their oral health. Method and Materials: This cross-sectional study was carried out on 113 undersupervision children.The clinical examinations focused on dental status, expressed as DMFT (Decayed, Missed, Filled Permanent Teeth) index,following WHO standards methodologies. Clinical examinations and personal interviews to investigate the related factors to oral health were conducted by a single investigator. Results: The level of DMFT was estimated at 1.32±0.86. Among the relevant factors, the reason for visiting the dentist (p‹0.0001) and duration of stay in the center (p‹0.04) had a meaningful relation to DMFT index of more than 2. Conclusion: The community under the research has a good condition as compared with the WHO goal. Further studies are recommended due to meaningful relation between DMFT index and the reason for visiting dentists as well as the duration of stay in the center. Keywords: DMFT index, Oral health, Governmental Round-The-Clock Centers, under-supervision children
Submitted: 10 Sep 2010 Accepted: 23 Dec 2010
Introduction Measures of caries prevalence are indexes of Dental caries is a public health problem that affects decayed (D), missed (M), and filled (F) permanent pre-school and school children all around the world, teeth (T) or surfaces (S), ie, DMFT or DMFSindex leading to pain, chewing difficulties, general health (8). For the first time at a national level in 1995, the disorders, speech and psychological problems, and mean DMFT of 12 year old Iranian children was 2.0, poor quality of life (1-4). Insufficient oral health which indicated that the oral health status of this age profoundly affects a person’s quality of life (5, group could be classified in the low range (mean 6).Information on caries prevalence and severity, DMFT 1.2-2.6) compared with other countries shows the basis of caries preventive programs and worldwide. In second national survey in 2004 the indicates treatment necessity in the population (7). mean DMFT for 12 year old Iranian children was
* All correspondences to Dr. Soleimani Email
Iranian Rehabilitation Journal 51 1.9 and this was consistent with the oral health goals light, using a disposable mirror (Atlas Co., Iran), a set by the World Health Organization (WHO) for disposable explorer (Atlas Co., Iran),a torch (Philips 2010, albeit far from the goals set for 2020 co, Germany) and a sterile cloth (to remove material (9).Considering the condition of special groups alba and debris from the teeth). The study protocols (such as under supervision children) in every society were approved by the Research Committee of is essential to estimate the real health situation. The Faculty Research Section. To determine the intra- risk of caries significantly increases among examiner reliability, 10% of the total samples was adolescents with a high consumption of cariogenic reexamined during the data collection (Kappa=0.98). snack and low oral hygiene. It is also influenced by Then the level of DMFT measured among the maternal socio-economic background and subjects with 95% confidence interval. The effect of educational level (10), as well as dietary, hygienic, related factors on DMFT was studied with chi- and other socio-economic factors indicating the square test, the significance level was considered as importance of preventive educational programs and P Value <0.05. a comprehensive caries prevention scheme for children (11). Results The aim of this study was to assess the caries Of the 113 children examined, 35.4% were caries prevalence in 12- years old under supervision free and 16.8% had DMFT of 2 or more. Of total healthychildren living in governmental round-the- DMFT, 46.4% were due to decayed (D), 2.6% due to clock centers in Tehran and to assess the influence missed (M), and 51% due to filled (F). The mean of the factors which are related to their oral health level of DMFT was estimated at by using the indexes for decayed, missed, and filled 1.32±0.86.Considering the normal variations, the teeth (DMFT). studied community had normal distribution. Chart 1 shows the mean D,M,F and DMFT for each child. Method This cross-sectional study was based on clinical data 1.32 from clinical examinations and questionnaire. Study 2 0.61 0.67 sample consisted of all the113 twelve year- old 1 0.03 children (80 male,33 female) residing in the public 0 round-the-clock centers of Social Welfare Organization because of having no headman, in Tehran province (consisting Tehran, Shahre-Ray, Shemiranat) in 2007-2008.By an interview with each child’s caregiver and using medical information records these data were collected in a questionnaire: sex ratio (male/female),duration of staying in the Chart 1.Mean D,M,F and DMFT in the children center (less than3 years/3years and more), frequency of tooth brushing (once a day or more/ never or In 3 sections of Tehran province: Shemiranat, occasionally) and time of tooth brushing (after each Shahre-ray, and Tehran DMFTswere: mealtime/before bed time), frequency of dental visits 1.66±1/02;1.33±0/17, and0/90±0/27 respectively as (sometimes/never or when he or she had pain), date is showed in Table 1. of last dental visit (during last year/more than a year ago or not at all),cause of dental visit Table 1. The mean DMFT in governmental round -the - (checkup/pain), frequency of snack consumption clock centers children of social welfare organization in (never/less than 3 times a day/more than 3 times a cities of Tehran province Tehran day), time of snack consumption (after main Tehran Shemiranat Rey Place of Study Province course/between meals), occlusion related factors 1.32 1.33 1.66 0.9 DMFT (crowding/ spacing), oral hygiene instructor (parents/dentist/center’s caregivers). The most common time of tooth brushing was Before starting the examination process, there was a before bedtime. Most subjects were learned oral 20-30 minute communication to motivate the hygiene instructions from a dentist. children, then each subject was examined separately Data analysis indicated that there was no statistically with a trained examiner, in a room with adequate significant relation between the level of DMFT and
52 Vol. 9, No. 14, Oct. 2011 frequency/time of tooth brushing, frequency of hygiene instruction. Other factor as duration of stay dental visits, date of last dental visit, occlusion in the center and the cause of dental visit showed related factors (crowding/ spacing) and oral hygiene significant relation with DMFT score. The children, instructor. But there was a statistically significant who had DMFT score more than 2, have been lived relation between DMFT and the duration of stay in in the centers for 3 years and more and this the center (P< 0.001) and the cause of dental visit correlation was statistically significant; It must be (p<0.04). mentioned that the researchers did not have any Diet schedule in all centers were almost similar access to the pre-admission medical and hygiene following three main course schedule. Snacks were history of participants, including dental health status. not included in diet schedule in all centers, and the But it should be assumed that access to frequency of consuming snacks among the children carbohydrates was limited due to low income. was not exactly measurable. Because the children, Although they have yet better DMFT in comparing may had snacks from the sources out of the centers with 12 years school children in Tehran. Results also as donations and also they were not reliable to talk show those children in whom pain was the cause of about the frequency of use. dental visit had 6.2more time chance of having DMFT score more than 2 that is expectable. Discussion In a study on 13-18 year- old under supervision In this study which was aimed to determine the adolescents in Tehran in 1996, no relation was found DMFT status of 12 years old children, living in public between frequency and time of tooth brushing and round-the-clock centers of Social Welfare the source of oral hygiene learning with DMFT. In Organization of Tehran in 2008, the mean DMFT was another similar study in 1997-98 in Tehran, there estimated 1.32±0.86. In this study 35.4% of subjects was a significant relation between frequency of tooth were caries free and 16.8% had DMFT of 2 or more. brushing and frequency of dental visits and the So, according to goals of WHO in 2010 (that 12 Y/O DMFT score, but the oral hygiene instruction history children should have DMFT less than 2), it seems that and the time of living in the center had no significant the subjects were in desirable status. (12) relation with DMFT. V arasteh et al, showed the Many studies as Island 1998 (DMFT=1.5) (13), opposite finding in a research in 2003 (19). Portugal (DMFT=1.85)(14), Spain (DMF Our result indicated that the mean DMFT score in T=1.12)(15), Algeria (DMFT=1.63)(16) have Shahr-e-Rey is higher than Tehran and in Tehran reached the same results as this study. But there are DMFT score is lower than Shemiranat. This is also also some studies that have shown lesser level of indicated in a same study in 1997 (19). DMFT as England (DMFT=0.86), Bangladesh Because of a significant relationship between (DMFT=0.97) and South Africa (DMFT=0.25). duration of living in the centers and DMFT scores, These differences may be due to difference in race more surveys are recommended to investigate this and geographical region, research methodology correlation. Also, more attention to pay about oral sample size, sampling method, examination health and care in these children is advisable. instruments or applying preventive dentistry for under supervision children in some countries. In this Conclusion study about 51%of mean DMFT score of the As there was no relation between the variables of surveyed children, was contributed by restored teeth oral hygiene instructor, frequency and duration of (Filling/F), however in some studies as in England tooth brushing, frequency of dental visits and (17), Jordan (18), two studies on12 year old children DMFT, and according to high number of decayed in Gorgan in 2006 and in Robat-karim in 2001in teeth (D factor in DMFT) and also a positive relation Iran, DMFT score was most contributed by Decayed between the duration of living in center and DMFT teeth (D)(19). This shows that the surveyed score more than 2 in surveyed children, we can community has better oral care which leads to conclude that the lower DMFT score of children repairing and filling the decayed teeth. living in Boarding Centers of Social Welfare In this study there were no relations between DMFT Organization of Tehran in 2008 was due to their diet and the variables of frequency and time of tooth regimens and lack of snacks between meals in these brushing, frequency of dental visits, the date of last centers, and not because of more preventive dental visit, occlusion related factors and oral interventions.
