ISPO Short Course on the Orthotic and Therapeutic Management of Patients with Stroke Process Report Venue and Date Theoretical sessions held on 15th& 16thJanuary 2013 at Sri Lanka Foundation, 100, Independence Square, Colombo 07. Practical sessions held on 17thJanuary 2013 at Sri Lanka School of Prosthetics and Orthotics (SLSPO), P.O. Box 37, Ragama, Sri Lanka 1 Table of contents: Contents Background: ............................................................................................................................................ 5 Objective: ................................................................................................................................................ 5 Day I: ....................................................................................................................................................... 5 Inauguration:....................................................................................................................................... 6 Mr. Gilles Nouzies ........................................................................................................................... 6 Presentations ...................................................................................................................................... 7 Hans Arendzen (Doctor, ISPO) presented “Stroke: epidemiology, symptoms, causes and current medical care”: ................................................................................................................................. 7 Dr. Padma Guneratne ..................................................................................................................... 7 Dr. Munidasa ................................................................................................................................... 8 Liz Condie on “orthotic management and related therapies after stroke; what is the evidence?” ........................................................................................................................................................ 8 Prof. Hans – Movement disorders in neurological diseases of central origin: spasticity & tone ... 9 Roy Bowers (Orthotist, ISPO) presented Biomechanics of Normal and Stroke gait: ...................... 9 Mark Smith (PT, ISPO) - Early post-stroke therapy, physical assessment, aims, treatment ......... 10 Judy Ranka (OT, ISPO) - Occupational Therapy: Functional Capacity assessment, aims and treatment ...................................................................................................................................... 10 Dr. Padma Gunaratne (consultant neurologist, National Hospital of Sri Lanka) presented organization and structure of Stroke rehabilitation services in Sri Lanka. ................................... 11 2nd day: .................................................................................................................................................. 11 Presentations .................................................................................................................................... 11 Roy Bowers: Principles of lower limb orthotics – Benefits of AFOs: ............................................ 11 Prof. Hans - Botulinum Toxin, other medical management and surgery ..................................... 12 Mark Smith & Judy Ranka - Shoulder, upper limb and hand therapy: ......................................... 12 Judy Ranka: Ongoing community rehabilitation and self-care ..................................................... 12 Mark Smith– physical fitness training and self care ..................................................................... 13 V. Sasiraj, chief physio: Therapy for stroke patients in Sri Lanka ................................................. 13 Lasanthi Siriwardana – OT for patients with Stroke ..................................................................... 13 Mr. Mihiran – orthotic management of patients with Stroke in Sri Lanka ................................... 14 Liz Condie– outcome measures in Stroke Rehab: ......................................................................... 14 Roy Bowers: Structure of Best practice statement ....................................................................... 14 All faculties - Round table discussion “The future – possible changes to stroke services in Sri Lanka” ............................................................................................................................................... 14 Course evaluation feedback.............................................................................................................. 16 The most common responses are clubbed together as below for each questions. ............................ 16 Will you make any changes to the way you work (after the training), and if so how? ..................... 16 Have you learnt something new which you would like to practice in your set up, if so how? ......... 17 The International Society for Prosthetics and Orthotics (ISPO)............................................................ 17 Handicap International (HI) .................................................................................................................. 18 Annexure: .............................................................................................................................................. 