Musculoskeletal
Impairments at
Piña Palmera,
Mexico
A cross-sectional study to investigate the types and prevalence of musculoskeletal impairments in individuals at Piña Palmera rehabilitation center.
MAIN FIELD: Prosthetics and Orthotics AUTHOR: Alma Düring & Evelina Eklund SUPERVISOR:Louise Baek-Larsen
Summary
Aim: The aim of this thesis was to map specific musculoskeletal impairments experienced by adults with
physical disabilities at the Piña Palmera rehabilitation center in Mexico and to categorize them according to the ICF.
Method: This cross-sectional study was conducted through observations and a survey based on predefined
questions. The questions covered the individuals’ level of independence, pain, earlier treatment and biggest obstacle in daily life. The participants were observed when they received physical therapy or in their daily work at the center. The results from the survey and observations were later coded according to ICF. The participants were categorized and divided into groups depending on severity of their impairment: mild, moderate and severe.
Results: This study includes 17 participants, nine women and eight men. The age of the participants ranged
from 22 to 87 years (median: 44). The result shows an overview of the most common impairments that individuals’ who are visiting the center are affected by. The result also shows all the codes for each individual on the ICF-components.
Conclusion: The group with severe loss of function had higher level of problem on the investigated
components of ICF. Assistive device that should be prioritized is AFO.
Sammanfattning
Muskuloskelettära funktionsnedsättningar på Piña Palmera, Mexico.
En tvärsnittsstudie för att undersöka typerna och prevalensen av muskuloskelettära funktionsnedsättningar hos individer på Piña Palmera rehabiliteringscenter.
Syfte: Syftet med denna studie är att kartlägga de specifika muskuloskelettära funktionsnedsättningarna
hos vuxna människor med fysiska funktionshinder på Piña Palmera rehabiliteringscenter i Mexico samt att kategorisera dessa enligt International Classification of Functioning, Disability and Health.
Metod: Denna tvärsnittsstudie genomfördes genom observationer och ett förberett frågeformulär.
Frågeformuläret innehöll frågor som rörde individens självständighetsförmåga, smärta, tidigare behandlingar samt deltagarens självupplevda största hinder i vardagen. Deltagarna observerades under besök hos fysioterapeuten eller i deras vardagliga arbete på centret. Resultatet från intervjun och undersökningarna kodades enligt ICF och deltagarna delades in i grupper beroende på grad av funktionsnedsättning, mild, medel eller svår.
Resultat: Denna studie inkluderar 17 deltagare, nio kvinnor och åtta män. Deltagarnas ålder är mellan 22
och 87 år (median: 44 år). Resultatet ger en överblick på de vanligaste funktionshindren hos individer som besöker centret. Resultatet visar också kodningen för varje individ för fyra olika komponenter inom ICF.
Slutsats: Gruppen med svår funktionsnedsättning hade högre problemgrad på alla ICF-komponenter,
vilket var väntat. De assisterande hjälpmedlen som bör prioriteras för centret är AFO.
Content
Abbreviations and Definitions ... 1
Introduction ... 2
Musculoskeletal impairment ... 2
Assistive devices ... 2
Access to assistive technologies ... 2
Background ... 4 Mexico ... 4 Piña Palmera ... 4 GATE ... 4 Agenda 2030 ... 5 ICF ... 5 Premise of thesis ... 8 Aim ... 8 Method ... 9 ICF-codes ... 11 Data analysis ... 11 Ethical considerations ... 13 Bias ... 14 Result ... 15 Discussion ... 18 Result ... 18 Components ... 18 Methodological discussion ... 21 Data collection ... 21 Access to rehabilitation ... 22 Data analysis ... 23 Assistive devices ... 23 Conclusion... 27 Acknowledgements ... 27 References ...28 Appendix 1 ... 31
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Abbreviations and Definitions
ADL Activity in Daily Living
AFO Ankle Foot Orthosis
BSP-ICF Biopsychosocial International Classification of Functioning GATE The Global Cooperation on Assistive Technology
HD Hip Disarticulation
ICF International Classification of Functioning, Disability and Health
KAFO Knee Ankle Foot Orthosis
KO Knee Orthosis
MFS Minor Field Study
NE Nationalencyclopedin
STROBE The Strengthening Reporting of Observational Studies in Epidemiology
UN United Nations
WHO World Health Organization
Component The four different components in the ICF-coding framework: body function, body structure, activity & participation and environmental factors (Socialstyrelsen, 2015).
Disability An umbrella term for impairments and limitations of activity and participation. A disability is the interaction between the body functions and structures and the society that create barriers (WHO, 2020).
Domain The definition of each ICF-code, example b280=pain (Socialstyrelsen, 2015). Impairment In the context it includes problems in body function or structure such as a
significant deviation or loss (WHO, 2002)
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Introduction
Musculoskeletal impairment
Musculoskeletal impairments affect the locomotor system and can include impairments of bones, muscles, joints and tendons (WHO, 2019). The negative impact of musculoskeletal impairments on the physical function and quality of life of people living in developing countries is considerable (Loyola Sánchez et al., 2014). According to the World Health Organization almost 15% of the world's population have some form of disability (WHO, 2018b). In order to prioritize interventions, it is necessary to understand the types and prevalence of musculoskeletal impairments in various countries. In 2010 it was estimated that 5.1% of the total population in Mexico had a physical impairment. This data however is based upon national consensus data and does not provide sufficient detail regarding the specific types of impairments experienced by Mexican citizens (Guzman & Salazar, 2014).
Assistive devices
According to World Health Organization assistive devices and technologies are those whose primary purpose is to maintain or improve an individual’s functioning and independence to facilitate participation and to enhance overall well-being. They can also help prevent impairments and secondary health condition. Assistive devices that facilitate mobility are important for people with physical disabilities to help increase levels of activity and participation. Mobility aids include wheelchairs, crutches, prostheses and orthoses (WHO, 2018a).
More than one million people are in need of assistive devices. In 2030 it is expected that this number will double since global ageing is rising. Only one of ten individuals in need of assistive technologies currently have the access to them. This affects participation, access to education and work for the younger population and the possibility to live healthy and independent lives for the elderly. Assistive devices help individuals maintain or improve their independence and well-being. They can also have a positive impact on the socioeconomic status for the affected family (WHO, 2018a).
A physical impairment is often associated with poverty caused by reduced participation in education, work or community life. This is especially the case in developing countries where 90% of children with disabilities do not attend school at all (UN). Assistive technologies are also facilitating participation in education and work.
Unfortunately, access to assistive technologies is particularly limited in developing countries and help from non-governmental organizations is needed to provide the necessary services and comply with the Convention of the Rights of Persons with Disabilities (Borg, Lindström, & Larsson, 2009).