Iranian Rehabilitation Journal 53
References of dental caries in Sicilian schoolchildren. Med. Sci. Monit. 1. Dukić W, Delija B, Lulić Dukić O. Caries prevalence among 2010 Oct;16(10):PH83–89. schoolchildren in Zagreb, Croatia. Croat Med J. 2011 11. Campus G, Lumbau A, Lai S, Solinas G, Castiglia P. Dec;52(6):665–671. Socio–economic and Behavioural Factors Related to 2. Rosenblatt A, Zarzar P. The prevalence of early childhood Caries in Twelve–Year–Old Sardinian caries in 12- to 36-month-old children in Recife, Brazil. Children. Caries Research. 2001;35(6):427–434. ASDC J Dent Child. 2001 Dec;69(3):319–24, 236. 12. Axelsson P. An introduction to risk prediction and 3. Filstrup SL, Briskie D, da Fonseca M, Lawrence L, Wandera preventive dentistry. dentistry1th Ed, Germany, A, Inglehart MR.Early childhood caries and quality of life: quintessence publishing Co. 1999;114,255. child and parent perspectives. Pediatr Dent. 2002 13. Eliasson S.T. Caries decline among Icelandic children. J of Dec;25(5):431–440. Dental Research 1998; 77:5, 1330 Abstract# 38. 4. Sheiham A. Oral health, general health and quality of life. 14. De Almeida CM, Petersen PE, André SJ, Toscano A. Bulletin of the World Health Organization. 2005 Changing oral health status of 6-and 12-year-old Sep;83(9):644–644. schoolchildren in Portugal. Community Dental Health. 5. Al-Malik MI, Holt RD, Bedi R. Erosion, caries and rampant 2003;20(4):211–216. caries in preschool children in Jeddah, Saudi Arabia. 15. Liorda JC, Brado M & Cortes J, Spanish oral health survey Community Dentistry and Oral Epidemiology. 2002; 7:19-63 2002;30(1):16–23. 16. Bourgeois D, Benodbelhafid M, PerdrixG. Prevalence of 6. Caban-Martinez AJ, Lee DJ, Fleming LE, Arheart KL, central decay and treatment need in Algerian school children LeBlanc WG, Chung-Bridges K, et al. Dental care access and adolescents in the Constantine area. Community Dent and unmet dental care needs among U.S. workers The Oral Epidemoil 1991; 19: 239. National Health Interview Survey, 1997 to 2003. JADA. 17. Pitts NB, Evans Dj, Nugent ZJ, Pine CM. The dental caries 2007 Feb 1;138(2):227–230. experience of 12-year-old children in England and Wales. 7. Wyne AH. Caries prevalence, severity, and pattern in Surveys coordinated by the British Association for the Study preschool children. J Contemp Dent Pract. 2007 of Community Dentistry in 2000/2001. Community Dent Dec;9(3):24–31. Health. 2002 Mar;19(1):46–53. 8. National Caries Program-NIDR. The prevalence of dental 18. Albashaireh Z, Hamasha AH. Prevalence of dental caries in caries in United States children, 1979-1980. NIH 12-13-year-old Jordanian students. SADJ. 2002 Publication No. 82-2245;1981. Mar;57(3):89–91. 9. Bayat-Movahed S, Samadzadeh H, Ziyarati L, Memary N, 19. Shafizade N, AskariZadeh N, Fatehi R. Assessing DMFT Khosravi R, Sadr-Eshkevari PS. Oral health of Iranian index and related factors in 12 year old children under- children in 2004: a national pathfinder survey of dental supervision of WelfareOrganization in Tehran during 1385- caries and treatment needs.. EMHJ.2011; 17 (3): 243-249. 86. Islamic Azad University, Tehran, Iran 1386-87. (MSc. 10. Pizzo G, Piscopo MR, Matranga D, Luparello M, Pizzo I, Thesis in Persian language). Giuliana G. Prevalence and socio-behavioral determinants
54 Vol. 9, No. 14, Oct. 2011 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Original Article
Effects of Task Related Training and Hand Dominance on Upper Limb Motor Function in Subjects with Stroke
Mohammed Azam Khan; Fuzail Ahmad; Jamia Hamadard. New Delhi. India Jamal Ali Moiz, PhD.; Majumi M.Noohu*, PhD; Jamia Millia Islamia, New Delhi. India
Introduction: Recovery of upper limb motor function in stroke is limited. Different approaches are used to improve the upper limb function, but none has satisfactory results. The present study investigated the effect of task related training and role of hand dominance in upper limb motor function rehabilitation in stroke population. Method an Material: A convenient sample of 32 subjects divided into 4 groups with 8 subjects each took part in the study with an experimental design. The group 1, experimental dominant hand group, consisted of subjects with dominant hand paresis, the group 2 consisted of subjects with non dominant, group 3 & 4 consisted of dominant (dominant hand control group) and non dominant hand paresis (non dominant hand control group) .The group 1 and 2 received task related training and conventional therapy, while group 3 & 4 received conventional physiotherapy. All patients were assessed prior to training 4 weeks & after the 4 weeks of training program by using Chedoke Arm & Hand activity Inventory Score form, this score were used to find the difference between and within groups. Results: A within group analysis showed that there is a statistical significant difference for Chedoke Scores between pre training and post training in group 1, 2 and 3 but no significant difference in group4. There was no significant difference between group1 post training scores; there was a significant difference in post training scores group 1 and group 3. There was no significant difference in post training scores between group 3 and group 4. The comparison between group 2 and 4 group showed no significant difference in post training scores. Conclusion: From this study it is evident that task related training and hand dominance play an important role in upper limb rehabilitation. KeyWords: Task related training, hand dominance, stroke, upper limb function
Submitted: 10 Sep 2010 Accepted: 04 Nov 2010
Introduction hand affected. It is not known whether these Stroke has devastating consequences on individual’s individuals will gain better outcome than those who physical and cognitive abilities.(1) The likelihood of had their non-dominant hand affected form stroke.(3) improvement after stroke varies with nature and Recent trails emphasis the practice of task related severity of the initial deficit. Approximately 35% of movements. Many different task oriented practices survivors with initial paralysis of the leg do not strategies have shown significantly greater benefit regain useful function. Six months after stroke, from more intensive therapies that involve training about 65% of patient cannot incorporate the affected in specific skills as compared with only several hand into their usual activities.(2) hours a week of general rehabilitation spread among Studies report that 45 to 50% of individuals sustain a many activities.(4) Recently Salbach et al reported left hemisphere lesion and therefore right-sided benefits of task related practice on locomotion in paresis. In as much as up to 80% of people are right people with stroke.(5) Bllehasset al support the use side dominant, a significant proportion of individuals of additional task related practices of during who experience a stroke will have their dominant rehabilitation.(6)
* All correspondence to: Majumi M Noohu, Email: < [email protected]>
Iranian Rehabilitation Journal 55 Task-specificity, practice, goal-setting, feedback and study and they were thoroughly explained about the motivation are considered important elements in study process. Subjects were matched by using two motor learning. In practice, it appears that repetition subsets of the Motor Assessment Scale (MAS).(9) alone is less effective than repetition with variable On the upper arm subset, seated subjects were asked practice (7) As we know that in motor learning the to hold their arm in 900 of the shoulder flexion for 2 degree of performance improvement is dependent on seconds, while maintaining some external rotation. the amount of practice. It is also known from the On the hand movement subset, subjects were asked motor learning literature that variable practice is to extend the wrist while holding a cup upright, with more effective than massed practice. Introducing the forearm resting on the table. task variability in any given session increases Subjects in group 1 and 2 received physiotherapy retention (8) Task related training provides and task related training. For Task related training variability during treatment session as different familiar objects were used that vary in size, shape & objects are used. Many different task oriented weight (50-500 gm) including coffee mugs, tea cups, practice strategies have shown significantly greater plastic balls, books and writing and eating utensils. benefits from more intensive therapies that involve The objects were placed ipsilateral, contra lateral training in specific skills, as compared with only and midline on the table. Participants got an hour general rehabilitation.(4) therapist-supervised reach-to-grasp training 5 times There are not many studies which have reported the per week for 4 weeks (total 20 sessions)8 effect of task related training and effect of hand Progression criteria were established by increasing dominance in functional regain in stroke survivors. repetitions, increasing object size and weight, as The current study was done to find out the effect of well as increasing the distance at which objects were task related training and to examine do hand manipulated. The subjects in l group 3 and 4 dominance play a role in reaching activities in stroke received conventional physiotherapy program for survivors. upper limb. Trunk movements (sagital displacement, rotation) were prevented by verbal cues and therapist Method support. Rest periods of 1 to 2 minutes were A convenient sample of 32 subjects took part in the permitted when necessary to avoid fatigue. study with an experimental design. The group 1 All patients were assessed prior to training 4 weeks consisted of subjects with dominant hand paresis and & after the 4 weeks of training program by using received task related training and conventional Chedoke Arm & Hand activity Inventory Score therapy (experimental dominant hand group). The Form. Scoring is done on a 7-point ordinal scale group 2 consisted of subjects with non dominant (1=total assistance and 7=complete independence). hand paresis and received task related training and Scoring is based on the percentage of contribution of conventional therapy (experimental non dominant each task by the paretic upper limb. For example the hand group). Group 3 & 4 consisted of dominant individual will score 7 on the jar opening task if he (dominant hand control group) and non dominant or she were able to hold the jar in the non paretic hand paresis (non dominant hand control group) hand and open it with paretic hand. A score of 3 respectively and they received conventional means that the individual is able to use the paretic physiotherapy. All subjects were right hand hand to stabilize and manipulate the jar but requires dominant. Subjects were randomly assigned to hand over hand guidance (50%-75% contribution of different groups. The study was approved by the paretic upper limb). High internal consistency research and ethics committee of Jamia Hamdard, (Cronbach alpha=.98) and excellent inter rater New Delhi, India. reliability (ICC= .98), The age, gender and duration of onset of hemiplegia Construct validity (r=.81-.93) and face and content were obtained from the patient’s history and medical validity have been reported (10). records. Stroke location was identified by computed tomography or magnetic resonance imaging of the Data Analysis brain. The subjects were selected on the basis of Statistical analysis was performed using the SPSS following criteria, such as, 6 months post stroke, Software (version 14). Demographic data of all arm/hand paresis and subjects with aphasia and subjects including age, sex, type of stroke, side of cognitive deficits were excluded. The consent of the hemiplegia and hand dominance were descriptively subjects was obtained before enrollment into the summarized. The dependent variables for statistical
56 Vol. 9, No. 14, Oct. 2011 analysis were Chadoke hand inventory scale scores. Results Within group comparison was done by using A total of 32 patients with 8 subjects in each group Wilcoxon-Singed Ranks Test and for the between and (mean±SD) age of the subjects were 53.18 ±5.56 group analysis Mann-Whiteny test was used. A level years who participated in this study. The duration of of significance of p < 0.05 was used for all analysis stroke (mean±SD) was 16.50±5.09 months. The to determine the statistical significance. mean +SD of age and duration of stroke, group wise is summarized in table 1.
Table 1. Demographic profile of the subjects Age (years) Duration of the stroke (months) Group (Mean±SD) (Mean±SD) Group 1(n=8) 55.58 + 6.43 14.38 + 3.06 Group 2(n=8) 52.00 + 3.92 15.00 + 4.75 Group 3(n=8) 54.63 + 4.20 16.13 + 5.66 Group 4(n=8) 50.75 + 6.81 16.87 + 5.89
A within group analysis showed that in group 1 and 2 (z=1.84, p=0.033) . In the group, group 3 There group 2 there is a statistical significant difference for was significant difference (z=2.00, p=0.023) but no Chedoke Scores between pre training and post significant difference in group 4 (z=1.63, p=0.051) training scores, group 1 (z=2.54, p=0.005) and group (table 2).
