Investigation of the evaluative methods used by physical therapists in the specificity of the functional neurology

Correspondence to:: Gustavo Christofoletti – Universidade Federal de Mato Grosso do Sul – Avenida Universitária, s/n – Setor Universitário – Caixa postal 549 – CEP: 79060-900 – Campo Grande (MS), Brasil – E-mail: g.christofoletti@ufms.br Presentation Jun. 2012 – Accepted for publication: Jan. 2013 – Financing source: Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) – Conflict of interest: nothing to declare – Approval at the Ethics Committee n. 1.989/2011. ABSTRACT | Neurofunctional clinical evaluation represents one of the most important activities of physical therapists. However, differences in diagnostic methods cause discrepancies between physical therapy prescription and prognosis. Thus, the aim of this study was to analyze and discuss the evaluation methods and techniques used by physical therapists bound to popular healthcare assistance, in the specificity of the neurofunctional area. To accomplish this research, a cross-sectional design study was conducted. The sample consisted of physical therapists specialized in neurofunctional rehabilitation registered in the Regional Council for Physical Therapy and Occupational Therapy of Mato Grosso do Sul (Conselho Regional de Fisioterapia e Terapia Ocupacional, CREFITO–13), who work in hospitals, universities and clinics of the city of Campo Grande, Brazil. Data were analyzed using descriptive and inferential (χ) statistics, under a 5% level of significance (p<0.05). Regarding the results, all physical therapists had concluded graduation five years before. Responses regarding the physical examination were similar between professors and clinical physical therapists (p=0.81), which did not happen on the anamnesis (p=0.02). Items such as cognitive functions and social determinants of health were answered by less than 15% of subjects, and about 70% of respondents said they do, but do not register, the patients’ evaluation. In conclusion, there is not a standardization of the physiotherapeutic Investigation of the evaluative methods used by physical therapists in the specificity of the functional neurology Investigação dos métodos avaliativos utilizados por fisioterapeutas na especificidade da neurologia funcional Investigación de los métodos de evaluación utilizados por fisioterapeutas en la especificidad de la neurología funcional Juliana dos Santos Llano, Hevelyn Cristhiana Ferreira Silva de Miranda, Lilian Assunção Felippe, Larissa Pires de Andrade, Tânia Cristina Dias da Silva, Gustavo Christofoletti


INTRODUCTION
There is no doubt that physical therapy is gaining more and more space in the world.The physical therapy practice based on evidence, minutely detailed in the guidelines of the WCPT (International abbreviation for the World Confederation for Physical Therapy) represents a gain to the profession, and the classical worldview based on the philosophy of "trial and error" has changed for a scientistic strategy governed by need of a previous attestation [1][2][3] .The decision-making process of the professional about the best treatment must involve information technology, those mechanisms that gives access to scientific data supporting with proved interventionist precedent or not 4 .
The evolution that the profession has been passing in various countries is increasing and by evidence of the methods and techniques used.The phisycal therapists profile is changing, through which the clinical skill should involve the ability to manage, evaluate, observe, prescribe, treat and comunicate 5 .However, many reports point to a phisycal therapists difficulty in developing a diagnostic hypothesis correct, corroborating a main concern in treatment evaluation methods 6,7 .
The physical therapeutic assessment represents one of the most important actions of the professional.
Classically subdivided in anamnesis and physical examination, it is through it that the professional becomes able to prescribe and interventionist goals outline.In a complex and delicate situation involving the evaluation methods and techniques in the patient, the disease appears, although relevant to the definition of the conduct to be developed by the professional, consists of only one of the data recorded during the anamnesis and should not be used exclusively to guide the assitence.
The physical therapist evaluation represents one of the most important actions of the professional.Classically subdivided in anamnesis and physical examination, it is through it that the professional becomes able to prescribe and to outline interventionist goals.In a complex and delicate situation involving the evaluation methods and techniques in the patient, the disease, although relevant to the definition of the conduct to be developed by the professional, consists of only one of the data recorded during the anamnesis and should not be used exclusively to guide assistance 8 .
applied.Thus, the objective of this work was to analyze the evaluation methods and techniques used by physical therapists linked to health care of the population, in the specificity of functional Neurology.