Access to assistive technologies
For the assistive technologies to be appropriate in a developing country context, the devices need to suit the environment and be affordable for the user (Magnusson, 2014).
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It is important to consider the environmental conditions when manufacturing assistive devices and in what context the assistive device will be used. For example, in developing counties clients might not wear shoes on a daily basis and the assistive device needs to be durable in the daily activities. The device needs to be available in the country, to fit properly and be kept maintained at an economical efficient price (Borg et al., 2009).
According to the UN development program, 80% of persons with disabilities live in developing countries (UN). In a study by Gupta et al. (2011), health related services in the global situation were investigated. The result shows large differences across countries. Low income countries reported less availability of skilled health personnel (Gupta, Castillo-Laborde, & Landry, 2011). WHO estimates that only 5-15% of persons in need of assistive devices have access to them (WHO, 2018a).
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Background
Mexico
Mexico is a country located in southern North America and has a population of 130.8 million people. There is poverty in the country which splits the inhabitants and leads to unemployment and inequality (NE).
Guzman and Salazar (2014) found that the prevalence of persons with physical impairments in Mexico has increased from 1.8% to 5.1% over a decade (2000-2010) (Guzman & Salazar, 2014). The prevalence of musculoskeletal impairment in indigenous communities overall is unknown, but in Mixteca, Oaxaca 45.1% of the indigenous people had an impairment and much pain, which negatively affected their activity level (Julian-Santiago, Garcia-Garcia, Garcia-Olivera, Goycochea-Robles, & Pelaez-Ballestas, 2014). Since the need of rehabilitation in Mexico increases, the Mexican Institute of Social Security (MSSS) implemented first-level rehabilitation services in 2003. These includes physicians, physio therapists, social workers and nurses. In 2014 there were 46 facilities which have increased the access to rehabilitation services in Mexico with 60% over the past ten years (Guzman & Salazar, 2014). Mexico have the last 15 years implemented several laws about the social inclusion and discrimination for individuals with disabilities (Madans, Loeb, & Altman, 2011). The state must promote, protect and ensure the individuals and guarantee accessibility to buildings and services. Despite the reform in healthcare, little is known about how the real-life situation in Mexico looks like for a person with disability (Guzman & Salazar, 2014).
In Mexico musculoskeletal impairments are considered an economic burden on both the health care system and the individuals. A study performed in 2005, shows that musculoskeletal pain affects 25.5% of the population in Mexico (Clark, Denova-Gutiérrez, Razo, Rios-Blancas, & Lozano, 2018).
Piña Palmera
Piña Palmera is a rehabilitation center located in the southern part of Mexico. The main focus for this rehabilitation center is to strengthen network-based rehabilitation in the area. The organization is based on the convention for human rights, the UN convention of the rights of persons with disabilities and Conventions of the rights of the Child (UN). Piña Palmera offers a variety of rehabilitation services, some of the clients live at the center full time and others come for physical therapy. Currently there is no personnel educated in Orthotics and Prosthetics at the center and access to assistive technologies is severely limited (Palmera, 2019). Piña Palmera works together with their clients to help them become more independent. The goal of this intervention is that clients will be able to live by themselves and provide care for themselves.
GATE
GATE was developed by the World Health Organization in 2014 to improve access to assistive technology in developing countries. The goal for the initiative is to improve access to high-quality affordable assistive products globally (WHO). To achieve this goal the focus is on five areas: people, policy, products, provision
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and personnel. GATE published a list of priority assistive products in 2016 to improve access. This list shows the 50 most important assistive technologies in the world. Included on this list are canes, wheelchairs for bath/toilet, crutches and lower limb orthoses and prostheses (WHO, 2016). This list can be applied to the work done in Piña Palmera to help prioritize the resources since they have limited or no access to assistive technologies.
Agenda 2030
Agenda 2030 is 17 global sustainable development goals aimed to implement the human rights for everyone, eradicate poverty and hunger, achieve gender equality and protect the planet and the natural resources. The focus on all 17 goals is sustainable development in three forms: economic, social and environmental (UN). This Minor Field Studies thesis (MFS-thesis) will contribute to mainly two of the ten goals: goal number 3, good health and well-being and goal number 10 reduced inequalities.
Goal 3, Good health and well-being
According to the United Nations’ organization the definition of this goal is “Ensuring healthy lives and promoting the well-being at all ages is essential to sustainable development” (UN). This goal targets child health, maternal health and HIV/AIDS, malaria and other diseases. 50% of the population do not have access to essential healthcare (UN).
This MFS thesis will help to sustain this goal by creating evidence for the future development of global health and well-being. This goal is also relevant for this MFS thesis since good health is a basis for the quality of life.
Goal 10, Reduced inequalities
This goal highlights how important it is to work for a society where no-one is left behind and works for equality among nations and individuals. An equal society depends on equal rights between the genders, religions, races, ages and physical impairments. The goal also focuses on income equalities and the growth of the income pro capita. According to Nationalencyklopedin, there is a big different between incomes in Mexico, which leads to huge differences in the living conditions for the Mexican population (NE).
This goal is especially relevant for this MFS thesis since the study is going to involve people with physical disabilities and their rehabilitation. Rehabilitation and mobility are important aspects to make everyone involved in society (WHO, 2018b).
ICF
The International Classification of Functioning, Disability and Health (ICF) is both a conceptual framework and a classification system developed by the World Health Organization. ICF provides a useful framework for monitoring and describing health outcomes and changes in health status from a biopsychosocial perspective . It is also a classification system that can be used as a tool to create a standard language when classifying functioning, disability and health on both individual and population level. In the classification
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system there are three different components; Body Functions Structures, Activity and Participation and Environmental Structures (WHO, 2002).
The conceptual framework is based on a biopsychosocial perspective, which is a combination of the medical and social aspects of a disability. It gives a multidimensional model of ICF by denoting the positive and negative aspects of funtioning and disability from a biological, individual and social perspective (WHO, 2013). When coding individuals according to ICF,the context is influenced by the characteristics of both the individual and the environment. The junction between individuals and activity might vary even when the individuals engage in the same activity (Lygnegård, 2018). BSP-ICF consists of nine components, shown in figure 1. Talo and Rytökoski (2016) describes that this version of doing a classification of the functioning and disability gives a better organized result (Talo & Rytökoski, 2016).
