M4H

dari tak sama menjadi beda...
dari diam menjadi tak bersuara...
lalu apakah diam itu emas..??
mungkin benar bagi para investor Freeport...
tapi tidak bagi para penambang...

aku berlari mengejar angin
menempuh hidup yang kian berliku
mengejar layang-layang yang putus dari mimpiku
lalu aku terdiam dan tak bersuara
di langit kulihat aura

ini bukan tentang makna atau apapun juga
hanya mengikuti apa yg terlintas di hati
dan saat matahari menjdi mata hati
di bagian hati yang manakah ia akan terbit?

seorang pujangga mengarang syair
dia mengarang, tapi bukan dikarang-karang
karena isinya tentang kebenaran
yang ia temukan di sela-sela batu karang

tentang bulan yang tak pernah purnama
tentang seseorang yang tak punya nama
tulisan ini dibuat begitu saja
tak ada arti tak ada makna

TWO days before his 40th birthday, Michael Matin of New York suffered a stroke that left him paralysed on one side of his body. After three years of physiotherapy, he had regained control of his left leg, but not the use of his arm.

In an attempt to recover some arm movement, last August Marin began three months of therapy with two trial robotic rehabilitation devices. He is now able to do push-ups. "They're not perfect gym push-ups, but I'm getting there," he says.

Each year 700,000 people in the US and 130,000 in the UK suffer a stroke, making it the biggest cause of severe disability in both countries. Standard physiotherapy can work well for some people, but it is expensive so patients often spend only a short time with a therapist. The standard of therapy can also vary hugely between practitioners, producing variable results. Improving stroke rehabilitation could clearly benefit millions.

Now it looks like robotic devices that help patients practise moving paralysed limbs could do just that, and are showing great promise in trials. "Robots offer consistency," says Steven Cramer, a neurologist at the University of California, Irvine, who is working on a robot to restore hand and wrist use. Unlike people, robots are very good at repeating precisely the same movement over and over. "They can also record accurately what a patient does, connect with computers in a way humans cannot, and communicate accurately from a distance, opening the door for tele-rehab," Cramer says.

Robots designed to restore movement to the shoulder and elbow, leg, wrist, hand or ankle are already being tested with people. "In the next five to 10 years, therapeutic robots will be present in all clinics and at home," says Hermano Igo Krebs, a robotic rehabilitation specialist at the Massachusetts Institute of Technology. Such robots should also help people with other diseases that affect movement, such as Parkinson's and multiple sclerosis, he says.

Cramer's team, for example, has developed a prototype device called Howard, or Hand-Wrist Assisting Robotic Device, to help people regain the ability to grasp and release objects. Three straps secure the pneumatically operated robot around the hand, while the patient's arm is fixed in a padded splint mounted on a movable platform. By moving the pads next to the patient's fingers and hand, the robot can flex or extend all four fingers together, or the thumb or wrist alone. Sensors measure the movement of each pad, which allows software to track the patient's movements as they go through a series of exercises involving grasping and releasing objects, or playing computer games that require them to squeeze virtual lemons to fill a cup, for example.

In its "active assist" mode, the software monitors to what extent the patient is able to carry out an action unassisted, and tells the robot to provide the appropriate level of pressure to help them to complete the move if they cannot do it on their own. Requiring a patient to start the movement and then actively helping them to complete it is crucial, Cramer says. "In completing the task, you're teaching the sensory cortex what that feels like. The sensory cortex talks to the motor cortex. So by doing this, you're instructing the motor cortex in how the movement should go."

Cramer recently carried out a study in which 13 people who had suffered a stroke at least three months before, and so were past the time when they were likely to experience spontaneous recovery, received 15 2-hour sessions with Howard over three weeks. By the end of the trial, their ability to undertake real-world tasks, such as gripping a glass or picking up a phone, had improved by almost 10 per cent. A different test of their overall manual dexterity, which involved moving blocks from one side of a box to another, showed a 20 per cent improvement. "These were highly significant gains," says Cramer.

Marin, meanwhile, owes his improvement to two devices: a wrist rehabilitation robot and a robot called MIT-Manus, which exercises the shoulder and elbow, both developed at MIT by Krebs and his colleagues. Marin was part of an ongoing trial of the robots. The wrist robot comprises two side-mounted motors attached to a support frame, which allows the patient to flex or extend the wrist, and move the hand left or right. Patients wear a virtual reality headset and perform a variety of simple exercises. As with Howard, if the patient can't complete a task, the robot steps in. Matin says the robotic assistance is barely noticeable. "In the beginning it was hard for me to move, but the robot was so smooth you didn't really notice."

Patients taking part in the three-month trial at Burke Rehabilitation Hospital in White Plains, New York, which will ultimately involve 200 people, receive an hour of therapy three times a week. Krebs will present preliminary results, based on 36 volunteers, at a conference on rehabilitation robotics in Noordwijk, the Netherlands, in June. These show improvements of about 10 per cent in arm and wrist movements, something that for patients with severe, chronic impairment is "remarkable and very promising", says Krebs.

Meanwhile, the US Department of Veterans Affairs is running a clinical trial of MIT's wrist robot, alongside arm and hand robots, at four hospitals. It is also testing an "anklebot" on stroke patients at a hospital in Baltimore, and on people with multiple sclerosis at a hospital in West Haven in Connecticut. The anklebot, also developed at MIT, fits around the leg like a brace to provide assistance and support when walking. It is designed to help prevent falls, as well as improving people's mobility and gait after a stroke. "Based on the outcome, the VA might adopt robotics in all its rehabilitation facilities," says Krebs. The West Haven trial should also reveal whether other patient groups can show the same levels of benefit from robot therapy as stroke patients.