Table 2. Within Group Comparison of Chadoke hand inventory scores Pre training Post training Group Chadoke Hand Inventory Chadoke Hand Inventory Score Z P Score (Median±SD) (Median±SD) Group 1(n=8) 21.00±1.66 23.50±1.06 2.54 0.005 Group 2(n=8) 21.50±2.85 22.50±3.56 1.84 0.033 Group 3(n=8) 20.50±1.18 21.00±1.12 2.00 0.023 Group 4(n=8) 20.50±1.66 21.00±1.38 1.63 0.051
Using Mann-Whitney Test for Chedoke Post Score it p=0.004) (table 4). There was no significant was found that there was no significant difference difference between the pre training (z=0.16, p=0.87) between group1 and group 2 on both pre training (table 3) and post training (z=0.32, p=0.74) (table 4) (z=0.37, p=0.70)(table 3) as well as post training scores between group 3 and group 4. The scores(z=0.96, p=0.33)(table 4). comparison between group 2 and 4 group showed no Between group comparison of group 1 and group 3 significant difference in pre training (z=1.12, showed no significant difference in pre training p=0.26) (table 3) and post training scores (z=1.34, scores (z=0.75, p=0.44) (table 3) but there was a p=0.17) (table 4). significant difference in post training scores (z=2.88,
Table 3. Comparison of pre training Chadoke hand inventory scores between groups Chadoke Hand Inventory Score Chadoke Hand Inventory Score Group Comparison Z P (Median±SD) (Median±SD) 21.00±1.66 21.50±2.85 Group 1 vs Group 2 (Experimental dominant hand group- (Experimental non dominant hand group- 0.37 0.70 Group 1) Group 2) 21.00±1.66 20.50±1.18 Group 1 vs Group 3 (Experimental dominant hand group- 0.75 0.44 (Dominant hand control group- Group 3) Group 1) 21.50±2.85 20.50±1.18 Group 3vs Group 4 (Dominant hand control group- (Non dominant hand control group- 0.16 0.87 Group 3) Group 4) 21.50±2.85 20.50±1.66 Group 2 vs group 4 (Experimental non dominant hand (Non dominant hand control group- 1.12 0.26 group- Group 2) Group 4)
Iranian Rehabilitation Journal 57 Table 4. Comparison of post training Chadoke hand inventory scores between groups Chadoke Hand Inventory Score Chadoke Hand Inventory Score Group Comparison Z P (Median±SD) (Median±SD) 23.50±1.06 (Experimental 22.50±3.56 (Experimental non dominant Group 1 vs Group 2 0.96 0.33 dominant hand group- Group 1) hand group- Group 2) 23.50±1.06 (Experimental 21.00±1.38 Group 1 vs group 3 2.88 0.004 dominant hand group-Group 1) (Dominant hand control group- Group 3) 22.50±3.56 ±2.85 21.00±1.12 Group 3 vs Group 4 (Dominant hand control group- (Non dominant hand control group- 0.34 0.74 Group 3) Group 4) 22.50±356 (Experimental non 21.00±1.38 Group 2 vs group 4 dominant hand group- (Non dominant hand control group- 1.34 0.17 Group2) Group 4)
Discussion and repetitive movements may be attributed to this As hypothesized, subjects with dominant hand significant difference. paresis improved significantly. Subjects in group 1 There are studies that have examined the role of were given additional task related training. There hand dominance in stroke patients. In the present was also significant improvement in subjects of study task related training and the role of hand group 2 and group 3 but this was lesser than dominance in stroke rehabilitation was examined. experimental dominant hand group. These results Subjects in dominant hand paresis improved after support the use of task-related training during stroke the treatment session. Harris et al showed that the rehabilitation and influence of hand dominance in tendency to use the dominant hand may lead to a rehabilitation. The result of the present study gets better pre stroke neuromuscular condition of the the support from the work done by Blennerhassett et dominant hand (e.g., stronger muscles, more al (6). There was significant improvement in their efficient motor unit recruitment) compared to the subjects in terms of functions after applying non dominant hand (3). However their study was additional task related training but in their study unable to show any difference between dominant hand dominance was not taken in to account. and non dominant hand scores for activities of daily The subjects of the present study improved their livings. Its being suggested that the more use of the reaching and grasping ability after four weeks of dominant hand may produce a training effect, giving intervention. Again this was most significant in it and benefit over the non dominant hand. The issue group 1 subjects. The reason behind this gain may of handedness in healthy individuals using be that during intervention familiar objects were transcranial magnetic stimulation found that the given. It has been proved by Thielman et al that the threshold required to produce movement was higher stroke subjects may gain functional improvement in the non dominant hand. This suggests differences when they are given familiar object and emphasis is in motor cortical output for dominant and non given on functional goals (8). This can be due to that dominant hand movement. Therefore, if the patient gets more encouragement and motivation dominant hand is affected by the stroke, it may when he can use objects of daily living. Another demonstrate less impairment immediately following possible explanation of the results of this study may the stroke owing to its protective effect (3). be “use dependent plasticity”. We know that in the Another factor that can be a cause of good chronic stages of a stroke, the brain is still “plastic” improvement in dominant hand group is motivation. and can reorganize in response to appropriate According to Harris et al if the dominant hand has stimulus (4). been affected by the stroke, individuals may be more The gain in group 3 subjects were less but motivated to use their dominant hand during significant. In the present study the subjects in group recovery because they are not used to using their 3 were given conventional physiotherapy including non- dominant hand for daily tasks. In contrast, if passive active movements and strengthening. It has the non-dominant hand is affected individual may been proved that repetitive passive active movement have little motivation to use this hand in daily task training can improve upper limb motor function and making it difficult to promote the use of the non- activities in patients with chronic stroke with all dominant hand (3). Patients with dominant hand degrees of upper extremity paresis. Strength gain affection tend to show better course of recovery than
58 Vol. 9, No. 14, Oct. 2011 the patients with non dominant hand and this should Conclusion be kept in mind while formulating and implementing The results of the study showed that task related treatment for stroke survivors. The study should be training is effective in treatment of stroke patients carried on larger sample for better understanding of and patients with dominant hand paresis may task related training and effect of hand dominance in recover better than the subjects with paresis of non- recovery process after stroke. dominant hand. However it cannot be neglected that the patients in later stage of stroke develops compensatory or adaptive behavior to accomplish the activities of daily living.
References 6. Blennerhassett J, Dite W Additional task-related practice 1. O'Connor RJ, Cassidy EM, Delargy MA. Late improves mobility and upper limb function early after multidisciplinary rehabilitation in young people after stroke. stroke: a randomised controlled trial. Aust J Physiother. Disabil Rehabil. 2005;27:111-116. 2004;50:219-224. 2. Dobkin BH. Clinical practice. Rehabilitation after stroke. N 7. Kollen B, Kwakkel G, Lindeman E. Functional recovery Engl J Med. 2005; 352:1677-1684. after stroke: a review of current developments in stroke 3. Harris JE, Eng JJ. Individuals with the dominant hand rehabilitation research.Rev Recent Clin Trials. 2006;1:75- affected following stroke demonstrate less impairment than 80. those with the nondominant hand affected. Neurorehabil 8. Thielman GT, Dean CM.A.M. Gentile, PhD Rehabilitation Neural Repair. 2006;20:380-389. of reaching after stroke: Task-related training versus 4. Ward NS, Cohen LG. Mechanisms underlying recovery of progressive resistive exercise. Arch Phys Med and Rehabil. motor function after stroke.Arch Neurol. 2004 ;61:1844- 2004:85;1613-1618. 1848. 9. Carr JH, Shepherd RB, Nordholm L,Lynne D. Investigation 5. Salbach NM , Mayo NE ,Robichaud-Ekstrand S, Hanley JA, of a New Motor Assessment Scale for Stroke Patients. Phys Richards CL,Wood-Dauphinee S,The Effect of a Task- Ther.1985; 65:175-180.. Oriented Walking Intervention on Improving. Balance Self- 10. Barreca SR, Stratford PW, Lambert CL, Masters LM, Efficacy Poststroke: A Randomized, Controlled Trial.J Am Streiner DL. Test-retest reliability, validity, and sensitivity Geriatr Soc 2005; 53:576–582. of the Chedoke arm and hand activity inventory: a new measure of upper-limb function for survivors of stroke.Arch Phys Med Rehabil. 2005 ;86:1616-1622.
Iranian Rehabilitation Journal 59 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Review
Spasticity: a review of methods for assessment and treatment
Mohammad Amouzadeh Khalili*; Masoumeh Rasulzadeh Semnan University of medical sciences, Semnan, Iran
Spasticity is the condition resulting of corticispinal damage as occurs in some neurological diseases. The aim of the article is to review the literature on assessment and treatment of spasticity and spastic limbs. The assessment and treatment methods are studied the study involves different method of mangement of spastic limbs in depth. Different method of evaluation of spasticity, including biomechanical and clinical assessment are reviewed and also some of the most common treatment methods of spasticity are studied. A number of methods for assessment and treatment of spasticity are reviewed, some of methods commonly used for assessment or management of spasticity, depend on the condition of the patient and the aim of the therapist a method may empoyed. Key words: spasticity, spastic limb, assessment of spasticity, management of spasticity
Submitted: 19 Aug 2010 Accepted: 02 Nov 2010
Introduction described that the positive and negative symptoms of Spasticity, derived from the greek word spastikos (to spasticity are independent symptoms and depend on tug or draw) is characterised by resistance to passive the place and amount of lesion and spontaneous movement of a joint, usually in a variable manner so improvements. that positive symptoms (dynamic that there is a velocity dependent increase in assessment) are abnormal behaviour including all resistance often associated with a sudden giving way exaggeration of normal phenomena, ie; (so called claps-knife effect) (1). hyperreflexia. The negative symptoms (static Patients with brain lesions often display hypertonia, or assessment) are motor control or preference deficits spasticity; spasticity is a motor disorder characterized including weakness, loss of function and dexterity . by a velocity-dependent increase in tonic stretch Spasticity occurs in many neurological condition, reflexes with exaggerated tendon jerks, resulting from depending on the nervous system involvement the hyperexcitability of the stretch reflex (2) characteristic of the spasticity is variable, spasticity The prevalence of cerebral palsy was reported to be not only limits function but may lead to existing 3.6 per 1000 in 8-years-old children and the majority flexion contractture (6). of children with cerebral palsy are affected by Spasticity is present in a group of muscles rather spasticity(3). More than 80% of people with spinal than a particular muscle. When spasticity is present, cord injury have spasticity, and many have greater all muscles of the related limb are adopted to the disability because of Spasticity develops gradually pattern of spasticity (flexion or extension), in the over several months after injury (4). In spasticity the case of the patient with spasticity in extensor normal reciprocal innervation is disturbed and muscles of the lower limb, spasticity will present in during movements undesirable co-contraction of extensors, adductors and medial rotators of the hip, different muscle groups occures and prevents skillful extensors of the knee and plantar flexor of the foot movements causing loss of function in patients Colin (7). Khalili and Yadegary described that manual and Daly(5) stated that movements disorders as a dexterity affected by spasticity and dependent on result of upper motor neuron damage are known as coordination between the central nervous system, either positive or negative symptoms. They peripheral nerves and the upper limb muscles (8).