Figure 1: The difference between ICF and BPS-ICF (Talo & Rytökoski, 2016)
Within the ICF, human functioning is classified on three problem levels: the body, the whole person and the whole person in a social context (WHO, 2002). As such, the components of health can be classified under three domains shown in figure 2; body structure, body function, activities and participation. Within the ICF classification system, outcome measures can be conceived as falling along a continuum, from those addressing issues related to body structure and function to those addressing activity and participation (Salter et al., 2005).
ICF can be used at individual level, institutional level and social level. At the individual level ICF can help to evaluate a person’s level of functioning, for individual treatment planning, to evaluate treatment or other interventions and for interprofessional work within physicians, occupational therapists and other health workers. At the institutional level ICF can be used for example for training and education and for quality improvement and development. On the social level ICF can be used for; needs assessments, changes to social policy and definitions for anti-discrimination legislation (WHO, 2002).
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The purpose to use ICF for this MFS-thesis is to be able to create a common language to describe health and health related conditions at Piña Palmera. To get a result that is understandable between the different professions within the healthcare process but also social workers and the individuals with disabilities. This tool is used to describe and document disabilities in a way that different countries and different parts of the healthcare can take part of the result from this MFS-thesis. It is anticipated that this classification system will facilitate the possibility to compare and evaluate different treatments for future research. This can be used to assign goals, needs and follow up results (Socialstyrelsen, 2019).
Figure 2. Framework of International Classification of Functioning, by the World Health
Organization in 2001 (WHO, 2002).
To code according to ICF
The International Classification of Functioning, Disability and Health is based on several components with different domains based on four letters followed by up to five numbers. The letters are b for body functions,
s for body structures, d for activity and participation and e for environmental factors. Upon recomendation
from the Swedish National Board of Health and Welfare only the three digit catorizing is needed for a mapping (Socialstyrelsen, 2019). For example, mobility is d4 and walking is d450.
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Classification of the problem
The classification of the level of the problem is applied to the end of the code- For example a person who has a mild problem with walking is at level 1 and is coded d450.1 (Socialstyrelsen, 2015).
Code Level of problem Percentage affected
xxx.0 No problem 0-4% xxx.1 Mild problem 5-24% xxx.2 Moderate problem 25-49% xxx.3 Severe problem 50-95% xxx.4 Total problem 96-100% xxx.8 Not specified xxx.9 Not applicable
Figure 3. ICF-codes are used to do a classification of the level of the problem
Premise of thesis
Given that access to assistive technologies is severely limited at the Piña Palmera rehabilitation center, it is necessary for staff at the center to plan and prioritize how assistive technology services can be introduced and what specific devices can be provided. This will require training of staff in provision of assistive technologies and will also require access to materials and products.
As a first step in this process it is necessary to gain a clear understanding of the types of impairments that individuals attending the center have. Based upon the data from this MFS thesis, staff will be able to identify the specific impairments that would benefit from provision of assistive technologies and prioritize their delivery.
Aim
The aim of this thesis was to map the specific musculoskeletal impairments of individuals visiting Piña Palmera rehabilitation center in Mexico and to categorize them according to the International Classification of Functioning, Disability and Health to gain more knowledge about the level of problems within the four selected domains.
It is anticipated that the proposed MFS-thesis will facilitate planning for future assistive device service provision by providing staff with clear indication of the types of impairments that are most prevalent and could be managed with specific assistive devices.
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Method
This is a cross-sectional study that was conducted in accordance with the STROBE-guidelines (STROBE). The MFS-thesis took place in March 2020 in Zipolite, Mexico and was a study that included a survey and observations of the clients at Piña Palmera. Prior to the visit, Jönköping University staff members Nerrolyn Ramstrand and Ann Johansson have established a relationship with staff at this center. This project was conducted in collaboration with two Occupational Therapy students who were investigating the same patient population, but focusing on social inclusion.
Participants
Participants for the study were individuals at Piña Palmera Rehabilitation Center who have a physical impairment. The participants were selected by staff at the center to ensure that they were eligble for the study and did not have any cognitive impairment. There were five inclusion criterias to participate in the study, the individual...:
1. is a client receiving services from Piña Palmera.
2. answered “yes” to at least one of the questions on the screening survey. 3. is over the age of 18.
4. can understand written and spoken Spanish. 5. understand the aim and goals of the study.
Prior to the investigation a member of the staff asked for informed consent without the presence of the investigators.
Location
The study took place at Piña Palmera rehabilitation center. Staff at the center agreed to support the project and allowed access to their facilities. A registred physiotherapist agreed to supervise data collection.
Procedure
Screening Survey: Individuals who agreed to participate in the study were initially completing a screening survey consisting of 7 questions. The survey was translated to Spanish and reviewed by staff at Piña Palmera to ensure content validity. The screening survey is developed by Atijosan et.al (2007).
Questions included in the survey were:
1. Is any part of your body missing or misshapen? 2. Do you have any difficulty using your arms? 3. Do you have any difficulty using your legs?
4. Do you have any difficulty using any other part of your body? 5. Do you need a mobility aid or a prosthesis?
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If the answer is “yes” on any of the previous questions: 7. Has it lasted more than one month?
If a participant answered “yes” to any of questions 1-6 and “yes” on question 7, they were eligible to take part in the study (Atijosan, Kuper, Rischewski, Simms, & Lavy, 2007).
Genral information: The participant´s general demographic information was collected. Questions were developed for the purpose of this study and the questions were developed to be easy to answer. The answers to the questions included details related to the patients age, sex, whether they live in a rural or city setting, prior experiences with rehabilitation services and cause of their disability. The questions were translated into Spanish and the aswers were recorded with consent from the participants. The recordings were saved confidentially and were deleted when the data had been analyzed. The questions asked were the following:
How old are you?
Are you able to move independently? at you home
to a bus station or supermarket
Have you received any treatment to improve your mobility? in case of yes, when and what?
Do you have any assistive devices today? in case of yes, what?
Have you had any assistive devices earlier?
When do you feel that your physical health limits you the most? give an example of a situation
Do you experience any pain?
in case of yes, where or when? What setting do you live in?
if you live in a city, how big is the city?
Observational studies. The investigators were observing the participant in their every day life at Piña Palmera and when they visited the physioterapist to determinate the impact of the impairments. If possible the investigators were observing the severity of each impairment.
The investigators carefully documented:
• The part of the body affected and nature of impairment. • Aetiology (if known).
• Severity. A classification if the loss of function is mild (5-24% loss), moderate (25-49% loss) or severe (50-90% loss).
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ICF-codes
For this study the ICF coding tool was used to specify the problems related to four components: body function, body structures, environmental factors and activities and participation. The ICF tool was carefully read through and then different chapters were selected to fit the aim of this study.