Krebs hopes that patients like Marin will soon have access to entire "gyms" of therapeutic robots, each for a different part of the body. Such facilities could be particularly useful for practising coordinated and physically demanding movements such as climbing stairs, says Etienne Burdet, who is developing a range of robotic rehabilitation devices at Imperial College London, including a robot designed to help patients recover the fine movements needed for handwriting. This is because although therapists can help people exercise individual muscles, physically supporting a patient while they carry out a coordinated task is much more difficult. Robots, in contrast, can easily provide both support and assistance, Burdet says.

Even better, studies have shown that patients strongly prefer robotic therapy to home-based exercises, so patients will be more likely to complete the rehab programmes, says David Reinkensmeyer, a biomedical engineer also at UC Irvine. He has developed a number of rehabilitation robots, including a robotic arm therapist called ARM Guide. However, he cautions that such active-assist studies usually compare the results of robot therapy with standard physiotherapy regimes, rather than with a matched amount of non-assisted therapy.

"We don't know if you would get the same benefit if you turned the motors off and practised the same amount," Reinkensmeyer says, "although we do know that it would be more frustrating, and clinical compliance to such a regime might ultimately be less."

Human physiotherapists need not fear they will be pushed out of the picture entirely by robotic colleagues, however. With robots taking care of the movement training, therapists will have more freedom to focus on educating patients to live with their disability, and on managing pain.

If Marin's experience is anything to go by, patients will take well to such a regime. "The robot has made such a difference to my life. I have seen a physical difference that has translated into my emotional well-being," he says. "I really hope these robots get used all over the world."
Source Citation
Young, Emma. "Tireless, reliable physio-robots take on stroke paralysis: robots offer the perfect combination of strength and precision to help patients rebuild vital motor skills." New Scientist 194.2598 (2007): 24+. Gale Sciences Standard Package. Web. 17 May 2010.
Sumber : PowerSearch

Abstract:

Background Joint pain, specifically chronic knee pain (CKP), is a frequent cause of chronic pain and limitation of function and mobility among older adults. Multiple evidence-based guidelines recommend exercise as a first-line treatment for all patients with CKP or knee osteoarthritis (KOA), yet healthcare practitioners' attitudes and beliefs may limit their implementation. This systematic review aims to identify the attitudes, beliefs and behaviours of General Practitioners (GPs) regarding the use of exercise for CKP/KOA. Methods We searched four electronic databases between inception and January 2008, using subject headings to identify studies examining the attitudes, beliefs or behaviours of GPs regarding the use of exercise for the treatment of CKP/KOA in adults aged over 45 years in primary care. Studies referring to patellofemoral pain syndrome or CKP secondary to other causes or that occurring in a prosthetic joint were excluded. Once inclusion and exclusion criteria were applied, study data were extracted and summarised. Study quality was independently reviewed using two assessment tools. Results From 2135 potentially relevant articles, 20 were suitable for inclusion. A variety of study methodologies and approaches to measuring attitudes beliefs and behaviours were used among the studies. Quality assessment revealed good reporting of study objective, type, outcome factors and, generally, the sampling frame. However, criticisms included use of small sample sizes, low response rates and under-reporting of non-responder factors. Although 99% of GPs agreed that exercise should be used for CKP/KOA and reported ever providing advice or referring to a physiotherapist, up to 29% believed that rest was the optimum management approach. The frequency of actual provision of exercise advice or physiotherapy referral was lower. Estimates of provision of exercise advice and physiotherapy referral were generally higher for vignette-based studies (exercise advice 9%-89%; physiotherapy referral 44%-77%) than reviews of actual practice (exercise advice 5%-52%; physiotherapy referral 13-63%). Advice to exercise and exercise prescription were not clearly differentiated. Conclusions Attitudes and beliefs of GPs towards exercise for CKP/KOA vary widely and exercise appears to be underused in the management of CKP/KOA. Limitations of the evidence base include the paucity of studies directly examining attitudes of GPs, poor methodological quality, limited generalisability of results and ambiguity concerning GPs' expected roles. Further investigation is required of the roles of GPs in using exercise as first-line management of CKP/KOA.

Full Text :
COPYRIGHT 2010 BioMed Central Ltd.

Authors: Elizabeth Cottrell (corresponding author) (equal contributor) [1]; Edward Roddy (equal contributor) [1]; Nadine E Foster (equal contributor) [1]

Background

Joint pain, specifically chronic knee pain (CKP), is a frequent cause of primary care consultations and limitation of function and mobility among older adults. Approximately 25% of adults aged over 45 years have previously experienced knee pain lasting over a month or had an episode of knee pain in the last year and prevalence increases with age [1, 2, 3]. More than 90% of GPs manage at least one patient with severe knee pain over a two-week period [4]. In the UK, the National Institute for Health and Clinical Excellence (NICE) has recognised the importance of good management of peripheral arthritis by publishing guidelines, Osteoarthritis: the care and management of osteoarthritis in older adults , in February 2008 [5].

Evidence suggests that exercise improves functioning and symptoms in CKP/KOA [6] and has the supplementary benefits of improved cardiovascular status [7], emotional wellbeing [7] and proprioception [6]. Multiple generic, secondary and primary care guidelines recommend management for CKP and/or knee osteoarthritis (KOA) [6, 8, 9, 10, 11, 12, 13]. These, and a Cochrane review [14], conclude that exercise is beneficial and should be a first-line management strategy for CKP/KOA [5, 6, 12, 15, 16].

Providing advice to exercise will not necessarily improve patient outcomes. Patients must translate advice into action. They must follow advice correctly, for adequate time and with adequate intensity to improve function and symptoms. Patients may undertake exercise independently from GPs or other healthcare practitioners' advice [17]. Without instruction, motivated patients may exercise with little or no benefit [18].

As CKP/KOA is commonly managed within primary care, it is logical that GPs should implement guideline recommendations and advise patients to adopt and maintain exercise activity. GPs may advise patients to exercise, prescribe specific exercises of particular type, duration or frequency, or refer patients to another professional, for example a physiotherapist.