* All correspondances to: Mohammad Amouzadeh Khalili, Email:
Iranian Rehabilitation Journal 61 documentation between the individual and all the facilitation, and nerve block The aim of such services involved in their care (19) . techniques would be to help patients to obtain as "Theorically, the best chance for full functional much normal active movements as much as possible, recovery would be total anatomical restoration of the but the therapist must be trained in each method(20, lost neurons and axonal corrections. This would 24). Stretching in spasticity can improve muscle require replacement of the lost neurons, regeneration flexibility, reduce muscle stiffness, and improve of injured axons and restoration of synaptic contacts function. Clinically, a number of stretching that were lost(20). techniques is used including static, dynamic, Current clinical management of spasticity involves a Proprioceptive Neuromuscular Facilitation (PNF) wide variety of therapies ranging from noninvasive for improvement of spastic limbs (25). (eg, oral administration of antispastic drugs, Electrical stimulation of muscles and nerves has physiotherapy) to invasive procedures (eg, surgical been used in the rehabilitation of patients with rhizotomy). The type and rate of treatment depend neurological problem to reduce spasticity and on the levels of spread (diffuse versus focal) and improve limb functions, this method can be applied disability caused by spasticity. for children and adults with spasticity(10), Vodvonik Bavikatte and Gabe in 2009 proposed the following and co-workers suggested that about one-half of aims for management of spasticity(20); randomly selected spinal cord injury patients with 1. Improve function- mobility , dexterity knee joint spasticity might benefit electrical 2. Symptom relief (Ease pain- muscle shortening, stimulation(26). Khalili and Hajhassanie applied tendon pain, postural effects, decrease spasms, electrical stimulation on spastic limb of children orthotic wearing) with cerebral palsy and reported that electrical 3. Postural- Body image stimulation may contributing improvement of 4. Decrease carer burden- care and hygiene, spasticity in children(10). Various electrical changing position, dressing stimulation modalities have been used to reduce the 5. Optimise service responses- to avoid unnecessary level of spasticity. These conditions vary from treatments, facilitate other therapy, delay/ prevent surface electrical stimulation of muscles to electrical surgery stimulation of the peripheral and central nerves. Shaw and Rodgers(22) described that pharmacological, Electrical stimulation of peripheral nerves would Physical and surgical treatments are currently employed block sensory and motor muscle activity and may in spasticity management. prevent the transmission of residual voluntary Pharmacological: The most commonly used activation of muscles that might remain after antispastic drugs are Baclofen, Benzodiazepine, incomplete spinal cord injury(4). It has been Clonidine, and Ttizanidine. Each of these drugs reported that the load that is applied to paralyzed could be used alone or in combination with the muscle during an electrical stimulation training others to obtain a desired effect and are administered program is an important factor in determining the orally or intrathecally(4) . amount of muscle adaptation that can be Physical modalities: Simple physical treatments such achieved(27). as correct positioning, stretching and exercise Davis and co-workers (28) explained some of the therapy are recommended for use in the first stage of advantages of electrical stimulation leg exercise treatment (22). Collin and Daly stated that include augmented “cardiorespiratory fitness, rehabilitation techniques, positioning, splinting, and promotion of blood circulation in the leg, increased stretching have a large part to play(5). DeSouza and activity of specific metabolic enzymes or hormones, colleages proposed that an approach to rehabilitation greater muscle volume and fiber size, enhanced that views the in the individual in his or her social, functional exercise capacity like strength and family, work and cultural roles, informs the therapist endurance, and altered bone mineral density.” about the impact of disability on the individual Positive psychosocial adaptations have also been lifestyle(23). reported among SCI individuals who undergo FES A number of investigators studied to determine a exercise. suitable method for the treatment of patients with Peripheral nerve block in control of spasticity: Nerve neurological conditions, ie; stretching, cooling block can be used in the treatment of spasticity. muscle and heat, Bobath technique, Brunnstrome Nerve block refers to the application of a chemical technique, proprioceeptive neuromuscular agent to a nerve to either temporarily or permanently
62 Vol. 9, No. 14, Oct. 2011 impair the function of the nerve. The agents most term and long term rehabilitation programmes by frequently used are phenol, alchol and local reduction of spasticity in a particular muscle anesthethetics(29). Khalili and co-workers used the group(32). Side effects and complications: A technique by the application of phenol for peripheral number of investigators reported that following nerve to block electrical stimulation of the motor nerve block tenderness and swelling occurred in the nerve innervate to the related (spastic) muscles(30). injection area(32). Some other investigators have Since then the technique has been widely developed reported that more complications occur using nerve (24, 30). Rekand proposed that Botulinum toxin block, they reported development of paresthesia in a combined with physiotherapy and orthopedic number of patients (31). Choi and co-workers surgery is effective treatment of localized pointed out that it is possible to cause allergic spasticity(11). Viel and colleages proposed that reaction, hematoma, pain, burning sensation, regional blocks have a threefold use in patients with paresthesia, trismus, infection, and edema in the painful spasticity including diagnostioc, prognostic, injection site of the limb(33). and therapeutic, peripheral neurotic blocks are easy Glenn stated that a burning sensation may be felt by to perform, effective, and inexpensive(30). the patient, following motor point nerve block but no Spasticity in agonist (spastic) muscles resists serious side effects occur particularly if injection is antagonist movements and prevents limb function. If carried out by an experienced person who is aware spasticity in agonists can be relieved by using nerve of the nerve block complications(29). block, strengthening of antagonist muscles will be Contracture and surgery: One of the most common possible and limb function will improve (29). complications of spasticity is contracture, When It has been claimed that phenol nerve block can there is imbalance between agonist and antagonist prevent surgery(30). Petrillo and Knoploch(31) muscles, and if the limb is kept in a static position, employed nerve block on the tibial nerve on 92 spasticity may start during a short time (31) patients with severe spasticity of plantar flexors and proposed that for treatment of the flexion contracture ankle invertors. Nineteen of patients had had using surgery, 50% of recovery can be expected indication for surgery. The authors reported that without a major complication. However, after after nerve block, the range of movements improved surgery serial casting is recommended for further in all of them and surgery was prevented. However, correction. this study did not accurately investigate nerve block Occasionally orthopaedic or neurosurgical effects in preventingsurgery, and further research procedures may be recommended. These can include required. Sciatic nerve block: Injection to the sciatic myelotomy (severing of tracts in the spinal cord) and nerve can reduce spasticity in the hamstring rhizotomy (resection of posterior roots)(34). muscles. Injection facilitates it, positioning and standing transfer, also range of motion of the knee is Conclusion improved and contracture and pressure sores are A number of methods for assessment and treatment prevented. Injection facilitates heel strike during of spasticity are reviewed, some of the common walking(30). methods of spasticity assessment or management, Musculocutaneous nerve block: Injection of the depend on the patient’s condition and the therapist’s musculocutaneous nerve may reduce spasticity in goal of treatment, in prefering a method. So the biceps and improve flexion contracture of the developing, standardizing, and validating clinically elbow(30). If there is a severe hypertone in the relevant spasticity scales is necessary. Also it is brachioradialis muscle and elbow movement is noted that studies to establish efficacy of the current limited, motor point block of the brachioradialis therapies and to find effective treatments to help muscle is useful to reduce spasticity of the people with spasticity. brachioradialis muscle(31). Advantages of nerve block: Nerve block may be a useful technique to reduce spasticity and obtain hand function and gait Acknowledgment: improvement. In preparation for this article we wish to Range of motion and activities of daily living are acknowledge from the School of Rehabilitation, improved by using nerve block(24). Further more, it Semnan University of Medical Sciences, and all the has been suggested that application of nerve block is staff of the School. a valuable treatment between the period of short
Iranian Rehabilitation Journal 63
References 19. Thompson, Jarrett L, LockleyL, Lockley L Stevenson VL, 1. Losseff N, Thompson A. The medical management of Clinical management of spasticity, J Neurol Neurosurg increased tone. Physiotherapy. 1995;81(8):480-484. Psychiatry 2005;76:459-463 2. Lamy JC ; Wargon I; Mazevet D; Ghanim Z; Pradat-Diehl P 20. Bavikatte G and Gaber T, Approach to spasticity in general and Rose Katz R, Impaired Efficacy of Spinal Presynaptic prctice, British Journal of Medical Practitionres, 2009; 2(3): Mechanisms in Spastic Stroke Patients, P. 29-34. Brain. 2009;132(3):734-748. 21. Selzer ME, Mechanisms of Functional Recovery in 3. Delgado MR, Hirtz D, Aisen M, Ashwal S, Fehlings DL, Traumatic Brain Injury, Neurorehabil Neural Repair 1995; McLaughlin J, Morrison LA, Shrader MW, Tilton A, 9: 73-82, Vargus-Adams J. Practice parameter: pharmacologic 22. Shaw L and Rodgers H, Botulinum Toxin Type A for Upper treatment of spasticity in children and adolescents with Limb Spasticity after Stroke, Expert Rev Neurother. 2009; cerebral palsy (an evidence-based review): report of the 9(12): 1713-1725 Quality Standards Subcommittee of the American Academy 23. DeSouza L, Bates D, and Moran G., Multiple sclerosis, , In; of Neurology and the Practice Committee of the Child Stokes M, Neurological Physiotherapy, 1998; Mosby, UK, Neurology Society. Neurology. 2010, 26;74(4):336-43 P. 133-148. 4. Elbasiouny SM, Moroz D, Bakr MM, MD, and Mushahwar 24. Jeong-Yi K., Ji Hye H., Joon-Sung K ., Botulinum toxin a VK, Management of Spasticity after Spinal Cord Injury: injection into calf muscles for treatment of spastic equinus Current Techniques and Future Directions, Neurorehabil in cerebral palsy: a controlled trial comparing sonography Neural Repair. 2010, 24 (1); 23-33. and electronic stimulation-guided injection techniques: a 5. Collin C and Daly G., Brain injury, In; Stokes M, preliminary report, American Journal of Physical Medicine Neurological Physiotherapy, 1998; Mosby, UK, P. 91-103. & Rehabilitation, 2010; Vol. 89 (4) P. 279-286. 6. Thornton H and Kilbride C (1998) Physical management of 25. Nordez A, Gennisson JL, Casari P, et al. Characterization of abnormal tone and movement , In; Stokes M, Neurological muscle belly elastic properties during passive stretching Physiotherapy, Mosby, UK, P. 313-325. using transient elastography J Biomech, 2008; 6: 2305– 7. Atkinson HW, Aspects of neuro-anatomy and physiology. In 2311. Downie, PA. ed. Cash’s textbook of neurology for 26. Vodovnik L, Bowman B, Hufford P. Effects of electrical physiotherapists, 1995; 4th ed. London: Mosby, Chapter 4. stimulation on spinal spasticity. Scand J Rehabil Med. 8. Khalili MA and Yadegary H, Comparison of the level of fine 1984;16:29–34. movements development in children of rural and urban 27. Crameri RM, Cooper P, Sinclair PJ, Bryant G, Weston A., nersury in Semnan, Koomesh, Persian, 2004; 5(1&2), P. 53- Effect of load during electrical stimulation training in spinal 61. cord injury. Muscle Nerve. 2004; 29(1):104-11. 9. Biering-S_rensen F, Nielsen JB and K Klinge K, Spasticity- 28. Davis GM, Hamzaid NA, Fornusek C. Cardiorespiratory, assessment: a review, Spinal Cord, 2006; 44: 1–15 metabolic, and biomechanical responses during functional 10. Khalili MA and Hajihassanie A, Electrical simulation in electrical stimulation leg exercise: health and fitness combination with passive stretch has small effects on knee benefits. Artif Organs. 2008; 32(8): 625-9. range of motion and spasticity in children with cerebral 29. Glenn MB. Nerve blocks for the treatment of spasticity. In: palsy: a randomised controlled trial, Australian J of Katz RTPhysical medicine and rehabilitation: state of the art Physiotherapy, 2008; 54: P. h85-9. reviews. Philadelphia: Hanley & Belfus; 1994; pp. 481-505. 11. Rekand T, Clinical assessment and management of 30. Khalili AA, Harmel MH, Forster S, Benton JG. Management spasticity: a review, Acta Neurol Scand: 2010, 122 (Suppl. of spasticity by selective peripheral nerve block with dilute 190): 62–66. phenol solutions in clinical rehabilitation. Archives of 12. Fleuren, JFM, Voerman GE, Erren-Wolters1 CV, Snoek, Physical Medicine & Rehabilitation 1964; 45: 513-518. GJ, Rietman, JS, Hermens, HJ, and Nene, AV, Stop using 31. Petrillo CR and Knoploch S, Phenol block of the tibial nerve the Ashworth Scale for the assessment of spasticity, J. for spasticity: A long-term follow-up study, Disability & Neurol. Neurosurg. Psychiatry. 2010; 81:2. Rehabilitation, 1988, Vol. 10(3) , P. 97 - 100 13. Khalili MA, Assessment in movements and functional 32. Viel E, Pellas F, Ripart J, Pélissier J, Eledjam JJ., Peripheral rehabilitation of children, Koomesh, Persian, 2007, Vol. 8, nerve blocks and spasticity. Why and how should we use (4); P. 205-210. regional blocks? Presse Med. 2008; 37(12):1793-801. 14. Khalili MA. Quantitative sports and functional classification 33. Skeil DA, Barnes MP. The local treatment of spasticity. Clin (QSFC) for disabled people with spasticity. Br J Sports Med Rehabil 1994; 8: 240-6. 2004;38:310–13. 34. Keenan MA. Management of the spastic upper extremity in 15. Nuyens G, De Weerdt W, Ketalaer P, et al. Interrater the neurologically impaired adult. Clin Orthop Relat Res reliability of the Ashworth scale in multiple sclerosis. 1988;233:116–125. Clinical Rehabilitation.1994; 8:286–292. 35. Garland D.E. Lilling M and Keenan MA, Percutaneous 16. Josien C. van den Noorta , Vanessa A. Scholtesb, phenol blocks to motor points of spastic forearm muscles in Jaap Harlaara, Evaluation of clinical spasticity assessment in head-injured adults, Arch Phys Med Rehabil, 1984; 65: pp. Cerebral palsy using inertial sensors, Gait and Posture, 243–245 2009; 30(2); P. 138-143. 36. Choi EH, Seo J Y, Jung BY, and Park W, Diplopia after 17. 17)White H, Uhl TL, Augsburger S, Tylkowski C. inferior alveolar nerve block anesthesia: Report of 2 cases Reliability of the three-dimensional pendulum test for able- and literature review, Oral Surgery, Oral Medicine, Oral bodied children and children diagnosed with cerebral palsy. Pathology, Oral Radiology, and Endodontology. 2009; Gait Posture. 2007;26:97–105 . 107(6): P. e21-e24 18. Khalili MA, Inter-rater and intra-rater reliability of A angle 37. Ko Ko C, and Ward AB. Management of spasticity. Br J measurements, Saudi J Disabil Rehabil, 2003, Vol.9(1), 12-15. Hosp Med 1997;58(8):400-405.