To code body function the domains b2 and b7 were selected, the domain for b2 is ”sensory functions and pain”, this was used to determinate the impact of pain for the participants. the domain for b7 is ”neuromusculoskeletal and movement-related functions”. This was selected to determinate how the body factors affected the participants’ mobility.
To code body structures, the domains s1 and s7 was selected. The domain for s1 is ”structures of the nervous system”, this was selected to determine if the central nerve system was the cause of the participants mobility. The domain for s7 is ”structures related to movement”, this was selected to determine the affected area, upper extremity, lower extremity or additional specified musculoskeletal structures related to movement.
To code activities and participation, the domains d2 and d4 were selected. the domain for d2 is ”general tasks and demands” this was selected to determine if the participant could organize and carry through with a daily routine. The domain for d4 is ” mobility” and was selected to determine how the participant mobility affected their participation in daily life.
To code environmental factors, the domain e1 was selected. The domain e1 ”products and technology” was selected to determine if the participants had access to product and technology to improve their mobility on 3 levels. The levels were product and technology for personal use and daily living, product and technology for personal indoor and outdoor mobility and transportation and products and technology for employment (WHO, 2017).
Data analysis
On the recommendation of the Swedish National Board of Health and Welfare the instruction for using the ICF coding tool was carefully reviewed before the data collection (Socialstyrelsen, 2019).
The procedure for the data analysis was made in five steps. The first step is to decide which components were going to be used for this particular study. The second step was to train on how to use the codes. The training consisted of reading through the Swedish National Board of Health and Welfare´s instruction for using the ICF coding tool and going through the coding structure and coding rules. The third step was to independently code the data by levels 0-4 without discussion with the other investigator. Step four was to discuss the selected codes to see if agreements were made and when the investigators agreed to the codes the last step was to gather the codes and apply into an excel document for collection.
In a study by Cieza et al (2005), it has been recommnded not to use the classification of problem codes xxx.8 “non specified” or xxx.9 “not applicable” when linking health status to ICF. This
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recommendation is made to allow researchers to systematically compare concepts in the ICF coding tool. If the codes ”non specified” and ”not applicable” is used it prevents this from being comparable (Cieza et al., 2005). This recommendation was followed during the coding process.
All data collected were compiled into one document together with the ICF-codes and the participants were divided into three groups depending on the severity of their disability; mild, moderate or severe. The median of each ICF-domain were compared between these three groups to see if there were any differences, the range of the ICF-levels are reported to see the distribution of levels in each group.
Results for each participant were used to assign ICF codes detailing the specific types and severity of impairments experienced by each participant.
Descriptive statistics were used to identify types of musculoskeletal impairment, causes and diagnoses.
Based upon the results recommendations were made regarding prioritizing services and device provision.
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Ethical considerations
The investigators together with their supervisor have performed a self-review of ethical considerations by completing the form from the research ethics committee at School of Health and Welfare, Jönköping University. There were no doubts regarding the 21 different questions and everyone agreed on how all the principles would be handled.
Prior to the study all participants were provided with information that described the study, made it clear that their participation was voluntary and that their choice to participate or withdraw would not affect their healthcare or services provided by Piña Palmera. This information was provided by a physiotherapist in Spanish to avoid any misunderstandings. The physiotherapist asked to get informed consent from the participants without the investigators presence. All participants in the study were at the time of data collection attending Piña Palmera to receive services for their impairment.
It was not expected that the questions in the survey would create a feeling of discomfort, however to avoid this, participants were informed prior to the study that they did not have to answer any questions that would make them feel uncomfortable.
The answes from the survey were recorded with consent of the participant and reviewed by the investigators together with the interpreter to make sure all answers were correctly translated. Data collected were remaining confidential and names of participants was not recorded.
Since data was collected on a vulnerable group with musculoskeletal impairments extra precautions were taken. If any unexpected impairments were found during the study, the students were refering to the physiotherapist responsible for the individual’s rehabilitation, not the participant. It was not anticipated that the data collection would expose the participants to any risk of any harm either physical or psychological.
The invesigators got the information about each participants’ diagnosis from the physiotherapist at Piña Palmera.
When analysing the data the results were grouped and coded to numbers and it was thereby not possible to identify individuals. All information from the observations were used for the purpose of this MFS-thesis only. All data will be maintained on a password protected computer owned by the students. Upon completion of the study data will be archieved by the course co-ordinator.
Participants with cognitive difficulties were not included in the data collection. It was important that all the participants were able to understand all the conditions described above. To ensure this, the physiotherapist helped to choose participants who were eliglible for this MFS-thesis.
If any participant were expressing feelings of discomfort during the survey, the physiotherapist supervising the project was going to step in and assist. The physiotherapist could address the participants directly without any language barriers.
Precautions were taken not to suggest any assistive device or talk about the rehabilitation process in front of the participant. This could give false expectations of the aim of the study.
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Bias
Both surveys were translated into Spanish by an interpreter to make sure all the participants understood the study.
There was an interpreter present for all contacts between the investigators and the clients to avoid any misunderstandings.
The investigators are unexperienced in judging level of impairment (mild, moderate and severe) and had very little time to do this since they only met the participants once.
It is important to consider that some clients might be suffering from pain, odema and other swelling depending on day and time. This might not represent their avarage standard at the obervations.
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Result
The aim of this thesis was to map the musculoskeletal impairments of individuals visiting Piña Palmera rehabilitation center in Mexico and to apply the ICF classification system.
Participants
In this study 17 particiapants were included, nine women and eight men between 22 and 87 years of age (median: 44). All participants had musculoskeletal impairments, two were congenital, three due to an infection, six traumatic and six with different etiologies. These etiologies included: juvenile idiopathic arthritis, hemiparesis, rheumatoid arthritis, spinal disc herniation, scoliosis, and plantar fasciitis. The participants were divided into three groups depending on the severity of their musculoskeletal impairment, mild (n=7), moderate (n=5) and severe (n=5). In Appendix 1, all collected data is presented.
In table 1 the ICF-codes for each domain and the median level of problem for the three different groups of musculoskeletal impairments severities is presented. The level of problem is graded on a scale from 0 to 4 according to the ICF classification system. The range of each group´s lowest and highest level on that specific level and mean is also presented. The results for each group are summarized below.
Table 1: The median and range of each group and domain. The numbers show the level of problem
according to the ICF-levels. Level of problem for each code is graded on a scale ranging from 0 to 4.