METHODOLOGY
A cross-sectional study was carried out with physical therapists in neurofunctional area, from the registry provided by the Regional Council for Physical Therapy and Occupational Therapy of Mato Grosso do Sul (Conselho Regional de Fisioterapia e Terapia Ocupacional, CREFITO-13).The search involved working professionals in assistance (basic and specialized attention) and teaching (University) neurofunctional physical therapy of the city of Campo Grande (MS).
Professionals were included with latu sensu and/or strictu titration in neurofunctional area (regarding to resume Lattes CNPq) registered in CREFITO-13 and residents in the city of Campo Grande (MS).Physical therapists that did not work with any activity related to the area were excluded.
From the identification of the participants, the researchers contacted them to explain the objectives and goals of the project.An interview consisting in the application of a questionnaire prepared by the researchers themselves was made, which were issues related to the routine and professional experience.In addition, was asked to the participant what steps of the evaluation currently searched he found important to be improved.All information collected were entered on the worksheet, maintaining the anonymity of the respondents and their respective institutions.
About the analysis of the data, we used descriptive (mean and standard error) and inferential (χ 2 ) statistics, this being applied in order to compare the answers of the physical therapists of assistance and University environments.It was admitted to a level of significance of 5% and ethical support was obtained by the Research Ethics Committee of the Federal University of Mato Grosso do Sul.

RESULTS
The analysis undertaken for this study involved physical therapists that works in 6 hospitals, 6 universities and  About the prevalence of the responses of the participants in the anamnesis and physical examination, most professionals delimited physical examination as an integral part of physical therapist evaluation; there was not significant difference between the responses of teachers and clinical physiotherapists (p=0.81).The opinions about anamnesis were divergent, showing a significant difference between the responses of the two groups (p=0.02).Such data will be available in table 1.
Tonus, muscle strength, sensitivity, reflection, balance, coordination and gait were the topics most answered by the participants in the physical examination.In contrast, cognitive function and activities of daily life were answered by less than 15% of the interviewee.On the anamnesis, the majority of interviewee remembered general data, main complaint, history of the disease and familiar/personal antecedents.Only two physiotherapists have shown concern about the social determinants of the patients health.
When asked about a possible need for improvement in some evaluation topic, 21.7% of interviewee said to be satisfied with the current rating.The remainder of the sample suggested improvement in physical examination items -being too requested the changes in functionality and analysis of activities of daily living of patients.No physiotherapist said that they use permanent materials (such as electromyography, balance platform, load cells and others) to assist in the development of diagnostic hypothesis.