Vol. 8 – No. 11 64۶۴ Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Short communication
Patient Centered Model of Care - A Positive Impact on Treatment Outcome in a Rehabilitation Hospital in Saudi Arabia
Rana Siddiqui; Asirvatham A. Robert*; Shaiza Irfan, PhD. Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia
Patient-centered model of care (PCMC) is a philosophy and mindset that requires a high level of commitment and significant adjustments in organizational structures. The patient-centered care (PCC) concept is based upon communication and involvement of both patients and their families in the treatment options and the potential outcome, thus empowering the patient and family. The PCC is a quality benchmark that is multidimensional and entails all aspect of how services are delivered to patients. The objective of this study was to study the effectiveness of PCC on the treatment outcome of a Rehabilitation Hospital in the Kingdom of Saudi Arabia. The survey was conducted during the January 2009 to July 2010 at Sultan Bin Abdulaziz Humanitarian City (SBAHC), Riyadh, Saudi Arabia. A total number of 1125 patients participated in the questionnaire and surveys. This paper provides an in-depth discussion of the concepts and evidence regarding PCC, a comprehensive review of approaches, action plan and an examination of activities at SBAHC, Riyadh, Saudi Arabia. Keywords: Patient centered model, Rehabilitation, patient satisfaction, Saudi Arabia
Submitted: 25 Aug. 2010 Accepted: 22 Nov 2010
Introduction patients participated in the questionnaire and Patient-centered model of care (PCMC) is a surveys. promising approach in improving patient treatment outcome and decreasing burden of care for person Patient and Family Involvement in Plan of Care: and family served and other stakeholders. This paper In PCC, patients become active participants in their provides an in-depth discussion of the concepts and own care and receive services designed to focus on evidence regarding patient-centered care (PCC), a their individual needs and preferences, in addition to comprehensive review of approaches, action plan advice and counsel from health professionals 1. and an examination of activities at Sultan Bin Patient or patients’ advocate voices patients’ needs Abdulaziz Humanitarian City (SBAHC), Riyadh, and expectations. Every member of the treating team Saudi Arabia. The paper focuses on strategies that is an advocate of the patient. Patient and family can be used by health care organizations by participate with goal setting and active involvement implementing patient-centered care approach. The of patients and family help us to change the manner PCC includes but not limited to patient and family and focus of the communication with our patients. involvement in plan of care, family and caregiver Treatment team comes up with a patient-driven education, achieving optimal patient satisfaction and interdisciplinary collaborated and coordinated care ensuring patient privacy and respect. The objective plan. Accepting patients as partners led us to a of this study was to study the effectiveness of PCC problem-solving environment leading to an on the treatment outcome of a Rehabilitation increased patient satisfaction. In this study we found Hospital in the Kingdom of Saudi Arabia. The that 80% of our inpatients said that family survey was conducted during the January 2009 to conferences were beneficial and 83% of our July 2010 at Sultan Bin Abdulaziz Humanitarian inpatients said that they were able to decide their City, Riyadh, Saudi Arabia. A total number of 1125 goals in their plan of care2.
* All correspondences to: Alwin Robert, Email:
Iranian Rehabilitation Journal 65 Patient, Family and Caregiver Education: In Saudi and preference. Provided education is documented Arabia a paid care giver is generally involved with and checked for understanding and accuracy at the patient care. We have an interdisciplinary patient, receiver’s end through teach-back method. 3 Patient family and caregivers education program in place. It education documentation is one of our service starts right from the pre-admission phase and delivery efficiency outcome measures. It documents continues through booking, admission, length of stay discussion of patient treatment, home exercise and discharge process. Education is provided for post program and use of equipment/devices. Data shows discharge, continuum of care in home or work set up not only high patient education documentation through various modes according to patients’ needs compliance but also increased compliance (Figure 1 ).
Figure 1. Patient Education Documentation
Patient Satisfaction: The World Health Report things that we are doing well. Patient satisfaction and emphasizes responsiveness of health systems as a infection control reporting emphasized the need of hot crucial component of their overall performance and cold tray line that was implemented as proposed defining responsiveness as the way the system by the team. In the past the SBAHC has organized responds to non-health aspects, and whether it was improvement projects around areas of patient meeting or not meeting patient expectations 4. In this dissatisfaction that resulted in improved satisfaction study patient satisfaction survey is conducted monthly results. As per Jan 2010 – Sep 2010 patient satisfaction for all service areas. It shows to our patients and their results shows that 96 % of our inpatients and 93 % of families that we value their input and are interested in our outpatients said that they would recommend our quality, and continuously looking for ways to improve. services to family and friends (Figure 2 & 3). We get a lot of positive reinforcement about the many
Figure 2. Inpatient Satisfaction
66 Vol. 9, No. 14, Oct. 2011
Figure 3. Outpatient Satisfaction
Patient Privacy: Respecting privacy and patients' patient dignity, privacy and confidentiality is a satisfaction are amongst the main indicators of quality of component of the job description of all staff. The results care and one of the basic goals of health services 5. In indicated that, during Jan 2009 - Aug 2010, our inpatient this study we ensure that patients are treated with dignity satisfaction results showed 96% satisfaction towards and respect, in environments that meet their needs for patient privacy (Figure 4). personal privacy. Demonstration of preservation of
Figure 4. Inpatient Privacy Respected
Information Sharing with Patient and Family: on the 'Patient and Family Information Needs Sharing health information with patients and family Assessment Analysis', it is evident that our inpatient through accessibility to medical record upon request is population prefers paper based information (Figure 5). yet another adjunct to patient empowered care. Based
Figure 5. Information provided to patient rights and responsibilities
Iranian Rehabilitation Journal 67
Patient Outcome Analysis: Research shows that empower staff with tools for delivering services with orienting the health system around the preferences PCC approach. Although our work is in process, we and needs of patients has the potential to improve believe we have made significant progress in coming patients' satisfaction with care as well as their up with a model of care: one that places the patient clinical outcomes. We regularly and systematically and family in the centre of our service delivery. A reviews data from outcomes of the person served patient and family centered model of care is a that is related to goals achieved and their satisfaction journey not a destination. As we go forward, we are with services delivered. 99% of our patients returned planning to study more thoroughly to measure the to their home/community after their discharge. impact of our PCMC on our patients and staff. We hope that others will benefit from our experience, Conclusion and will join us in finding new ways to integrate the The SBAHC identified and implemented new tools voices of patients and families into the pattern and and ways towards PCC culture and philosophy. A delivery of healthcare. PCC campaign was launched to educate and
References 3. Shepperd S, Parkes J, McClaran J, Phillips C. Discharge 1. Agency for Healthcare Research and Quality, "Expanding planning from hospital to home. Cochrane Database of Patient-Centered Care To Empower Patients and Assist Systematic Reviews 2004, Issue 1. Art. No.: CD000313. Providers," Research in Action, issue 5 (2002), under DOI: 10.1002/14651858.CD000313.pub2. subtitle, "Health Care Evolves Toward a Patient-Centered 4. World Health Organization. The World Health Report 2000. Model," http://www.ahrq.gov/qual/ptcareria.htm.> Health Systems. Improving Performance. World Health (6) Institute of Medicine, Crossing the Quality Chasm, 6. Organization Geneva, Switzerland 2000. 2. Marchland, Lucille; Kushner, Kenneth. Getting to the heart 5. Nayeri ND, Aghajani M. Patients' privacy and satisfaction in of the family conference: The residents' perspective. the emergency department: a descriptive analytical study. Families, Systems, & Health, Vol 15(3), Fal 1997, 305-319. Nurs Ethics. 2010 17:167-77.
68 Vol. 9, No. 14, Oct. 2011 Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011
Case report
Efficacy of Mindfulness-Based Cognitive Therapy on Depressed Mothers with Cerebral Palsy Children
Zahra Sedaghati Barogh; Jalal Younesi, PhD*; Fateme Shoaei, MSc.; Siyamak Tahmasebi ,PhD University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
Objectives: Findings Demonstrated that Parent of Children With Cerebral Palsy Experience Elevated Level of Distress, Depression, Anxiety, Posttraumatic Stress Symptom and Subjective Symptom of Stress. Depression is a common condition that typically has a relapsing course. Effective interventions targeting relapse have the potential to dramatically reduce the point prevalence of the condition. Many of studies have shown that Mindfulness based cognitive therapy (MBCT) is an intervention that has shown efficacy in reducing Depression syndrome and depressive relapse. In This Study, Effectiveness of Mindfulness –Based Cognitive Therapy (MBCT) on Reduction of Depression in Mothers of Children with Cerebral Palsy was examined. Method and Material: Three Mothers Whose Children Had Cerebral Palsy Were Diagnosed to Have Depression Symptoms, Using Beck Depression Inventory II, Structured Clinical in This Experimental Signal - Case Study .After The Baseline was Determined, Subject Attended on Eight –Session Program of Mindfulness - Based Cognitive Therapy . Results: The Comparison of Baseline and Post - Test was Showed That Depression Symptom has decreased through MBCT. Improvement Quotient for Depression of each Subject was good. Conclusion: Data Showed that MBCT Reduced Depression Symptoms in Mothers of Children With Cerebral Palsy. Keywords: Mindfulness Based cognitive therapy, Mindfulness, Depression, Cerebral Palsy.