MEDIAN RANGE ICF-code MILD LOSS OF FUNCTION MODERATE LOSS OF FUNCTION SEVERE LOSS OF FUNCTION MILD LOSS OF FUNCTION MODERATE LOSS OF FUNCTION SEVERE LOSS OF FUNCTION Body Functions Pain b280 2 2 3 (1-2) (0-3) (1-4)
Mobility of joint functions b710 1 1 3 (0-2) (0-2) (3-4)
Stability of joint functions b715 0 2 4 (0-1) (1-4) (3-4)
Muscle power functions b730 0 2 3 (0-2) (2-4) (2-4)
Muscle tone functions b735 0 0 0 (0-0) (0-4) (0-4)
Muscle endurance functions b740 1 3 3 (0-2) (2-4) (3-4)
Motor reflex functions b750 0 4 3 (0-0) (0-4) (1-4)
Involuntary movement reaction functions b755 0 0 0 (0-0) (0-0) (0-4) Control of voluntary movement functions b760 0 2 3 (0-1) (1-3) (0-4) Involuntary movement functions b765 0 0 0 (0-0) (0-0) (0-4)
Gait pattern functions b770 1 3 4 (0-1) (2-4) (3-4)
Body Structures
Structure of brain s110 0 0 0 (0-0) (0-3) (0-4)
Spinal cord and related structures s120 0 2 0 (0-2) (0-4) (0-0)
Structure of upper extremity s730 0 0 3 (0-2) (0-3) (0-4)
Structure of lower extremity s750 1 3 4 (0-2) (0-4) (3-4)
Additional musculoskeletal structures related to movement s770 1 0 4 (1-2) (0-3) (4-4)
Activities and Participation
Carrying out daily routine d230 1 1 3 (0-2) (0-1) (2-4)
Changing basic body position d410 0 1 4 (0-1) (0-2) (2-4)
Transfering oneself d420 1 3 4 (0-1) (1-4) (2-4)
Lifting and carrying objects d430 0 3 3 (0-2) (0-3) (2-4)
Fine hand use d440 0 0 3 (0-0) (0-0) (0-4)
Hand and arm use d445 0 0 3 (0-0) (0-0) (0-3)
Walking d450 1 3 4 (0-2) (3-4) (3-4)
Moving around d455 1 2 3 (1-2) (1-3) (2-4)
Moving around in different locations d460 1 3 4 (1-2) (3-4) (3-4) Moving around using different equipment d465 1 4 4 (1-2) (3-4) (4-4)
Environmental factors
Products and technology for personal use in daily living e115 0 0 2 (0-0) (0-2) (0-4) Products and technology for personal mobility and transportation e120 0 1 1 (0-0) (0-3) (0-3) Products and technology for employment e135 0 0 0 (0-0) (0-0) (0-4)
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Mild loss of function
There is a total of seven participants represented in this group (n=7). The participants in group ”mild” all had different impairments but no impairment which could not be treatable was found. The participants had the following impairments; plantar faciitis, scoliosis, overstrain of knee, shortness of akilles tendon, spinal disc hernaition, undiagnosed backpain and whiplash. This group had the lowest level of problem in all domains of the five investigated levels (0-4). In all the domains except b280 pain, the median was either 0 or 1, which shows that the participants had 0=no problem to 1=mild problem in their daily life.
When it comes to range, the group with mild severity had a narrow range on almost all the investigated domains, the widest range was three. In table 1, it shows that the range had relative low levels (less than 0-2) compared to the other groups. This shows that the participants within this group had similar levels of problems.
Moderate loss of function
In the group where the participants were classified with moderate severity there was a total of five participants (n=5). The majority of these participants had the same diagnosis. The participants in this group had the following impairments; postpolio (n=3), spinal cord injury and lumbago. All the participants in this group only had problems in the lower extremity. In this group the highest problem level was 4, this applies to b.750 motor reflex functions and d.465 moving around using different equipment. The domains in the component “body functions” which had the highest levels were b740 muscle endurance functions, b750 and b770 gait pattern functions with the median level 3 and the domain for motor reflex functions, with the median level 4.
Within the domain Activity and Participation, the highest problems levels were found for the domains; d420 transferring yourself, d430 lifting and carrying objects and d460 moving around in different locations with the median of 3 and d465 moving around using different equipment which had a median of 4. This was higher levels compared to the group with mild loss of function.
When it comes to range, the group with moderate severity had a wider range compared to the group with mild severity on almost all the investigated domains. The widest range was five. In table 1, it shows that the range was wider when it comes to the domains for body structures. In the component for activities and participation, the range was narrower compared to the other components for this group, but the levels were higher. This shows that this group had similar levels of problems when it comes to activities and participation.
Severe loss of function
In the group classified as severe there were a total of five participants (n=5). In this group all of the participants had different impairments. The impairments were; juvenil idiopatic arthritis, cerebral palsy, rheumatoid arthritis, hip disarticulation amputation and hemiparesis. This was the group which had the highest levels within all the four different components. Of the three different severity groups, this group
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was the one which experienced most pain with the median of 3 on level of problem, which gives the ICF-code b280.3 = severe problem with pain. All participants except for one had problems in both upper and lower extremity. In the body function component there were two domains which had the median of 4 on level of problem, b715 stability of joint functions and b770 gait pattern functions. This group also had high levels on all domains under the activities and participation component. The activities and participation component was the most affected.
Three of the patients in this group had issues with contractions in their joints. The contractions were affecting joints in the arms, hands, rotator cuff, hips, knees and ankle joint due to the diseases cerebral palsy and rheumatoid arthritis. One of the participants in this group was bilateral amputated through the pelvic bone. This participant had a spinal cord injury that caused complete loss of motor function bilateral in the legs prior to the amputation.
The range for this group is wider compared to the other groups. Several of the investigated domains have a range between 0-4. This shows that the severe group represents high and low levels on almost every domain. The median shows that the participants in this group have high levels even though the range is wide.
Table 2 shows the mean for the four components in the International Classification of Functioning, Disability and Health. The purpose of the table is to see which one of the components that are most affected. In this case “Activities & Participation” is the most affected component for all the groups. The table gives an overview of the difference in the mean for the three groups and if one group have higher level on a specific component.
Table 2: The mean of all domains under each ICF-component for the three groups.
Mild Moderate Severe
Body Functions 0,5 1,7 2,5
Body Structures 0,6 1,3 2,4
Activities & Participation 0,7 2,0 3,4
Enviromental Factors 0,0 0,5 1,5
All but one of the participants, were in need of assistive devices. Seven of the participants already had an assistive device, for example a wheelchair, canes or orthoses. 13 of the participants had recieved treatment prior to this study. Treatment in this case included physical therapy and drugs. Seven of the participants were in need of more than one assistive device.
The participant who had no possibility to increase the mobility with the help of an assistive device is the participant with sciatica due to spinal disc herniation.