18 Course Programme ........................................................................................................................... 18 Profiles of resource persons ............................................................................................................. 21 Pre/Post test ..................................................................................................................................... 24 Acronyms: HI – Handicap International ISPO – International Society for Prosthetics and Orthotics MoH – Ministry of Health MoSS – Ministry of Social Services LRH – lady Ridgway Hospital OT - Occupational Therapist/Occupational Therapy P&O – Prosthetist and Orthotist/Prosthetics and Orthotics PT – Physiotherapist/Physiotherapy RRH – Rehabilitation and Rheumatology Hospital, Ragama SLAPO - Sri Lanka Association for Prosthetics and Orthotics SLOT - Sri Lanka Association of Occupational Therapists SLSOT - Sri Lanka Society of Occupational Therapists SLSP - Sri Lanka Society of Physiotherapy SLSPO – Sri Lanka School of Prosthetics and Orthotics THB – Teaching Hospital Batticaloa Background: Handicap International Sri Lanka, in consultation with the Sri Lanka Association for Prosthetics and Orthotics (SLAPO), Sri Lanka Society for Physiotherapy (SLSP) , Sri Lanka Society for Occupational Therapy (SLSOT) and the International Society for Prosthetics and Orthotics (ISPO), organized the Short Course “ Orthotic and Therapeutic Management of Patients with Stroke”. The course was partly funded under Europe Aid and USAID. The course organized through international and national faculties to improve the technical skills and theoretical knowledge of the professionals working with patients with stroke in order to provide better quality treatment in the country. This occasion also brought together professionals and gave an opportunity to strengthen the multidisciplinary practice in the physical rehabilitation sector of Sri Lanka. The short course Organised by Handicap International Sri Lanka and International Society for Prosthetics and Orthotics (ISPO) with active collaboration with Ministry of Health - Government of Sri Lanka Sri Lanka Association for Prosthetics and Orthotics (SLAPO) Sri Lanka Society of Physiotherapy (SLSP) Sri Lanka Association of Occupational Therapists Sri Lanka Society of Occupational Therapists (SLSOT) and Sri Lanka School of Prosthetics and Orthotics(SLSPO) Objective: The objective of the course was to improve the technical (clinical) skills and theoretical knowledge of the professionals (PT, OT, PO, Doctors) on evidence based management of stroke towards the multidisciplinary practice in the physical rehabilitation sector in Sri Lanka and the region. Day I: Registration of participants: Participants received resource kit containing manual of all presentation to be used in training and pen, writing pad, name badge. They have been asked to verify their correct names on registration sheet as these names had to appear in certificates. Inauguration: Ms. Tiruni (communication coordinator, HI-Sri Lanka) welcomed the guests and participants. She invited all dignitaries to light the lamp to formally inaugurate the training. After lighting of lamp, dignitaries and guests shared the dais. Mr. Gilles Nouzies (Director, Handicap International-Sri Lanka) during inaugural address welcomed the organisers, funders and participants and said, ““In Sri Lanka since Picture 1: Mr. Gilles, Director, Handicap International Sri Lanka addressing the participants during inauguration 2004, we have placed much emphasis on physical rehabilitation services and better inclusion of persons with disabilities in society. We are supporting the creation or development of P&O clinics and rehabilitation departments in various hospitals. Training sessions such as this are our part of commitment to support the ministry of health as well as the professional associations and civil society to develop the quality of rehabilitation services available in the country. Stroke is becoming one of the leading causes of adult disability in Sri Lanka; as 1 out of 110 people suffer from Stroke each year. Several decades of scientific research show that physical rehabilitation is responsible for most of the recovery experience by patients. This course will prepare you to better deal with Stroke consequences through interdisciplinary approaches and finally contributing to better care of patients with Stroke. I wish all of you a very quality learning sessions and would like to conclude thanking the resource persons who have come from all around the world and from Sri Lanka to make this short course success”. Following which Dr. Liz Condie (Course Co-ordinator/Task officer for stroke, ISPO) presented a brief outline of ISPO short course, about ISPO and its presence, structure, mission, vision. Few excerpts of presentation included; ISPO is truly multidisciplinary, it involved in academic courses, publishes works and documents. ISPO is working globally with more than 40 member societies. She introduced the team of ISPO resource persons and stressed on research based evidences as core of the course. She welcomed and thanked all. She appreciated the excellent organisation of course in Sri Lanka. The inaugural session concluded with the thanks note by Mr. Yuban Malla (Programme Manager, HI-Sri Lanka). He extended gratitude to all organisers, trainers and participants. He also thanked and appreciated Mr. Kithsiri Liyanage, Mr. Subhabrata Samal and other HI team members for their determination