Submitted: 18 Jan 2011 Accepted: 28 Feb 2011
Introduction when child experiences functional limitations and Cerebral palsy (CP) is a disorder of posture and possible long term dependence (4). movement as a consequence of non-progressive Mothers of children with different level of disability injury to the immature brain. The estimated tolerate high level of stress. Children with chronic incidence of CP is 2.0 to 2.5 per 1000 live births in medical conditions cause depression (5), emotional developed countries (1). Children with CP have and behavioral problem in their mothers (6). significant limitations in the activities of daily living In the study of Ones and his colleagues (3) mothers such as feeding, dressing, bathing, and mobility (2). having CP children had depressive symptoms and Although motor dysfunction is the defining clinical lower quality of life, in addition Manual(7) reported feature of CP, sensory, cognitive, and verbal 30% of mothers having CP Children had the impairment in addition to learning difficulties and symptom of depression above cut off on center for behavioral problems can also be seen in this Epidemiologic Studied- Depression (CES-D) Scale condition (3). Limitations can result in requirements Short Form and the other study by Chey (8) and et al for long-term care that far exceed the usual needs of (2009) showed that the prevalence of depression in children as they develop (1). Care giving is a normal mother with cerebral palsy 84% and in mothers part of being the parent of a young child whereas group of control 33%.In general ,Many studies have this role takes on an entirely different significance shown that depression in mothers of children with
* All correspondence to: Jalal Younesi, Email:
Iranian Rehabilitation Journal 69 cerebral palsy is more than common in mothers of normal life impossible. (20) .It appeared that there is normal children. (9-15) a relationship between child's disability and the Like other mothers, mothers suffering from maternal mental health problems that may affect depression want the best for their children. But each other. common symptoms of depression, such as anxiety, Many of intervention on depressed mothers with sadness, fatigue, and poor concentration, can affect cerebral palsy child are child- centered, another parenting ability and the relationship between a words, In this case, using approaches to mother and her both normal child and child with rehabilitation of children with cerebral palsy for disabilities.(65-70) As a result, maternal depression improved motor function and its effect on the is associated with a range of poor outcomes for improvement of maternal depression were examined children, including difficulties in mastering age- (3, 9). Despite , no or little positive results in this appropriate developmental tasks, reduced language style of type of intervention on maternal depression; ability (16), problems in social and emotional (3,9,10) other interventions, including adjustment, and deficits in cognitive functioning psychotherapy intervention on these mothers has (17). For example, infants with depressed mothers been used very little or not at all. may have difficulties forming emotional bonds with Depression is serious health problem. The usual caregivers and may be less responsive to others, less treatment offered is antidepressant medication, active, fussier, and slower to walk or vocalize (18). which often yields unwanted side effects, Toddlers with depressed mothers may exhibit compromising patient compliance (21,22) .Cognitive attention problems and poor self-control, while for therapy (CT) and psychopharmacology have been school-age children and adolescents, maternal the mainstays of treatment for depression and depression is associated with school problems and relapse prevention, yet relapse remains a significant low self-esteem. Children of depressed mothers are risk for this mental illness (23-26) .Consequently, also at higher risk of developing mental disorders the development of effective strategies to prevent themselves (19). .In general, Depression affects relapse is very important. almost all aspects of life and can eventually make
Table1. Characteristics of mothers and their children Participant A Participant B Participant C Age of child (years) 6 4 4 Gender Boy Boy Boy Type of cerebral palsy Spastic (Hemiplegia) Spastic (Diplegia) Spastic (Hemiplegia) Age of mother 35 41 39 Occupation of mother Housewife Typist at home Housewife Number of children 2 1 2
Mindfulness-based cognitive therapy (MBCT) is an Participations learn to engage in sustained alternative, psychological intervention designed for observation of these phenomena, with the tendency prevention of relapse in recurrent depression. (27) of interest and curiosity, and to accept them as they MBCT1, can reduce depression and anxiety are, without trying to change or escape them. symptoms. More recently, MBCT was shown to help The present study aimed to evaluate the effectiveness individuals discontinue antidepressants after of MBCT on reduction of depression symptoms in recovering from depression.(28) Overall, Apart from mothers of children with cerebral palsy. the studies (29,30,31) that showed relapse The present study is an effectiveness study and not preventing effect of MBCT in previously depressed efficacy study. Efficacy studies examine the effects patients, there are now a number of reports of treatment in randomized controlled trials, demonstrating that MBCT can successfully reduce involving participants, using a highly structured symptoms in currently depressed patients.(32,33) treatment manual for a narrow problem focus. MBCT includes mindfulness practice designed to Effectiveness studies examine the consequences of cultivate nonjudgmental observation and acceptance treatment conducted in non-research based clinical of bodily sensation, cognition, and emotions. setting and purposive sampling. The aim of such research is to maximize the external validity or generalization of results to various settings. 1 -Mindfulness based cognitive therapy
70 Vol. 9, No. 14, Oct. 2011 Materials and methods episode. (27)Instead of trying to eliminate or fix the Participants negative thoughts and emotions which precede Participants in this study consisted of three mothers depressive episodes, mindfulness-based cognitive who were selected from among mothers who were therapy teaches the person to allow them to occur referred to University of Social Welfare and and become aware of what he or she is experiencing Rehabilitation Centers for the rehabilitation of their during their onset. (37) Ideally, in understanding children. Facilitator screened interested subjects for these processes, one would be able to recognize the inclusion and exclusion criteria. Inclusion criteria were onset of symptoms and prevent them from (A) Diagnosed with depression by a psychiatrist and developing into a depressive episode. MBCT is an Possessing 19 score and above in Beck Depression eight week program which uses mindfulness Inventory-II (BDI-II) ;( B) Meeting criteria for exercises and homework to engage clients in depression determined by the modified version of the experiencing the present and to avoid worrying structured clinical interview for DSM IV (34) ;( C) about its relation to the past or future .(38) Medically stable patients with current associated major How does the intervention work? Individuals who depression, substance abuse and /or dependence and are depressed tend to interpret their life experiences psychosis and disabled were excluded from the study in a negative and biased way. These opinions lead to because of low concentration and orientation. All the be universal, self-critical, and involve the past and children were boys with cerebral palsy spastic type. future. Over time, these individuals develop (Ages 4-6).All the children lived with their parents. automatic, habitual patterns based on associated thoughts and moods. As these patterns develop and Procedure become automatic, the negative thoughts may easily The method used in this study the single- case perpetuate the sad moods previously associated with experimental design. In analyzing the data in the the same or similar thoughts, thus it becomes easier single case study, the dependent variable for the for the individual to fall into a downward spiral of possible changes resulting from the independent depression. (29) As this process progresses, even variable can be read in two ways. (35) The first mild changes in mood may lead to major changes in criterion is to draw the graphs of subjects’ functions thinking, a concept termed cognitive reactivity. of the baseline and the intervention phase, and then Using MBCT strategies, these individuals learn to compare them; and the second criterion is to recognize and welcome these patterns in order to consider the slopes in each of the two –step graph- understand them. This means that MBCT elements line during the intervention. Thus, any trends or of cognitive therapy that is consistent with slopes in each stage are examined. In this study, the nonjudgmental acceptance of the experience and Improvement quotient was used to show treatment living in the moment. A decentered view of thoughts effect clearly. We subtracted the pretest scores from is emphasized, in which participants are encouraged the post-test score and then divided the attained to view their thought as transient mental events number by the pretest score. (36) rather than as aspects of themselves or as necessarily The Baseline included three measures of maternal accurate reflections of reality or truth. (39) depression using the Beck Depression Inventory, Mindfulness based intervention consists of the before the intervention. The measurements were development of a particular kind of attention, performed at the end of second, forth, sixth and characterized by a nonjudgmental awareness, openness, eighth sessions to monitor the changes. Participants curiosity, and acceptance of internal and external present attended in treatment for eighth consecutive weeks experiences, which allows practitioners to act more for tow hour individually. reflectively rather than impulsively.(40-42)
Intervention Mindfulness-based cognitive therapy (MBCT) is a synthesis of mindfulness-based stress reduction, mindfulness meditation, and traditional cognitive behavioral therapy. MBCT strategies help individuals recognize and understand the automatic patterns of sensation, cognition, behavior, and emotion which ultimately lead one to a depressive