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Discussion
This study was conducted at Piña Palmera Rehabilitation Center in Zipolite, Mexico, during March 2020. The aim of this thesis was to map the musculoskeletal impairments of people visiting Piña Palmera rehabilitation center in Mexico and to apply the ICF classification system to gain more knowledge about the level of problems within the four selected domains, which was fulfilled.
Result
The result of this MFS-thesis gives an overview of specific musculoskeletal impairments experienced by adults with physical disabilities at Piña Palmera. Coding individuals according to ICF was done successfully.
The range of the ICF-problem levels in table 1 show that there was a variation between the participants within the same group. For example, the domain b760, the median level for the different groups were 0, 2 and 3, but the range was 0-1 for mild, 1-3 for moderate and 0-4 for the severe group. This shows that even though the median was high for the severe group, there were at least one participant that had a 0=no problem, with the function to control voluntary movements, but most of the participants in that group had high levels, since the median is 3.
Components
Body Functions
In the component ”body functions” data was collected during observations and the component consisted of eleven domains. These eleven domains were chosen to fit the aim of the study. One of the domains which was extra important was domain b.280 pain. The reason why this one was considered as important was that if the participants experienced pain in any part of their body it might affect the other components. One example is the ability to walk. If the participant experienced pain while walking it would be the primary focus in their rehabilitation and from our perspective, and possible assistive devices that could help to ease the pain. Since pain can provide a protective mechanism of changes in movement patterns, it is important to ensure that the individuals are as pain-free as possible (Hodges & Smeets, 2015). There were only two participants who were given the highest level of the problem classification scale, 4 on this specific domain. These participants were diagnosed with rheumatoid arthritis and had wheelchairs and canes to facilitate mobility when experiencing pain in the affected joints. Only one participant did not experience any pain at all, this participant was diagnosed post-polio and was grouped in “moderate loss of function”. As seen in table 1, the groups with mild and moderate loss of function both had the median 2 in domain for pain, which gave the ICF-code b280.2 moderate problem with pain. Another domain that stands out in the component “Body Functions” was b770 gait pattern functions. According to table 1, the group with severe loss of function have the median 4, which gave the ICF-code b770.4 total problem with gait pattern functions (range: 3-4) which means that most of the participants did not have a gait pattern at all, there was only one participant that was able to walk a very short distance with support. It was easy to see on which level of
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problem to code this domain since the observations of the participants were made during their work at Piña Palmera or when they visited the physiotherapy.
In the domain b750, motor reflex functions, the group with moderate loss of function had a higher median level of disability than the group with severe loss of function. This was due to that three of the participants in the moderate group were diagnosed with post-polio and did not have the motor reflex function in their lower extremity. The other two participants in this group had a spinal cord injury and lumbago which had affected their motor reflex functions. In the group with severe loss of function all the participants had problems with their motor reflex functions. Therefore, the group with moderate loss of function had a higher median level on that specific domain and the range was wider. The three domains b735 muscle tonus functions, b740 muscle endurance functions and b750 motor reflex functions were hard to code since they only were investigated during observations. The other domains in this component were easier to code since they were more distinct to distinguish during observations or could be found in the survey.
Body Structures
The component for body structures is the component where the coding represents which structure of the body that is affected. It was decided to collect data about the impairments that caused the biggest problem if a participant had several impairments.
Two of the participants had the level 4 on domain s110, which gave the ICF-code s110.4 total problem with structures of the brain. These individuals had cerebral palsy and stroke and had also high levels on s750 lower extremity and s730 upper extremity since the whole body was affected due to the brain injury. The two participants with rheumatoid arthritis had high problem levels level at both upper and lower extremity, at level 3 and 4. Five of the participants had impairments that were connected to the spinal cord, s120 spinal cord and related structures. These problems were classified as level 2, 3 and 4 and were due to post-polio and spinal cord injury and affected the lower extremity. The remaining participants who had problems with upper extremity were due to lumbago, scoliosis and whiplash.
In table 1 it can be seen that the participants which had problems in only the lower extremity were participants in the mild loss of function group except for the participant who was amputated through the pelvic bone. These participants had the impairments plantar fasciitis, overstrain of knee and shortness of triceps-surae tendon.
Activities and Participation
The result shows that this component had the highest level of problem level of all the groups. This component tells how the impairments affect the daily life for the participants for example, d230 carrying out a daily routine.
This component includes fine motor skills for example d440 fine hand use and gross motor skills, for example d430 carrying and lifting objects. The remaining domains build on each other, from d455 moving around, d460 moving around in different locations and d465 moving around using different
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equipment. All the participants had either the same level in these three specific domains or added one level for each domain. This result was expected since moving around is the first step. If an individual has problems with this domain, it can be anticipated that the individual will have problems in moving around in different locations and using different equipment too. The domain d465 moving around using different equipment refers to being unlimited. For example, using diving equipment and dive or using skiing equipment while being able to ski (WHO, 2017).
This domain and the result of the survey may not only be due to the participants impairment, the access and poverty most likely have crucial role. According to Propper et al (2007) individuals living in rural settings travel almost twice as far to get healthcare (Propper, Damiani, Leckie, & Dixon, 2007). This was not something that was studied in this MFS-thesis, only the possibilities due to the individual’s impairments were investigated.
Environmental factors
The environmental factors were limited to only include the domains related to products and technology. This was of interest since it was the access to assistive devices that were investigated.
The access to assistive devices were experienced to be very limited for the three investigated domains. This limited access seemed to be related to the fact that many of the individuals did not have knowledge about how or where to get assistive devices or even that there are assistive devices that could help to improve their mobility. The individuals who had assistive devices had paid for the devices by themselves, which could lead to an economical burden for these individuals. Some of the participants did not have the economy to be able to access assistive devices. This might be the reason why eleven of the participants were categorized with 0 level of problem, as in no problem at all, since they did not have an assistive device. Mexico is the eleventh largest economy in the world (Bank, 2020) but the situation in the rural settings did not show any signs of this. A lot of the families in the rural areas lived in poverty.
One of the reasons for how the participants in this MFS-thesis knew about Piña Palmera Rehabilitation Center were due to the reputation and that the services the center provided were the only one they could access. Even if the individuals had access to assistive devices, they might not be able to use them since the villages are not adapted, for example, entrances were not wide enough or had high steps, which is one of the most common barriers for people with wheelchair (Welage & Liu, 2011). The participants who already had assistive devices have borrowed them from the center except for one participant who had paid an orthotist to do individual manufactured ankle-foot-orthoses.
The center worked to adapt the assistive devices to help the individuals increase mobility with the assets at the center. They had a building called ”Carpinteria” which was a small joinery where the workers built tilting boards, standing shells for the kids and special chairs to use in the showers. One of the participants with no mobility in the legs had an assistive device for employment from the joinery. This was a tilting board which worked in a way that the individual could lay on the stomach and use the hands freely which is a more ergonomic working setting compare to sitting in the wheelchair and lean forwards.
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The group with severe loss of function was the group who had the highest levels of problems under this component, because they had major problems with their mobility.
Methodological discussion
Sample
The investigators wanted to observe and conduct a survey of a representative part of the clients that have received rehabilitation services at Piña Palmera. There were both individuals who lived at the center and are provided care 24 hours per day and individuals visiting the center to receive rehabilitation services every week. Each month there are around 60 individuals visiting the physiotherapy. Not all of them were eligible for the study due to the inclusion criteria since individuals under the age of 18 and individuals with cognitive impairment were excluded. The physiotherapist asked the eligible individuals for consent and if they wanted to participate, none of the individuals who were asked said no. Every individual that agreed to participate met the conditions in the first screening with the seven questions.
The size of the sample were 17 participants. The investigators were supposed to stay at the center for eight weeks in total, but due to extraordinary circumstances with covid-19 the stay had to be shortened by four weeks. If the stay would have lasted the full eight-week period, the sample would most likely have been bigger, and it would then have been possible to do a more specific description of the musculoskeletal impairments for the individuals that receive rehabilitation at Piña Palmera. In order to do a mapping, it is important that a representative part of the total population is represented. The investigators are aware that the sample size might not fulfill this, but still think that 17 participants are enough to get an overview of which types of musculoskeletal impairments that are more common and what kind of treatment the center have the resources to provide.
Consent
Prior to the study, the investigators prepared a written consent form which was not used due to cultural reasons upon recommendation from the staff at Piña Palmera. Instead a verbal consent was provided by the physiotherapist in charge. The physiotherapist was local and could address the participants without any language barriers. This was done without the presence of the investigators; it was important from a socio-cultural and ethical view. Due to the socio-cultural differences and language barriers it is not sure if the participants were to expect something in return by signing a form. To sign a form in oppressive regimes can be problematic and, in some cases, dangerous. It is preferred to give verbal consent, that has been witnessed and verified , and not written consent when conducting a study in developing countries (Shapiro & Meslin, 2001).
Data collection
The questions for the survey were translated to Spanish by the interpreter and the survey session were recorded. Every participant was asked for consent before the recording started. The participants were asked
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for consent to be observed to collect data which were going to be used in the study and consent to record the conversation. The recordings facilitated the possibility to go through the answers again later to make sure the answers were correctly understood.
To collect background information about the participants eight questions were developed for the purpose of this study. The questions were developed in a way to make it easy and quick to answer. No open-ended questions and no questions that could be misunderstood. The age and living setting were collected to be able to compare data during the data analysis. It was of interest for the investigators if the living situation could affect the impairment. This however did not seem to affect the collected data. All the participants lived in a rural setting or in smaller cities.
To be able to collect data about activities and participation, questions about if the participants were able to move in their home, to the supermarket and to the public transport were asked. Activities and
participation was the component where most of the participants had problems. The participants were also
asked to give an example of a specific situation when they experienced that the physical health was a limit in the daily life.
Questions about earlier treatments to increase mobility were also asked. This was to investigate the access to healthcare in the area. The majority (n=15) of the participants had not received earlier treatment except from physiotherapy, four of the participants had their first experience with physiotherapy when data was collected.
It was also of interest to investigate if the participants had received assistive devices, which only one of the participants had. The participant who had customized assistive devices was a participant with post-polio. This participant had two ankle-foot-orthoses with the purpose to stabilize the ankle joint while walking. It is important to note that not all the participants had this opportunity. Both economic and environmental factors will affect this opportunity.
The last question of the survey was about pain and if the participants experienced pain, where and when. This was important for this study since pain can have a big effect on other investigated domains. When an individual is experiencing pain, it can prevent them from participating in daily life activities. It was also of interest for the investigators to look into if the pain could have been prevented with assistive devices.
Access to rehabilitation
The rehabilitation center was the only one providing these types of services within a radio of five hours which lead to a variety of disabilities being represented. The center was known in the area for rehabilitation and habilitation for kids. For many of the people that visited Piña Palmera it was their first experience with healthcare. It became clear that the majority of the individuals were not aware what the cause of their disability was. The access of healthcare is a major problem in Mexico both from a economical and accessibility point of view (Clark et al., 2018). For several of the individuals who were visiting the center,
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the progression of their disabilities could have been prevented by having access to appropriate treatment earlier.
Data analysis
To analyze the data, the participants impairments were categorized according to the International Classification of Functioning, Disability and Health. There was no participant coded with level eight or nine, due to the recommendation from the study of Cieza et al. This did ease the data analysis since every code from each participant could be used. The document by WHO about how to code according to ICF were read through carefully and 29 domains that could be appropriate for this study were chosen. It was important that the domains were applicable on the participants.
All the domains were of importance to get a reliable result, but especially the domains: b280 pain, d230 carrying out daily routine, d420 transferring oneself, d450 walking, d460 moving around in different locations, e115 products and technology for personal use in daily living and e120 products and technology for personal mobility and transportation. These domains were important since they gave an easily understandable overview with information of how each participant´s mobility of the whole body was. This also shows if the participants were in need of any assistive devices. How an individual walk or move oneself gives information about muscle strength and range of motion in the joints. The observations in the participants everyday life also gave information about if or what kind of obstacles they experience and if it would have been possible to solve them with an assistive device.
Assistive devices
It was considered that 16 of the participants were in need of an assistive device to improve their mobility since everyone (n=17) had the ICF-code d455.1 or a higher problem level on that domain. This means that they have a mild or higher problem level with moving around without help. The participant who most likely will not improve the mobility with an assistive device was the participant with sciatica due to spinal disc herniation. 16 participants had level 1 or higher at d.450, walking. The one participant with level 0 had a whiplash-injury.
Multiple of the participants would increase their mobility with an assistive device like an orthosis. Since their impairment limits their ability to walk or move around, an orthosis could for example stabilize the ankle joint for the individuals that have problem with instability in their feet.
It is anticipated that assistive devices like orthoses or corsets could help multiple of the participants, since their impairment limits their ability to walk or move around. For example, the participants with post-polio have the problem with instability in their ankle joint while standing. If they would have an orthosis that stabilize the ankle joint, they might feel more secure which can improve their gait pattern.