and endeavour in organising training so well. Picture 2: Mr. Yuban delivering thanks note Presentations Hans presented symptoms, medical care”: Arendzen (Doctor, ISPO) “Stroke: epidemiology, causes and current Prof. Hans presented the global picture of stroke as it is the single biggest cause of disability in UK, further noted that, treating hypertension can reduce the risk of a stroke by up to 40%. It is estimated that stroke is the third highest1 cause of pre mature deaths as per the government statistics in 2010 in Sri Lanka and the non communicable diseases are accountable to 65% of all deaths. He also discussed risk factors of stroke and symptoms of stroke. He explained treatment phases (Acute, rehabilitation and care). Further elaborating the rehabilitation section, he broke the rehabilitation treatment process in to three steps as mobilisation, speech and communication followed by motion therapy. He also elaborated on early supported discharge (home care) and after care (consulting/advice). He concluded by saying exercise programme do benefit the patients with stroke. Dr. Padma Guneratne “epidemiology and medical management in Sri Lanka” Dr. Padma Gunaratne (Consultant Neurologist, Sri Lanka) and president, National Association of Stroke started with a case study on differential diagnosis (sudden onset) of stroke and the extent of recovery of personnel affected by stroke followed by discussed about the pathological classification of stroke (Infarctions, haemorrhages) and described epidemiology as; stroke prevalence is more in men (Male/female- 2:1), 25% of stroke occur in less than 65 years of age, higher incidence in lower socio economic category, prevalence to be 1% in Sri Lanka2. The clinical protocol and common practices for investigations of patients with stroke at National Hospital, Colombo in Sri Lanka is explained during the session. She further gave an overview on medical (treatment) management of Stroke and also discussed the prognosis of stroke. 1 Global burden of diseases, injuries, and risk factors study- 2010; Sri Lanka. 2 Epidemiology of stroke in the districts of Colombo, Sri Lanka Dr. Munidasa, Consultant, Rheumatologist and Medical Rehabilitation, RRH, Ragama presented “Rehabilitation of stroke in Sri Lanka”. He introduced the current infrastructure to deal with stroke in the country (like number of stroke units, facilities in teaching hospitals, HR structure etc). He also shared that majority of teaching, general and base hospitals have PTs/OTs. It is proposed that each province (9) should have one stroke rehabilitation unit, though at the moment Sri Lanka has 5 rehabilitation Hospitals dedicated to medium term and long term rehabilitation care. The criteria for admission to a stroke rehabilitation unit mentioned and Dr. Munidasa shared the deficiencies in the rehabilitation hospitals mainly due to poor awareness among clinicians to refer to the rehabilitation hospitals. The patients go back to the community during the acute phase which results to clients’ reliance on traditional treatment. Limited access to transport, built environment, income generation, poor utilisation of social service schemes by stroke clients are mentioned to be among the major barriers for stroke rehabilitation in Sri Lanka. Post this session, a panel discussion on all above sessions was organised. Few important questions posed by participants and ISPO team were raised to be taken care by the professionals/Ministry for better care of the patients with sroke: Do the hospitals have psychologists to deal with post stroke mental health? Is pain considered an issue in stroke patients’ management in Sri Lanka? What efforts do the Government of Sri Lanka makes on patients with stroke, who loss of their livelihoods? In which phase of treatment do P&Os get involved in Sri Lanka? Liz Condie on “orthotic management and related therapies after stroke; what is the evidence?” She shared about ISPO consensus conference on “orthotic management of stroke patients” held in September, 2003 in Netherlands. The objective of the consensus conference was to review the existing literature and evidence based practice, identify gaps, discuss key questions and strategise the implementation of findings etc. She mentioned about the orthotics management that are recommended including the advantages and disadvantages. The devices used at various stages of stroke rehabilitation are Ankle Foot Orthosis (AFO) non-articulate, AFO articulate, Posterior Leaf Spring (PSF), Pre- fabricated AFO (Off-the-self), and AFO for early weight bearing. She included the related physiotherapy for the devices used for stroke patients. She also mentioned not to forget Knee Ankle Foot Orthosis (KAFO) that can be prescribed in case the knee joint of the patient shows instability and deformity; and about the surgical interventions for lower limb and upper limb as well as the therapy and splinting for upper limb for stroke patients. The application of Pharmacology (drugs, botux etc) were discussed as part of the management of the stroke during the session. Prof. Hans – Movement disorders in neurological diseases of central origin: spasticity & tone Starting with the basics of the neural requirement of the movements is explained as 1. To start as required; 2. To adjust the strength to the environment 3. To stop when necessary and the need of optimal muscles function to carry out the above process. In case of Upper Motor Neuron (LMN) diseases, which is a case