Iranian Rehabilitation Journal 71 Eventually, the individual would be able to teaching mindful eating and mindful labeling on recognize the onset of these patterns, and disrupt the thoughts, feelings and behaviors. automatic processes (feedback loops) thus, is In the seventh session, goals and techniques believed, by modifying the neural circuits in their included symptom of depression and rumination brain that are involved with emotion (e.g. amygdala, thinking.we educated accept your rumination hippocampus. (43) thinking without judgment and used diffusion Essentially MBCT is thought to alter the technique for reduction of it. emotional/cognitive and physiological experiences In the eighth session, goal and technique included of the present in order to treatment and prevent how can I best take care of myself? And using what depressive relapse in the future (38). Research you have learned to deal with future mood and shows that such cognitive behavioral strategies may reviewing the insights and found the most useful actually modify similar brain circuits which are techniques of mindfulness by the client, identifying targeted by medications. (44) obstacle to practice mindfulness, providing a checklist of techniques included in the program. Therapeutic Package In this study, the intervention include in our manual Instrument were provided in eight sessions. Beck Depression Inventory-II (BDI-II) Goals and techniques in the first session included The Beck Depression Inventory-Second Edition building a rapport with the client, obtaining (BDI-II)(45) is a 21 –item scale and one of the most information from the client, providing psycho widely used self –report measures of depression . education on mindfulness, CBT, depression, Beck mentioned the alphas of 0.93 for college identifying automatics thoughts and leading the students and 0.92 for outpatients, in Steer et al study; client through a guided mindfulness meditation. an alpha of 0.92 for the BDI-II was reported. Beck In the second Session, goals and techniques included reviewed 11 studies that showed the BDI is capable ‘stepping out of automatic pilot’ (acting without of discriminating between groups that differ in level conscious awareness), having a childlike Curiosity of depression. 35 synchronic validation studies and Mindful eating Body scan (intentionally compared BDI with other depression ratings. bringing awareness to bodily sensations) Fourteen other studies indicated the correlations In the third session, goal and technique included between the clinical scales and BDI; coefficients of dealing with barriers (Awareness of how the chatter psychiatric patients ranged from 0.55 to 0.96 with a of the mind influences feelings and behaviors), mean of 0.72. The correlation between the earlier Being compassionate with yourself and short version of BDI and (BDI-II) was 0/93 and kappa breathing meditation agreement was 0.70. (46) Goals and techniques in the fourth session helping the client recognize that most of her thought are not Result facts, teaching the client to use the thought record, Participant A educating client about cognitive distortion. Diagram1 shows that the participant’s depression Goals and techniques in the fifth session included level is 20-24 in BDI-II approximately at the educating staying present with awareness of baseline statement. These scores are moderate rates attachment and aversion, being patient; then, of depression in BDI-II. She obtained a score of 19 diaphragmatic breathing and sleep hygiene; next, in BDI-II at end of session 2; and this reduction teaching the client a brief body scans exercise to continued until the end of the intervention.as in last reduce muscle tension. session, her score in posttest measurement was 11 in In the sixth session, goal and techniques included BDI-II. That indicates reduction in symptoms of acceptance of thoughts and emotions as fleeting depression. Her Percent of recovery was %50.74 for events; next, introducing mindful daily activity, depression. (See Figure 1)
72 Vol. 9, No. 14, Oct. 2011
Fig. 1 Participant A Percent of recovery
Participant B BDI-II and at end of session 2. Her scores in last Diagram 2 shows that participant's depression levels post-test measurement were 12 in BDI-II that were 32-41 in BDI-II approximately at the baseline indicate reduction in symptoms of depression. Her statement. These scores are severe range of Improvement quotient was %66.67 for depression. depression in BDI-II. She obtained a score of 23 in (See Figure 2)
Fig. 2 Participant B Improvement quotient
Participant C end of session 2. Her scores in last post-test in BDI-II that indicate ١٣ Diagram 3 shows that participant's depression levels measurement were are 34-38 in BDI-II approximately at the baseline reduction in symptoms of depression. Her statement. These scores are severe rate of depression Improvement quotient was %63.55 for depression. in BDI-II. She got the score of 24 in BDI-II at the (See Figure 3)
Iranian Rehabilitation Journal 73
Fig. 3 Participant C Improvement quotient
All participants showed scores of 20-41 at the doubt, guilt and shame, which contributes to the baseline statement that indicated Moderate (20-28) deterioration of the quality of life of parents. (52) and severe depression (29-62) in BDI-II. Visual Experiencing severe anxiety (e.g. before making a observation of diagrams demonstrates the decline of crucial decision) often times leads to feelings of scores. Post- test of three participants (A, B and C) helplessness and lack of control, and this in turn may is in low or no depression remains. contribute to feelings of parental incompetence .(3, 53)Fatigue and frequent loneliness lower resistance Discussion to stress and disturb the normal regulation of This current study, According to the Ingram, Hayes, emotions(53) Moreover, Brehaut et al(54) found that and Scott theory (2000), explains the result on the over the year’s parents of children with cerebral effects of MBCT on depressed mothers with cerebral palsy, compared with parents of healthy children, palsy child in four areas to evaluate the performance more frequently complain of experiencing severe of Cognitive Therapy. (46) and chronic stress, emotional and cognitive Universality of change (what is the percentage of the problems, as well as report numerous somatic improvement?) complaints. In this study, participants also had many Differences between base line and post-test scores problems, including difficulty eating (part A), lack demonstrated that examinees show positive of concentration, decreased libido (part B), sleep improvement on Beck depression scales. The disturbances (55) (part c), fatigue, lack of energy, percentages of recovery on depression were: social isolation, problems with spouse. At the end of participant A: %50.74; participant B: %66.67; and the final sessions, the participant had a better participant C: %63.55 solution for their problems and relationship with These results are consistent with recent studies their spouse and children. Baer (56) argues that in investigating the relationship between mindfulness mindfulness, several mechanisms can reduce the and predictors of depression (47,48)which have symptoms, including: shown that mindfulness functions as a protective • Cognitive change factor against known correlates of depression • improved self-management Symptoms (e.g., rumination, negative cognitions). • Exposure to painful experiences leading to reduced Generality of change (what are the changes in emotional reactivity. relation to critical situations and jobs?) Cognitive change—also called metacognitive The more complex the form of cerebral palsy, the awareness—is the development of a “distanced “or less favorable the prognosis for the child's “decentered” perspective in which patients psychomotor development and a potentially greater experience their thoughts and feelings as “mental risk of disturbances in the quality of communication events” rather than as true, accurate versions of and interaction with the parents (49, 50). The reality. This is thought to introduce a “space” situation of parents of children with cerebral palsy is between perception and response that enables considered so stressful that it can be compared with patients to have a reflective—rather than a reflexive the situation of parents of children with cancer (51) . or reactive—response to situations, which in turn The difficult and constant struggle to improve the reduces vulnerability to psychological processes that child's health and development is accompanied by contribute to emotional suffering. Some preliminary
74 Vol. 9, No. 14, Oct. 2011 evidence suggests that MBCT-associated increases Conclusion in metacognitive awareness reduce risk of In summary, the current study demonstrated that depressive relapse. (57) Mindfulness-Based Cognitive Therapy has a significant effect on depression and on our samples. Safety The depression changed in different ways. Due to Comparing the participants’ scores at base line, post- the psychological interviews which the Facilitator test, and follow up in depression showed a great deal carried out with mothers, this treatment approach of improvement on the scales, and led to a full significantly improved the relationship of these recovery. However, the recovery rate was different mothers with themselves, and their families, and also from patient to patient. This treatment approach did improved their social functions. The outcomes are not show any side effects. coherent with the results of the studies which emphasize the Effectiveness of MBCT for treatment Stability (Treatment Achievements) of depression, anxiety and stress and to improve Follow up result (30 days after the last therapy psychosocial adjustment of people. (31, 58-64) session) indicated that depression of participants A Acknowledgment and C maintained in the score of less than 13 which We would like to thanks research section of indicates the state of no depression or least University of Social Welfare and Rehabilitation depression. Participant B with the score of 14 was Sciences, Tehran, Iran. categorized in a range of 14-19 with a diagnosis of We also would like to appreciate the mothers of mild depression; and it can be stated that MBCT children with cerebral palsy who have given us their provided them with a relative stability. valuable time and they trust us.
References 12. Bumin G, Gunal A, Tukel S. Anxiety, depression and quality 1. Raina P, O’Donnell M, Rosenbaum P, Brehaut J, Walter SD, of life in mothers of disabled children. SDU Tip Fak Derg. Russell D, et al. The health and well-being of caregivers of 2008;15(1):6–11. children with cerebral palsy. Pediatrics. 2005;115(6):626–36. 13. Unsal-Delialioglu S, Kaya K, Ozel S, Gorgulu G. 2. Erkin G, Aybay C, Kurt M, Keles I, Cakci A, Ozel S. The Depression in Mothers of Children With Cerebral Palsy and assessment of functional status in Turkish children with Related Factors in Turkey: A Controlled Study ;Int Rehabil cerebral palsy (a preliminary study). Child Care Health Res . 2009;32(3):199. Dev.31:719-25. 14. Mehmedinović S vSARIĆ E, Poljić A Bratov, Mujanović A. 3. Ones K, Yilmaz E, Cetinkaya B, Caglar N. Assessment of "Religiosity AND Depression IN Mothers of Children with the quality of life of mothers of children with cerebral palsy Cerebral Palsy: Correlation Analysis." The Journal of (primary caregivers). Neurorehabil Neural Repair. 2005; 19: International Social Research.2011;4(16): 292-297. 232-7. 15. Diwan S, Chovatiya H, Diwan J. Depression and Quality of 4. King S, Teplicky R, King G, Rosenbaum P. Family-centered Life in Mothers of Children With Cerebral Palsy .NJIRM. service for children with cerebral palsy and their families: a 2011;35(15.53):81–90. review of the literature. Semin Pediatr Neurol. 2004;11:78-86 16. Huang LN, Freed R. The spiraling effects of maternal 5. Götz I, Götz M. Cystic fibrosis: psychological issues. depression on mothers, children, families and communities. Pediatric Respire Rev. 2000;1(2):121-7 Issue Brief. 2006;2. 6. Bristol MM, Gallagher JJ, Schopler E. Mothers and fathers 17. Gurian A. Mother blues–child blues: How maternal of young developmentally disabled and nondisabled boys: depression affects children. New York University Child Adaptation and spousal support. Dev. Psychol Study Center Letter. 2003;7(3). 1988;24(3):441-51 18. Center for Disabilities and Development,(2000) “Fact Sheet 7. Manuel J, Naughton MJ, Balkrishnan R, Smith BP, Koman on Maternal Depression,” EPSDT Care for Kids Newsletter LA. Stress and adaptation in mothers of children with (Iowa City, IA: University of Iowa Hospitals and Clinics). cerebral palsy. J Pediatr Psychol. 2003;28(3):197-201. 19. Wessel R. Xtria Research Team (2000). Maternal 8. Echey.Ijezie,Ngozi.C.Ojinnaka,Sylverstero.Tloeje(2009) depression: A review of current literature. 2004 Prevalence and Pattern of Children With Cerebral Palsy in 20. Sharghi A, Karbakhsh M, Nabaei B, Meysamie A, Farrokhi Enugu Nigeria ;Vol38No 1p129-140 A. Depression in mothers of children with thalassemia or 9. Prudente COM, Barbosa MA, Porto CC. "Relation Between blood malignancies: a study from Iran. Clinical Practice and Quality of Life of Mothers of Children With Cerebral Palsy Epidemiology in Mental Health. 2006;2(1):27. and the Children Motor Functioning, After Ten Months of 21. Hollon SD, DeRubeis RJ, Shelton RC, Amsterdam JD, Rehabilitation Rev Latino-am Enfermagem. Salomon RM, O’Reardon JP, et al. Prevention of relapse 2010;18(2):149–55. following cognitive therapy vs medications in moderate to 10. Sajedi F, Malekkhosravi GH, Karimlou.M, Vameghi R. severe depression. Archives of general psychiatry. "Depression in Mothers of Children with Cerebral Palsy and 2005;62(4):417. Its Relation to Severity and Type of Cerebral Palsy. Acta 22. Hollon SD, Muñoz RF, Barlow DH, Beardslee WR, Bell Medica Iranica. 2010;48(4):250–4. CC, Bernal G, et al. Psychosocial intervention development 11. Lambrenos K, Weindling AM, Calam R, Cox AD. The for the prevention and treatment of depression: promoting Effect of a Child s Disability on Mothers Mental Health. innovation and increasing access. Biological psychiatry. Arch Dichild; 1996;74(2):115–20. 2002;52(6):610–30.
Iranian Rehabilitation Journal 75 23. Meyer TD, Scott J. Cognitive behavioural therapy for mood 43. Siegel DJ. The mindful brain: Reflection and attunement in disorders. Behavioural and Cognitive Psychotherapy. the cultivation of well-being. WW Norton; 2007. 2008;36(6):685. 44. Porto P, Oliveira L, Mari J, Volchan E, Figueira I, Ventura 24. DeRubeis RJ, Hollon SD, Amsterdam JD, Shelton RC, Young P. Does cognitive behavioral therapy change the brain? A PR, Salomon RM, et al. Cognitive therapy vs medications in systematic review of neuroimaging in anxiety disorders. The the treatment of moderate to severe depression. Archives of Journal of neuropsychiatry and clinical neurosciences. general psychiatry. 2005;62(4):409-416. 2009;21(2):114–25. 25. Rush AJ, Beck AT, Kovacs M, Hollon S. Comparative 45. Beck AT, Steer RA, Ball R, Ranieri WF. Comparison of efficacy of cognitive therapy and pharmacotherapy in the Beck Depression Inventories-IA and-II in psychiatric treatment of depressed outpatients. Cognitive therapy and outpatients. Journal of personality assessment. research. 1977;1(1):17–37. 1996;67(3):588–97. 26. Eaton WW, Shao H, Nestadt G, Lee BH, Bienvenu OJ, 46. Snyder CR, Ingram RE. Handbook of psychological change: Zandi P. Population-based study of first onset and chronicity Psychotherapy processes & practices for the 21st century. in major depressive disorder. Archives of General John Wiley & Sons; 2000. Psychiatry. 2008;65(5):513-520. 47. Michalak J, Heidenreich T, Meibert P, Schulte D. 27. Segal ZV, Williams JMG, Teasdale JD. Mindfulness-Based Mindfulness predicts relapse/recurrence in major depressive Cognitive Therapy for Depression: A new approach to disorder after mindfulness-based cognitive therapy. The preventing relapse. 2002. New York: Guilford.. Journal of nervous and mental disease. 2008;196(8):630–3. 28. Grabovac AD. Mindfulness-based interventions: Effective 48. Shapiro SL, Oman D, Thoresen CE, Plante TG, Flinders T. for depression and anxiety. Current Psychiatry. Cultivating mindfulness: effects on well-being. Journal of 2009;8(12):39. clinical psychology. 2008;64(7):840–62.. 29. Teasdale JD, Segal ZV, Williams JMG, Ridgeway VA, 49. LA K. Smith BP. Shilt JS. Cerebral palsy. Lancet. Soulsby JM, Lau MA. Prevention of relapse/recurrence in 2004;363(9421):1619–31. major depression by mindfulness-based cognitive therapy. J 50. Gasińska M, Lejman T, Sułko J. Prognozowanie chodzenia u Consult Clin Psych. 2000;68(4):615. dzieci z mózgowym porażeniem dziecięcym. (w:) Karski T, 30. Ma SH, Teasdale JD. Mindfulness-based cognitive therapy Królewski J, red.(2004) Mózgowe porażenie dziecięce. for depression: replication and exploration of differential Leczenie operacyjne zniekształceń spastycznych kończyn. relapse prevention effects. Journal of Consulting and Biblioteka Ortopedii Dziecięcej t. VII. Lublin: Wyd. Clinical Psychology. J Consult Clin Psych.2004;72(1):31 Folium, (In Polish) 31. Kuyken W, Byford S, Taylor RS, Watkins E, Holden E, 51. Hung JW, Wu Y-H, Yeh C-H. Comparing stress levels of White K, et al. Mindfulness-based cognitive therapy to parents of children with cancer and parents of children with prevent relapse in recurrent depression. J Consult Clin physical disabilities. Psycho-Oncology. 2004;13(12):898–903. Psych.2008;76(6):966-978. 52. Eker L, Tüzün EH. An evaluation of quality of life of 32. Finucane A, Mercer SW. An exploratory mixed methods mothers of children with cerebral palsy. Disabil Rehabil. study of the acceptability and effectiveness of mindfulness- 2004;26(23):1354–9 based cognitive therapy for patients with active depression 53. Wanamaker CE, Glenwick DS. Stress, coping, and and anxiety in primary care. BMC psychiatry. 2006;6(1):14. perceptions of child behavior in parents of preschoolers with 33. Kingston T, Dooley B, Bates A, Lawlor E, Malone K. cerebral palsy. Reh Psychol. 1998;43(4):297-312. Mindfulness-based cognitive therapy for residual depressive 54. Brehaut JC, Kohen DE, Raina P, Walter SD, Russell DJ, symptoms. Psychology and Psychotherapy: Theory, Swinton M, et al. The health of primary caregivers of children Research and Practice. 2007;80(2):193–203. with cerebral palsy: how does it compare with that of other 34. Spitzer M, Gibbon R,Williams MJ. Washington ,DC Canadian caregivers? Pediatrics. 2004;114(2):e182–e191. :American Psychiatric Association.1997 55. Yook K, Lee S-H, Ryu M, Kim K-H, Choi TK, Suh SY, et 35. Kazdin AE. Research design in clinical psychology. New al. Usefulness of mindfulness-based cognitive therapy for York: Macmillon, 1992 treating insomnia in patients with anxiety disorders: a pilot 36. Hamidpour H, Sahebi A, Tabatabaei M. [comparison of study. The Journal of nervous and mental disease. effectiveness and efficacy of Beck cognitive therapy and 2008;196(6):501–3. Teasdale cognitive therapy in treatment depression(Persian)] 56. Baer RA. Mindfulness training as a clinical intervention: A .Iranian Journal of Psychiatry and Clinical Psychology conceptual and empirical review. Clin Psychol Sci Prac. (Andisheh and Raftar). 2005;11(41):150-60 2003;10(2):125–43. 37. Williams, M., Teasdale, J., Segal, Z., Kabat-Zinn, J. The 57. Teasdale JD, Moore RG, Hayhurst H, Pope M, Williams S, mindful way through depression: freeing you from chronic Segal ZV. Metacognitive awareness and prevention of unhappiness. The Guilford Press: New York, 2007 relapse in depression: empirical evidence. J Consult Clin 38. Dimidjian S., Kleiber BV, Segal ZV. Mindfulness-based Psych. 2002;70(2):275-87. cognitive therapy. In: Kazantzis N, Reinecke M, Freeman A. 58. Van Aalderen JR, Donders ART, Giommi F, Spinhoven P, Cognitive and behavioral theories in clinical practice.eds. Barendregt HP, Speckens AEM. The efficacy of NY: Guilford Press,2010: 307-331 mindfulness-based cognitive therapy in recurrent depressed 39. Huss DB, Baer RA. Acceptance and Change The Integration patients with and without a current depressive episode: a of Mindfulness-Based Cognitive Therapy Into Ongoing randomized controlled trial. Psychological Medicine. Dialectical Behavior Therapy in a Case of Borderline 2011;1(1):1–13 Personality Disorder With Depression. Clinical case studies. 59. Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of 2007;6(1):17–33. mindfulness-based therapy on anxiety and depression: A 40. Bishop SR, Lau M, Shapiro S, Carlson L, Anderson ND, meta-analytic review. Journal of consulting and clinical Carmody J, et al. Mindfulness: A proposed operational psychology. 2010;78(2):169-83. definition.. Clin Psych . 2004;11(3):230–41 60. Eisendrath S, Chartier M, McLane M. Adapting 41. Kabat-Zinn J. Wherever you go, there you are: Mindfulness mindfulness-based cognitive therapy for treatment-resistant meditation in everyday life. Hyperion; 1995. depression. Cognitive and behavioral practice. 42. Marlatt GA, Kristeller JL. Integrating spirituality into 2011;18(3):362–70. treatment: Resources for practitioners. In: Miller WR, ed. 61. Barnhofer T, Crane C, Hargus E, Amarasinghe M, Winder Mindfulness and Meditation. Washington DC: American R, Williams JMG. Mindfulness-based cognitive therapy as a Psychological Association,1999
76 Vol. 9, No. 14, Oct. 2011 treatment for chronic depression: A preliminary study. 66. Weissman MM, PRUSOFF BA, Gammon GD, Behaviour Research and Therapy. 2009;47(5):366–73. MERIKANGAS KR, LECKMAN JF, KIDD KK. 62. Eisendrath SJ, Delucchi K, Bitner R, Fenimore P, Smit M, Psychopathology in the children (ages 6–18) of depressed McLane M. Mindfulness-based cognitive therapy for and normal parents. J.Am.Acad.Child Psychiatry. treatment-resistant depression: a pilot study. Psychotherapy 1984;23(1):78–84. and Psychosomatics. 2008;77(5):319–20. 67. Cooper SF, Leach C, Storer D, Tonge WL. The children of 63. Ree MJ, Craigie MA. Outcomes following mindfulness- psychiatric patients: clinical findings. J.Psychiatry. based cognitive therapy in a heterogeneous sample of adult 1977;131(5):514–22. outpatients. Behav Cog Psychother. 2007;24(02):70–86. 68. Rutter M, Quinton D. Parental psychiatric disorder: Effects 64. Kenny MA, Williams JMG. Treatment-resistant depressed on children. Psychol.med. 1984;14(04):853–80. patients show a good response to mindfulness-based 69. Diego MA, Field T, Hernandez-Reif M, Cullen C, cognitive therapy. Behav Res Ther. 2007;45(3):617–25. Schanberg S, Kuhn C. Prepartum, postpartum, and chronic 65. Khanjani ZPD, Hadavandkhani FM, Hojaji SNBA. depression effects on newborns. Infant Behav Dev. "Externalizing Disorders The Role of Anxiety and 2004;67(1):63–80. Depression of Mothers in Mental Health of Adolescent 70. Keller D, Honig AS. Maternal and paternal stress in families Girls. Journal of Clinical Psychology .2010;2(15). with school-aged children with disabilities. American Journal of Orthopsychiatry. 2010;74(3):337–48.
Iranian Rehabilitation Journal 77
Author Guidelines
Manuscripts for Iranian Rehabilitation Journal should follow the following instructions:
1. MANUSCRIPT TYPES ACCEPTED The editorial policy of the Iranian Rehabilitation Journal (IRJ) is to encourage the publication of evidence-based research articles related to rehabilitation. IRJ publishes articles within the more basis aspects of rehabilitation in following forms: A-Original Research Articles: Original Research Articles must describe novel and significant observations and provide sufficient detail so that the findings can be critically evaluated and, if necessary, repeated. B-Reviews: Reviews are selected for their broad general interest; all are refereed by experts in the field who are asked to comment on issues such as timeliness, general interest and balanced treatment of controversies, as well as on scientific accuracy. C-Case Reports/Case series: Authors are invited to submit case reports on clinical topics of relevance to the aim and scope of the Iranian Rehabilitation Journal. The reports should not be more than 2000 words. D-Commentaries: Are opinion pieces on topics of general interest to the rehabilitation community.
2. MANUSCRIPT SUBMISSION PROCEDURE Manuscripts can be submitted in the following ways: A-Electronically via the online submission site http://www.irjrehab.com. The use of an online submission and peer review site enables immediate distribution of manuscripts and consequentially speeds up the review process. B-E-mail submission. Submit all materials electronically to [email protected] or [email protected] Submit manuscript and all materials as one electronic file, except for tables and figures. C-Via Post. You can post the CD of the article and 3 copies to editorial address: Iranian Rehabilitation Journal, University of social welfare and rehabilitation sciences Evin, Kudakyar Ave., Tehran 1985713831, IRAN
3. MANUSCRIPT FORMAT AND STRUCTURE 3.1. Format Language: The language of publication is English. Abbreviations, Symbols and Nomenclature: Iranian Rehabilitation Journal adhere to the conventions outlined in Units, Symbols and Abbreviations: A Guide for Medical and Scientific Editors and Authors. 3.2. Structure All manuscripts submitted to the Iranian Rehabilitation Journal should include: Title page, abstract, main text, acknowledgements, references and tables, figures and figure legends as appropriate. Title: Title page should include title; name of authors, complete names of institution for each author, and the name, address, telephone number, fax number and e-mail address for the corresponding author. Abstract: Abstract should include Objectives, Methods, Results, and Discussion (for Original articles) contain at most 250 words with 3 to 5 keywords. Main Text of Original Research Articles: should include Introduction, Materials and Methods, Results and Discussions. Introduction: should be focused, outlining the historical or logical origins of the study and not summarize the results; exhaustive literature reviews are not appropriate. Materials and Methods: must contain sufficient detail such that, in combination with the references cited, all experiments reported can be fully reproduced. Results: should present the observations with minimal reference to earlier literature or to possible interpretations. Presentation of data with tables, related figures and appropriate graphs is encouraged. Discussion: may usefully start with a brief summary of the major findings, but repetition of parts of the abstract or of the results section should be avoided. Main Text of Reviews and Case Reports: need not follow the usual divisions of original research articles, but should contain appropriate headings and subheadings. Acknowledgements: should proceeded by the References. References: References should be numbered consecutively in the order in which they are first mentioned in the text. Identify references in text, tables, and legends by English numerals in parentheses. Use the style of the examples below, which are based on the formats used by the NLM in Index Medicus. The titles of journals should be abbreviated according to the style used in Index Medicus. Journals Lobbezoo F, van der Zaag J, Naeije M. Bruxism: its multiple causes and its effects on dental implants - an updated review. J Oral Rehabil. 2006; 33: 293-300 Books: Fejerskov O, Kidd E. (eds) Dental caries: The Disease and its Clinical Management. Copenhagen: Blackwell Munksgaard; 2003. Tables, Figures and Figure Legends Tables: should be double-spaced with no vertical rulings, with a single bold ruling beneath the column titles. Units of measurements must be included in the column title. Figures: All figures should be planned to fit within either 1 column width (8.0 cm), 1.5 column widths (13.0 cm) or 2 column widths (17.0 cm).