The implementation of guideline recommendations about exercise as a core management strategy for CKP/KOA may be influenced by the attitudes and beliefs of GPs regarding the use of exercise for this patient population. However, the nature of such attitudes/beliefs and the extent to which GPs recommend or use exercise for CKP/KOA is uncertain. A systematic literature review was conducted to investigate the attitudes, beliefs and behaviours of GPs, regarding exercise for CKP/KOA in adults aged 45 years or older.

Methods

Search terms were chosen to identify research studies pertaining to CKP/KOA, exercise, GPs, attitudes or beliefs and behaviours, see Table 1. EC searched the databases MEDLINE, EMBASE, PsycINFO and CINAHL. Search terms were exploded and titles and abstracts were searched within articles from the database inception date to January 2008. Duplicates were removed. Title and abstracts of identified articles were reviewed. Articles failing to meet inclusion criteria and/or meeting at least one exclusion criterion were excluded. The full text of all remaining articles was reviewed, exclusion and inclusion criteria reapplied and non-relevant papers discarded. Additional relevant papers were sought from reference lists during full text review and from research team members who had identified them in previous CKP research. ER and NF independently reviewed the eligible literature for study inclusion. Where needed, authors were contacted to clarify/request data. Relevant papers published in non-English languages were translated.

Table 1 caption: Search terms used [see PDF for image]

Quality assessment

All relevant studies were independently quality assessed by EC and either NF or ER using The Newcastle Critical Appraisal Worksheet (NCAW) [19], designed for any study type, and the Critical Appraisal Skills Programme (CASP) Qualitative Research Assessment Tool, designed for qualitative studies [20]. Disagreements were resolved through discussion by the initial assessors or using a third assessor.

Inclusion criteria

Articles were relevant if they were empirical studies about knee pain, specifically CKP/KOA in adults over 45 years; related to primary care, included information about exercise and contained details about the attitudes, beliefs and/or behaviours of GPs towards exercise for CKP/KOA. There was no limit on research methodology or language of the original article. For this review, a working definition of CKP was mechanical knee pain, with or without loss of function, and with or without radiographic changes consistent with KOA, that has lasted for at least three months. Radiographic confirmation of KOA was not required due to the discordance between pain and OA-related radiographic changes [21].

Exclusion criteria

Studies were excluded if they referred to patellofemoral pain syndrome alone, or CKP/KOA resulting from trauma, malignancy, infection, inflammatory arthritis or secondary to other diseases, or that occurring in a prosthetic joint.

Attitude, beliefs and behaviour

The constructs of attitudes, beliefs and behaviours are complex. Therefore, for the purpose of this study, the following simplified working definitions were agreed among the authors and used. An attitude is defined as "a settled way of thinking" [22]. A belief is "an acceptance that something exists or is true" [22] or "a firmly held opinion or conviction" [22]. Attitudes and beliefs may be reported by study participants; alternatively they may be implied by physician behaviour. We reviewed reported and observed behaviours described by each study and considered whether these implied positive or negative attitudes and/or beliefs to exercise. For example, if a physician suggested rest for CKP/KOA in a study, the data was extracted as an implied belief that exercise for CKP/KOA would not be positive for the patient. Both implied and reported attitudes and beliefs were included and highlighted as such.

Behaviours are the ways in which one acts or conducts oneself [22]. Behaviours can result from attitudes and beliefs but may not truly indicate these. Behaviours can be reported or observed. Physician self-reported clinical management constitutes "reported behaviour". Data on "actual behaviour" refers to that which has either been collected through direct observation, patient report or from case-note or medical record review.

Advice to, or prescription of, exercise?

The distinction between prescribing and advising exercise was defined by the amount and type of information relayed to the patient. To "prescribe " exercise, GPs should inform patients of the required type, duration and frequency of exercise. Exercise "advice " implies that the GP has recommended the patient to exercise and may have provided broad categories of exercise to undertake. GPs may "prescribe" or "advise" exercise through referral to a physiotherapist. Provision of an exercise leaflet is an easy and reproducible way of GPs providing consistent information to patients. However, leaflet provision may be considered to be either advice to exercise or prescription of exercise depending upon the information contained within it. Exercise prescription, however, requires information regarding the type, duration and suggested frequency of exercise which are likely to vary, at least initially, from patient to patient. Therefore, as a leaflet can only provide general, rather than patient-specific, advice, information leaflets were classified as advice to exercise rather than an exercise prescription for the purposes of this study.

Results

Literature search

After removal of duplicates, 2135 articles were identified. Twenty papers reporting 20 different studies undertaken between 1992 and 2007 fulfilled the inclusion and exclusion criteria (Figure 1). Five articles described both attitudes and beliefs as well as behaviours of GPs, therefore of the 20 relevant articles, seven described attitudes and beliefs of GPs towards exercise for KOA [23, 24, 25, 26, 27, 28, 29] [Additional File 1] and eighteen described behaviours of GPs regarding exercise for CKP/KOA [4, 23, 27, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42] [Additional File 2].

Figure 1: Flow chart demonstrating results of literature search for attitudes, beliefs and behaviours of GPs about exercise for CKP/KOA . [see PDF for image]

Additional file 1: Summary of studies investigating the attitudes and beliefs of GPs towards exercise for KOA . Table detailing the studies that were included in the literature review that investigated the attitudes and beliefs of GPs towards exercise for knee osteoarthritis including information on the study population, study method, type of exercise under investigation, a summary of the findings and limitations to the quality of the paper and further comments on the paper

Additional file 2: Summary of studies investigating the behaviours of GPs towards exercise for CKP/KOA . Table detailing the studies that were included in the literature review that investigated the behaviours of GPs towards exercise for CKP/KOA including information on the study population, study method, type of exercise under investigation, a summary of the findings and limitations to the quality of the paper and further comments on the paper.