in stroke, there are high incidence and prevalence of spasticity. This is poorly understood and defined among the professionals and in the literatures. Therefore, the treatment process is mostly on the basis of” trial and error”. He defined, the problem in case of spasticity due to stroke is of two types as mechanical and Neural; and suggests the treatment follows should be targeted to both the segments. In case of mechanical; plaster casting, orthotics, orthopaedic surgery; and for Neural; medicine (baclofen), bottilinum toxin, functional electrical stimulations etc suggested as treatment plans. He further entered the details of the assessment and the common errors happens by the treating professionals during assessment of patients with stroke. Roy Bowers (Orthotist, ISPO) presented Biomechanics of Normal and Stroke gait: In the beginning, Roy explained about the normal gait and explained in detail the Stance phase of the affected side and the swing phase of the un-affected side as major concern while evaluating the gait of the patients with Stroke. He also explained about ground reaction force in each phases of the gait. Coming to the gait of a patient with stroke, he explained the biomechanics of affected leg through a video presentation showing before and after using an AFO to demonstrate ground clearance, initial contact, knee hyperextension etc. He emphasised the accommodation of gastrocnemius in the orthotic management to manage better not only the ankle but also the knee and hip problems. Giving emphasis on selecting the correct orthosis, he concluded the presentation as below AFOs must correct the alignment of foot and ankle, AFO must take account the length and tone of the Gastrocnemius muscle, AFOs can have significant role on the movement of knee and Hip, AFOs can be used for therapeutic intervention. Mark Smith (PT, ISPO) - Early post-stroke therapy, physical assessment, aims, treatment While introducing the definition of physiotherapy, Mark stated that a stroke unit reduces up to 23% of the mortality in a year among the patients of stroke. He also detailed about the function of the units as multidisciplinary includes staff education and involvement of patients and carers in the assessment and treatment process. In physical assessment, he included, history in terms of story (nature of complaint, symptoms, acute/chronic condition, age, occupation etc), muscle strength, quality of movements, neurological testing, balance and proprioception (Berg balance Scale, Functional Reach Test etc). Various treatment approaches in physical therapy are also discussed during the session such as hands on vs hands off, Bobath, motor relearning/movement science etc. Judy Ranka (OT, ISPO) - Occupational Therapy: Functional Capacity assessment, aims and treatment Introduced Occupational Therapy (OT) as client centred, enables participation, and the role and the importance of OT to be a part of the stroke rehabilitation team. She introduced the categorization and consequence of health conditioned described in the ICD-10 (International Classification of Disease and Related Health Problem) and detailed about the Occupational Therapy performance Model (Australia). Through the model, she explained about the impact in the political and economic life of a person with stroke through (further broken down to) physical, social, psychological, cognitive, sensorial and cultural aspects. She introduced various assessment tools such as Canadian Occupational Performance Measures (COPM) to measure the change in performance and satisfaction; Goal Attainment Scaling (GAS); Task performance Mastry (TPM); The Perceive, Recall, Plan and Perform (PRPP) assessment etc and the use of the same in assessing the patients with stroke and measure the changes. Followed by she detailed about the treatment plan and intervention methods. Intervention methods stated are as below 1. Build client capacities to apply strategies to meet the demands at occupations 2. Grade occupations 3. Support through assistive devices, 4. Adaptive devices, 5. Removal of contextual barriers and building support, and 6. Practice performance in context Dr. Padma Gunaratne (consultant neurologist, National Hospital of Sri Lanka) presented organization and structure of Stroke rehabilitation services in Sri Lanka. She presented the organisational structure and hierarchy of Ministry of Health (MOH) and Ministry of Social Services (MOSS) in relation to the management of stroke. There are about 30 neurologists and 26 CT (Computerised Tomography)-Scan machines available in Sri Lanka. She strongly advocated to plan for at least one stroke unit at every teaching and provincial hospital to establish in phases, even though there are no luxury of having the OTs in the same, mentioning that there are very less OT graduates in Sri Lanka. Dr. Padma also mentioned about the social service schemes available for the patients with stroke are as below Provision of housing grants and accessibility facilities for houses Vocational training Counseling services Monthly public assistance and self‐employment assistance Medical assistance Assistive devices Social security board Community based rehabilitation programme 2nd day: Presentations Roy Bowers: Principles of lower limb orthotics – Benefits of AFOs: In the presentation, Roy detailed about the functional problems influenced by AFOs, designs of various AFOs and indications for each, casting and cast modification, tri-planar control of the