Nine of the participants expressed that their biggest physical limitation was moving outside their homes, which might be due to environmental factors. In the rural settings, where seven of the participants
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lived, they might not have the same possibilities to adapt to the community in the same way as they have in the cities. In Zipolite, the town where the MFS-thesis data collection was conducted, the supermarkets and public transport were not adapted for wheelchairs.
For some participants a customized wheelchair would be a better option than orthoses or canes to ease the pain while walking. It was not anticipated that orthoses would relieve all the pain. In a rural setting assistive device could become a problem when the individuals wanted to move outside their homes since the environmental setting might not be adapted to this.
Table 4 shows the proposed primary need of orthopedic devices among the participants. This is only a proposed solution for each specific impairment. Some of the participant were in need of more than one assistive devices. The proposed solution does not require that the specific device was appropriate for the individual.To be able to know that, more background information and a physical assessment would be needed. One of the participants were in need of insoles. It was not precluded that insoles could increase the mobility and relieve pain for other participants, but that will need further assessments.
Table 4: The need of different devices.
Affected structure Proposed solution Quantity
Lower back Corset 4
Neck Neck stabilization orthosis 1
Ankle AFO 7
Ankle + knee KAFO 4
Knee KO 2
Contraction in joints AFO/HAND ORTHOSES/KO 3
Foot INSOLES >1
Hip disarticulation PROSTHETIC LEGS OR ADAPTED
CUSION FOR WHEELCHAIR
1
There might be other assistive devices that would be more appropriate for each individual, for example the participant with bilateral hip disarticulation. This participant was bilateral amputated through the pelvic bone and could be in need of prosthetic legs, but it was not anticipated that it would improve the mobility since learning to handle prosthetic legs would be a major engagement. This participant had a spinal cord injury that caused complete loss of motor function bilateral in the legs prior to the amputation, which could have affected the muscles needed for walking with hip disarticulation prosthetics. Even if the participant would had the muscle function that was needed, it is important to keep in mind that high level amputees have the greatest rejection rate among prosthetics user (Van der Waarde, 1984). It could possibly have been more useful to have a wheelchair and customize a cushion that suited the participant. This reasoning is applicable to other contexts. The healthcare in Sweden and other developed countries would most likely
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have provided individuals in similar cases with a customized cushion instead. A customized cushion for a wheelchair is supposed to provide even pressure and support for an individual who sits down in their chair during the whole day.
Another example was the participants with lower back pain. The underlying reason might be something else that would not be relieved by a corset, for example different length of the legs or misalignment in the foot. This displayed the importance of having background information about each individual before giving them an assistive device.
The possibilities to help participants to increase their mobility with orthoses were good, for example with prefabricated orthoses. This was a proposed solution due to economic and temporal reasons since the orthoses do not need to be manufactured individually. The prefabricated orthoses can be adjusted to fit individuals with specific needs.
The participant whose mobility could not be increased with assistive devices had sciatica, due to spinal disc herniation. Sciatica is a symptom which causes nerve pain which extends from the buttock down in the legs (Ropper & Zafonte, 2015). The current treatment for sciatica is prescription of drugs and neurosurgery (Koes, van Tulder, & Peul, 2007).
Purpose with recommended assistive devices
The aim with these specific devices was to help the individuals to improve the functions in the joints with stabilization or to help stretch the muscles. Four of the participants were in need of a corset, the function with the corset is to stabilize and relieve the spine to ease the backpain. The participants in need of AFO, KO or KAFO needed the function to stabilize the knee- and/or ankle joint or to prevent contractions in these joints. The three participants that were in need of hand orthoses all have problems with contractions. The main purpose of the orthoses to those individuals was to prevent progression of the contraction. At least one of the participants were in need of insoles, but since no assessments were conducted on the participants, it is not known exactly which specific functions the insoles should have, this demands further assessments.
Importance of introducing assistive devices
Conditions were experienced, for example cerebral palsy, where the progression of contractions could have been prevented earlier by orthoses or stretching. Stretching is a tool that is used to treat and prevent contractures (Katalinic, Harvey, & Herbert, 2011). AFO, hand orthoses and orthopedic shoes are examples of assistive devices that could help to prevented progression of contractions. Several of the participants could have improved their mobility if they had had access to treatment earlier. A study conducted by Farmer et al. (2005) has shown that individuals with contractions due to neurological conditions can improve range of motion in the joints by the use of a dynamic orthosis (Farmer, Woollam, Patrick, Roberts, & Bromwich, 2005). There is also research that states that joints that already are affected by contractures can be treated to reverse some of the contractions. Ghai et al. (2013) describes in their study that splints can improve the range of motion in joints which already are affected by contractions (Ghai, Garg, Hooda, & Gupta, 2013). These findings strengthen the recommendation of orthoses to these specific individuals. If these
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participants had gotten the right treatment earlier, the range of motion in the affected joints could have been wider, which could have increased their mobility. It is important to prevent further deterioration which could lead to pain and less mobility.
A study by Terjesen et al (2000) states that progression of the misalignment of the spine is 4.2 degrees per year in individuals with scoliosis (Terjesen, Lange, & Steen, 2000). If the participants with scoliosis had had access to the right assistive devices it could have prevented the progression.
Lack of earlier research
In the area where this MFS-thesis took place there is a lack of earlier research. Borg, J., Lindström, A., & Larsson, S. (2009) have described in their study from 2009 that there is little to no academic knowledge on assistive technology in the developing country context (Borg et al., 2009). This is something that was experienced while searching for academic articles to collect background information and compare this result with earlier research. The knowledge about assistive technologies would be of interest to investigate furthermore in the developing country context. During this minor field study, it was experienced that the participants had little knowledge about their conditions and where to get help, if even possible. There was no opportunity to ask the participants about their experienced of access to healthcare. It would have been interesting to investigate the main reason why individuals do not seek healthcare in a developing country context whether it is because of the lack of access, knowledge, economy or something else.
Is there a need of prosthetists and orthotists at Piña Palmera?
We stayed at Piña Palmera rehabilitation center for a month. At the center we worked together with occupational therapist students, physiotherapists and the individuals with musculoskeletal impairments among other volunteers. It is learned that in Mexico, since there was a very limited access to professions like prosthetists and orthotists, the physiotherapist and occupational therapist are manufacturing all the assistive devices. These professions had knowledge in the same area but not as specified as a prosthetists and orthotists and from our experiences we think that the center could benefit from having a prosthetists and orthotists in place.
The results from this study can help the staff at Piña Palmera Rehabilitation Center to get information about the prevalence of the musculoskeletal impairments among the individual that the center provides care for, but also how they can be provided with specific assistive devices that can be provided at Piña Palmera. In a rural setting like where Piña Palmera is located at, there are many opportunities to create assistive devices, but it demands creativity.