Of the 20 papers, three focussed on the management of patients with CKP, 16 focussed on patients with KOA, symptoms of KOA or clinical diagnosis of KOA, and one differentiated between CKP and KOA. The four studies that related specifically to CKP [30, 35, 38, 40] were UK studies. Definitions of CKP and KOA used by many studies were unclear and/or inconsistent.

Of the studies investigating attitudes and beliefs of GPs towards exercise for KOA, one was performed in the UK, one in the Netherlands, two in Canada and three in France. One of the latter three also included practitioners from Belgium, Italy, Spain and Switzerland. Seven of the 18 studies investigating the behaviour of GPs regarding exercise for CKP/KOA were conducted in the UK. Of the remaining studies, two were from France, three from USA, two from Canada and one each from Netherlands, Germany, Czechoslovakia and Italy.

Multiple methods were used to investigate attitudes and behaviours of GPs, these included physician questionnaires (n = 9), patient interviews (n = 5) and questionnaires (n = 4), case-note reviews (n = 3) and physician interviews (n = 1).

Quality Appraisal

Both quality assessment tools [19, 20] highlighted similar strengths and weakness of the studies. Disagreements between assessors occurred in 8% of initial decisions and all were resolved. A summary of the agreed quality assessment results, using the NCAW, are provided in Additional File 3 and further details can be found in Additional Files 1 and 2.

Additional file 3: Quality appraisal of papers found using The NCAW . Table summarising the points of The Newcastle Critical Appraisal Worksheet that each study met or did not meet during quality assessment following assessment by two independent assessors with resolution of any disagreements occurring through the use of a third independent assessor.

All articles clearly stated the research question, study type and outcome factors. Most articles failed to provide details of ethical approval, and whilst most described their sampling frame, many used small sample sizes of specialist groups or volunteers in limited geographical areas.

Most studies had low response and/or follow-up rates and were therefore open to response bias. Response rates ranged from 7.4%-94% for the studies examining GPs' attitudes towards exercise for KOA and from 27-94% for studies investigating behaviour. Seven of the fifteen relevant studies (47%) had a response rate lower than 50%. Few studies explored the extent and/or likelihood of non-response bias.

Study methods potentially introduced problems, for example, use of lists/multiple-choice response options or structured questionnaires may promote over-reporting of actual behaviours. Recall bias is also inherent in any study relying on patient report.

Studies often failed to discuss the researcher-participant relationship, or how the study tools were developed. The clinical utility of one study [31] was limited by the question posed, "do you provide or refer for the following treatments?" This questioning style attempts to assess whether GPs ever used certain treatments and fails to provide meaningful insight into regular practice.

Attitudes and Beliefs Concerning Exercise

Of the seven studies reporting attitudes of physicians towards exercise for KOA five used physician-completed questionnaires [24, 25, 26, 27, 29], one used patient interviews [28] and the other physician interviews [23]. Of these, three directly investigated the attitudes of GPs [23, 26, 29] but two of these studies focussed on attitudes towards guidelines recommending exercise for KOA [26, 29]. Of the remaining four studies, attitudes of GPs were indirectly gained from patient interviews [28] or were implied; as GPs suggested rest, rather than exercise [24, 25, 27].

A wide range of attitudes of GPs towards exercise for KOA was highlighted, from GPs believing exercise should not be used i.e. they advised rest [24, 27], to almost total agreement with guideline recommendations for the use of exercise for KOA [26] [Additional File 1]. Of the seven studies that investigated attitudes and beliefs of GPs towards exercise for KOA, three implied less than positive attitudes [24, 25, 27]. Hendry et al [28] used patient report, to highlight positive and negative attitudes towards exercise for KOA although the opinions of GPs were not always clear. de Bock et al [23] detailed GP's positive attitudes about physiotherapy compared to pharmacological therapy.

Behaviour Concerning Exercise

Within the 18 studies investigating behaviour of GPs regarding exercise for CKP/KOA, eight presented information on "reported behaviours" of GPs [4, 24, 25, 26, 27, 30, 31, 33]. The remaining 10 studies detailed "actual" behaviour using; patient questionnaires (n = 3) [34, 38, 39], patient interviews (n = 3) [32, 37, 40], case-note review (n = 3) [23, 35, 41] and patient questionnaires and interviews (n = 1) [36]. These studies suggest variable inclusion of exercise by GPs in the management of CKP/KOA [Additional File 2]. Although 99% of GPs reported ever providing advice or referring to a physiotherapist [31], the frequency of actual provision of exercise advice or physiotherapy referral was lower. Estimates of provision of exercise advice and physiotherapy referral were generally higher for vignette-based studies (exercise advice 9%-89% [4, 24, 25, 26, 27, 30];physiotherapy referral 44%-77% [27, 30, 33]) than reviews of actual practice (exercise advice 5%-52% [23, 32, 36, 40, 41, 42]; physiotherapy referral 13-63% [23, 34, 35, 37, 38, 39, 40]). Of the studies specifically concentrating on CKP, 18-40% patients had received or been referred for physiotherapy [35, 38, 40], 44-54% of GPs stated they would refer to physiotherapy and 59-76% stated they would advise on knee joint exercises for such patients [30].

Discussion

Guideline recommendations emphasise exercise as a core first-line management strategy for CKP/KOA in primary care [15] and the UK Department of Health's 2006 Musculoskeletal Services Framework [43] recognised exercise as beneficial in people with osteoarthritis and thus information should be provided to patients to "promote exercise". A systematic literature review was conducted to investigate the attitudes, beliefs and behaviours of GPs, specifically relating to exercise for CKP/KOA.