foot and ankle, articulated AFOs and footwear considerations. While entering in to details, he discussed about the walking speed, energy consumption, Gait symmetry, and various other complications in the lower limb that affect the gait such as equinus, supination, knee hyperextension, spasticity, hip extension etc. He explained that a well prepared AFO will influence in reducing complications except the spasticity and hip extension (the last two). In the later part of the presentation, all the corrections mentioned were explained and the process to be followed at the time of measurement and rectification of an AFO. Followed by he explained the shoe modifications that could affect positively in correcting deformity and provide support for better a gait. He concluded the presentation with the following points. AFOs can be very beneficial in the management of neurological conditions Correct AFO selection/prescription is critical The rigid AFO is a very powerful biomechanical tool Correct casting position is critical Skilful and accurate fit are critical Tuning is vital to optimise gait Prof. Hans - Botulinum Toxin, other medical management and surgery In continuation to his previous presentation in the day – 1; he started with the treatment options such as oral spasmolytics (baclofen, tizanidine), nerve blocks, Botulinum toxin, functional electrical stimulation and surgery. He detailed about the procedure, indication, contra-indication and the achievable result of the Botulinum toxin. He also suggested surgery (anterior tendon transfer) for equino-varus as an alternative treatment for those having inadequate AFO/shoe fitting, recurrent equines deformity (twice after Botolinum), and barefoot walking. He concluded his presentation emphasizing on multidisciplinary analysis and combined treatment approach (physical therapy, orthotics, spasticity treatment and surgery) Mark Smith & Judy Ranka - Shoulder, upper limb and hand therapy: Mark explained about the shoulder pain after stroke; relevant shoulder anatomy; evidence for management; management of the hemiplegic shoulder after stroke; evidence and rationale for treatment in his presentation on “Upper limb involvement in stroke”. He also explained about the structure, common complications and the management of shoulder for patients with stroke. Followed by, Judy discussed the details of common problems with use of hand following stroke (arm & hand use scale, specific hand patterns) and evidence-based approaches to improve hand function and use of arm in patients with post stroke. She explained in detail about the upper limb performance assessment and its stages and therapeutic measures for the hand and upper arm. Judy Ranka: Ongoing community rehabilitation and self-care Judy explained about the principles of ongoing care in the community (early supported discharge and community participation & long term recovery) and Present selected evidence regarding effectiveness of community based therapy) She explained that the transition from hospital to community is crucial, so that the goal set for the person is continued at the community. She also mentioned that, using the technology (such as Skype), the rehabilitation team could be in touch with the patients in their community. Peer support given importance in her speech in this session. Mark Smith– physical fitness training and self care Physical fitness improves Cardio-respiratory fitness (central and peripheral components) Muscular strength (maximum force that can be generated by a muscle) and muscle power (rate at which muscular force can develop during a single muscle contraction) Body composition (relative amounts of muscle and adipose tissue) The recommendation made on types of exercises are Aerobic – consists of rhythmic, repeated and continuous movements of the same large muscle groups for at least 10 min at a time. Eg. Walking, cycling, jogging, continuous swimming, classes Resistance exercise (strength training) – activities that use muscular strength to move a weight or work against a resistive load. Eg. Weight lifting and exercises using weight machines in gyms Flexibility training – mainly stretching aimed at increasing or maintaining range of motion at joints And detailed about the exercises and their modifications for the patients with stroke. He also mentioned the Risk associated with exercise and the adaptations needed for the specific conditions after stroke. How does physical activity help prevent strokes can be found in the link www.exerciseafterstroke.org.uk V. Sasiraj, chief physio: Therapy for stroke patients in Sri Lanka In Sri Lanka, the PT (physiotherapy) training started in 1956, emphasising the PT care for the stroke patients, Mr. Sasiraj stated that only 20% of population over 65-year will be covered through PTs by 2020. It was observed that the Government focus increased in recruitment of PTs from the year 2000. Talking about the protocol of therapist in assessment, plan the treatment, implement the treatment, Evaluation, communication among team is not followed. The role clarity among the rehabilitation professional is abysmal with clear overlapping of professional role especially among PTs and PTs. This has resulted to lack of collaboration among professionals working in the field of rehabilitation. Recommendations made during the presentation are: Knowledge in orthotics for PTs should be updated regularly to effectively treat patients with stroke, more orthotists deployment to meet the