DISCUSSION
Neurofunctional assistance, to be considered ideal, should follow the following systematization: 1) physiotherapist evaluation; 2) construction of Physical therapeutic diagnosis and prognosis; 3) development and implementation of the therapeutic program; 4) planning for high; and 5) guidance for maintenance of acquired conditions.It is therefore of great importance to carry out a full and detailed assessment, before which a mistaken assessment will tend to generate two consequences: or the patient will be subjected to improper treatment or benefits from physical therapy will not be proved 11,12 .
The findings of the anamnesis corroborate the critical constants of own professionals before the shortage of methods used to analyze the functionality and daily life.Of the activities observed in this study, most professionals values the classic items of anamnesis, as general data, history of current disease and family/ personal background.Important items, which examine the sociocultural reality of the patient (like shelter, basic sanitation, means of transport and other), were discussed by only 8.7% of respondents.In spite of the determinants of health are still overlooked by many, Buss and Pelligrini-Filho 13 argue that is proven to influence of such factors, often of social origin, economic, cultural, behavioral, and psychological health problems of the population.
The notion of health as absence of disease is a reflection of the health model process and health care history.Still found in current health services, the health work is based on the taylorista model, where interaction between members of the same team is complicated 14 .In the biomedical model, the explanation of healthdisease process tends to be restricted to pathophysiological aspects, at the expense of their functional, social and cultural expressions.As noted, many of the physical therapists presented the classical worldview, restricting its assessment to the peculiarities of clinical condition 15 .The findings of the anamnesis corroborate the critical constants of own professionals before the shortage of methods used to analyze the function and activities of patients daily life.This fact is due to the restriction of classical analysis focused on the disease, in which the human functionality and activities of daily life are under valued 16 .
Similarly, the techniques applied in the physical examination suggest the original idea of physical therapy as a health area that studies, prevents and treats kineticfunctional disorders that becomes from changes in organs and systems of the human body.Although we believe that this definition is still current to set the physical therapy, we should consider recent findings by the neuroscience that demystifies many automatic movements and reflexes of cerebral origin, and extend physical therapist action on cognitive-behavioral disorders 17,18 .
Another interesting data observed in our study is that none of the professional uses permanent materials such as electromyography, balancing platform and load cells, to assist in the preparation of functional diagnosis.On that subject, recent studies classify health technology as being "hard", "hard-light" and "mild".Although the hard technologies (exemplified by permanent equipment above) are rich and widely trusted, we believe that non-use in the clinic is the high price of such equipment, which restricts their stay in highly especialized centers 19 .
Remember that the initial idea of this research was to analyze the evaluation methods used by physiotherapists linked to different levels of health care of Campo Grande (MS).However, we did not find physiotherapists in the basic assistance of the city that favored the inclusion criteria.Similarly, in the hospital area, no professional analyzed showed the minimum required in titration neurofunctional area.There were zero participants of the basic attention and that is because the professionals had public health graduate, as well as in the hospital environment, where they still gives priority to hiring physical therapists intensive care team experts in cardio-respiratory area 20 .
As a limitation of this work, it is likely that some professional has not been included in this study because of the absence of lattes or lack of updating the same electronic site of the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).Even if the possibility of such a bias, we must consider the study published by Lane 21 in which the researcher argues that the Lattes platform is an instrument of great national scientific contribution, and has important international recognition.Given this, any health care professional acting at various levels of patient care should be entered in this database.And the sample restriction to professional experts in neurofunctional area was critical to the results obtained in our study to not suffer influence of low experience of some physical therapists in this area.
Sample loss consisted of another limitation of our study.As defined in the survey, the main recruitment difficulties were lack of time, lack of interest and unavailability of subject to participate.This brings us to a complex analysis: while the evidence-based physical therapy represents the central element of contemporary physical therapy and its use is very important for the proof of a particular treatment, some professionals seem to underestimate the importance of the diagnostic standardization, even knowing that a inappropriate prescription produces serious and ineffective results for patients 19 .
The current routine of the physiotherapist at the clinic and the high fill rate "requires" many professionals to reduce or even dismiss the use of evaluations.Thus, the therapy is often developed according to the patient's own report on previous treatments or based on observation at the session.In our study, we observed that approximately 70% of the participants do not record the physical therapeutic evaluation performed.Although the World Confederation for Physical Therapy (WCPT) emphasize the obligatoriness of a professional to document, to put the date and authenticate the evaluate assessments 22 , some professionals argue that many times the patient arrives with a fixed number of sessions, it is not interesting to use one of the few patient sessions for its evaluation and registration.This argument is refuted by studies developed by Coffin-Zadai 7 and Jette et al. 23 , that shows that serious diagnostic errors were promoted by physiotherapists, which endanger the prognosis, prescription and the therapeutic follow up.
Besides, it is important to remember that the nonrealization of the evaluation procedure by the physical therapist represents a throwback to the profession, by pairing moments prior to 1963, when physical therapy in the country was seen as a helper to the medical area, without the task of developing diagnostic evaluation 24 .
Given the lack of evaluative standards, it becomes apparent that the development of a standardized application form is very important to the professional class, making it possible to compare results obtained in different parts of the country.Despite the major challenge in developing such an instrument, it is important to say that this should present options which allows the insertion of topics that the physiotherapist judge it necessary, for the evaluation procedure does not become a mechanical task, automatic and involuntary.

CONCLUSION
Through the results obtained in this study, it can be concluded that there is no standardization of Physical therapeutic methods and techniques applied in the patient affected with neurofunctional dysfunction, making it difficult to unify its prescriptive and prognostic analysis.
Many professionals do not register their evaluations, making it hard to analyze the benefits of the therapeutic procedure.The low prevalence of responses involving social determinants of health, in the anamnesis, shows a dependency of the classic vision of a professional physical therapy, centered on the neurological disease, which neglects the social aspects of the individual.

Figure 1 .
Figure 1.Sample selection process flowchart 39 clinics of Campo Grande (MS).As seen in Figure1, in initial sample of 51, only 21 institutions participated, representing a loss of 58,8%.The factors related to low participation of physical therapists in this study are due to: a) in hospitals, lack of professionals with minimum degree required in this study; b) in universities, difficulty of recruitment; and c) in clinics, unavailability of time, withdrawal of participation and lack of professionals with minimum degree.Regarding the basic attention, no physiotherapist was included, because no one fits the criteria adopted in this research.So, out of a total of 51 institutions surveyed, only 21 were included in this survey, representing a sample of 23 physical therapists.All physiotherapists were graduated more than 5 years ago, and has exercised this function for 11.3±2.1 years and the clinical physiotherapists for 7.3±1.9years.The average patients assisted weekly by physiotherapists was 24.6±4.6, the most of it took 45 minutes of session per patient.All physiotherapists teachers described that have a standard assessment form in the institution and only two clinical physiotherapists declared having * Six physiotherapists docents were included in this study a pre-drawn model to be applied.Most professionals analysed (69.5%) said perform physiotherapist evaluation in patients, but do not have time to register it.

Table 1 .
Prevalence of responses obtained in the anamnesis and physical examination