Summary of Results

A paucity of studies investigating attitudes and behaviours of GPs regarding exercise for CKP/KOA was identified. This systematic review identified studies that utilised a range of methods including qualitative and quantitative approaches. This prevented use of a single quality assessment tool. Thus two tools were used for each study and provided similar results. Response rates varied widely (7-94%), but were generally poor with 47% of studies having a response rate lower than 50%. Therefore non-response bias may lead to unrepresentative estimates of broader GP populations. Most studies used descriptive questionnaire or interview methods.

Attitudes and beliefs towards exercise for KOA appear to be diverse and, overall, exercise of any type appears to be under-used, -advised and/or -prescribed by GPs managing CKP/KOA. Although 99% of GPs reported ever providing advice or referring to a physiotherapist [31], the frequency of actual provision of exercise advice or physiotherapy referral was lower (6-63%). The methodology used within the study resulted in further differences in the estimates of provision of exercise advice and physiotherapy referral. Use of vignette-based studies generally yielded higher estimates than reviews of actual practice. Results also differed depending on how physicians were questioned about their behaviour. Some studies asked about the GPs' "ever use" of exercise whilst others asked about specific cases. The former style unsurprisingly yielded higher proportions of GPs referring patients with CKP/KOA to physiotherapy [31]. In studies examining "actual" behaviour there was a higher referral rate to physiotherapy than GP provision of advice to exercise. This may result from uncertainty of GPs about the optimum exercises to advise/prescribe or from time restrictions imposed on GPs' patient consultations.

Inconsistencies and/or ambiguity in methodology, definitions, attitudes, beliefs and behaviours under investigation both hindered direct comparison of results and may partly explain the variability observed. Studies investigating attitudes and beliefs of GPs towards exercise for KOA used undefined, non-specific terms such as "suggest" and "recommend". Only one study [28] acknowledged the management spectrum for CKP/KOA, from advice to exercise through to specific exercise prescription. Terminology describing GPs' behaviours included "provide", "prescribe", "recommend", "instruct" and "advise", however, these terms were not defined. Commonly, definitions of the term "exercise" were missing from papers, thus it could not be determined if "exercise" referred to general aerobic exercise, specific quadriceps strengthening exercises, range of movement exercises or all three [Additional File 2].

Findings in relation to existing literature and guidance

Individual studies investigating attitudes, beliefs and behaviours of GPs regarding exercise for KOA have commented on the under-use of non-pharmacological treatment modalities and, specifically, exercise. A Canadian study, excluded from this literature review due to uncertainty about the relevance of the sample, found that only 63% of patients with KOA symptoms had ever been recommended to undertake exercise [44]. The results of our review support these findings. The frequency of use of exercise for CKP/KOA appears similar to that for hip [45] and back pain [46]. A USA study reported that only 17% of GPs suggested exercise of any type and only 14% referred patients to physiotherapy for hip pain [45]. Another USA study stated 29% of patients had been "prescribed" exercise by a physician for back pain [46].

The Department of Health's Musculoskeletal Framework [43] describes the roles of GPs as being a "direct route into the NHS" and "gatekeepers for other services". It explicitly describes education resulting in reduced prescribing of non-steroidal anti-inflammatory drugs and that GPs undertake a large number of joint injections, however it does not mention the role of GPs in providing exercise advice or prescriptions. Reference within the Framework to the primary care team may result in the locus of responsibility for exercise prescription and/or initiation being shifted away from the GPs themselves and on to allied healthcare professionals. These factors may result in varied attitudes and behaviours of GPs depending upon their local service configuration and on their interpretation of their responsibilities within the national Framework. The Framework's Hip and Knee Pain flow chart describes "active management", "facilitate self-management" and "give patient information" as roles of GPs, however, which indicates that GPs should be providing the recommended information on exercise for such conditions.

Limitations of this study

The key limitation of this systematic review is the paucity of studies found. This indicates that the review topic is relatively under-researched. Few studies described CKP as per our working definition, although many studied KOA, which usually follows a chronic course.

The methodologies used within the included studies may introduce some inaccuracy, for example, it seems that studies that solely relied on GP self-report may have over-estimated exercise behaviours. Further, reliance on patient report of GP behaviours may result in recall bias and under-reporting of behaviours, and record review is only as accurate as the notes made and thus may result in under-reporting of behaviours. Our use of implied beliefs, obtained through extraction of study data may have further skewed data if the physicians' advice to rest did not always indicate a less than positive attitude towards exercise. Such implied beliefs may be biased by multiple unmeasured influences. The interpretation of the terms "exercise" and "rest" may have been different for the authors and the physicians taking part in the study. A physician may advise "rest" from usual physical activities if these are usually of high intensity or knee straining but not be advising complete rest of the knee. However, this latter point was not the case in the study by Chevalier et al [24] as the proportion of patients provided with "joint sparing advice" decreased as the rates of advice for "strict bed rest" increased. The frequency with which GPs exhibited implied negative attitudes and beliefs about exercise for CKP was low, therefore, by eliminating the studies from which implied attitudes and beliefs were extracted, there is still a spectrum of opinion ranging from the more negative and/or ambivalent approaches such as that exercise is unable to change symptoms [23] and that it will at least be less harmful than alternatives [23] through to positive attitudes that physicians generally agree with the use of exercise [29] and almost total agreement with recommendations that include exercise for CKP/KOA [26].

No studies examined the explanations underlying the reported attitudes so it is difficult to draw strong conclusions from the data regarding attitudes. However, published discussions suggest factors that may negatively affect GP's attitudes: exposure to contradictory information [26], concern about lack of efficacy [23] and potential for harm [27].

Clinical and research implications resulting from this study

Small response rates and use of specialist groups of GPs limited the generalisability of the results of many studies. Such samples may provide over-estimates of exercise behaviour. Given the apparent under-use of exercise by GPs for patients with CKP/KOA, it is possible that the true pattern of practice is even further from exercise recommendations in available guidelines. The negative clinical effect of this apparent under-use of exercise use may be further exaggerated if patients are unable to translate advice or instructions into correctly executed and frequently performed exercises. Dexter et al [32] noted that of those that had been advised to exercise for hip and/or knee OA only 63% did so. In addition, only 10% of patients who were undertaking strengthening and/or stretching exercises of the hip or knee were performing these correctly and regularly.

Individual studies suggested potential reasons for the apparent under-use of exercise by GPs. These include, uncertainty about the role of GPs in relation to exercise for CKP [47, 48] and/or appropriate types [36] of exercise, uncertainty of the correct exercise "prescription" [14, 47]; lack of awareness about the guidelines [26]; the belief that patients will not exercise [49]; the presence of comorbidities [48]; increasing patient age [47, 48]; and limited access to services [50]. Barriers imposed by healthcare systems such as unclear referral criteria, limited onward referral to other healthcare professionals and limited consultation time may prevent GPs from providing their desired management. Østbye et al [51] reinforced the latter issue by identifying that provision of comprehensive management for ten common chronic diseases, including arthritis, exceeds the total time GPs have for all patient care [51]. Future research should focus on consistent investigation of attitudes, beliefs and behaviours of GPs regarding the use of exercise for CKP. Research should identify, or confirm suggested, barriers to the use of exercise for CKP and thus full implementation of national guidelines. System barriers and GP attitudes and behaviours, may vary within and between countries due to local and national differences in healthcare provision. Therefore, further research should utilise large, nationally representative samples of GPs.

The role of GPs in initiating exercise for CKP/KOA was not outlined in studies or guidelines, including the recent NICE guidelines [5, 15]. Primary care guidelines recommend "exercise" as a core management approach for CKP/KOA [15] but provide no explicit expectations about whether GPs should refer patients for exercise therapies, advise general or specific exercises, or prescribe exercises. The expected roles of GPs in initiating and supporting exercise in patients with CKP thus requires clarification. Work must also identify the optimal means of supporting and educating GPs at the clinical, educational and service level, to improve certainty and confidence about the value of exercise and to use the exercise recommendations in practice.

Conclusions

Our systematic review has highlighted a paucity of studies investigating, and variability in, the attitudes, beliefs and behaviours of GPs regarding the use of exercise for CKP. However, this treatment modality appears to be underused by GPs. Future work should investigate the attitudes, beliefs and behaviours of GPs regarding exercise for CKP and clarify the expected roles of GPs to help support the translation of best practice recommendations into everyday clinical care.

Abbreviations

CASP: Critical Appraisal Skills Programme; CKP: chronic knee pain; GP: general practitioner; KOA: knee osteoarthritis; NCAW: Newcastle Critical Appraisal Worksheet; NICE: National Institute for Health and Clinical Excellence; PCP: primary care physician

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

EC carried out the literature search, quality assessment and data extraction. ER and NC assessed identified literature for eligibility, confirmed accurate and consistent data extraction and undertook quality assessment. All authors participated in the design of the study and helped to draft the manuscript. All authors read and approved the final manuscript.
Sumber : PowerSearch

Kesalahpahaman tentang olahraga, dapat mengganggu usaha seseorang untuk mencapai hasil yang diinginkan saat berolahraga atau melakukan latihan fisik.

Berikut ini 10 mitos yang berkembang seputar olahraga/latihan fisik.

Sebut saja Martina Navratilova salah satu petenis profesional perempuan berhasil menyangkal salah satu anggapan yang paling susah ditentang, bahwa perempuan itu memiliki stamina dan daya tahan yang kurang dibandingkan dengan laki-laki. Itulah sebabnya pada olahraga tenis, perempuan dibatasi hanya bermain tiga set, sementara laki-laki bisa sampai lima set. Pada kenyataannya, perbedaan fisiologis yang membuat laki-laki lebih berotot daripada perempuan tidak serta merta berujung pada adanya perbedaan daya tahan antara laki-laki dan perempuan. Perempuan juga bisa melakukan berolahraga, sekeras dan selama yang dilakukan oleh laki-laki. Justru perempuan lebih cepat proses pemulihan staminanya setelah melakukan olahraga yang melelahkan dibanding laki-laki.

Ketika para ilmuwan dan atlit perempuan berhasil mematahkan anggapan/mitos tersebut di atas, gagasan-gagasan kuno dan tak berdasar lainnya tentang olahraga terus bertahan, bahkan muncul kesalahpahaman-kesalahpahaman baru. Gagasan-gagasan yang tidak benar tersebut dapat menghalangi seseorang untuk melakukan berolahraga bahkan bisa membuang waktu, tenaga, dan uang dengan percuma untuk olahraga yang tak bermanfaat, bahkan malah berbahaya terhadap kesehatan. Berikut ini 10 ketakutan yang tak beralasan, pemahaman-pemahaman negatif dan harapan-harapan palsu tentang latihan olahraga.

1. Anggapan : Olahraga yang berat lebih besar manfaatnya dibandingkan olahraga ringan

Faktanya : Olahraga yang berat dapat meningkatkan kapasitas aerobik seseorang jauh lebih banyak dibandingkan olahraga ringan atau olahraga sedang. Walaupun hal itu bisa meningkatkan performa atlit, bukan berarti itulah yang diperlukan untuk mendapatkan kesehatan yang prima. Tingkat kematian akibat penyakit jantung koroner, kanker , dan sebab-sebab lainnya, setelah digabungkan jauh lebih rendah pada orang-orang yang melakukan olahraga sedang daripada orang-orang yang tidak melakukan olahraga sama sekali dan hanya sedikit lebih rendah pada orang yang melakukan olahraga berat dibandingkan yang melakukan olahraga sedang. Hal yang sama berlaku juga pada kasus diabetes mellitus tipe II, yang sejauh ini merupakan jenis yang paling umum.

Di samping itu olahraga ringan dan sedang mampu mengurangi stress, kecemasan dan tekanan darah seefektif olahraga berat. Selain itu olahraga ringan seperti berjalan dapat mengontrol berat badan seefektif olahraga berat seperti jogging, karena jumlah kalori yang terbakar ditentukan oleh banyaknya langkah bukan oleh cepat atau lambatnya langkah tersebut. Dan pada kenyataannya justru olahraga ringan sedang lebih efektif dibandingkan olahraga berat bagi kebanyakan orang, karena mereka mampu berjalan lebih jauh dari yang mampu mereka tempuh dengan berlari.

Jadi lebih baik melakukan olahraga ringan secara rutin daripada melakukan olahraga berat tapi tak teratur.

2. Anggapan : kita bisa mengurangi lemak pada bagian tertentu tubuh kita dengan melakukan latihan pada bagian tersebut.

Faktanya : tidak ada pengurangan bagian seperti itu. Ketika kita melakukan latihan, kita memproduksi energi dengan membakar lemak yang ada di seluruh bagian tubuh kita, bukan hanya pada otot-otot yang paling banyak digunakan. Pada kenyataannya, gen kita bisa menentukan lemak yang terlebih dahulu hilang dari bagian tubuh kita misalnya wajah dan lengan kita lebih dulu dibandingkan perut walaupun yang kita lakukan adalah latihan otot perut. Bagaimanapun juga, melatih bagian tertentu tubuh seperti perut, dapat memberikan manfaat tersendiri pada bagian tersebut : memperkuat otot perut dapat membuat seseorang lebih langsing.

Jadi lemak yang hilang dari tubuh kita juga ditentukan oleh gen.

3. Anggapan : semakin banyak keringat yang keluar saat olahraga, semakin banyak lemak yang dihilangkan

Faktanya : semakin keras kita berolahraga, semakin banyak kalori yang dibakar dalam periode tertentu, sehingga semakin banyak kita kehilangan lemak. Tapi seberapa banyak kita berkeringat tidak selalu mencerminkan seberapa keras olahraga yang kita lakukan. Beberapa orang cenderung mengeluarkan keringat terus menerus disebabkan oleh berat badan, kondisi lemah atau keturunan. Dan setiap orang lebih berkeringat ada cuaca panas, terik atau saat memakai pakaian tebal daripada saat cuaca dingin, lembab, atau saat memakai pakaian berpori. Kita mungkin berpikir kita akan mengeluarkan keringat yang banyak saat cuaca lembab, padahal udara yang lembab memperlambat terjadinya evaporasi tubuh.

Berolahraga pada cuaca panas atau dengan pakaian plastik penurun berat badan, akan membuat kita benar-benar mengeluarkan keringat yang banyak dan berat badan kita akan turun dengan segera. Namun berat badan yang hilang tersebut hampir semuanya adalah air yang kita keluarkan lewat keringat. Berat badan kita akan kembali seperti semula saat kita memulihkan stamina kita dengan minum air setelah olahraga. Lebih lanjut, kita akan mengalami keletihan yang berlebihan jika kita memaksakan diri berolahraga pada suhu panas atau dengan pakaian plastik yang mencegah keringat berevaporasi.

Jadi banyak berkeringat bukan tidak selamanya bagus.

4. Anggapan : Minuman isotonik dapat membantu kita melakukan olahraga yang aman dan efektif.

Faktanya : minuman isotonic mengandung dua kandungan utama yang secara teoritis bermanfaat bagi atlit, yaitu natrium yang membantu tubuh menyimpan persediaan air, dan gula yang dibakar oleh tubuh menjadi energy. Tapi sangat sedikit orang yang melakukan olahraga yang keras sampai menyebabkan natrium dari tubuhnya dikeluarkan melalui keringat, atau menggunakan semua persediaan karbohidratnya, yang diubah menjadi gula oleh tubuh. Seseorang harus melakukan jogging paling tidak dua jam misalnya untuk membuat cadangan karbohidratnya berkurang. Jadi selama kita tidak melakukan lari marathon atau olahraga yang sangat melelahkan sekali, dengan air putih saja sudah cukup untuk memulihkan kondisi tubuh kita.

Jadi jika tidak melakukan jogging selama dua jam atau latihan yang berat sekali, maka air putih lebih baik daripada minuman isotonik.

5. Anggapan : Senam aerobik cenderung membuat kita merasa lapar, sehingga membuat usaha untuk menurunkan berat badan jadi sia-sia.

Faktanya : senam aerobik seperti jogging dan jalan cepat cenderung meningkatkan nafsu makan seseorang, namun tampaknya hanya jika orang tersebut membutuhkan kalori ekstra. Penelitian menunjukkan bahwa orang-orang kurus yang melakukan latihan seperti itu , merasa lebih lapar, sehingga mencegah mereka untuk menjadi lebih kurus. Sebaliknya, latihan tersebut tidak meningkatkan nafsu makan pada orang gemuk, sehingga latihan ini seharusnya dapat membantu mereka untuk lebih langsing.

Jadi senam aerobik menyebabkan rasa lapar pada orang yang kurus sehingga bisa menjadi lebih berisi, tapi tidak untuk yang memang sudah gemuk.

6. Anggapan : latihan kekuatan otot tidak dapat membantu seseorang untuk menjadi lebih kurus, karena membakar sedikit kalori dan malah menambah massa otot.

Faktanya : latihan kekuatan otot baik menggunakan beban, mesin, atau karet, secara substansial dapat meningkatkan jumlah kalori yang dibakar oleh tubuh. Sebuah sesi khusus, di mana seseorang beristirahat sebentar setelah melakukan latihan pembentukan otot akan membakar kalori setidaknya secepat yang dilakukan saat berjalan. Latihan sirkuit, di mana kita berpindah dengan cepat dari latihan kekuatan otot yang satu ke latihan kekuatan otot yang lain akan membakar kalori lebih cepat dari kecepatan pembakaran kalori saat kita berjalan. Selanjutnya tubuh kita akan membakar kalori selama berjam-jam setelah melakukan salah satu jenis latihan tersebut. Dan yang lebih penting, otot yang telah dilatih akan cenderung membakar kalori dengan cepat, walaupun saat kita tidak sedang melakukan latihan.