demand in the country and the role of each of the rehabilitation professional treating the patients with Stroke should be clear, and the professionals should have the spirit to work as a member in the rehabilitation team. Lasanthi Siriwardana – OT for patients with Stroke She introduced occupational therapy, explained role and goals of OT in Stroke, Shared to start OT from acute stage. She gave an overview of OT in different stages of Stroke Mr. Mihiran – orthotic management of patients with Stroke in Sri Lanka He started with an overview of evolution of PO profession in Sri Lanka. He shared regarding conventional AFOs; indications, contraindications, advantages, disadvantages of orthotics. He also mentioned the different possibility and design of orthotic devices used to restore the function of the patients with stroke. Mr. Mihiran also discussed the measures to achieve orthotic goals in stroke management Liz Condie– outcome measures in Stroke Rehab: Escaped the session due to lack of time and went to the session: Mark presented National guideline development Talked about available documents (guidelines) which can later lead to strategy documents and help the country (Sri Lanka) to formulate the guideline for stroke care. Roy Bowers: Structure of Best practice statement H e talked about some of the recommendation of the above guidelines (like including orthotists in team) Family and clients can also use these guidelines to ask for specific services All faculties - Round table discussion “The future – possible changes to stroke services in Sri Lanka” Responding to the presentation of Mr. Sasiraj on PT manufacturing simple orthotic devices for the patients with stroke due to un-availability of the orthotists; a participant raised question of the role clarity among the professionals and advocated to be within the speciality and expertise of each professionals in order to enhance interdisciplinary practice. The president of the Sri Lanka Association for Prosthetics and Orthotics said that the government should recruit more P&Os in order to meet the need. At present, there are only 20 P&Os to meet the need of 20 million people in the country. Liz recognised the need for more person power in the rehabilitation sector and suggested the professionals to present the need to the government through evidences and data. Talking on the inter- disciplinary practices; there is willingness among professionals to work together as a team and the need is to take forward the willingness to practice through good leadership. A participant from Odisha, India shared to have started a common website for rehabilitation professionals to encourage inter-professional communication as a pilot to encourage interdisciplinary approach. The additional problem of person with disabilities in Northern Province of Sri Lanka was discussed to have deployment of the rehabilitation professionals (especially OTs) as a priority. Responding to the question of Liz to use Tele-health to reach remote areas; it is understood that it is yet to be taken into consideration. In some areas, there are limitations of resources such as electricity, IT (information technology) equipments are not available especially in Northern province. Still knowing the rapid development in IT sector in Sri Lanka, it was considered to give some solution to the absence of rehabilitation professionals in remote locations in the country. Psychological management (knowing that the Northern Province affected by war) is very important in Northern Province. And there are hardly any professionals available for the entire province. The OTs are replacing of Psychologists. In connection of rehabilitation care to Community Based Rehabilitation (CBR) services, HI (Anita Pearson, Technical Unit Coordinator) said, there is a need to strengthen CBR programmes, strengthening DPOs, and trying to improve the networking among stake holders in the field of disability. All the participants agreed to the point that the linkage between the policy makers/decision makers and the rehabilitation professionals is very poor in Sri Lanka. HI (Gilles Nouzies, Country Director) agreed to the fact and said that MoH is in process of developing a strategy for rehabilitation services. This will be the right time to involve ourselves. Day III: (a separate section will be reported with the video of the practical sessions). Wes is directly in touch with the ISPO team on this. Therapy group/Splint Orthotic group Exposure visit Course evaluation feedback The most common responses are clubbed together as below for each questions. Will you make any changes to the way you work (after the training), and if so how? - Will pay more attention to ankle at the time of measurement (casting) Will be refer to the clinical evidences available Will use enhance knowledge in orthotics manufacturing Will be able to better assess my clients Will discuss with my team (Other members in rehabilitation team) to provide the best possible treatment Will consider more interactions and communication with other team members and focus on multidisciplinary work Will do detailed functional and biomechanical assessment Will increase the orthotic prescription understanding the usefulness Will orgnise training for doctors and PTs in my area Will work based on evidence based practice Will duly refer the patient to PT dept Any suggestion/comment to improve the course? - - - Local resource persons should be briefed more on what they have to speak so that it does not convey wrong message. HI to raise the question on professionals’ standard and role clarity in Sri Lanka. This will help us to promote health professions multi disciplinary approach by reducing overlap between professional services. Time needs to be planned better to avoid hurry, the lectures should be better understood if presented in a slower pace. More practical sessions required, measurement/assessment tol in OT should have been expanded more than presenting all tools. HI could have included all participants for practical sessions The length should be at least for 5 days. Time was embarassing (5 pm is too late) lead to us to go home lately, otherwise it was important. Time allocated to each session was not enough for question/answer, should have time for understanding each profession with each other. The training has covered very basic, general part of stroke, I wil suggest to cover talk on some specific technique and new advancement. Course should be inteactive, need to minimise the content and more discussion on specific topic. Difficulty to follow the course continuously without break, so irritating. Schedule is too tight and 8:30-5 is too long - In future, HI should allow orthotic technician for practical training not only P&O In this time, communication is poor, send proper letters and it will help to get permission. Should inform the professionals through relevant officials regarding any workshop. - Asking question at the end of each session is helpful. Anyone will forget the questions if to be asked ony at the end of the 2nd day. Course evaluation Practical: Have you learnt something new which you would like to practice in your set up, if so how? - Absolutely, this type of course should continue every year. - AFO manufacturing procedure was very new for me. - Optimum outcome of the patient should be through the approach of multidisciplinary team work. Will advocate for the same at my work place. - How important is a multiple team work in rehabilitation. - Importance of fine tuning of AFOs is very effective. I will practice to master it. - Learnt splinting to manage intrinsic thumb more appropriately. - Learnt a lot regarding gait analysis which I will practice in my set up. - Do more facilitation to improve function. - Learnt how orthosis and physiotherapy can improve the gait. - Please conduct such trainings regular y, its very useful. Any suggestion/comment to improve the practical sessions (under course)? - Practical session should continue at least for 2 days. Decrease the time for theory by giving time and increase practical sessions. More hands on by participants in small group required. Should be more organised, fair to everyone. Can make improvement in time management It would have been good if we got chance to practice (under the supervision of the trainer). Therapy session for OT should have also been better organised. Need more practical session for upper limb splinting. Please give video for demonstration. More focus was on lower limb while managing upper limb is more challenging. Since it was difficult for all professionals to take part in workshop so same should be conducted in other parts of country. Continue for other non communicable diseases. Sound system should be from beginning. Time was a constraint. The International Society for Prosthetics and Orthotics (ISPO) was founded as a NGO in 1970 in Copenhagen, Denmark. ISPO contributes throughout the world in all aspects of science and practices associated with the provision of prosthetic and orthotic care, rehabilitation engineering and related areas such as wheeled mobility. ISPO works worldwide to enhance the quality of life for people with physical disabilities who require improvements in mobility or independence. As an international multidisciplinary organization, it effectively promotes the provision of quality services, innovative technology, clinically relevant research and education in the field of rehabilitation for persons with physical disabilities. ISPO currently represents over 50 Member Societies (MS) and 3,000 individual members in over 90 countries around the world. ISPO contributes to a world where all persons have equal opportunity for full participation in society. For details, please refer - www.ispoint.org Handicap International (HI) is an international aid organization specializing in the field of disability. Non-governmental, non-religious, non-political and non-profit making, it works alongside persons with disabilities & other vulnerable groups, whatever the context, offering them assistance and supporting them in their efforts to become self-reliant. HI is working in Sri Lanka since 2004 and is one of the key organizations in the disability sector in the country. It is committed to strengthening the physical rehabilitation services aiming at supporting infrastructure development; sustainable production and distribution of prosthetic & orthotic, mobility, and adaptive devices; mentoring and building capacity of the professionals and key actors in the physical rehabilitation sector; and sustainable quality service delivery in Sri Lanka. It also offers a dedicated website (www.rehabmonitor.org) to provide training and knowledge management solutions to persons working with persons with disabilities at various levels. For details regarding activities of Handicap International, please refer- www.handicap-international.org Annexure: Course Programme Programme schedule ISPO Short course to be held