Dalam sebuah studi kasus, latihan kekuatan selama tiga bulan dapat meningkatkan rata-rata tingkat pembakaran kalori tubuh sebanyak 7 % dan membakar 4 pon lemak. Dan yang tidak kalah penting, lemak yang berhasil dibakar tidak berpengaruh terhadap penambahan 15 % terhadap jumlah kalori mereka. Jika para peneliti tidak mendorong mereka untuk mempertahankan berat badan mereka dengan makan lebih banyak dari keinginan mereka untuk makan, makan dapat dipastikan berat badan mereka akan turun drastis.
Latihan kekuatan otot sangat membantu dalam program diet komprehensif, yang meliputi senam aerobik (membakar banyak kalori selama latihan dan beberapa kalori setelah latihan) dan diet kalori rendah tingkat sedang. Penelitian baru-baru ini menemukan bahwa wanita yang menjalani diet ketat tingkat sedang, dan melakukan latihan salah satu dari latihan kekuatan otot atausenam aerobik berat badannya menurun lebih banyak daripada yang hanya diet tanpa latihan. Tapi wanita yang melakukan kedua jenis latihan tersebut secara bergantian berat badannya menurun paling banyak.

Jadi dengan melakukan latihan pembentukan otot dapat meningkatkan jumlah lemak yang dibakar oleh tubuh dan peningkatan massa otot membuat seseorang terlihat proporsional.

7. Anggapan : latihan kekuatan otot dapat membentuk otot dan tulang, tapi tidak ada manfaatnya untuk jantung.

Faktanya : latihan kekuatan otot dan senam aerobik adalah cara latihan yang ideal tidak hanya untuk pinggang tapi juga untuk jantung. Salah satu analisis dari 11 uji klinik, ditemukan bahwa latihan kekuatan otot dapat mengurangi jumlah kolesterol jahat LDL (walaupun sedikit berpengaruh juga terhadap kolesterol baik HDL). Sebaliknya, senam aerobik justru dapat meningkatkan jumlah kolesterol baik HDL dan sedikit berpengaruh terhadap kolesterol jahat LDL. Lebih lanjut beberapa studi menganjurkan latihan kekuatan seperti halnya senam aerobik untuk mengurangi tekanan darah (namun sebelumnya periksa tekanan darah terlebih dahulu sebelum melakukan program pembentukan otot, karena latihan ini dapat meningkatkan tekanan darah selama latihan, sehingga bagi yang hipertensi bisa diantisipasi). Dan satu lagi manfaat terakhir, latihan kekuatan otot dapat mengurangi serangan jantung akibat penggunaan tenaga secara tiba-tiba atau tak biasa, misalnya memindahkan perabotan atau menyekop salju.

Jadi latihan kekuatan otot selain bermanfaat untuk tulang dan otot, juga baik untuk jantung.

8. Anggapan : ketika kita berhenti berolahraga, otot kita akan berubah menjadi lemak.

Faktanya : kurang olahraga akan menyebabkan otot-otot mengecil dan mengurangi tingakat pembakaran kalori tubuh. Kurangnya aktifitas itu sendiri selanjutnya dapat mengurangi jumlah kalori yang dapat dibakar oleh tubuh. Jadi orang yang berhenti berolahraga memang terancam untuk berlemak. Tapi itu tidak berarti bahwa otot akan berubah menjadi lemak, karena keduanya merupakan jaringan yang sama sekali berbeda. Ini juga tidak berarti lemak akan langsung tertimbun begitu saja di sekitar otot kita jika kurang olahraga, karena kita bisa mengantisipasinya dengan mengurangi jumlah kalori yang dikonsumsi saat kita berhenti berolahraga (walaupun cara terbaik untuk menjaga tubuh tetap proporsional adalah dengan diet dan latihan yang teratur).

Jadi ketika kita berhenti berolahraga kita dapat mengurangi penimbunan lemak dengan mengurangi jumlah kalori yang dikonsumsi.

9. Anggapan : pembentukan otot dapat mengurangi kegesitan

Faktanya : jika kita melakukan latihan kekuatan otot tanpa menggerakkan sendi secara penuh (sesuai jarak gerak sendi maksimalnya), maka fleksibilitas (kegesitan) kita memang akan menurun. Tapi latihan kekuatan otot justru akan meningkatkan fleksibilitas seseorang jika dia saat latihan dia menggerakkan sendinya secara penuh. Melakukan stretching (peregangan) setelah latihan pembentukan otot dapat membantu menjaga kelenturan tubuh kita (stretching sebaiknya dilakukan sebelum dan sesudah melakukan senam aerobik).
Jadi latihan pembentukan otot tidak mengurangi fleksibilitas, justru meningkatkannya jika dilakukan dengan benar.

10. Anggapan : latihan kekuatan otot cenderung membuat fisik wanita menjadi seperti laki-laki (tomboy).

Faktanya : sangat sulit bagi kebanyakan wanita untuk memiliki otot yang besar. Hal ini disebabkan karena wanita hanya memiliki sedikit hormon testosteron yang mempengaruhi pertumbuhan otot. Baik pria maupun wanita, dapat memperkuat ototnya ketimbang memperbesarnya dengan latihan melawan tahanan atau beban ringan sebanyak 25 kali dibandingkan dengan melakukan sedikit latihan berat.

Jadi perempuan yang melakukan latihan kekuatan otot tidak serta merta menjadi seperti laki-laki.

Referensi : spritual.com.au