in Colombo from 15 th to 17th Jan’13 Day-1 ; Tuesday 15th January-2013 at SFI Time Description of activity/subject Lead Person/presenter 8.30-9.00 Registration Ishika 9.00-9.30 Welcome and opening Liz Condie (Course Coordinator, ISPO), Gilles (Country Director, HI-Sri Lanka), Representatives from MoH and MoSS 9.30-9.45 Introduction to course Liz Condie (Course Coordinator, ISPO) 9.45-10.30 Stroke: epidemiology, symptoms, causes and current medical care Prof. Hans Arendzen (Doctor, ISPO) 10.30-11.00 Break 11.00-11.30 Epidemiology and medical management in Sri Lanka Padma Guneratne (Consultant Neurologist, Sri Lanka) 11.30-12.00 Rehabilitation of Stroke in Sri Lanka Dr. Munidasa, (consultant, Rehabilitation Consultant, RRH, Ragama) 12.00-13.00 An international consensus conference on orthotic management of stroke patients Liz Condie 13.00-14.00 Lunch 14.00-14.45 Tone and spasticity Prof. Hans Arendzen 14-45-15-30 Biomechanics of Normal and Stroke gait Roy Bowers (Orthotist, ISPO) 15.30-16.00 Break 16.00-16.45 Early post-stroke therapy, physical assessment, aims, treatment Mark Smith (PT, ISPO) 16.45-17.30 Occupational Therapy: Functional Capacity assessment, aims and treatment Judy Ranka (OT, ISPO) 17.30-18.00 Organization and structure of Stroke rehabilitation services in Sri Lanka. Padma Gunaratne (NB: Roy Bowers casting 2demo patients during this day, Orthoses to be ready for Day 3) Day 2; Wednesday 16th January 2013 at SFI 08.30-.9.30 Principles of Lower limb orthotic management Roy Bowers 09.30-10.30 Continuing therapy and gait training Mark Smith 10.30-11.00 Break 11.00-11.45 Botulinum Toxin, other medical management and surgery Hans Arendzen 11.45-12.30 Shoulder, upper limb and hand therapy Judy Ranka 12.30-13.30 Lunch 13.30-14.15 On going community rehabilitation and self-care 14.15-15.00 Therapy and orthotics for stroke patients in Sri Lanka. V.Sashiraj (PT, Sri Lanka) Judy Ranka/Mark Smith L. Siriwardana (OT, Sri Lanka) U. Mihiran (P&O, Sri Lanka) 15.00-15.30 Outcome measurement Liz Condie 15.30-16.00 Break 16.00-16.30 National guideline development Roy, Mark, Hans and Judy 16.30-17.30 Round table discussion “The future – possible changes to stroke servicesIn Sri Lanka” Chairman – Liz Condie Discussants – all faculty and participants 17.30-17-45 Presentation of Certificates Gilles, Nouzies, Liz Condie and all international Faculties Day 3; Thursday 17th January 2013 at SLSPO, Ragama 09.00-12.30 Workshop – 1 Orthotists (Demonstration: Casting, Rectification and Manufacture) Workshop – 2 (Demonstrations and small group working): bed positioning, transfers, shoulder management, strength, posture, balance training, gait reeducation, hand function and low – temperature thermoplastic orthosis fabrication, cognitive management, nerve blocks) 12.30-03.30 Lunch 13.30-15.00 Fitting and checkout laboratory (2 patients previously cast and fitted by Roy) 15.00-16.00 Clinical problem solving session All faculty (Questions raised by participants, discussed/answered by faculty) 16.00 Closing remarks, presentation of certificates Gilles Nouzies, Liz Condie, all faculties. Profiles of resource persons International Resource Persons for the ISPO short course on ‘Orthotic and therapeutic management of stroke’ Pre/Post test Post / PostTest for ISPO Short Course Orthotic & Therapeutic Management of Stroke At: Colombo, Sri Lanka Date: 15th, 16th and 17th January, 2013 1. According to the World Health Organization Report which one of following is false? 1. 15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled. 2. 15 million people live with stroke worldwide. Of these, 10 million are permanently disabled. 2. Which of the following is correct? 1. Muscle tone must be high enough to provide stability 2. Muscle tone must be low enough to provide stability 3. Which among the following is not considered the benefits of AFOs? (Tick) 1. Walking speed 2. Weight bearing 3. Knee hyperextension control 4. Spasticity 4. Indicate true or false for following statements: 1. AFOs must correct the alignment of the foot and ankle 2. AFOs may not take account of the length and tone of the gastrocnemius muscle 5. Which of the following does not result from Botulinum Toxin: 1. Reduces tone/spasticity 2. Better foot contact 3. Improves walking speed 6. Most common causes of Stroke: 1. Vascular blocking 2. Vascular rupture 7. Which of the following doesn’t describe correct rating of Goal Attainment Scale? 1. +2: Much more than expected 2. -2: Much more than expected 3. 0: As expected 4. +1: Somewhat more than expected 8. Match the following contextual factor with respective barriers: 1. Physical a. Light, temperature, humidity 2. Sensory b. Steps, passages, furniture 3. Cognitive c. Interactions, expectations 4. Socio-Cultural d. Stimulation, Comprehension 24 9. Constraint Inducted Movement Therapy (CIMT) is applicable to: 1. Those with some isolated upper limb control (wrist) 2. Those with no wrist control 10. Which of the statement/s is correct? 1. Evidence of repetitive function & strength training in stroke management is very good 2. Evidence on Lycra cuffs, elastic bandages in stroke management is also very good 3. Evidence on botox in stroke management is too week. 11. Match the following areas of assessment with concerned tests: 1. Mobility a. Barthel Index 2. Function b. Hospital Anxiety and Depression Scale 3. Mood c. Timed Up and Go Inputs from: Mr. Vivek Singh, Regional Technical Coordinator, Handicap International – India. EDIUM: