iranian rehabilitation...

Iranian Rehabilitation Journal The official Journal of the University of Social Welfare and Rehabilitation Sciences

Editor-in-Chief Asghar Dadkhah, PhD., Professor University of Social Welfare and Rehabilitation sciences Tehran, Iran [email protected] Executive Manager Maryam Ranjbar [email protected] EDITORIAL BOARD Harizuka Susumu, PhD., Professor Kyushu University, Fukuoka, Japan Helander Einar, PhD., President Community Based Rehabilitation Organization, Lisbon, Portugal Hosseiny Seyed Ali, PhD., Assistant professor University of Social Welfare and Rehabilitation sciences, Iran Kamali Mohammad, PhD., Associate professor Iran University of Medical Sciences, Iran Kumar Surender, PhD. Professor Chikushi Jogakuen University, Japan Lotfi Gharahbagh Yunos, PhD., Assistant professor University of Social Welfare and Rehabilitation sciences, Iran McConkey Roy, PhD., Professor University of Ulster, Northern Ireland Mirzamani Syd Mahmood, PhD., Associate professor Baqiyatallah University of Medical Science, Tehran, Iran Nillipour Reza, PhD., Professor University of Social Welfare and Rehabilitation sciences, Iran Reife Carol, PhD., Associate professor Leiden University, Leiden, The Netherlands

Iranian Rehabilitation Journal is an international forum for the publication of peer-reviewed novel papers on the rehabilitation, with two issues published per year. The journal strives to provide its readers with a variety of topics, including: investigations of clinical and basic research in various special needs groups; original articles; hypothesis formation; literature reviews; case reports; short communications, special reports; letters to the editor; discussions of public policy issues and book reviews, methodology in physical and mental rehabilitation, epidemiological studies on disabling conditions and reports on vocational and socio-medical aspects of rehabilitation. Contributions from all parts of the world and from different professions in rehabilitation are welcomed. Please read the "Author Guidelines" carefully for details on the submission of manuscripts, the journal's requirements and standards.

Journal Citation Reports®: ISC(Islamic world Science Citation); IMEMR(Index Medicus for WHO); Magiran; Iran Medex; DOAJ (Directory of Open Access Journals) Editorial Contact Iranian Rehabilitation Journal (IRJ) University of social welfare and rehabilitation sciences Evin, Kudakyar Ave., Tehran - 1985713831, Iran Tel/Fax: +98-21-2218-0082

[email protected] http://www.rehabj.ir

EDITOR’S NOTE

IRJ (Iranian Rehabilitation Journal) is now included in the Directory of Open Access Journals.

Iranian Rehabilitation Journal is the only English journal in Rehabilitation and research in Middle East. Number fourteen of this journal is going to be published with variety of articles in rehabilitation issues. We welcome original articles, reviews and case reports. Open Access Journal is a journal that uses a funding model that does not charge readers or their institutions for access. DOAJ - Directory of Open Access Journals is one of them and it is our pleasure to announce that IRJ has been added to the directory of DOAJ. You can reach to Journals and articles from http://www.doaj.org/. University of social welfare and Rehabilitation sciences is supporting IRJ to facilitate researches and scholars by updating articles online. Please do visit IRJ website regularly www.rehabj.ir.

Asghar Dadkhah, PhD. Editor-in-Chief

CONTENTS

Original Articles

A comparison between three methods of language sampling: Freeplay, narrative speech and conversation 4 Yasser Rezapour Mirsaleh, Kianoosh Abdi, Hossein Rezai, Parisa Aboutorabi Kashani The state of Deterministic Thinking among mothers of autistic children 10 Mehrnoush Esbati Expressive language development in 45 cochlear implanted children following 2 years of implantation 14 Seyed Basir Hashemi,; Leile Monshizadeh Physical Appearance Concern Questionnaire (PACQ) in Iranian population 18 Katayoun Khadem, Asghar Dadkhah, Vahid Kazemi Gender difference in TEOAEs and contralateral suppression of TEOAEs in normal hearing adults 22 Farzaneh Zamiri Abdollahi; Yones Lotfi The impact of coping strategies on burden of care in chronic schizophrenic patients and caregivers 26 of chronic bipolar patients. Morteza Khajavi, Mansoureh Ardeshirzadeh, Susan Afghah, Behrooz Dolatshahi Effect of Time Constraind Induced Therapy on Function, Coordination and Movements of Upper 32 Limb on Hemiplegic adults Masoud Gharib, Hooman Ghorbani, Mehdi Abdolvahab, Nader Fallahi, Masoud Kasechi Challenge of Private Rehabilitation Centers and Welfare Organization (Behzisti) 37 Roghiye Akbari, Mohammad Kamali, Hasan Ashayeri, Narges Shafaroodi Identification of Genetic Polymorphism Interactions in Sporadic Alzheimer’s disease Using Logic 45 Regression Najimeh Tarkesh Esfehani, Mahdi Rahgozar, Akbar Biglarian, Hamidreza Khorram Khorshid Dental status and DMFT index in 12 year old children of public care Centers in Tehran 51 Nasim Shafiezadeh; Farin Soleimani; Nahid Askarizadeh; Saeedeh Mokhtari; Reza Fatehi Effects of Task Related Training and Hand Dominance on Upper Limb Motor Function in Subjects 55 with Stroke Mohammed Azam Khan; Fuzail Ahmad; Jamal Ali Moiz, Majumi M.Noohu

Reviews/Short communication Spasticity: a review of methods for assessment and treatment 60 Mohammad Amouzadeh Khalili ; Masoumeh Rasulzadeh Patient Centered Model of Care - A Positive Impact on Treatment Outcome in a Rehabilitation 65 Hospital in Saudi Arabia Rana Siddiqui ; Rober A. Asirvatham; Irfan Shaiza

Case Report Efficacy of Mindfulness-Based Cognitive Therapy on Depressed Mothers with Cerebral Palsy Children 69 Zahra Sedaghati Barogh; Jalal Younesi, Fateme Shoaei, Siyamak Tahmasebi

Iranian Rehabilitation Journal, Vol. 9, No. 14, 2011

Vol. 9, No. 14, Oct. 2011 4

* All correspondences to:Hossein Rezai; Email: <[email protected]>

Original Article

A comparison between three methods of language sampling: Freeplay, narrative speech and conversation

Yasser Rezapour Mirsaleh

Allameh Tabatabaee University, Tehran. Iran

Kianoosh Abdi University of social welfare and rehabilitation sciences, Tehran. Iran

Hossein Rezai* Semnan University of Medical Sciences,.Samnan, Iran

Parisa Aboutorabi Kashani Azad University Central Tehran Branch,.Tehran, Iran

Objectives: The spontaneous language sample analysis is an important part of the language assessment protocol. Language samples give us useful information about how children use language in the natural situations of daily life. The purpose of this study was to compare Conversation, Freeplay, and narrative speech in aspects of Mean Length of Utterance (MLU), Type-token ratio (TTR), and the number of utterances.

Method and Materials: By cluster sampling method, a total of 30 Semnanian five-year-old boys with normal speech and language development were selected from the active kindergartens in Semnan city. Conversation, Freeplay, and narrative speech were three applied language sample elicitation methods to obtain 15 minutes of children’s spontaneous language samples. Means for MLU, TTR, and the number of utterances are analyzed by dependent ANOVA.

Results: The result showed no significant difference in number of elicited utterances among these three language sampling methods. Narrative speech elicited longer MLU than freeplay and conversation, and compared to freeplay and narrative speech, conversation elicited higher TTR.

Conclusion: Results suggest that in the clinical assessment of the Persian-language children, it is better to use narrative speech to elicit longer MLU and to use conversation to elicit higher TTR.

Keywords: Conversation, Freeplay, narrative speech, Language sampling. Submitted: 10 Apr 2011 Accepted: 12 Sep 2011

Introduction The spontaneous language sample collection and analysis has an important role in evaluation of children's language skills (1-4). Because of the limitations of standardized language tests and the lack and unavailability of these tests in Persian language, the necessity for application of the spontaneous language sample analysis in the assessment of language skills of Persian children is obvious. Since language sampling embraces both the content and context of language use, it can present more detailed information for planning intervention. Also, representativeness and effect of conversational context that are of special importance when trying to

collect language samples, cannot be ensured by applying standardized language tests as the only method of language assessment. That is because representativeness can only be achieved by engaging the child and the conversational partner in a real conversation on topics of interest to the child (5). Standardized language tests are highly structured and cannot ensure obtaining a representative sample of child’s language. There are several common methods of language sample elicitation. Among these methods, Conversation, freeplay, and storytelling are the prominent ones (6).These methods elicit language samples containing different linguistic items.

Iranian Rehabilitation Journal 5

Conversation is a dialogue or discourse between the child and his partner and maybe about some aspects of the child’s every day experiences that are irrelevant to the immediate situation (7). Questions, topic imitation, request to repair and source of difficulty are common methods to elicit conversational language sampling (8).As a language sampling method, one of the limitation of the conversation is that the quantity and types of the child’s utterances obtained via conversation can easily be influenced by the features of the interaction in which the conversation takes place (9).Being highly structured, Lack of spontaneity of the language samples elicited by conversation is another limitation of this language sampling method (10).But, in the other side, conversation is a beneficial method, because language samples which elicited by conversation are very structured; All participants responded to the same questions in the same order, and all participant likely supposed the necessity of answering all of the questions that posed to them (11). To obtain child’s narrative speech sample, a verity of strategies may be used by the examiner. Some of these strategies include using stories with universal appeal, stories that present a puzzle, stories that are unique to the child’s experience (12), retelling stories driven from books (13), films, and pictures (5).Results of several studies show that compared to freeplay, retelling the stories elicit more complex language samples and less complex language samples than the conversation does (10). To reduce the influence of speaking partner and conversational setting on the child’s language output (14), clinicians use freeplay for collection of language samples that are more spontaneous in nature. But, eliciting language samples via freeplay causes several problems. First, while a child is in a freeplay context, collecting a spontaneous language sample that is representative of his expressive capabilities is a time consuming process. This is because the time required providing the child the opportunities to reveal all his structural and conversational behaviors are extensive. Second, another major limitation of freeplay is that different play materials and toys influence the use of language by children (15).In freeplay method, language samples elicited during clinician-child or child-peer interaction, when the child plays with age-appropriate toys. In freeplay context, the clinician invites the child to join a play and then initiates the play by himself. The clinician would play alone with

the child in a way that his play seems to be natural and appropriate. If the child was quiet for extended times, the clinician can evocate him to talk by asking several questions such as “what are you doing?” or “what will happen next?” (11). Language samples elicited by these three methods are evaluated by several criteria. For example, following seven criteria are among the most common criteria applied in several studies to analyze the language samples: number of utterances, diversity of syntactic structures, mean length of utterances (MLU), the number of syntactic error, type-token ratio (TTR) and proportion of complex syntactic utterances (1,11). Several studies evaluate spontaneous language samples which elicited by different methods. Results of one study showed that language samples elicited by conversation are more qualitative than those elicited by freeplay (1). Results of a comparison between conversation, freeplay and narrative as methods of language sample elicitation showed that freeplay elicited more number of utterances than narrative speech, but less proportion of complex syntactic utterances than narrative and conversation. Also, compared to freeplay and conversation, narrative speech samples elicited less mean length of utterances (MLU). Finally, one study indicated that compared with conversation and freeplay, narrative speech is better for eliciting more language structures (11). In Persian language, results of one study indicated that there was no significant difference between language samples collected by picture description and conversation in the number of verbs in the sentence and in MLU (16). Another study compared speech quality indices of spontaneous language samples elicited in children of Semnan, Tonekabon and Birjand cites in Iran. MLU and number of verbs were higher in Semnanian children’s language samples than in Tonekabonain and Birjandian ones, but the number of dependent clauses was higher in language samples of Tonekabonain and Birjandian children than in Semnanian ones. These results showed that cultural and linguistic differences can result in the differences in the language samples (17). Finally, there is controversy in the Persian literature regarding the gender effect of on MLU. One study showed no significant difference in MLU in two genders (18) while another study indicated significantly larger MLU in girls than boys (19). The purpose of present study was to compare conversation, freeplay, and narrative speech on some aspects of language elicited in five-year old Persian

Vol. 9, No. 14, Oct. 2011 6

language children. Due to the effect of age, gender, culture and language on features of language samples elicited by the studied methods, we limited the participants to five year old Persian language children of Semnan city. Concerning the obvious importance of obtaining spontaneous language samples in the assessment of children with language disorders and due to the lack and unavailability of standardized language tests in Persian language, Present study aimed to set the stage for the future development of better assessment protocols in Persian language. According to the electronic search of the authors of the present study, in no study in Iran, comparing of conversation, freeplay and narrative speech was done on the aspects of language elicited. Comparing of the language samples obtained by these three methods of language sampling in Persian, can guide our clinicians to select the best method of eliciting a special linguistic feature. The following questions were considered in the present study:

1. Among conversation, freeplay, and narrative speech which one can elicit more number of utterances?

2. Among conversation, freeplay, and narrative speech which one can elicit longer MLU?

3. Among one can elicit more MLU which one can elicit more TTR?

Method Participants Statistical population of the present study included all the five-year-old Persian language boys resident in Semnan City in 2007. By cluster sampling method, a total of 30 Semnanian five-year-old boys with normal speech and language development were selected from Semnan kindergartens. To this aim, we first listed all the active kindergartens of the city and then randomly selected 6 of them. Finally, among the five-year-old boys enrolling each of these six kindergartens, five boys were randomly selected. The boys between the ages of four years and six month and five years and six month were selected as five-years-old boys. Before the children enrollment in the kindergartens, they had their mothers as their primary caregivers. Written consent for the children’s participation in the study was acquired from their mothers. Identification of children with normal hearing, speech, and language development were accomplished by interviewing the mothers and the kindergarten staff.

Language samples of the 30 children were elicited using three methods of language sample elicitation including conversation, freeplay, and storytelling. The language samples, lasting 15 minutes, were obtained by collecting five minutes of spontaneous language samples elicited using each three mentioned methods of language sampling. Methods of language elicitation Methods of eliciting language samples which used in the present study are described below. Conversation:

1. The researcher asked the child several questions about his family, his friends, school activities, and favorite television programs.

2. The researcher gave verbal imperatives to the child such as “please tell me about toys or puppets you like to play with.

3. The researcher encouraged the child to explain how to play a game.

4. The researcher requested the child to describe one picture from a set of pictures and then researcher guessed which picture has been described (10, 11,20).

Freeplay: In this study, language samples elicited during researcher-child interactions when the child played with age-appropriate toys or puppets (2, 7, 21).To decrease the influence of nonlinguistic context on children’s language output, same toys or puppets were used for all the participants. Narrative speech:

1. The researcher requested the child to tell a story about a particular topic.

2. The researcher requested the child to tell a folk story (for example, Bozboz-e-Ghandi story in Iran.

3. The researcher gave a prompt to the child such as picture series and then requested him to tell a story about it.

4. The researcher told a story and then requested the child to retelling it (10, 11,20).

To keep the situations similar for all participants, we used the same tasks and materials in administering each method. In conversation, we asked the same questions for interacting with the participants. In freeplay, we used the same toys, and in narrative speech, we used the same picture series and requested all participants to tell us about the same folk story.


Criteria and data analysis Language samples elicited by each method were audiotape recorded and were transcribed by the first author. Language samples elicited by conversation, freeplay, and narrative speech were compared in aspects of three language evaluation criteria): Number of utterances, b) Mean length of utterances, and c) Type-Token ratio.

a) Number of utterances: number of utterance is the sum of single words, single phrases and dependent clauses.

b) Mean length of utterances (MLU): This criterion was acquired from dividing the number of morphemes used in each language sample by the total number of utterances elicited.

c) Type-Token ratio (TTR): Type-Token ratio was calculated by dividing the number of different words (types) by the total number of words (tokens) (22).

To evaluate the reliability of language samples analysis, third author of the present study randomly analyzed 20 language samples again. Internal validity for number of utterance was 100%, for MLU was 100% and for TTR was 98%. Results The mean and standard deviation of the number of utterances, MLU, and TTR of language samples elicited by conversation, freeplay, and narrative speech are presented in table 1.

Table 1. Mean and Standard Deviation of Number of utterances, MLU, and TTR of language samples elicited by conversation, freeplay, and narrative speech

Methods N Number of utterances MLU TTR Mean SD Mean SD Mean SD Conversation 30 67.07 23.26 3.32 0.68 0.63 0.13 Freeplay 30 54.5 24.48 3.28 0.99 0.53 0.12 Narrative Speech 30 57.4 20.05 4.02 1.26 0.49 0.12

The results of repeated-measures one-way analysis of variance (ANOVA) to compare mean of

conversation, freeplay, and narrative speech in number of utterances, presented in table 2.

Table 2. Results of ANOVA for comparing number of utterances of language samples elicited by

conversation, freeplay, and narrative speech SS df MS F P value

Treatment (tre) 2599.22 2 1299.6 Between Subjects (BS) 18844.2 29 649.8 Within Subjects (WS) 27724.82 60 426.08 Residual (R) 25125.6 58 433.2 Total (T) 74293.85 89

3.01 0.056

There was no significant difference among three methods of language sample elicitation in the number of elicited utterance F (2, 58)=3.01, (P=0.56).

Compared by elicited MLU, a significant difference among three methods of language sample elicitation was observed (F (2, 58)=5.41, P=0.07) (table 3).

Table 3. Results of ANOVA for comparing MLU of language samples elicited by conversation, freeplay, and narrative speech

SS df MS F P value Treatment (tre) 10.4 2 5.2 Between Subjects (BS) 38.28 29 1.32 Within Subjects (WS) 66.08 60 1.1 Residual (R) 55.68 58 0.96 Total (T) 170.45 89

5.41 0.007

The Tukey HSD test was used to pairwise comparison between the methods. There was a significant difference between MLU elicited by narrative speech and conversation (HSD (3, 60) =

3.68, P>0.5), and narrative speech and freeplay (HSD (3, 60) = 3.89, P<0.5). MLU elicited by narrative speech method was significantly longer than MLU elicited by conversation and freeplay.

Vol. 9, No. 14, Oct. 2011 8

There was no significant difference between MLU elicited by conversation and freeplay (HSD (3, 60) =0.44, P>0.5). The data of Table 4 show that there was a significant difference among TTR elicited by three language sampling methods (F (2,58)= 6.73, P=0.01). Pairwise comparisons showed a significant difference between TTR elicited by conversation

and freeplay (HSD (3, 60) = 3.44, P<0.5) and conversation and narrative speech (HSD (3,60)=4.28, P<0.1).TTR elicited by conversation method was significantly more than TTR elicited by freeplay and narrative speech. The results of Tukey HSD test showed that no significant difference between TTR elicited by freeplay and narrative speech (HSD (3, 60) =1.37, P>0.5).

Table 4.Results of ANOVA for comparing TTR of language samples elicited by conversation, freeplay, and narrative speech

SS df MS F P value Treatment (tre) 0.31 2 0.15 Between Subjects (BS) 0.81 29 0.028 Within Subjects (WS) 1.59 60 0.026 Residual (R) 1.28 58 0.022 Total (T) 3.99 89

6.73 0.001

Conclusion The results of the present study indicated that there was no significant difference among number of utterances elicited by conversation, freeplay, and narrative speech. This finding is not consistent with those of a similar study indicative of higher number of utterances elicited by freeplay than by conversation (11). However, similar to the present study, the results of the mentioned study (11) showed that there was no significant difference between number of utterances elicited by conversation and narrative speech. Inconsistency between the results of present study and previous studies may be caused by individual differences between participants. Some children are extravert and talkative, and therefore have high number of utterances, but other children may be introvert and laconic and therefore have low number of utterances. Concerning the evident influence of child’s conversational partner on his communication aspects (23), difference between the investigators of this and the previous studies could be another reason for the reported inconsistency. Results of a study showed that a difference up to four words in utterance length in homogenous populations can be observed by changing the researcher eliciting the child’s language sample (24). Also, change in the topic of conversation results in difference in the number and the length of utterances elicited during language sampling. So, difference in the topic of conversations and stories could be another reason for the inconsistent results. To reduce the influence of change in topic of conversation and stories, in the present study the applied conversational topics and questions for language sampling kept constant among all the participants.

For language sampling, from 50 to 100 utterances are considered as sufficient to have a representative sample (1, 25). In this study more than 60 utterances provided by the three elicitation methods. Hence, all three methods provided sufficient utterances for clinical use. Results showed that compared to conversation and freeplay, narrative speech yelled longer utterances. This finding is consistent with those of other recent studies (11, 26). Therefore, to have a language sample with longer utterances, it is suggested to use narrative speech which according to the result of this study, elicites more complex language. In the other hand, compared to narrative speech andfreeplay, language samples provided by conversation resulted in more TTR. This finding is in agreement with a smillar study (27). Hence, to have a language sample with more TTR it is better to use conversation for language sampling. The results of the present study suggest an implication for clinical practice. Apart from the observed differences in freeplay, conversation, and narrative speech methods, it is suggested to apply all these three methods when trying to collect their language sample to elicit more language abilities of children. This study sets the stage for future investigations on spontaneous language analysis of Persian children. It is suggested to include children with language impairments in the future studies, because the participants of the present study were selected among typically developing children who expected to have higher language proficiencies when compared to language impaired children. To increase the extent to which the results of the present study can be generalized, inclusion of children from different ages and inclusion of girls in the similar future studies are suggested.


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13. Gibbons J, Anderson DR, Smith R, Field DE, Fischer C. Young children's recall and reconstruction of audio and audiovisual narratives. Child Dev. 1986; 57 (4):1014-23.

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18. Maryam AB. [Mean length of utterance in typically developing children in Shahre Babak. Tehran (Persian)].Thesis for bachelor in Linguistics. Iran University of Medical Sciences 2000.

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Vol. 9, No. 14, Oct. 2011 10

* All correspondence to: Mehrnoosh Esbati, E-mail: <[email protected]>

Original Article

The state of Deterministic Thinking among mothers of autistic children

Mehrnoush Esbati, Msc*

University of social welfare and Rehabilitation sciences, Tehran, Iran

Objectives: The purpose of the present study was to investigate the effectiveness of cognitive-behavior education on decreasing deterministic thinking in mothers of children with autism spectrum disorders.

Method and Materials: Participants were 24 mothers of autistic children who were referred to counseling centers of Tehran and their children’s disorder had been diagnosed at least by a psychiatrist and a counselor. They were randomly selected and assigned into control and experimental groups. Measurement tool was Deterministic Thinking Questionnaire and both groups answered it before and after education and the answers were analyzed by analysis of covariance.

Results: The results indicated that cognitive-behavior education decreased deterministic thinking among mothers of autistic children, it decreased four sub scale of deterministic thinking: interaction with others, absolute thinking, prediction of future, and negative events (P<0.05) as well.

Discussions: By learning cognitive and behavioral techniques, parents of children with autism can reach higher level of psychological well-being and it is likely that these cognitive-behavioral skills would have a positive impact on general life satisfaction of mothers of children with autism.

Key words: Cognitive-Behavior Education, mothers of autistic children, Deterministic Thinking Submitted: 10 Feb 2011 Accepted: 22 Jul 2011

Introduction Raising a child is stressful for all parents; however parents of children with disabilities may have additional sources of stress (1). Autism is one of the disorders that make parents lives more difficult. Gray and Holden (2) found that mothers of autistic children reported more parent and family problems and perceived negative child characteristics than the mothers of children with Down syndrome or no disability. Also Olsson and Hwang cited in Baker-Ericzen(1) reported that mothers of children with autism showed higher depressive level than mothers of children with no disability. It was also stated that parents of children with autism had higher depression than parents of children with mental retardation, Down syndrome and no disability (3). When the mothers and fathers of children with autism were the focus of the study, mothers of children with autism were found to have more stress than fathers (4). Spousal blaming may be another factor that causes stress in mothers of children. Fathers of children with autism may blame their

wives for creating this condition in their children especially if the child is male (5). Parents are always at the centre of treatment. Their session is central to the cure. All attempts at planning intervention and treatments should involve a close working relationship between the professional and the family, always keep in mind the need of filling the gap between science, culture, beliefs and the individual needs of children and their families (6). The rehabilitation and education of children with autism is the focus of the arrangements in the special education centers; however, the other family members, especially the mothers who are the prime caregivers need to be informed and supported for both the well-being of the family and the child. As in our society mothers are the primary caregivers of the children, they have more difficulties in raising and daily care of the child than fathers. Also mothers have responsibilities related to other family member needs and their own personal needs which may cause greater stress and problems for them. All of


these pressures for mothers of autistic children cause increasing risk of psychological problems such as depression, anxiety, distress, poor marital adjustment, and poor parent-child interaction, less satisfaction with life, social isolation, low self esteem and hopelessness. Cognitive approaches believe that mental health is dependent on people’s perceptions and explanations of events and the world (7). Also people’s feedbacks and cognitions toward themselves and the world play an important role in their vulnerability when encounter to psychological complexities (8). One of the most important cognitive distortions is deterministic thinking (9). Deterministic thinking is a kind of distortion that conclusively considers an event equal to something else. Deterministic thinking is about absoluteness and ignorance probability in incidents and their inferences. On the other hand, this distortion interferes in the conclusion of the situation (positive and negative) and it causes people to have a sensitive reaction towards changing of the old mental patterns. Its deletion leads to adjustment between hope and fear of occurrence in people (10). Cognitive-behavioral education is a psycho educational approach which is mixed of cognitive restructuring and behavioral interventions. This intervention emphasizes the relationship between thoughts, feelings, and behaviors, and includes four treatment modules: training relaxation, increasing enjoyable activities, cognitive restructuring, and social skills/assertiveness training (11). Regarding to negative correlation between mental health and cognitive distortions (7,12), and as deterministic thinking is a major cognitive distortion (9), by helping mothers of autistic children to decrease their deterministic thinking, they can achieve higher level of mental health and cope much better with their problems and treat more effectively with their children. So this study will investigate the effectiveness of cognitive-behavioral education on decreasing deterministic thinking among mothers of autistic children. Material and Method In a quasi experimental study with pre-post test and control group design 24 mothers of autistic children

who were referred to counseling centers of Tehran and their children disorder had been diagnosed at least by a psychiatrist and a counselor were randomly selected and randomly assigned into two groups: control and experimental. Before starting intervention both groups were given a pre test. Then experimental group participated in 8 educational sessions and control group did not get any intervention. Finally 4 days after the last session both groups answered post test. The education program consists of cognitive restructuring and behavioral interventions. The intervention emphasizes on the relationship between thoughts, feelings, and behaviors. Also behavioral intervention is consist of increasing pleasurable activities, learning social and communication skills, relaxation training, and assertiveness training. The Measurement tool was Deterministic Thinking Questionnaire. The questionnaire developed based on theoretical basics related to cognitive theories and clinical experiences by Younesi (13). This questionnaire is a valid and reliable measure that the concurrent validity was established by correlating it with Beck depression inventory (r=0/33). The questionnaire is a 36-items self report inventory, and each item is scored on a 4 point Likert-type scale ranging from 1 (completely disagree) to 4 (completely agree). Scores can range from 36 to 144. Higher total score signify a higher level of deterministic thinking and the cut-off point is 75. The four sub-scales of deterministic thinking are: interaction with others, absolute thinking, prediction of future, and negative events. Hypothesis of this research was: Cognitive-behavioral education decreases deterministic thinking among mothers of children with autism spectrum disorders. Analysis of covariance has been performed to evaluate the efficacy of intervention and all answers were analyzed in SPSS. Results According to the use of Kolmogorov–Smirnov test for testing normality of demographic variables distributions in two groups, results which are shown in Table (1) indicates that distribution of demographic variables in both experimental and control group is normal (P<0.05).

Table 1. K-S test for normality of demographic variables distribution Experimental Group Control Group Demographic Variables

K-S test P value K-S test P value Age 0.859 0.452 1.24 0.091

Level of education 0.956 0.320 0.815 0.520 Marriage duration 0.774 0.587 0.815 0.520

Vol. 9, No. 14, Oct. 2011 12

Level of education in experimental and control groups compared by Chi-square test and there was no significant difference between two groups. Also age and marriage duration were compared by using independent T-test and there was no significant difference regarding age and marriage duration between two groups. Considering the outcome of analysis of covariance which are shown in Table 2; after controlling pre test

scores, F score of absolute thinking, negative events, future prediction, interaction with others and deterministic thinking is significant and shows that cognitive-behavioral education has decreased deterministic thinking and four sub scale of it among mothers of autistic children with significance values of P<0.05.

Table 2. Analysis of covariance for effectiveness of cognitive-behavioral education

Source Sum of squares df Mean squares F P value Pre test 64.37 1 64.37 53.45 0.001 Absolute thinking

Intervention 164.23 1 164.23 136.37 0.001 Pre test 82.65 1 82.65 44.58 0.001

Negative events Intervention 228.63 1 228.63 123.33 0.001

Pre test 58.91 1 58.91 28.28 0.001 Prediction of future

Intervention 105.94 1 105.94 50.85 0.001 Pre test 55.35 1 55.35 28.71 0.001

Interaction with others Intervention 92.37 1 92.37 47.91 0.001

Pre test 83.08 1 83.08 49.14 0.001 Deterministic thinking

Intervention 153.95 1 153.95 91.06 0.001 * P<0.05

Discussion The purpose of this study was to investigate the effectiveness of cognitive-behavioral education on decreasing deterministic thinking among mothers of autistic children. In cognitive intervention phase, education was focused on revision of incorrect beliefs and cognitions. It seems that cognitive revisions caused reduction of annoyance and anger, increased attention to positive aspects of child behaviors, decreased cognitive distortions such as mind reading, foretelling, negative labeling, and deterministic thinking. To decrease deterministic thinking specifically Test of Reality technique was educated and it seems this technique helped mothers’ perceive their lives realities and thus absoluteness and equalities in their mind were decreased. Also the cognitive restructuring module was helpful in changing negative expectations and attributions related to child behavior that may influence parenting as treatment response. Behavioral education phase consists of relaxation training, increasing pleasurable activities, and assertiveness training. The relaxation techniques helped mothers be relaxed during punishment situations and ignore mildly inappropriate behaviors. Also mothers expressed that they could control their anger better. Sevin also showed that the most mentioned issue by mothers of children with autism was related to anger management and they need to

learn how to manage their anger (14). Since mothers of children with autism often spend all of their time to do parenting or work obligations, they have little time to do things that they enjoy, so by doing pleasant activities they probably reached more positive feelings about themselves and life. Johnston & Goldberg also indicated the positive effect of doing pleasurable activities on mothers.(15) Finally, mothers of disabled children are required to be assertive in discipline situations with their children, in advocating for their children’s educational needs, and in responding to critical family members. So assertiveness training is useful for them. The parents of children with autism often feel hopeless and blame themselves for the situation (16) and may have stress, depression, and anxiety. So by learning cognitive and behavioral techniques they can reach higher level of psychological well-being and it is likely that these cognitive-behavioral skills would have a positive impact on general life satisfaction of mothers of children with autism, regardless of their current levels of depressive symptoms or anxiety. Besides the interventions in cognitive-behavioral education, mothers stated that concepts and techniques were clear and easy to understand. Also they appreciated the trainers’ communication and were satisfied to speak with the other mothers with the same problems.



References 1. Baker-Ericzn MJ, Brookman-Frazee L, Stahmer A. Stress

Levels and Adaptability in Parents of Toddlers With and Without Autism Spectrum Disorders. Research and Practice for Persons with Severe Disabilities. 2005;30(4):194–204.

2. Gray DE, Holden WJ. Psycho-social well-being among the parents of children with autism.Journal of Intellectual and Developmental Disability. 1992 Jan;18(2):83–93.

3. Yirmiya N, Shaked M. Psychiatric disorders in parents of children with autism: a meta-analysis. Journal of Child Psychology and Psychiatry. 2005;46(1):69–83.

4. Moes D, Koegel RL, Schreibman L, Loos LM. Stress Profiles For Mothers And Fathers Of Children With Autism. Psychological Reports. 1992 Dec;71(3f):1272–4.

5. Trigonaki N. Parents of children with autism and the five basic needs. International Journal of Reality Therapy. 2002;21(2):13–4.

6. Schulman C, Zimin R, Mishori E. Concluding Comments Chapter 16 inSchopler E, Yirmiya N, Shulman C, Marcus LM, editors. The Research Basis for Autism Intervention.1st ed. Springer; 2001.

7. Sommers-Flanagan J, Sommers-Flanagan R. Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques [Internet]. Wiley; 2012 [cited 2013 Feb 11]. Available from: http://books.google.com/books?hl=en&lr=&id=Qt0DK0PsmHgC&oi=fnd&pg=PR11&dq=Counseling+and+psychotherapy+Theories+in+context+and+practice+Sommers-Flanagan&ots=fRcM2kv9Rf&sig=Gi9uQGrVDlLGr7G_VR-1zCvLmTw

8. Warner R. Environment of Schizophrenia: Innovations in Practice, Policy and Communications. Brunner-Routledge; 2000.

9. Younesi J. The role of cognitive distortion (Deterministic thinking) on Psychological pathology. J. Iranian Psychol. Assoc. 2004;3(12):73–86.

10. Honarian M, Younesi J, Shafiabadi A, Nafissi G. “The impact of couple therapy based on attachment” in deterministic thinking and marital satisfaction among couples. International Journal of Psychology and Counselling. 2010;2(6):91–9.

11. Chronis AM, Gamble SA, Roberts JE, Pelham WE. Cognitive-behavioral depression treatment for mothers of children with attention-deficit/hyperactivity disorder.Behavior therapy. 2006;37(2):143–158.

12. Baron J. Thinking and deciding [Internet].Cambridge University Press; 2000.

13. Younesi J, Mirafzal A. Development of deterministic thinking questionnaire. th European congress of psychology. Prague Czech Republic. 2007.

14. Sevim B. The effects of stress management program for mothers of children with autism [Internet]. Middle East Technical University; 2007 [cited 2013 Feb 11]. Available from: http://etd.lib.metu.edu.tr/upload/12608638/index.pdf

15. Johnston E, Goldberg S, Morris S, Livenson J. Stress in UK families conducting intensive home-based behavioral intervention for their young children with autism and Down syndrome. Journal of Autism and Developmental Disorder. 2001;31:327–36.

16. Fleischmann A. Narratives Published on the Internet by Parents of Children With Autism What Do They Reveal and Why Is It Important? Focus Autism Other DevDisabl. 2004 Feb 1;19(1):35–43.


Vol. 9, No. 14, Oct. 2011 14

* All correspondences to: Leile Monshizadeh; Email:<[email protected]>

Original Article

Expressive language development in 45 cochlear implanted children following 2 years of implantation

Seyed Basir Hashemi, MD; Leile Monshizadeh*, MSc; Shiraz University of medical sciences,Shiraz, Iran

Introduction: Profound hearing loss encounters children with delay in speech and language. As it is known language acquisition in young deaf children is a lengthy process, but cochlear implanted children have better spoken language skills than if they had not received the device. According to the importance of cochlear implant in deaf child's language development, this study evaluates the effect of different variables on child's language performance.

Method and Material: 45 cochlear implanted children were tested, all of whom had used the device for at least 2 years. In order to evaluate the children, the NEWSHA test which is fitted for Persian speaking children was performed and language development of the children was compared through stepwise discriminative analysis.

Results: After evaluation of the effect of different variables like child's age of implantation, participating in rehabilitation classes, parent's cooperation and their level of education, we came to a conclusion that the child's age of implantation and rehabilitation program significantly develop the child's language performance.

Discussion: The value of cochlear implant in improvement of deaf children in speech language perception , production and comprehension is confirmed by different studies which have been done on cochlear implanted children. Also, the present study indicates that language development in cochlear implanted children is highly related to their age of implantation and rehabilitation program.

Key words: Language development, Expressive language, Cochlear implant, Age, Rehabilitation

Submitted: 04 Dec 2010 Accepted: 11 Apr 2011

Introduction Children with significant congenital or prelingual deafness shown to have noticeable delays in their mastery of all aspects of the spoken language (1,2). When hearing aids provide little or no benefit, cochlear implants seem to provide oral access to language. As the acquisition of spoken language by young deaf children is a lengthy process, measuring outcomes in those with implant requires time. Preliminary data suggest that the cochlear implanted children have better spoken language skills than if they had not received implants (3, 4). It is because of the fact that cochlear implants apparently restitute the inner ear functions and increase consciousness of pre- and post lingual deaf children (5). However, not all deaf cases make equal benefits from the implantation of this electronic device and several

variables seem to have critical effects on linguistic performance after implantation. For some, a cochlear implant allows the full development of linguistic competence and provide marked benefits in a wide range of psychological and social abilities, whereas others remain language delayed or develop a functional but imperfect command of language(5). This may depend on various factors like child's age of implantation,… . So, this study is done with the aim of the evaluation of the impact of child's age of implantation, participating in rehabilitation classes, parent's cooperation and their educational level on language development of 6 years old cochlear implanted children, who received the device at least 2 years before.


Method and materials 45 cochlear implanted children who were at the age of 6 years old and had been implanted at least 2 years before were selected. After that the expressive language subset of NEWSHA test was performed on them. The NEWSHA test which is fitted for Persian speaking children from birth to 6 years old consist of a set of scales for testing the child's audition, receptive and expressive language, speech, cognition, social communication, and motor development. The test result divided children into 13 groups from birth to 6 years old. For example it may be possible that the expressive language age of a 5 years old child equals to a 3.5 years old child. As it discussed before, in the present study the expressive language subset of NEWSHA test was performed and data analysis was done through stepwise discriminative analysis.

Results The main purpose of this study was to evaluate the expressive language development in cochlear implanted children based on their age of implantation, participation in class, learning ability, parent's level of education and cooperation. The results of expressive language test separated the children into 2 groups: the weak group who could answer the questions that were related to an approximately 3 years old child and the strong group whose expressive language age and chronological age were the same as each other. To assess the effect of different variables like child's age of implantation, participation in rehabilitation classes, learning ability, parent's level of education and their cooperation, stepwise discriminant analysis was done .The results are illustrated in 2 tables below.

Table 1. The effect of different variables on child's expressive language

Wilks' Lambda

Exact F Step Entered Statistic df1 df2 df3 Statistic df1 df2 Sig.

1 class .443 1 1 43.000 54.156 1 43.000 .001

2 age1 .405 2 1 43.000 30.895 2 42.000 .001

Table 2. Analysis of the variables

Step Tolerance F to Remove Wilks' Lambda

1 class 1.000 54.156

class .998 46.750 .855 2

age1 .998 3.937 .443 According to the above tables, the child's improvement in expressive language was highly related to the age of implantation and his participation in rehabilitation classes. Also, the Eigen value=1.47, Wilks' lambda=0.405 and p<0.001 confirmed this finding.

In addition, the standardized canonical discriminant function coefficient was -0.380 with age and 0.942 with participation in classes. Based on the discriminant function which included child's age of implantation and participation in classes, 93.3% of the predictions in discriminant analysis were correct predictions.

Table 3. Child's age of implantation and rehabilitation class

Predicted Group Membership

group

0 1 Total

0 27 2 29 Count

1 1 15 16

0 93.1 6.9 100.0 Original

% 1 6.2 93.8 100.0


Vol. 9, No. 14, Oct. 2011 16

Discussion Cochlear implants enable different degree of improvement for deaf patients in the areas of speech and language perception, production and comprehension depending upon the extent of their hearing loss and other variables (5). According to the present study, two important factors that have significant impact on child's performance after cochlear implantation are the child's age of implantation and his participation in rehabilitation classes. In other word, the younger children who completely participated in rehabilitation program developed in expressive language acquisition significantly. Over the past several years , the lower age limit for implantation has decreased, with the current age limit of 24 months. At birth, the cochlea has already reached adult size and the related structures are appropriately developed by the age of two (6). However, considering the critical periods for auditory system and language acquisition(7) and the negative correlation between age at onset of deafness and the development of speech perception, speech production and language competence following an implantation, it is clear that younger children can derive significant benefits from an implantation (6). Implantation may also result in better speech perception and overall linguistic performance in children as young as 16 months (8), probably because it reduces the language development delay. A study in 1997 indicated that gains in receptive and expressive language are highly related to children's use of the device and participation in rehabilitation program. The two discussed variables will help the cochlear implanted children in language development similar to that is observed in normal hearing children (9). The patients response therefore progress from a phase of sound detection to speech discrimination to the ability to repeat fragments of speech and finally to true understanding of speech (10). Cochlear implants may also make it possible to have access to auditory perceptual information otherwise unavailable. Speech perception is enhanced by increasing the auditory signals. Research results of speech perception tests, one year following implantation were significantly higher than pre-implantation observations in a majority of prelingually deaf children, even when preoperative levels suggested a limited verbal ability(5). Miyamoto et al (11), also showed a pattern of word identification development in their implanted

children, with no great changes in performance after 6 months of experience; the largest performance occurred one year after operation and rehabilitation, followed by steady improvement. In another study,100% of phoneme detection was achieved 3 months after implantation in children with prelingual deafness, whereas both identification of closed-set word and sentence and open-set recognition increased gradually, reaching 100% and 80% respectively, by 48 months of implantation and rehabilitation(12). The primary role of cochlear implant is to enable speech perception. One of the secondary important roles is to let the speech production and help patients acquire and produce consonants and vowel features which are difficult for individuals with profound hearing loss. Language development in implanted pre lingually deaf children may be significantly faster than predictions based only on maturation of unimplanted peers would suggest. At the 12 months post operative interval, expressive language scores have been shown to be higher than the predicted corresponding scores based on non-operated peers-this effect was not seen at the 6 months interval. Although, implanted children were delayed compared to normal hearing children at each interval tested, their rate of language growth matched that of hearing controls. What implanted children have gained in expressive language were similar to those expected from hearing children and more than those expected from unimplanted deaf children at each testing interval from 6 months to 2.5years after implantation. There is however, significant interpersonal variability in linguistic abilities following the operation, with some patients reaching near normal language level, whereas others remain delayed and show a wide gap between linguistic age and chronological age(3). Support from home and school, (re) habilitation, and education are essential factors that determine linguistic improvement (7, 9) and permit the achievement of adequate phonetic and phonological competencies. An implantation should be done in case that the cochlear implant center can offer multidisciplinary team support before the operation, as well as immediate and intensive speech rehabilitation in which both parents and teachers must cooperate (10). The rehabilitation program may take months and lasts longer for prelingually than postlingually deaf patients (13).To develop hearing and speech abilities, patients must receive adequate stimulation. The habilitations should focus on the use of audition


to optimize language development and production skills. Parents are encouraged to preferentially use audition in their interactions with children (14) and guide them into auditory-verbal education and linguistic interactions on a daily basis (15). Finally, either oral (speech, listening) or total (sign plus speech and listening) modes of communication may be applied to help the child being improved in learning language.

Acknowledgment: We thank parents and children who cooperated to do the test. Conflict of interests: The authors declare that they have no conflict of interests.

References 1. Geers A,Moog J. Spoken language results: vocabulary,

syntax, and communication. Volta Rev.1994;96:131-148. 2. Kretschmer R,Kretschmer L.Discourse and hearing

impairment. In: eds. School discourse problem. San Diego Calif: Singular publishing Group.1994;pp:263-296.

3. Miyamoto Rt, Svirsky MA. Robbins AM. Enhancement of expressive language in prelingually deaf children with cochlear implants. Acta otolaryngol.1997; 117:154-157.

4. Svirsky MA. Robbins AM , Krik KI, Pisoni DB, Miyamoto RT. Language development in profoundly deaf children with cochlear implants. Psychol sci .2000;11:153-158.

5. Ouellet C, Cohen H.Speech and language development following cochlear implantation. J Neurolinguistics.1999;12:271-288.

6. Miyamoto RT, Osberger MJ, Kessler K. Cochlear implant in aural re (habilitation)of adults and children. J otolaryngology head and neck surgery.1996;116:1142-52.

7. Lenarz T, Hartrampf R, Battmer RD, Bertram B, Lesinski A. Cochlear implant management of young children. J laryngorhinootologie .1996;75:719-26.

8. Parisier SC, Chute PM, Popp AL, Hanson MB.Surgical techniques for cochlear implantation in the very young child. J otolaryngology- head and neck surgery.1997;117:248-54.

9. Robbins AM,Suvirsky M,Krik KI.Children with implants can speak but can they communicate? J otolaryngology head and neck surgery. 1997;177:155-60.

10. Waltzman SB, Cohen NL, Spivasl L, Ying E, Brachett D,Shapiro W, Hoffman R.Improvements in speech perception and production abilities in children using a multichannel cochlear implant. J laryngoscope. 1990; 100:240-3.

11. Miyamoto RT, Osberger MJ, Robbins AM, Myres WA, Kessler K, Pope ML. Longitudinal evaluation of communication skills of children with single or multichannel cochlear implants. American j otology. 1992; 13:215-22.

12. Mondain M, Sillon M, Vieu A, Lanvin M, Rewilland- Artieres F, Tobey E, et al .Speech reception skills and speech production intelligibility in Frenchchildren with prelinguall deafness and cochlear implants. J otology head and neck surgery.1997;123:181-4.

13. Fry auf-Bertschy H, Tyler RS, Kelsay DM,Gantz BJ. Performance over time of congenitally deaf and post ling ally deafened children using multichannel cochlear implant. J speech and hearing research .1992;35:913-20.

14. Dawson PW, Blamey pj, Dettman SJ, Barker EJ, Clark GM.A clinical report on receptive vocabulary skills in cochlear implant users. J ear and hearing.1995;16:287-94.

15. Bertram B, Pad D. Importance of auditory verbal education and parents' participation after cochlear implant of very young children. Annals of otology, rhino logy and laryngology.1995;166:97-100.


Vol. 9, No. 14, Oct. 2011 18

* All correspondence to: Katayoun Khademi, E-mail: <[email protected]>

Original Article

Physical Appearance Concern Questionnaire (PACQ) in Iranian population

Katayoun Khademi* University of PayameNoor, Tehran, Iran

Asghar Dadkhah, PhD. University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Vahid Kazemi, MD. Islamic Azad University (Tehran Medical branch)

Objectives: The purpose of this study is to make questionnaire for screening body dysmorphic disorder sufferers in cosmetic clinics.

Method and Materials: A sample of 150 female patients with age average 29.4 years completed Physical Appearance Concern Questionnaire. It has been used as screening tool for screening patients with body dysmorphic disorder symptoms in cosmetic clinics.

Results: Result of reliability analysis (α=0.908) and validity have shown the effectiveness of this questionnaire for recognizing individuals with BDD symptoms.

Conclusion: Physical appearance concern questionnaire can be used in cosmetic clinics for identifying BDD sufferers among clients, with score for the severity of symptoms.

Keywords: Physical appearance; Iranian; Physical appearance concern questionnaire Submitted: 11 Jul 2011 Accepted: 02 Sep 2011

Introduction Body dysmorphic disorder (BDD) is a partly common and sometimes serious psychiatric illness that is probably undetectable and also it is classified as a somatoform disorder in DSM-IV-TR. Actually there is no assurance that body dysmorphic disorder has been belonged to somatoform category and beside that we can’t completely consider it in obsessive-compulsive disorder, it can be supposed to be in a spectrum (1). Maybe activity front striate systems and visual cortex involve in severity of BDD (2,3) and related with symptoms of obsessive thoughts and compulsive behaviors (2, 4). One of the most striking characteristic of this disorder is a preoccupation with an imagined defect in appearance or inappropriate concern with a slight physical flaw. Their main focus areas are usually the face, head, skin, hair, nose and etc. Although any body part can be involved in sufferer’s preoccupations. By definition, body dysmorphic

disorder causes excessively distress or impairment in social functioning (5-7). Body dysmorphic disorder with an onset in adolescence (4) influences 1-2% of the general population (8-11). Range of prevalence for BDD patients in both inpatients and outpatients are 13%-15% and for the community is0.7%-2.4% (5). In a study in plastic surgery settings, the rate of 7% has been reported (12) and 12% patients screened positive for this disorder in dermatology setting (13) and It is 3 to 16% in dermatological and cosmetic surgery patients (14,4). It seems to be essential for dermatologists to ask some questions for checking the existence of BDD like how much time they spend thinking about their perceived flaws each day or whose concerns cause clinically significant distress (15). Often sufferers from BDD tend to have cosmetic surgery for body part related to source of distress and with considering the high rate of this type of


patients (16), screening this disorder with using questionnaire in cosmetic clinics is suitable to avoid unsatisfying surgical outcomes (15). It is also fundamental that dermatologists be trained to detect patients with symptoms of BDD, because they are in a key position to separate sufferers and refer them to psychiatrist (4). The current study has prepared Physical Appearance Concern Questionnaire as screen tool for searching body dysmorphic disorder sufferers in cosmetic clinics among women patients. Materials and Method All participants were female and wanted to have cosmetic surgery like lip enhancement, rhino-plasty, breast augmentations, buttock augmentation, liposuction and etc. Most of them (70%) were single and age average was 29.4 years. The physical appearance concern questionnaire (PACQ) has been used as screening tool for indentifying patients with body dysmorphic disorder symptoms. Because of the high rates of co morbidity in patients with BDD, clinical interview seems to be necessary. Therefore, patients who diagnosed for BDD based on filled questionnaires were interviewed. The findings from the clinical interview have shown that PACQ could be useful tool for screening BDD patients. The Physical Appearance Concerns Questionnaire (PACQ) has been prepared as screen tool for searching patients with BDD in cosmetic clinics. The PACQ consists of 12 items that asks about features of BDD. The four sample items of PACQ have been listed below:

1- How much time do you spend each day thinking about your appearance?

2- Do you think that your physical concerns are excessive?

3- Do your appearance-related thoughts or behaviors cause you a lot of anxiety, sadness or shame?

4- Do you have problem in making or keeping relationships?

The result shows existence of BDD with the score of severity of disorder. This study was administered to 150 subjects in cosmetic clinics in Tehran, Iran.All of them complained of a defect in either one feature or several features of her body. All statistical procedures were carried out using SPSS statistical software (version 18 for windows). Results This 12-Item questionnaire assessing body dysmorphic disorder symptoms and graded by Likert scale (1=least impaired, 5=most impaired), the score is achieved by summing Q1-12. The total scores range from 12 to 60 with a higher score reflecting greater impairment and likelihood of diagnosis of BDD without clinical interview. Answers are among none, mild, moderate and severe. Validity of the questionnaire has been approved by number of university professors. Reliability analysis resulted in an internal consistency of Cronbach’s α=0.908 with corrected item total ranging from 0.54 to 0.76. Scale mean for each item deleted is between 21.12, 22.46 and variance rang changes from 65.75 to 70.45. All scale mean variance and Cronbach's Alpha with correlations have been shown in table 1.

Table 1. Mean, variance and Cronbach's Alpha for each item deleted

Item Scale Mean if Item

Deleted Scale Variance if

Item Deleted Corrected Item-Total

Correlation Cronbach's Alpha if

Item Deleted 1 21.4131 68.687 0.683 0.899 2 21.7933 67.360 0.709 0.897 3 21.4200 64.608 0.631 0.902 4 21.1200 65.757 0.659 0.899 5 22.2867 69.602 0.713 0.899 6 22.0400 65.247 0.765 0.894 7 22.4667 70.452 0.683 0.900 8 22.2733 71.220 0.565 0.904 9 21.5400 66.639 0.541 0.907

10 21.5267 66.640 0.578 0.904 11 22.2933 68.168 0.667 0.899 12 21.8467 66.600 0.645 0.900

Vol. 9, No. 14, Oct. 2011 20

The PACQ was found to be a reliable and valid instrument for screening individuals with symptoms of body dysmorphic disorder in cosmetic clinics. Discussion To our knowledge, this is the first study in Iran to prepare screening tool (PACQ) for body dysmorphic disorder in cosmetic clinic (dermatology setting and cosmetic surgery). All questionnaires have been filled by various dimensions of marital status, occupation and type of procedure sought. We recommend that patients with score 36 or more should be referred for further assessment. Scores between 12 to 36 needs psychological consult for assessing traits of BDD presence. There is no clue of BDD presence for patients with scores under 12. According to the filled questionnaires, most BDD patients have responded to questions 1, 3, 4, 10 and 9, which mean most concerns are in order as follows: checking appearance, time spending in a day, seeking reassurance from others, requests for surgery, being perfectionist. Other items in questionnaire like excessive preoccupation, comparing with models, distress, keep or making relationship, avoiding (places, people, and activities), critical view about one’s appearance and social impairment are placed in lower priority. Based on filled questionnaires among patients for cosmetic surgery, 54% have diagnosed for mild, 9% moderate, 3% severe BDD. It seems that BDD prevalence among cosmetic clinic patients are more than rhino-plasty patients in ENT clinics in Tehran, Iran. Fortunately, among BDD patients 81.82% have mild and 5.05% have severe disorder. Actually Subjects were evaluated with Clinical Interview after filling questionnaires for checking co morbid disorders. Obviously, for a final diagnosis, the clinical interview is required and should be done by qualified therapist with experience in treating body image concerns like BDD. The results supported the use of the questionnaire as specific screening instrument for BDD in cosmetic clinics. There are several possible explanations why we found an apparently higher rate of BDD. First, we haven't studied on specific procedure. Second, we selected patients from last season of the year that clinics have had high load of cosmetic surgery.

Third, previous study samples have differed in various ways like gender distribution which may have influenced the results and we just worked on female patients. There is another inventory in Iran for detecting patients for seeking rhino-plasty surgery named Body Image Concern Inventory (BICI); however it has been studying just for rhinoplasty and has shown 12.2% prevalence in subjects seeking rhino-plasty (17). Unfortunately there are few researches for BDD in cosmetic clinics in Tehran, Iran. There is another study in Tehran, Iran that has shown 31.5% prevalence for body dysmorphic disorder among 130 patients (mean=26.43, SD=6.29 years)seeking rhino-plasty in ENT clinics by using Body Dysmorphic Questionnaire (24).In another study in 2003 has found 20.7% for BDD in patients requesting rhino-plasty (18). With considering of developmental research on body dysmorphic disorder in the world in recent years, Iran has received little empirical attention in this area. Thus, further study is required. Unfortunately questionnaires such as the Body Dysmorphic Disorder Questionnaire (BDDQ) (19) have been validated in a dermatology setting (15) they have not been studied in a cosmetic surgery and also there is no score for the severity of symptoms. Another questionnaire like BDDQ to develop the Body Image Disturbance Questionnaire (BIDQ) that have been made by Cash and colleagues (20,21) has not been validated in people seeking cosmetic surgery and also it is hard to be accessed. In study of 17 BDD sufferers, BDD was diagnosed in 5 out of 17 (2).This under recognized is due to the lately being contained in DSM IV, thus, practitioner knowledge is not extensive (19). In another study has been shown that 76% of BDD patients were dissatisfied of their surgery outcomes (22). Therefore, it is not predictable how patients will respond to cosmetic surgery outcome, apparently these treatment are unlikely to be sufficient, it is critical that both dermatologist and surgeons screen patients for BDD and refer them for psychiatric treatments (23). With considering poor global insight and it’s correlation with symptom severity in BDD (24), More research is needed in the development of a screening questionnaire for recognizing patients with BDD in cosmetic clinics (18).


Eventually, by improving people awareness of BDD presence, sufferers can receive social support by friends and significant persons in their life, that is related with less severe body dysmorphic disorder symptoms in both gender (Marques, et al., 2011).

Almost all of the researches have been studying in cosmetic clinics or dermatology settings and there is no investigation for people with special needs, thus further research is required in the development of a screening questionnaire or interview for identifying patients with BDD with special needs.

References 1. Castle DJ, Rossell SL. An update on body dysmorphic

disorder.CurrOpin Psychiatry. 2006;19(1):74-78. 2. Feusner JD, Moody T, Hembacher E, Townsend J,

McKinley M, Moller H, et al. Abnormalities of visual processing and frontostriatal systems in body dysmorphic disorder. Archives of general psychiatry. 2010;67(2):197.

3. Feusner JD, Moller H, Altstein L, Sugar C, Bookheimer S, Yoon J, et al. Inverted face processing in body dysmorphic disorder. Journal of Psychiatric Research. 2010 Nov;44(15):1088–94.

4. Conrado LA. Body dysmorphic disorder in dermatology: diagnosis, epidemiology and clinical aspects. AnaisBrasileiros de Dermatologia. 2009 Dec;84(6):569–81.

5. Phillips KA, Menard W, Fay C, Pagano ME. Psychosocial functioning and quality of life in body dysmorphic disorder.Comprehensive Psychiatry. 2005 Jul;46(4):254–60.

6. Ishigooka J, Iwao M, Suzuki M, Fukuyama Y, Murasaki M, Miura S. Demographic features of patients seeking cosmetic surgery. Psychiatry and Clinical Neurosciences. 1998;52(3):283–7.

7. Bowe WP, Leyden JJ, Crerand CE, Sarwer DB, Margolis DJ. Body dysmorphic disorder symptoms among patients with acne vulgaris.Journal of the American Academy of Dermatology. 2007;57(2):222–30.

8. Otto MW, Wilhelm S, Cohen LS, Harlow BL. Prevalence of Body Dysmorphic Disorder in a Community Sample of Women. Am J Psychiatry. 2001 Dec 1;158(12):2061–3.

9. Rief W, Buhlmann U, Wilhelm S, Borkenhagen ADA, Brahler E. The prevalence of body dysmorphic disorder: a population-based survey. Psychological medicine. 2006;36(6):877–86.

10. Koran LM, Aboujaoude E, Large MD, Serpe RT. The prevalence of body dysmorphic disorder in the United States adult population.CNS spectrums. 2008;13(4):316.

11. Haas CF, Champion A, Secor D. Motivating factors for seeking cosmetic surgery: a synthesis of the literature. Plastic Surgical Nursing. 2008;28(4):177-182.

12. Sarwer DB, Crerand CE, Magee L. Body dysmorphic disorder in patients who seek appearance-enhancing medical treatments. Oral MaxillofacSurgClin North Am. 2010 Nov;22(4):445–53.

13. Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. Oxford University Press; 2005.

14. Conrado LA. (2009). Body dysmorphic disorder in dermatology: diagnosis, epidemiology and clinical aspects. An Bras Dermatol, 84(6):569-81.

15. Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A Screening Questionnaire for Body Dysmorphic Disorder in a Cosmetic Dermatologic Surgery Practice.Dermatologic Surgery. 2001;27(5):457–62.

16. Sarwer DB, Crerand CE, Magee L. (2010)Bodydysmorphic disorder in patients who seek appearance-enhancing medical treatments. Oral MaxillofacilSurgClin North Am,22(4):445-53.

17. Ghadakzadeh S, Ghazipour A, Khajeddin N, Karimian N, Borhani M. Body Image Concern Inventory (BICI) for Identifying Patients with BDD Seeking Rhinoplasty: Using a Persian (Farsi) Version. AesthPlast Surg. 2011 Dec 1;35(6):989–94.

18. Veale D, De Haro L, Lambrou C. Cosmetic rhinoplasty in body dysmorphic disorder. British journal of plastic surgery. 2003;56(6):546–51.

19. Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. Oxford University Press; 1996

20. Cash TF, Phillips KA, Santos MT, Hrabosky JI. Measuring “negative body image”: validation of the Body Image Disturbance Questionnaire in a nonclinical population.Body Image. 2004 Dec;1(4):363–72.

21. Hrabosky JI, Cash TF, Veale D, Neziroglu F, Soll EA, Garner DM, et al. Multidimensional body image comparisons among patients with eating disorders, body dysmorphic disorder, and clinical controls: A multisite study. Body Image. 2009;6(3):155–63.

22. Phillips KA, Hollander E, Rasmussen SA, Aronowitz BR. A severity rating scale for body dysmorphic disorder: Development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacology Bulletin. 1997;33(1):17–22.

23. Phillips K.A., Dufresne R.G. Body Dysmorphic Disorder: A Guide for Dermatologists and Cosmetic Surgeons. American Journal of Clinical Dermatology. 2000;1(4):235–43.

24. Eisen JL, Phillips KA, Coles ME, Rasmussen SA. Insight in obsessive compulsive disorder and body dysmorphic disorder.Comprehensive Psychiatry. 2004 Jan;45(1):10–5.

25. Kazemi V. [Association of body dysmorphic syndrome and rhinoplasty request ENT clinics in Tehran(Persian)]. Thesis for doctorate of medicine. Islamic Azad University college of Medicine; 2010: No 4607.

26. Marques L, Weingarden HM, LeBlanc NJ, Siev J, Wilhelm S. The relationship between perceived social support and severity of body dysmorphic disorder symptoms: the role of gender. RevistaBrasileira de Psiquiatria. 2011 Sep;33(3):238–44.


Vol. 9, No. 14, Oct. 2011 22

* All correspondence to: Farzaneh Zamiri Abdollahi ; Email:<[email protected]>

Original Article

Gender difference in TEOAEs and contralateral suppression of TEOAEs in normal hearing adults Farzaneh Zamiri Abdollahi*; Yones Lotfi, MD.

University of Social Welfare and Rehabilitation sciences, Tehran, Iran

Introduction: Otoacoustic emissions (OAEs) are sounds that originate in cochlea and are measured in external auditory canal and provide a simple, efficient and non-invasive objective indicator of healthy cochlear function. Olivo cochlear bundle (OCB) or auditory efferent system is a neural feedback pathway which originated from brain stem and terminated in the inner ear and can be evaluated non-invasively by applying a contralateral acoustic stimulus and simultaneously measuring reduction of OAEs amplitude. In this study gender differences in TEOAE amplitude and suppression of TEOAE were investigated.

Method and Materials: This study was performed at Akhavan rehabilitation centre belonging to the University of Social welfare and rehabilitation sciences, Tehran, Iran in 2011. 60 young adults (30 female and 30 male) between 21 and 27 years old (mean= 24 years old, SD=1.661) with normal hearing criteria were selected. Right ear of all cases were tested to neutralize side effect if there is any.

Results: According to Independent T-test, TEOAE amplitude was significantly greater in females with mean value of 24.98 dB (p-value <0.001) and TEOAE suppression was significantly greater in males with mean value of 2.07 dB (p-value <0.001).

Conclusion: This study shows that there is a significant gender difference in adult’s TEOAE (cochlear mechanisms) and TEOAE suppression (auditory efferent system). The exact reason for these results is not clear. According to this study different norms for males and females might be necessary.

Key words: TEOAEs, Contralateral suppression of TEOAEs, Efferent system, Androgen

Submitted: 17 May 2011 Accepted: 012 Sep 2011

Introduction Otoacoustic emissions (OAEs) are sound waves that originate from cochlea and emit back into the external ear canal. These sounds can be recorded in ear canal using a sensitive microphone (1). They are produced by active motions of the sensory hair cells of cochlea in response to auditory stimuli (2). OAEs are generated in the outer hair cells (OHCs) which have motility function. Active contractions of the actin and myosin in these cells produce a mechanism of frequency specific cochlear amplifier (3). There is consensus that OAEs are simple, efficient and non-invasive objective indicators of healthy cochlear function especially OHCs and OAE screening are widely used as a part of universal new-born hearing screening programs. OAEs, as part of the audio logical diagnostic test, can help for differential diagnosis among some hearing pathologies, can be used to monitor the effects of ear disease treatments and are useful in the selection of

hearing aids and surgical options. As a research tool, OAEs are non invasive tools for intra cochlear processes and have brought a new understanding about the nature of sensory hearing impairments (2). OAEs can be classified into two main responses: First, spontaneous otoacoustic emissions (SOAEs) - if response is being recorded in the external acoustic meatus without any auditory stimulation; Second, Evoked Otoacoustic Emissions (EOAEs) - when ear energy is being recorded in response to a kind of sound stimulus. Evoked otoacoustic emissions are also divided (based on stimulus type) into three emissions: Transient (TEOAE) - evoked by a brief sound stimulus, usually a click that has a wide range of frequencies; Distortion product (DPOAE) - evoked by two pure and simultaneous tones (f1 and f2) to produce a response based on intermodulation distortion in cochlea (for example 2f1- f2); Stimulus-frequency (SFEOAE) - evoked by a continuous and low intensity tone (4).


Auditory system consists of afferent and efferent systems that operate in together (5). Olivocochlear bundle (OCB) or auditory efferent system is a neural feedback loop which is originated from brain stem nuclei and terminated in the inner ear hair cells. This system has two subsystems: Medial olivocochlear bundle (MOCB) and Lateral olivocochlear bundle (LOCB). MOCBs originate in medial portion of superior olivary complex (SOC) and LOCBs originate from lateral part of SOC. Both of these subsystems have crossed (mainly MOCB) and uncrossed (mostly LOCB) projections (6). Stimulation of auditory efferent has been shown to have a suppressive effect on cochlear responses like OAEs and suppression of OAE has been used frequently in clinical and research settings because it assesses efferent pathways quickly and non-invasively (5). Activation of MOCS can be performed by delivering a contralateral acoustic stimulation and simultaneously measuring OAEs amplitude in test ear. Contralateral acoustic stimulation leads to attenuation of the OAE (7). Efferent auditory pathway modulates OHCs of cochlea, reduces action potentials of auditory nerve fibers, and involves in locating sources of sound and improving sound detection in noisy context (5). Auditory efferent system involves in anti-masking, protection from damage due to loud noise, auditory and visual attention and auditory development (6). Stimulation of MOCS provides protection against moderate levels of noise, encoding noise signals as well as selecting hearing attention (7). In this study gender difference in TEOAE amplitude and suppression of TEOAE was investigated. Materials and Methods This study was performed at Akhavan rehabilitation centre belonging to the university of Social welfare and rehabilitation sciences, Tehran, Iran in 2011. 60 young adults (30 female and 30 male) between 21 and 27 years old (mean age of both groups 24 years old with 1.66 standard deviation and 0.30 standard error of mean) from students and staff of Akhavan rehabilitation centre were selected. They had not any

previous ear disease or ear surgery and they were volunteers. The inclusion criteria were as follow: Normal otoscopy (by using Riester otoscope), hearing threshold ≤ 15 dBHL between 250 and 8000 HZ (by using Clinical Audiometer AC 33 and headphone TDH-39p of Telephonics), tympanogram type An and existence of acoustic reflex threshold between 500 and 4000 HZ (by using Zodiac 901 of Madsen). Right ear of all cases were selected for TEOAE and TEOAE suppression tests to neutralize side effect if there is any. Cases were instructed to lie down without movement on examination table. OAE and OAE suppression was tested (by using ILO292 of Otodynamics with ILO v6 software in an acoustic room). Probe was calibrated before examinations on daily bases with probe test cavity of Otodynamics. Nonlinear click with 80μs electrical pulse at a rate of 50/s, mean intensity of 84 dBpeak and 20 ms time window after stimulation was used. Rejection level was 6 percent. TEOAE stimuli were presented through probe 1 of ILO292 of Otodynamics. The contralateral acoustic stimulation (CAS) was a 70 dBSPL white noise delivered by probe 2 of device. Contralateral noise was linear and intermittent (every 3 seconds was turned on/off automatically). TEOAE test in right ear was done while intermittent white noise was simultaneously presented in contralateral ear. Device shows TEOAE amplitude without and with contralateral noise in two separate windows on screen at once. The difference between TEOAE amplitude with and without contralateral stimulation is suppression magnitude and it is due to efferent system activation. SPSS software ver. 13 was used for analyzing the data. Independent T-test was selected for analyzing data. The significance level for the statistic tests was set at 5% (p<0.05). Results Table 1 and 2 respectively show summary of TEOAE amplitude and TEOAE suppression in males and females.

Table 1: TEOAE amplitude in males and females TEOAE amplitude (dB) Males Females

Mean 20.96 24.98 Standard error of mean 0.34 0.42

Median 20.99 25.03 Standard Deviation (SD) 1.87 2.30

Lower 20.26 24.11 95% confidence interval for mean Upper 21.66 25.84 Total number 30 30

Vol. 9, No. 14, Oct. 2011 24

Table 2: TEOAE suppression in males and females

TEOAE suppression (dB) Males Females Mean 2.07 1.54

Standard error of mean 0.05 0.03 Median 2.04 1.54

Standard Deviation (SD) 0.27 0.16 Lower 1.97 1.48

95% confidence interval for mean Upper 2.18 1.60

Total number 30 30 One sample Kolmogorov-Smirnov test was used to determine if distribution of variables is normal. According to this test all variables were within normal distribution (p-value> 0.05): TEOAE amplitude p-value in males was 0.96 and in females was 0.98, TEOAE suppression p-value in males was 0.52 and in females was 0.97. So parametric Independent t-test was used to compare TEOAE amplitude and TEOAE suppression between men and women. Leven's test for equality of variances was not significant with p-value of 0.22 (p-value> 0.05) so variances of two groups were equal. The Independent T-test results show that there is a significant difference between males and females in TEOAE amplitude and TEOAE suppression. TEOAE amplitude was significantly greater in females with mean value of 24.98 dB (p-value <0.001) and TEOAE suppression was significantly greater in males with mean value of 2.07 dB (p-value <0.001). Discussion Several studies have shown gender influence on OAEs and contralateral suppression of OAEs. Cassidy and Ditty (2001) showed that in female newborns TEOAE is more powerful than male newborns. They suggested that OHCs in females respond more sensitive than in males (8). Durante and Carvallo (2006) found that gender has significant effect on TEOAE and contralateral suppression of TEOAE in neonates. They have shown that TEOAE was larger in female infants and suppression of TEOAE was larger in male infants. They explained this finding with differences in prevalence of SOAEs (SOAEs are more prevalent in female) and cochlear length (cochlea is longer in males) (9). Miller JD. (2007) examined cochlea length in males and females and found that gender difference in cochlea length was 3.36% (corresponds to 1.11�mm difference in length with 0.49 SD) (10). The shorter cochlea in females could lead to the higher amplitude of females' TEOAE response (9).

McFadden D. (1993) proposed that the amount of efferent inhibition is relatively less in females than in males. So OAE amplitude is greater in females and contralateral suppression of OAE is greater in males (11). McFadden D. Et al (2006) continued study of gender effects on OAE and indicated that in human beings and Rhesus monkeys, Click-Evoked Otoacoustic emissions (CEOAEs) are more powerful in females than males, and this gender difference is the result of greater exposure to androgens prenatally in males (12). Other works showed that this gender difference in OAE amplitude fluctuated seasonally and is related to the annual fluctuations of testosterone levels in male Rhesus. The CEOAEs of male Rhesus monkeys were weaker in the breeding season (when male androgen levels are high) than in the birthing season (when male androgen levels fall) (13). Al-Mana D. et al (2008) stated that it is possible that hormones contribute to pathophysiology of some auditory dysfunctions, including hyper acusis, tinnitus, Menière's disease and pre-menstrual auditory dysfunction and play role in modulating the auditory functions (14). McFadden D. et al (2009a,b) showed that in humans, OAEs have significant differences between males and females. From early studies on OAEs in humans, ear (right ear versus left ear) and gender differences were apparent. These effects have been shown in newborns and adults. In general, human females have stronger and more prevalent SOAEs and more powerful CEOAEs than males (15, 16). McFadden D. et al (2009) insisted that one obvious explanation for the gender difference in newborns is the differential prenatal exposure to androgens in two sexes (15, 16). All male mammals early in the course of prenatal development develop embryonic testes that begin producing the androgens that are responsible for masculinizing the prenatal body and brain (16). OHCs are the most important part in the production of OAEs. Thus, OHCs might have some differences


between males and females. The electro motility of OHCs is dependent to the prestin molecules in the walls of the OHCs, so any differences in prestin could be a major contributor to the OAE differences. Perhaps, for some reasons, women have, on average, more prestin molecules per OHC than men, or perhaps the prestin molecules in women OHCs are better aligned along the cell’s contraction axis. In either case, female OHCs would be capable of greater electro motility than male OHCs (16). Maruska K. and Fernald R. (2010) stated that gonadal and stress-related steroid hormones have influences on auditory function across vertebrates but the cellular and molecular mechanisms of steroid-mediated auditory plasticity at the level of the inner ear remain unknown. The peripheral and central auditory system of vertebrates is sensitive to sex- and stress-related steroid hormones, which can have strong effects on how an animal perceives acoustic information and behaves during social interactions. The steroid receptors have been found in the inner ear which suggests there might be a direct pathway for hormones to act on the peripheral auditory system. The expression levels of steroid receptors differ between the genders. In mammals, females often have "better" hearing (e.g., better high frequency hearing; shorter auditory brainstem response wave latencies) and presbycusis begins in

older age than males. Further, postmenopausal women who are on estrogen-based hormone replacement therapy (HRT) have better hearing than those who are not, while progestin-based HRT can diminish hearing ability. These sex and female ovarian cycle variations in hearing are attributed to the protective effects of estrogen and may be partially related to estrogen receptor (ER) expression in the cochlea (17). Conclusion This study among others shows that there is a significant gender difference in TEOAE (which is by product of cochlear mechanisms) and TEOAE suppression (which is due to effects of auditory efferent system on cochlea). The exact reason for these results is not clear but there are some hormonal and structural explanations. According to this study and other results, it might be necessary to have different norms for males and females, especially in newborn OAE testing to avoid any wrong interpretation. Acknowledgement: The authors wish to acknowledge the assistance of the students and staff of Akhavan rehabilitation centre of the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran, in collecting data.

References 1. McFadden D, Pasanen EG, Raper J, Lange HS, Wallen K.

Sex differences in otoacoustic emissions measured in rhesus monkeys (Macaca mulatta). Hormones and Behavior. 2006 Aug;50(2):274–284.

2. Kemp DT. Otoacoustic emissions, their origin in cochlear function, and use. Br Med Bull. 2002 Oct 1;63(1):223–241.

3. A L-D. [Otoacoustic emissions]. HNO. 1992 Nov; 40(11): 415–421.

4. Vasconcelos RM, Serra LSM, Aragão VM de F. Transient evoked otoacustic emissions and distortion product in school children. Revista Brasileira de Otorrinolaringologia. 2008 Aug;74(4):503–507.

5. Fronza AB, Barreto DCM, Tochetto TM, Cruz IBM da, Silveira AF da. Association between auditory pathway efferent functions and genotoxicity in young adults. Brazilian Journal of Otorhinolaryngology. 2011 Feb; 77(1): 107–114.

6. Zeng F-G, Martino KM, Linthicum FH, Soli SD. Auditory perception in vestibular neurectomy subjects. Hearing research. 2000;142(1):102–112.

7. Komazec Z, Filipović D, Milo\vsević D. Contralateral acoustic suppression of transient evoked otoacoustic emissions: Activation of the medial olivocochlear system. Medicinski pregled. 2003;56(3-4):124–130.

8. Cassidy JW, Ditty KM. Gender differences among newborns on a transient otoacoustic emissions test for hearing. Journal of Music Therapy. 2001;38(1):28–35.

9. Durante AS, Carvallo RMM. Changes in transient evoked otoacoustic emissions contralateral suppression in infants.

Pró-Fono Revista de Atualização Científica. 2006 Jan; 18(1):49–56.

10. Miller JD. Sex differences in the length of the organ of Corti in humans. The Journal of the Acoustical Society of America. 2007;121(4):EL151–EL155.

11. McFadden D. A speculation about the parallel ear asymmetries and sex differences in hearing sensitivity and otoacoustic emissions. Hearing Research. 1993 Aug;68(2):143–151.

12. McFadden D, Pasanen EG, Weldele ML, Glickman SE, Place NJ. Masculinized otoacoustic emissions in female spotted hyenas (< i> Crocuta crocuta</i>). Hormones and behavior. 2006;50(2):285–292.

13. McFadden D, Pasanen EG, Raper J, Lange HS, Wallen K. Sex differences in otoacoustic emissions measured in rhesus monkeys (Macaca mulatta). Hormones and Behavior. 2006 Aug;50(2):274–284.

14. Al-Mana D, Ceranic B, Djahanbakhch O, Luxon LM. Hormones and the auditory system: A review of physiology and pathophysiology. Neuroscience. 2008 Jun 2; 153(4): 881–900.

15. McFadden D, Martin GK, Stagner BB, Maloney MM. Sex differences in distortion-product and transient-evoked otoacoustic emissions compared. J Acoust Soc Am. 2009 Jan;125(1):239–246.

16. McFadden D. Masculinization of the Mammalian Cochlea. Hear Res. 2009 Jun;252(1-2):37–48.

17. Maruska KP, Fernald RD. Steroid receptor expression in the fish inner ear varies with sex, social status, and reproductive state. BMC Neuroscience. 2010 Apr 30;11(1):58.


Vol. 9, No. 14, Oct. 2011 26

* All correspondences to: Susan Afghah; Email: < [email protected]>

Original Article

The impact of coping strategies on burden of care in chronic schizophrenic patients and caregivers of chronic bipolar patients

Morteza Khajavi, MD; Mansoureh Ardeshirzadeh, MD; Susan Afghah*, MD; Behrooz Dolatshahi, PhD.

University of Social Welfare and Rehabilitation sciences, Tehran, Iran

Objective: One of the principles of mental health programs is burden and coping of caregivers of chronically mental disorders patients. In this regard, the aim of present study was to measure the amount of burden and relationship between burden and their coping strategies of caregivers.

Method and Materials: One hundred of main caregivers of patients (50 schizophrenic patients, 50 bipolar patients) from both Razi psychiatric hospital and clinic were enrolled to the study. The instruments were FBIS (Family Burden Interview Schedule) as well as Weintraub coping strategies check list (COPE). Chi-square, Pearson correlation coefficient and t-test were used for data analysis.

Results: The study showed that the mean of burden in caregivers of chronic schizophrenic patients was significantly (P<0.05) higher than that of bipolar patients (35.5 vs. 28.9). There was inverse correlation (but not statistically meaningful) between burden and problem focused coping strategy.

Conclusion: There was also a direct correlation between burden and emotional-oriented and less benefit and not effective coping strategies, but was not meaningful. Regarding the higher burden in caregivers of chronic schizophrenic patients, social support and offering health services to them seems to be necessary. Training of caregivers for problem-focused copings can also reduce the burden.

Keywords: Caregiver, Schizophrenia, Bipolar disorder, Burden, Coping Strategy.

Submitted: 19 Apr 2011 Accepted: 22 Sep 2011

Introduction Caregivers of mental disorders patients such as schizophrenia and bipolar disorders often tolerate high burden against compatibility with signs of their patients. Increase of burden has various subsequences for caregivers such as decrease in taking care of patients, family isolation, elusion of other relatives from them, decrease in social and mental supports of the patient and consequently to reject the patient and aggravation of disease which may be resulted in their homelessness (1). High burden in caregivers with a high expressed emotion may increase the probability of exacerbations and re-hospitalization (2). A study conducted in Japan indicated that educating coping strategies to the schizophrenic patients caregivers is useful for all caregivers particularly caregivers with high expressed emotion (3).

Some factors in psychiatric patients may affect taking care of the patient (4, 5). Such factors may include caregivers’ cognition estimation, coping approaches and social supports. Also upon assessment of the relation between such factors with mental burden and health of caregivers, it is specified that high level of mental burden may be related to: more repetition of negative and positive symptom behaviors, tending to application of coping approaches based on resolving the problem in facing with negative behaviors, not tending to application of coping approaches based on resolving the problem in facing with positive symptom behaviors. Falloon et al. (6) found that the caregivers who apply problem-centered approaches may show lower burden and better compatibility. A lower level of caregivers’ awareness may cause to more application of negative coping approaches by


them which may be resulted in a high level of mental burden (7, 8). The relatives of psychiatric patients may experience an expanded extent of emotional and practical tension (9). The impact of caregivers’ mental burden such as any other stress relates to recognition assessment of the problem by them and available resources for coping (10). Vulnerability of individuals against mental burden may be affected by coping strategies and available social supports (11). There is no direct relation between tension, mental burden feeling and their negative consequences, so that Lazarous and Folkman (12) believed that coping approaches by individuals may have intermediary role in the extent of mental burden feeling and their negative subsequences, so that application of problem-centered coping approaches may decrease extent of burden and emotional-centered and ineffective coping approaches may increase burden or may have no significant effect on compatibility. Therefore, by taking the listed cases into account the burden tolerated by caregivers of chronic mental disorders patients (Schizophrenia and bipolar disorders) may differ proportional to applied coping strategies. The study conducted by Lazarous and Folkman as stated by Hins and Co. indicated that application of coping strategies emphasizing on problem solving approaches is more compatible than emotional-centered coping approaches (12). A number of papers were also conducted in Iran on application of coping strategies while facing with stress and these studies showed that particular coping approaches more compatible in specific conditions. By assessing the relevant texts, it seems that in circumstances that the available problem may be solved problem-centered coping approaches are more compatible but in some cases that the problem may not be solved the emotional-centered approaches may also be compatible. As mental burden tolerated by caregivers of schizophrenic patients have been pointed out in papers mental burden tolerated by caregivers of bipolar patients have also been considered (13, 14, 15, 16). Method 100 caregivers (50 schizophrenic patients’ caregivers and 50 bipolar patients’ caregivers) referred to psychiatric clinic or Razi hospital was selected through convenient sample group method. The tools and instruments include a questionnaire on caregivers’ burden and Weinteraub coping strategies check list

(COPE). By use of T test and chi-square and Pierson correlation coefficient of findings were analytically analyzed. All samples are psychiatric patients’ caregivers whose patients were considered as schizophrenic or bipolar patients according to psychiatrist interview and according to DSM-IV diagnostic criteria and recourse to Razi psychiatric hospital or were hospitalized there. Studies were conducted on caregivers of such patients who have conditions for selection. Selection conditions 1. To meet DSM-IV criteria (in order to diagnose schizophrenic and bipolar disease), 2. The caregiver must be between 20-75 years old. 3. At least two years have passed from disease. 4. The caregiver must be in sound physical conditions. 5. The caregiver must not be dependent to any psychedelic drugs. 6. Each caregiver shall care only one patient. Taking samples was performed by use of convenient group sampling method. All caregivers declared their consent concerning filling questionnaire. 100 people were selected. 50 schizophrenic patients’ caregivers and 50 bipolar patients’ caregivers were selected and then assessed. Measurement Tools The following tools were applied for evaluating extent of burden and assessment of coping approaches applied by 50 schizophrenic and bipolar patients’ caregivers in this study: - Questionnaire concerning individual particulars (patient-caregiver), - Family burden interview schedule (FBIS) - Weinteraub coping strategies check list (COPE). Caregiver Burden Schedule This questionnaire was prepared by Pais and Kapur (17) which may be filled in form of a semi-constructed interview. This questionnaire may analyze caregivers’ burden in two objective or subjective dimensions. Each includes 24 clauses and 6 classes in total that each includes 3 options which evaluate the said dimensions in 0-2 scale in each clause. The maximum point in this scale is 48 and the minimum point is 0. The greater point indicates the higher extent of burden. This scale has a high static coefficient (72%) which was translated and applied in Iran by Malakouti and et. al

Vol. 9, No. 14, Oct. 2011 28

(18). According to the points gained in this scale, three categories including low burden (0-16), mean burden (17-32) and high burden (32-48) are achieved. Coping Strategies Check List This questionnaire is a multi-dimensional tool which analyzes various types of responding people to stress which was prepared by Carver, Schier and Weinteraub (19) and translated by Zolfaghari, Mohammadkhani and Ebrahimi Mohammadkhani (20) and revised by taking Iranian culture into account and by use of other available coping schedules. Since, the list does not contain all coping behaviors, the schedules analyzed in the study conducted by Epstein and Majer (21). This check list includes 72 clauses and 18 categories in total that each includes 4 options. Besides, according to theoretical scheme of the test, this list includes 4 general subjects including: Problem-Centered Coping 5 conceptual scales were allocated to problem-centered coping evaluation including the following categories: A) Active coping; B) Scheduled coping; C) Ceasing semi-ordinate activities; D) Avoiding impatient facing with problem or patience; and E) Seeking for operative social support. Emotional-Centered Coping 5 scales were allocated to emotional-centered coping evaluation including the following categories: A) Coping based on deny; B) Coping through seeking emotional social support; C) Coping through tending to religion; D) Coping based on acceptance; and E) Coping through positive re-interpretation. Low-Effective Coping and Ineffective Coping 3 scales were allocated to low-operative coping responses including the following categories: A) Centralizing on emotion and its express; B) mental non-engagement; C) behavioral non-engagement. 5 scales were allocated to inoperative coping responses including the following categories: A) Impulsiveness; B) Superstitious Thinking; C)

Wishful Thinking; D) Negative Thinking; and E) Using medicine and substances. Validity and Stability Carver and et al. (19) assessed the validity and stability of these tools through three separate studies on a group of students. The results of stability assessment through re-evaluation method indicated that the stability coefficient was between r=0.42 and r=0.76 for various scales. The results of the study conducted by Mohammadkhani (20) showed that this scale is a valid tool for evaluation of coping strategies. Also the stability of all its scales was assessed on a sample including 20 students through re-evaluation with a two-week interval. The highest stability coefficient was tending to religion i.e. r=0.95 and the lowest but the most meaningful stability coefficient relates to behavioral non-engagement i.e. r=0.63. The stability coefficient for the whole scale was reported as 0.93. Results The studies indicated that there is an inverse relation between extent of burden and problem-centered coping approaches, but it was not statically meaningful and there is a direct relation between extent of burden and emotional-centered, low-effective and ineffective coping approaches. Demographical study relating to the patients and caregivers of both groups indicated that notwithstanding the equal number of patients in both groups but the average age of schizophrenic patient is higher and that the number of employed bipolar patients is four times more than employed schizophrenic patients. Of course both groups were analyzed based on age category. Their caregivers were often illiterate. As to schizophrenic patients the father played role of caregiver (28%) more than mother (22%). The table 1 indicates that chronic schizophrenic patients’ caregivers meaningfully tolerate higher burden (p < 0.050) than chronic bipolar disorders patients’ caregivers (averagely 35.5 versus 28.9).

Table 1- Comparison of Burden Average of Schizophrenic and Bipolar Disorders Patients Caregivers

Group Number Average Standard Deviation

Extent Freedom degree

Meaningfulness level

Chronic Schizophrenic Patients Caregivers

50 35.54 8.6

Chronic Bipolar Patients Caregivers

50 28.94 11.5 3.14 49 0.003


Tables 2 and 3 indicate that although applying problem-centered coping approaches has an invert relation with the burden extent but it is not meaningful, and that the relation between emotional-

centered, low-effective and ineffective coping approaches applied by caregivers of both groups is direct but not meaningful.

Table 2-Relationship between Extent of Burden and Coping Approaches Applied by Schizophrenic Disorders Patients

Caregivers Coping Approaches of Chronic Schizophrenic Disorders

Patients Caregivers Number

Correlation coefficient

Reasonability level

Problem-centered coping approaches 50 -0.066 0.65 Emotional-centered coping approaches 50 0.082 0.57

Low-effective and ineffective coping approaches 50 0.045 0.75

Table 3- Relationship between Extent of Burden and Coping Approaches Applied by Bipolar Disorders Patients Caregivers

Coping Approaches of Chronic Bipolar Patients Caregivers Number Correlation coefficient Reasonability level Problem-centered coping approaches 50 -0.164 0.254

Emotional-centered coping approaches 50 0.005 0.972 Low-effective and ineffective coping approaches 50 0.189 0.188

Discussion The study indicated that burden tolerated by schizophrenic patients’ caregivers is meaningfully higher than chronic bipolar patients’ caregivers, so that burden average is 35.5 in schizophrenic patients’ caregivers and 28.9 in chronic bipolar patients’ caregivers. Since most human disorders are related to stress in some aspects (22) and the higher stress (23) and longer (24, 25) has more negative psychiatric and physiologic effects. Malakouti et al. (18) discovered in their studies that the extent of burden tolerated by chronic schizophrenic patients’ caregivers is higher than burden tolerated by other chronic mental disorder patients caregivers. A study conducted in India indicated that although in most studies the quality of chronic sever diseases such as schizophrenia and characteristics of caregivers in coping with mental disorder were pointed out but similar disorder like bipolar mood disorder are rather ignored (26). In a study conducted by Webb et al. (4) on the relationship between mental burden and mental health of chronic mental disorder patients caregivers and its relation to social support and coping approaches, they founded that mental burden along with higher frequency of positive and negative symptoms and mental health is related to lower frequency of positive symptoms and social support than coping approach applied by the caregiver. In this study the burden source in caregivers of both groups was more objective rather to be subjective that may be resulted from poor social supports such as out-patients, rehabilitation and long-term and

short-term hospitalization services or permanent care of the patient also the impact of presence of a mental patient on family's income and caregiver's gender. These findings conform to demand of schizophrenic patient caregivers who have severed symptoms and their caregivers must tolerate higher burden. A study conducted in Chili indicated that the extent of mental burden arises by lacking social rehabilitation schedules for mental disorders patient caregivers (27). The major hypotheses of the study was assessment of relationship between extent of burden with coping approaches that an invert but non-meaningful relation was recognized between problem-centered coping approaches and caregivers burden of both schizophrenic and bipolar patients groups in this research. Similarly there was a direct relation between emotional-centered, low-operative and inoperative coping approaches and extent of burden that was not statically meaningful. This result applies to both groups of schizophrenic and bipolar patients caregivers. A study conducted in India indicated that problem-centered coping approaches were rather applied by bipolar patients’ caregivers and emotional-centered coping approaches were rather applied by schizophrenic patients’ caregivers (28). Non-meaningfulness of these findings may be due to the low mass of sample in this study (100 samples), on the other part, the current sampling method was convenient group method from two centers, psychiatric hospital and Razi clinic that individuals who refer to this clinics due to their special

Vol. 9, No. 14, Oct. 2011 30

geographic location, are of a lower social – economic level as well as literature level. As indicated in tables relating to demographic specifications of samples, caregivers (whether male or female) are often illiterate that may be a factor influencing applied coping strategy and extent of burden. Of course, caregivers of such patients by referring to the said centers indeed applied problem-centered coping approach, but the domain of low or high application of this approach is limited among them that may be considered as another factor of non-meaningfulness of this relation. Vulnerability of individuals against mental burden may be affected by their coping strategies and available social supports (11). Thus the extent of burden arising from caring chronic mental patients may be different depending on coping approaches applied (29). In a study conducted in Japan indicated that in order to provide effective support for reducing caregiver burden the necessity of nursing and social support must be emphasized (30). In other words, a number of factors such as gender, race, social supports, level of literature, education and social class as well as characteristics of individuals and disease nature may all affect the type of applied approach that we could not control them due to restrictions of study. Restrictions of study 1- Disability in selecting cases randomly which require a national and comprehensive plan. Two centers i.e. Razi hospital and Razi clinic were

selected for sampling that may be considered as a factor for bias of choosing cases. 2- The sampling place is located at southern side of the city and the referees are generally chronic patients with multiple history of hospitalization. A great number of families refer to these centers for permanent care; also the geographical situation of Razi Psychiatric Hospital is an effective factor for selection of referees. Conclusion By use of the impact of type of coping strategies on extent of burden sustained to chronic schizophrenic and bipolar caregivers, training problem-centered coping strategies to caregivers may be considered as an approach for reducing burden tolerated by caregivers. Chronic mental disorder caregivers are a specific group in the society who has specific demands which must be recognized. As the starting point, development of supports such as training families, short-term hospitalization, psychiatric and professional rehabilitation and rendering services to patients at home may be pointed out. Also, the burden sustained to them may be reduced by planning medical sessions based on increasing use of problem-centered coping approaches, particularly concerning schizophrenic caregivers who tolerate higher burden. Acknowledgements: I hereby appreciate all personnel of Razi Psychiatric Clinic and Razi Hospital who extended their sincere cooperation towards this study.

References 1. Biegel D, Milligan S, Putnam P, Song L. Predictors of

burden among lower socioeconomic status caregivers of persons with chronic mental illness. Community Ment Health J. 1994 Oct 1;30(5):473–494.

2. Scazufca M, Kuipers E. Links between expressed emotion and burden of care in relatives of patients with schizophrenia. BJP. 1996 May 1;168(5):580–587.

3. Yamaguchi H, Takahashi A, Takano A, Kojima T. Direct effects of short-term psychoeducational intervention for relatives of patients with schizophrenia in Japan. Psychiatry and Clinical Neurosciences. 2006;60(5):590–597.

4. Webb C, Pfeiffer M, T K, Gladis M, Mensch E, DeGirolamo J, et al. Burden and well-being of caregivers for the severely mentally ill: The role of coping style and social support. Schizophrenia Research. 1998;34(3):169–180.

5. Lloyd H, Singh P, Merritt R, Shetty A, Yiend J, Singh S, et al. A Comparison of Levels of Burden in Indian and White Parents With a Son or Daughter With Schizophrenia. Int J Soc Psychiatry. 2011 May 1;57(3):300–311.

6. Falloon IRH, Pederson J, Al-Khayyal M. Enhancement of health-giving family support versus treatment of family

pathology. Journal of Family Therapy. 1986;8(4):339–350. 7. Lim YM, Ahn Y-H. Burden of family caregivers with

schizophrenic patients in Korea. Applied Nursing Research. 2003 May;16(2):110–117.

8. Baldassano C. Reducing the Burden of Bipolar Disorder for Patient and Caregiver. Medscape Psychiatry & Mental Health [Internet]. 2004;9(2).

9. Tsang HWH, Tam PKC, Chan F, Chang WM. Sources of burdens on families of individuals with mental illness. Int J. Rehabil Res 2003, 26: PP 123-130.

10. Eticson R, Eticson, Richard Hilgard, E. Field of Psychology. Barahani MT,et al. (Persian translators) Tehran: Roshd publications;1989

11. Sarason AJ, Sarason BA. Pathologic Psychology. Najarian B, Asgharimoghadam MA, Dehghani M. (Persian translator). Tehran: Roshd publications;1992

12. Lazarus R, Follkman S. Stress, Appraisal, and Coping. Springer Publishing Company; 1984.

13. Jungbauer J, Angermeyer MC. Living with a Schizophrenic Patient: A Comparative Study of Burden as It Affects Parents and Spouses. Psychiatry: Interpersonal and Biological Processes. 2002 Jun;65(2):110–123.


14. Jungbauer J, Mory C, Angermeyer MC. Does caring for a schizophrenic family member increase the risk of becoming ill: psychological and psychosomatic troubles in care givers of schizophrenia patients Fortschr. Neurol. Psychiatr. 2002 Oct;70(10):548–554.

15. Schmid R, Huttel G-U, Cording C, Spiessl H. Burden of caregivers of inpatients with bipolar affective disorder. Psychiatrische Praxis. 2006;33(1):155–156.

16. Reinares M, Vieta E, Colom F, Martinez-Aran A, Torrent C, Comes M, et al. What really matters to bipolar patients’ caregivers�: Sources of family burden. Journal of affective disorders. 94(1-3):157–163.

17. Pai S, Kapur RL. Impact of treatment intervention on the relationship between dimensions of clinical psychopathology, social dysfunction and burden on the family of psychiatric patients. Psychological Medicine. 1982;12(03):651–658.

18. Malakouti. Seyed Kazem and Co., Burden of caregivers of chronic mental disorders patients and their need to care and medical services, 1997, Hakim Journal, Summer 2003, 6th print, No. 2, p 8.

19. Carver CS, Scheier MF, Weintraub JK. Assessing coping strategies: a theoretically based approach. Journal of personality and social psychology. 1989;56(2):267.

20. Mohammadkhani, Parvaneh (1992), Assessing strategies for coping stress and symptoms in obsessive – compulsive patients (Thesis of MSc. in clinical psychology).

21. Epstein S, Meier P. Constructive thinking: A broad coping variable with specific components. Journal of Personality

and Social Psychology. 1989;57(2):332–350. 22. Shamloo, Saeed (2009) metal health, Tehran, Roshd

publications 23. Sarason IG. Social support personality and health. In

Ganise, M.P. (Ed). Individual Differences. Stress and health psychology. New York springer – verlag.1998;

24. Taylor SE. Health psychology (4th ed.). New York, NY, US: McGraw-Hill; 1999.

25. Fwuerstein, M. Labbe, E. and Kuczemexzyk, A. R. (1987) health psych. (2nd printing). Plenum press, New York and London.

26. Nehra R, Chakrabarti S, Kulhara P, Sharma R. Caregiver-coping in bipolar disorder and schizophrenia. Soc Psychiat Epidemiol. 2005 Apr 1;40(4):329–336.

27. Caqueo-Urízar A, Gutiérrez-Maldonado J. Burden of Care in Families of Patients with Schizophrenia. Qual Life Res. 2006 May 1;15(4):719–724.

28. Chakrabarti S, Gill S. Coping and its correlates among caregivers of patients with bipolar disorder: a preliminary study. Bipolar Disorders. 2002;4(1):50–60.

29. Hanzawa S, Bae J-K, Tanaka H, Bae YJ, Tanaka G, Inadomi H, et al. Caregiver burden and coping strategies for patients with schizophrenia: Comparison between Japan and Korea. Psychiatry and Clinical Neurosciences. 2010;64(4):377–386.

30. Hanzawa S, Tanaka G, Inadomi H, Urata M, Ohta Y. Burden and coping strategies in mothers of patients with schizophrenia in Japan. Psychiatry and clinical neurosciences. 2008;62(3):256–263.


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* All correspondence to: Nader Fallahian; Email: < N. Fallahian@uswr. ac. ir>

Original Article

Effect of Time Constraind Induced Therapy on Function, Coordination and Movements of Upper Limb on Hemiplegic adults

Masoud Gharib, MSc;

University of Social Welfare and Rehabilitation Sciences, Neurorehabilitation Research Center, Tehran, Iran.

Hooman Ghorbani, MSc; Mehdi Abdolvahab, MSc; Nader Fallahian*, MSc; Masoud Kasechi

University of Social Welfare and Rehabilitation Sciences,Tehran, Iran.

Introduction: Stroke, is one of the major causes of disability in adults .so, the patient may prefer to use the non- involved limb to perfom selfcare & named this phenomen learned non used. Constraint induced therapy is one of the rehabilitative interventions that can be effective in restoration of the function of the involved limb in some hemiparetic post stroke patients. purpose of this study was to investigate effect of time constraind induced therapy on function, coordination and movements of upper limb on hemiplegic adults.

Method and Materials: In an interventional design, 15 hemiplegic patients attended in stracture exrcises for 2 hours a day, 5 days a week for 12 weeks in during while for 5 hours a day, 5 days a week for 12 weeks, the sound limb was restricted within an arm sling for movement & dextrity assessment were used Fugl-Meyer & Minnesota Manual Dexterity Test.

Results: the results of Fugl-Meyer & Minnesota Manual Dexterity Test were significantly improved in patients, after the intervention(p<0.0 5).

Discussion: our study shows that using CIT in involved limb encouraged the patients to use their involved limb and improved function by conquering learned non-use of the limb. more research is necessary to define baselines or golden times for rehabilitation of the patients using CIT method.

Key words: Strok,constraint Induced Therapy, Function, Dextrity Submitted: 1 May 2011 Accepted: 22 Aug 2011

Introduction Stroke, is one of the major causes of disability in adults and in most of the times is accompannied by considerable motor functional loss(1). It results in hemiplegia, and functional impairment in performing activities of the daily living(ADL). Many researcher are interested in finding more effective treatment modalities(2). Recovering motor function and integration of recovered motor skills to improve functional independence level in ADL is one of the most important responsibilities of the ocupational therapists. Because of the importance of the upper limb for performing the activities of daily living, improving the function is one of the most important aspects of retrainning motor control, and has an important role in rehabilitation programs(3, 4).

Variety of methods have been used in rehabilitation of the stoke patients, such as biofeedback, neuromuscular stimulation, and motor learning. These methods may be effective in early functional restoration of the upper limb to perform ADL. When the function of one side is superior to the contralateral limb, the patient may prefer to use the sound limb to perfom selfcare. As the time passes after the stroke, patients use their non-involved limb to perform ADL(5). Taub described this phenomenom as “learned non-use” of the upper limb. In other words, as the patient finds the limb useless, learns to “non-use” it(6). Constraint induced therapy is one of the rehabilitative interventions that can be effective in restoration of the function of the involved limb in some hemiparetic post stroke patients(6, 7). “Constraind Induced Therapy”(CIT) and “forced


use” of the involved limb are new therapeutic intervantions. In these approaches the non-involved limb is restricted to encourage utilization of the involved limb via performance of functionl activities(8). Great amount evidence exists about the application of these methods in order to motor loss of the involved limb and improving the functional independence in strok. Also both Induced therapy and forced use of the limb include limitting the non-involved limb and performing excercises by the involved limb, These modalities are different from each other in types of excercises and time of the restriction. in forced use, the non -involved limb will be restricted and the patient has to perform all actions with the involves limb. in this method the exercises are not structured and the severity of excercises depends on the patient conditions. but constraind induced therapy is a structured exercise that includes shaping and repetitive tasks (7). CIT was first introduced on behavioral cognitive basic science researches on monkeys. the results showed when the limb has no function, the animal would not use the limb for the activities of daily living. as non-use of the limb that gradually results in persistent non-use of the weaker limb(6). In 2002, Page et al used CIT on 14 patients with stroke in 10 week interval, for 3 days a week; and found an improvement in results of the Fugl-Meyer test(9). In 2003, similar study was performed by Bonifer et al (10) on 7 patients with stroke after at least 1 year after the stroke. The patients had at least 10 degrees of wrist extension in involved limb and CIT was used for 3 weeks. The patients were asked to perform particular exercises, that cuased more use of involved limb both in clinic and in home, for 3 weeks, 5days a week for 6 hours a day. Fugl-Meyer test was also used to assess the movements befor and after the intervention. the results significantly improved after the intervention. In 2004, another research was carried out with Page et al(9) on 17 stroke patient, after 1 year of involvment. an intervention group of 7 patients were encouraged to use their involved limb to perform ADL. 4 patients received common treatments as the intervention group and 6 patients had no treatments. activities including writing, using utensiles, brushing teeth and combing own hair, while their non-involved limb was constrained by splint for 10 weeks, 5 days a week for 5 hours a day. the scores of Fugl-Meyer test was significantly improved in

intervention group compared to custom treatment and no treatment groups(p<0. 05). In 2005, Bonifer used CIT on 20 patients, 1 year poststroke(11). All subjects had 20 degrees of wrist extension. the patients were asked to use a mit on non-involved hand and perform CIT exercises for 6 hours a day in 3 weeks. The patients were assessed using the Fugl-Meyer test. The scores improved significantly after the intervention. In 2006, Wolf et al used CIT in post stroke patients, 3 to 9 months post stroke(12). the goal of this study was to evaluate the effectiveness of CIT on functional movements of the upper extremity in two week intervals for a period of twelve weeks. the movements of the non-involved hand of 22 patients was restricted with a mit. using the shaping technique, each patient was encouraged to use the involved limb. at the end, the results within this group was superrior than the control group in functional movement tests. Tarka et al used CIT in 27 patients with stroke. the non-involved limb of each patient was restricted within an arm sling for 2 weeks, 7 hourse a day. the patients completed CIT exersices for grasp-release and manipulation of small objects. This stuy showed that the functional movements of the involved limb improved significantly after the intervention(13). purpose of this study was to investigate effect of constraind induced therapy on function, coordination and movements of upper limb on hemiplegic adults. Materials and Methods In an interventional design, 15 hemiplegic patients (9 males and 6 females)&(9 right,6 left) were radomely selected from the patients referred to occupational therapy clinic of rehabilitation faculty of Tehran university. The average age of the patient was 60. 8 years, with Standard Deviation(SD) of 10. 8 years. Written contestant was acquired from the patients before the intervention. Demographic characteristics of the subjects are summerized in table 1. Inclusion criteria were: at least 1 year passed from the stroke no symptoms of frozen shoulder persist at the

onset of the intervention the ability to sit on the edge of the table for 10

minutes, to ensure required stability of the trunk the ability to obey the verbal and functional

commands at least 20 degrees of wrist extension preserved in

involved limb

Vol. 9, No. 14, Oct. 2011 34

Exclusion Criteria were: unwillingness of the patient to continue the

therapeutic sessions occurance of orthopedic desease recurrence of stroke or other neurologic conditions All patients completed specified routine occupational therapy exersices 45 minutes a day, 3 times a week meanwhile non-involved limb was constrained within an orthopedic sling (9) for 5 hours a day, 5 days a week for 12 weeks. Occupational therapy stays on the principle that using purposful activities can facilitate rehabilitation, so in this study we used aimed activitites to develope the required motivation for more use of the involved limb. In order to have the subjects perform a unique form of exersises, an educational video demonstration was recorded and the patients were asked to perfrom their exersises based on the media. these exersices include grasp and release of a tennis ball, openning and closing of the door, and utilizing a glass for drinking. Each

exersises was included of 10 minutes of practice and 10 minutes of rest. 2 sets of excerrcise, total of two hourse were performed with the involved limb while the sound limb was restricted within an arm sling. Fugl-Meyer Test was used to assess velocity and coordination in movements of shoulder, elbow, wrist and hand joints. Minnesota Manual Dexterity Test was also used to assess dexterity of the upper limb. Both tests were used before and after the intervention in two week intervals. Paired t-test was used to compare the score before and after the intervention. SPSS (version 11. 5) was used for data analysis. Results There are demografic characteristics of the patients in table (1). The results of Fugl-Meyer test are summerized in Fig (1). As it is demonstrated, the scores of the test were significantly improved in patients, after the intervention(p<0. 5).

Table 1: Demographic characteristics of the subjects

Standard Deviation Average variable

10.8 60.8 Age

(years)

5.05 67.87 Weight

(kilograms)

5.06 171.53 Height

(centimeters) 1.2 2.5 Time passed from storke (years)

Fig 1. Averages for scores of Fugl-Meyer test in involved upper limb during twelve week intervals. The results for Minnesota Manual Dexterity Test also improved and are summerized in Fig (2).

Twelfth week

Tenth week

Eighth week

Sixth week

Fourth week

Second week

Perivous intervention

week

Ave

rage

S

core


Fig 2. Averages for scores of Minnesota Manual Dexterity test in involved upper limb during twelve week intervals Discussion The results recommand that repeated and functional exercises, and implication of CIT approach can conquer learned non-use and improve utilizing of the involved limb, thus result in decreasing the disability. The significant improvements in scores may be attributed to several factors: improvement in physical abilities of the upper limb, changes in learned non-use behavior, or cortical neuroplasticity due to limb use. Also Taub et al(6) stated that any kind of technic that can encourge the patients to use involved limb can be effective in treatment, it seams that constraint induced therapy approach can result in cortex plasticity and functional improvement. repeated application of the involved limb is one of the primary factors in CIT approach. That may cause cortical neurplacticity that is nessessary for functional improvement. Great amount of evidence exist that recommands different merthods of exercises and repetitive use of the involved limb result in cortical neuroplasticity and funcitonal improvement. It seems that stroke patients grow more motor disability in involved limb, because they prefere to use non-involved(sound) limb and not use the involved limb for performing the activities of daily living. As the time goes on from stroke, learned non-use results in less use of the involved limb, and the limb becomes more and more non-used and weak. Short time treatment protocols can make functional improvements or cortical changes, cortical neuroplasticity depends on using the limb. In this study, we found added use of the involved limb can

enhanced functional skills and has a positive effect on cortical neuroplasty. The results of this study show that CIT could be an effective modality to overcome the learned non-use of limb after stroke. As the results of the Fugl-Meyer test demonstrate, we can suggest that CIT can facilitate functional changes. The results of this study were consistent with Page study in 2002(9) that used CIT on 14 stroke patients for 10 weeks, 3 days a week. Scores from the Fugl-Meyer were improved after intervention to more than 11 points, while in our study, the average score improved to 11. 07. In this study, the most improvment of the results of Fugl-Meyer test were found by the eighth week. but the results did not improved significantly in 9th to 12th week for shoulder, elbow, wrist and hand velocity, motion and coordination. some possible causes would be as follows: 1. Fugl-Meyer test items can not assess the changes and improvement of the motion in latest weeks of the study, after the patients improved in motor abilities. 2. the patients improved faster in the first 8 weeks of CIT. in other words the rate of improvment was higher in early weeks of intervention and it went more steady and stabilized during the latest weeks. Maybe the patients will not more improve a certain level using CIT. 3. maybe improvement in function of the upper limb has a kind of effect on performing activities of daily living, that can not be assessed using the Fugl-Meyer test, and other tests that assess the activities of daily living should be used. our results were also consistent with the findings of Bonifer in 2003(10) and 2005(11). also most of the

Twelfth week

Tenth week

eighth week

Sixth week

fourth week

Second week

Previous intervention

week

Ave

rage

S

core

Vol. 9, No. 14, Oct. 2011 36

participants of Bonifer’s study mentioned that after intervention they used their involvede upper limb(10), it dos not mean that the patients has gained the ability to independently use the involved limb, or the motor abilities has improved and reach the level of the time before the stroke. In Bonifer’s second study(11), the scores improved to 5. 6 points after 3 weeks of intervention, while in our study the scores improved 11. 07 points in 12 week. the higher scores found in our study may be

due to extended time of intervention(12 weeks) compared to 3 weeks of intervention in mentioned study. our study shows that using CIT in involved limb encouraged the patients to use their involved limb and improved function by conquering learned non-use of the limb. more research is necessary to define baselines or golden times for rehabilitation of the patients using CIT method.

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Falchini M. Recovery of functional status after stroke: post rehabilitationfollow-upstudy. stroke1993;24:200-205.

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3. Ekman L. Neuroscience: Fundamentals for rehabilitation USA: WB Saunders; 2002.

4. Gillen G, Burkhardt A. Stroke rehabilitation: a function-based approach. USA: Elsevier; 2004.

5. Pamela S, Vegher J, Gilewski M, Bender A, Riggs R. client-centered occupational therapy using constraint-induced therapy. Stroke.2005;14(3):115-121

6. Taub E, Miller N, Novack T. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil1993;74:347-354.

7. Morris D, Crago J, DeLuca S, Pidikiti R, Taub E. Constraint-induced movement therapy for motor recovery after stroke. Neurorehabilitation1997;9:29-43.

8. Andrew M, Gordon M. Methods of constraint –induced movement therapy with hemiplegic cerebral palsy. Arch Phys Med Rehab 2005;86:837-844.

9. Page S, SueAnn S, Johnson M, Levin P. Modified Constraint-Induced Therapy after Subacute stroke. J Intensive care Med2002;17:111-119.

10. Bonifer N, Anderson KM. Application of constraint-induced movement therapy for an individual With Severe chronic upper-extremity hemiplegia. Physical Therapy2003;83(4):384-398.

11. Bonifer N, Anderson K, Arciniegas D. constraint-induced therapy for moderate chronic upper extremity impairment after stroke. Brain Injury2005 May 2005;19(5):323-330.

12. Wolf S, Winstein C, Miller J, Taub E. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke. JAMA2006;296(17):104-296.

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* All correspondences to: Dr. Mohammad Kamali, Email: [email protected]

Original Article

Challenge of Private Rehabilitation Centers and Welfare Organization (Behzisti)

Roghiye Akbari

Ghaemshahr welfare organization, Mazandaran, Iran Mohammad Kamali*, PhD.; Hasan Ashayeri, MD.; Narges Shafaroodi

Iran University of Medical Sciences, Rehabilitation Research Center, Tehran, Iran

Studying the situation of providing services for people with disability are very important and in current situation which is dominate on system providing rehabilitation services in Iran, private rehabilitation centers can be the best and the most important focus for this study.

This research performed by qualitative method and with phenomenology type, and purposeful sampling did as purposeful and based on similar samples. The samples of this study consisted of 14 managers of private rehabilitation centers who had especial experiences about the theme of research and providing rehabilitation services. The method of executing research was base on deep and open semi-structured interview that use from method focus group discussion which is a type of semi-structure interview for collecting data from samples. Collected data were analyzed by written analyze method and used from suggested Van Manen suggestion method.

Managers of private rehabilitation centers meet different problems and confront with different situations in their centers. General problem which appear as a frame of problems related to private politic, especial problems related to private rehabilitation centers activities, and intra/extra communication. The delivery of services to private sector does not mean depriving the responsibility from Welfare Organization and its rehabilitation deputy. The organization should issue establishment license for private rehabilitation centers and administer it.

Keywords: Qualitative Research, Phenomenology, Lived Experience, Private Rehabilitation Center, Management.

Submitted: 17 Sep 2010 Accepted: 29 Sep 2010

Introduction Developing countries faced economic crises in 1980 decade. These crises made major hindrances in governments' capacities for investment in state-owned institutes. Regarding this issue, governments in different countries have thought in de-concentration as one of the possible solutions for the problem and it has been involved in governments' programs since long time ago. Several countries and governments are trying to execute this policy. De-concentration means the transmission of power, authority and responsibility of the government to state organizations, semi-independent institutes and cooperative or private units, and it's divided to different kinds. “De-concentration” is the power transmission from central offices to local ones with same executive structure. “Delegation” is the

transmission of authority and responsibility from central offices to semi-independent or autonomous institutes. “Devolution” is the transmission of authority and responsibility from central offices to separated management structures which are still managed by state managers. “Privatization” is the transmission of operative responsibilities and the ownership in some cases to the private providers mostly becomes in a contract style to satisfy the reciprocal expectations (1). With attention to increase the number of people with disabilities and their families who come to receive rehabilitation services and regarding the most important point in disability especially in first stages, is the rehabilitation and training of rehabilitation person (2). Thus investigating how these services are offering would be very important

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and incurrent situation and with operative condition which effect rehabilitation services offering in Iran, private rehabilitation centers would be the important focus in this study. It's clear that, in addition to reducing the government expenses help reaching the development targets and suitable distribution in services, access improvement and also the increment of quality and efficiency, are main targets of the De-concentration policy in general and creation of private rehabilitation centers in specific (1). In a research done by Giraldes (3) also quality and efficiency factors with their descriptions and all points that evaluated in each factor, have been used for comparing general and private hospitals. The expectation of increasing the quality and efficiency of services offering by private institutes can be raised from differences in management and organizing patterns between private and state-owned institutes, which studied and affirmed in a research done by Roman, Ducharme, and others (4) on general and subjective treatment programs for drug abuse. The cogency of implementation for De-concentration and privatization policy and on the other hand increasing disability and accordingly increasing society requirements to receive rehabilitation services, are decisive reason for clarifying the importance of private institutes in rehabilitation guidelines. Then promotion of quality level in these centers will improve the quality of rehabilitation services offering to the target society and finally will lead to reach the target which determined for privatization policy in health care services area such as rehabilitation .The evaluation scales for efficiency and efficacy in rehabilitation and education of people with disabilities, (which are the basic operations for private rehabilitation centers), are quality and condition of rehabilitation services offering in these centers and coincidence of their services and activities with standards . Then we were able to see the execution of privatization – one of De-concentration methods – in state welfare organization that transferred the responsibility of such services to the private institutes. In fact since 1984 in order to reduce the government's ownership and increasing the partnership of individuals and private organizations in rehabilitation services, daily and 24-hourcenters specialized for people with disability, seniors and chronic mental patients have been established in whole country by individuals and corporations that a

part of costs related to the services will be paid by government subsidies. Guerriere, et al (5) also mentioned on partnership of service receivers and the government in paying the costs, in their research on costs and determinant factors in health care with personal finance but great motion of the currently the daily and 24-hour rehabilitation services procedure for children with corporeal and intellectual disabilities, indistinct and blind children and also seniors and chronic mental patients is being done according to the welfare organization rules. Now over 1000 rehabilitation services offering centers are active in country. Here the manager's "motive" and their "knowledge" about "disability”, "rehabilitation" and "special education" for people with disabilities , and their viewpoints about these concepts can highly affect their activities performance (6) . It's clear that the implementation of private centers establishing policy by welfare organization doesn't relieve its responsibility from welfare organization in rehabilitation and education services offering to people with disabilities, and the organization should succor the private centers and the managers to abate the problems and difficulties with continued training programs and constant supervision on their activities. Thus getting knowledge and information about different insights and viewpoints of managers pertaining to establish private rehabilitation centers can help us to realize the problems and difficulties , and find effective and practical solution to abate the halves and reach the "efficacy and efficiency increasing" target . Then to reach the main target of describing the viewpoints and experiences of private rehabilitation center's managers about establishing and managing these centers and getting more knowledge and deeper insight at this background , we surveyed the viewpoints and experiences of private rehabilitation centers' managers about managing a rehabilitation center Through a research to be able to hand over the results and findings to the responsible and rehabilitation services renderers and then to become more familiar with difficulties and problems of centers' managers and affecting factors on rehabilitation services offering quality , and find easier ways of offering rehabilitation services in their centers (6) . Catalono, Kendall, Vandenberg, and Hunter (7) faced equal professional managers' experiences to investigate the subject of these persons' realization and knowledge toward people cooperation with each other and work together, in their research like any


other one, in this research, these were the questions to be answered after analyzing the findings. Questions are: 1- Which reason and motivational factors make a

person emprise a private rehabilitation center? 2- What kind of problems, the private rehabilitation

centers' managers faced in establishing and managing their centers.

3- Does the welfare organization's policy against the category of "Private rehabilitation centers" affect these centers' activities?

4- How much the human force and employees arrangement in private centers can be affected by managing styles and how effective can be the methods of management on the center.

5- Is it possible for the private center's manager to impart the partnership of disabled person's family and parents in directing the center, rehabilitation and education offering to this target society?

The researcher had to analyze the givens and information by recording and paying accurate attention to participants’ statements and then repeating the study of recorded point and deep seated investigating of got contents and communicates these contents to the research topic. Material and methods The present research has been done based on a phenomenological method and as a qualitative research. The decision to use qualitative methodology should be investigated accurately because regarding the nature of qualitative research is maybe excitingly severe and highly time taking. However this type of research gives a collection of rich information which is not reachable through statistical sampling techniques. Strauss & Corbin (8), claim that it's possible to use qualitative methods in order to realize phenomenon which was not realized well before. Qualitative methods give us a new scope from things which are not known well and offer more accurate information which are difficult to transfer through quantitative research. In quantitative research the prevailing sampling strategy is random sampling that depends on choosing an accident sample from a larger society. The purpose of random sampling is to generalize the research findings to the whole society in the next stage. On the other hand intended sampling is the most evident strategy in qualitative research. Purposive sampling searches rich samples of information which can be studied in details. (9)

In present research because of the qualitative type, the sampling has been done as intended and based on similar samples. According to the research aim the researcher start to choose intended sampling regarding the type of experiments (the private rehabilitation center managing). In fact, the participants have the same experience of managing the private rehabilitation center. And the similar samples in private rehabilitation center managing experience have been chosen. The participants were 14 managers from private rehabilitation center with education levels bachelors and master graduated in physiotherapy, psychology, exceptional children psychology, occupational therapy and management and had special knowledge and experiences in rehabilitation services. 4 of them were female and the others were male. With the factor of: having the established authorization for private rehabilitation center, with 3 years old average of the center and taking the management position. Considering these factors for participants in this research would be possible by asking them and referring to their center establishment files .the record of service of the private centers under management of participants in this research were between 4-14 years. There was no necessity for identification of whole participants and the exact number of them from the beginning. Repetition and conformation of last collected data would be the number of participants. Data collecting started by arranging 2 or 3 group discussion meetings with different members and continued by reach the end stage. After each focus group discussion meeting the meeting have been recorded and classified based on the interview guide and determined targets, and upon this collection the next meeting has been arranged. Analyzing started by defining the subjects came out of data, a process which sometimes we name it coding (10). During coding process the researcher should identify conceptive headlines, through them the phenomenon have been observed and will be categorized, and name them tentatively. The target is creating multi dimensional descriptive groups from a primary framework, for analyzing word, phrases and events that look similar should become categorized as same group. The next stage of analyzing includes reconsidering the known groups to identify relations between them, a complicated process, sometimes called axial coding (10). In present research, data analyzing has been done by written analyzing method using Van

Vol. 9, No. 14, Oct. 2011 40

Manen suggested style Van Manen (11) offers a primary regular structure for explanatory phenomenological research that is introduced in a model with 6 methodological contents, including these stages: 1. Having a tendency to a phenomenon which seriously makes us interested in our world. 2. Considering the experience as we live it not as we imaging it. 3. Thinking of basic and inherent contents that define the phenomenon's nature and specifications. 4. Description of the phenomenon through writing and rewriting art. 5. Keeping a strong directional training relation to phenomenon. 6. Balancing the research texture by observing and paying attention to details and totalities. To observe the ethical principles in present research together with providing a testimonial for which given to all participants in several stages and different times to any of the focus group members became a assured that all their sayings will stay confidential and in order to record their words in focus group interview nothing will change.

Results: Findings that will be explained in this section are part of a vaster study results came out of this research. Interview meeting which were transcribed and totalizing the participants' statements. In present research leaded to creating 50 subthemes and by classification of this subthemes, 11 themes have been found and in repetitive study and several considering of these themes and finally after totalizing all themes and subthemes it seemed that it's possible to take all statements of these people into account in 2 general grounds and put declared themes into these 2 general grounds and investigate the present research's topic on base of these 2 general grounds including: 1. The condition leads the person through deciding for establishing the center and executing this decision. 2. Condition the person faces, in managing the center. One of the main and basic themes of this research found around the communication with welfare organization that in declared experiences 9 subthemes came out from this main theme Shown in below table.

Table 1: The subthemes and related themes

Main theme Subthemes 1. CCaopula expert 2. LLaws and bylaws 3. GGradation of centers 4. TThe government subsidize and referrer referring 5. TThe view of organization to the centers 6. Supervision or interference? (What means supervision?) 7. TThe township welfare chief 8. WWorking place geography and type of the centers activities

Necessary relationship with Welfare Organization (Behzisti)

9. EExpectation from the welfare organization Thus we content to point to these theme and subthemes: 1. Copula expert As mentioned before the uttermost relations of a private rehabilitation center is the relation with the welfare organization according to participants' statements the most important link for this relations is the copula expert and they believe that his revenue and specifications can affect the center's activities. "What their expert say, wouldn’t be as a revelation. I also have experts and I'm also an expert and my experts are also skilled". 2. Laws and bylaws Description of each center’s activities is based on elements enacted in laws and bylaws and the

valuation of the centers will be done according to them. There are some points mentioned by participants especially around this topic. "Each year a new bylaw, each year a new circular, I feel they didn't reach to the common target even by themselves, because from the beginning, two "privatization" and "releasing" topics have been mixed up." "These changes in manuals confuse the person.” 3. Gradation of the centers The result of valuation will appear as a grade given to each center and this grade in fact will determine the amount of finance and benefits the center receives from welfare organization.


"They did a subtle action graded in 1, 2 and 3 but it also doesn't work.". 4. The governmental subsidize and referrer referring. Regarding the participants' statements the centers' activities are highly depended on subsidizes. "There are infirmities but it's not a good reason for reducing the subsidizes, they should not go immediately to the last step.” "They repeatedly say you have to stay quiet because you get subsidize.” 5. The view of organization (welfare organization) to the centers. The participants mentioned that, the act of the centers is in fact taking some responsibilities of welfare organization, and then they are like executing arms for the organization. "They don't care about the service offered and the type of services which the center should offer.”. "They say we should not pay attention to strong points and should never mention theme. We should only mention the weaknesses.” 6. Supervision or interference? (What means supervision?) Private rehabilitation centers became established under supervision of welfare organization and this supervision will be continued during their working. In this research some of participants believe that the description which the organization has about the supervision on centers' activities is not a suitable description and sometimes has some common point with interference in centers' management. "In my opinion it's not their business that how much salary I pay to my employee, it's related to job administration.” 7. The township welfare chief We mentioned that there is a relation between welfare organization and the centers that the managers think as the middle ring for these relations is copula expert but one who can highly affect this middle ring is the township welfare chief and his viewpoints thinking and acting. "Our organization management is inconstant; it's 8 years that I'm working and the welfare chief has changed several times.” "The new welfare chief is so much better for us because he thinks as we think and we are not against each other he completely understands us it's better for administrating the center.". 8. Working place geography and type of the center's activities Some of participant's statements mention to the geographic location and the covered area by the center according to type of disabilities, factors like

economic partnership of families in payment. The costs and fluency or difficulty in absorbing skilled experts will affect the center. "They should indicate the tuitions locally and describe the services according to the location. For example don't make equal the services offered in Tehran with those in township equal ". 9. Expectation from the welfare organization Some of participants stated some expectations in a frame of offering some services from welfare. Organization to private rehabilitation centers in order to help them in executing the activities and cooperation with them. "Exceptional children in Vardavard pay only 50000 Rials for dentist but children in our centers can't and any other dentist doesn't accept them because they are afraid of unconsciousness , they are afraid because these children have abnormal movements .". Discussion and conclusion The beginning point for private rehabilitation center activities is the decision the one makes to establish the center. Being subject of some conditions leads to this thinking and decision. If exiting condition can propel the person to establish a center and he or she can actualize the decision to establish the center, the managing and directing topic comes up (12). A private rehabilitation center's manager faces different conditions and problems in the way of his (her) management. General problems related to privatization policies and special problems related to private rehabilitation centers activities and their internal and external relations. As mentioned in previous sections, before 1984 the welfare organization was the main responsibility for rehabilitation services offering to disabled people, and after that it transferred gradually to the private sector. But this transferring doesn't mean depriving welfare organization from all responsibilities and this organization was responsible for supervising the private rehabilitation centers' activities, and issuing all establishing justifications. Therefore all private rehabilitation centers’ activities should be under supervision of this organization. Then regarding this procedure, welfare organization takes the greatest volume of external relations of private rehabilitation centers. There for utter most problems which involve the private rehabilitation centers' management are related to these relations with welfare organization. The connection between welfare organization and the private rehabilitation center in each county is

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"copula expert" who is appointed by rehabilitation deputy of province welfare office and is the responsible one for the coordination between private rehabilitation center and welfare organizations which transfers the problems and difficulties to the organization and help them to find ways to solve the problems. On the other hand it informs the centers managers about the laws and bylaws, sanctioned by province welfare office and country welfare organization to help them to take the opportunity to adjust and execute their activities according to, and coordinated with laws and bylaws. As we mentioned before all private rehabilitation centers' activities are under supervision of welfare organization and part of costs will be paid by government as government subside . And it will be different depending on the grade which the center can get through the province valuations (1, 2 or 3 grade), and here the report which prepared by copula expert looks very important. According to findings of this research practically this relation makes problems for the managers to understand and realize the problems and the copula expert become informed about them during his/her presence at the center , he/she should have enough knowledge and acquaintance about the activities and responsibilities of a private rehabilitation center and about the conditions there . It's highly depended on the copula expert's experience in this ground, as we investigated most of managers present in focus group interview meetings were interested in this point and mentioned that people who are appointed for this position have temporary presence in this position and there is no enough time to get experience and find information and knowledge related to this ground Then of this scant knowledge, will bring the utter most prejudice to the center and it's manager. Because regarding the determined responsibility for the copula expert and his/her key role in evaluation the results and determining the subsides. If he/she could not prepare a clear and exact report from the center (either in recording the points or showing disadvantages and deficiencies) it will definitely affect a majority of the center's activities in addition to working experience , training and retraining are factors which can reduce the experimenting time and increase the knowledge of copula expert about the problems in the centers and his/her authorities and about how to play his/her role in assisting the manager to administer his/her private rehabilitation center. Regarding our investigations as either the managers or the copula

experts mentioned there is a missing part in between. To conclude the participants' statements about copula expert we get results like the irrefragable effect of copula expert and his/her visits and reports to the welfare organization – which sometimes affects by personal opinions caused by scant knowledge in related ground – and problems like this which affect the centers' activities . On of other debatable problems is the gradation and government subside which is paid by the welfare organization to the centers. a great part of service offering quality in the centers depend on financial condition and as most of accepted cases in the center become enrolled through subsides , then a great part of financial problems will be considered through subsides . Then in this condition its irrefragable the dependence of the centers apostleship to subside paid by welfare organization. Then it would be easy to imagine, which problems the manager will face if he/she doesn't get the subsides in proper time, or be not able to enroll enough cases through subsides. Laws and bylaws and repeatedly changes in them after small changes in managers of welfare organization, and personal styles of managers in province and township level are the other problems which its minimum effect on the center's operation will be confusing the manager in implementing the plans related to determined responsibilities. Regarding the experiences of different managers cooperated with us in this research, we found that in determined criteria and scales for identifying the standards about the centers' activities, there are a lot of margins and offshoots in between which play down the importance of main targets in a center and the importance of target population of center's activities and apostleship of the center or make it equal with the importance of margins. Referring to the experiences mentioned by the managers in focus group interview meetings we found the effect of some other factors like adopted policies and type of acting of the "township welfare chief" against private rehabilitation centers and his/her acquaintance and belief about rehabilitation and activities and apostleship of private rehabilitation centers . The township welfare chiefs as the higher levels of managers should administer different departments and deputies like social, prevention engagement and rehabilitation. To manage all these sections' activities beside the frame mentioned by the rules for these sections' activities will definitely affect the


policies he/she adopt from each section and also the operation of personnel in each section – personnel include all staff in rehabilitation department, survey team those who work around private rehabilitation center activities and the copula expert – the higher level of this acquaintance and dominance will improve the acting of each section and it's staff. Regarding the important role of an organization's manager in creating coordination between his/her subordinate units, improving this coordination will help the side long wings of the rehabilitation department – that private rehabilitation centers are of these wings – in their operation and activities and it will be easier for the organization and the centers to reach their determined targets . Then it would be irrefragable the direct and indirect effects of the township welfare chief on the private rehabilitation centers' activities. The type of the center's activities and type of disabilities the center undertakes and service offering responsibility are the factors which affect the operation and activities of private rehabilitation centers from one viewpoint we may survey this factor from view of ease or difficulty of accommodating families to the policies which the center's manager contemplates to administer his/her center. For example, about therapeutic feedbacks from disabled people present in the center for instance the results would be more touchable and take less time in corporal – motional centers in comparison with mental centers, receiving these feedbacks from the parents will cause them to accept the conditions and accommodate themselves to the terms according to which the center's manager administrates his/her center – like transportation services costs and undertaking this responsibility by the families – whereas in comparison to mental centers. These payments and partnership will not appear easily and the manager will face problems about them. Another viewpoint we can contemplate for this view is the comparison between vocational training centers and other centers with a view to difficulties in finding referrers and substituting released ones and on the other hand , absorbing the cooperation and partnership of the families in different grounds of the center's activities . And this difficulty might be because of missing of engagement and ways to complete the treatment and training for disabled people who are in vocational training centers for treatment and training and have to leave after the period of time which welfare laws and bylaws

mentioned (5 years) . In fact "abettor workshops" subject – one of the ways to provide treatment and rehabilitation continuance for these people – was that all managers with responsibilities in vocational training centers mentioned on missing of that (as we investigated there are 4 active abettor workshops and one establishing one in the country) . The geographic region which the center acts, affects the private rehabilitation center's activities with a view of local culture and people's attitude against disability and rehabilitation, and it causes different experiences for managers present in focus group interview meetings In different geographic regions there are different cultures which definitely causes differences in attitude against social , political , economical , therapeutic this also includes rehabilitation and private rehabilitation center topics and this type of attitude will from part of private rehabilitation center working and it's manager's experiences . Because regarding type of private rehabilitation center's activities and human target society for its activities, people in each region will be outside customers. Another effect which is caused by this factor is substituting released referrers, that based on differences in disabled population in different townships and effect of economic and cultural texture in the township the list of waiting referrers has been reported different in different townships. The discussable point is not the differences in compression to the mentioned list, but is the effect of that on administrating and managing the center. A manager who has no problem in substituting released referrers can act easier and stronger in practicing his/her frames and rules for managing the center and can easily bind the families to pay all tuitions and partnership payments. Whereas the private rehabilitation center's activities should be done under supervision of welfare organization the determined confine for this supervision and contemplating a separation boundary between supervision and interference would be another factor which affects the private rehabilitation center's activities that has been mentioned by the managers present in this research. As they said, the experts who are responsible for this supervision should act in determined frame and through the purpose of helping the private rehabilitation center reach prescribed targets. While some of the managers present in research declared that these experts even enter some managing areas which are completely authorized by the manager himself/herself, in case of their supervision

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responsibilities – like determining the economic partnership of the families – or areas out of the private rehabilitation center's activities area – like type of fruit for feeding program – Regarding the likeness between welfare organization and exceptional education organization and considering more exceptional education organization in side services offering to disabled people covered by them there will appear some expects from these services offered in welfare organization (private rehabilitation center manager) and from receivers of these services (disabled people families) that stated as suggestions by participants of this research. From another view, the result comes out of this comparison, to outside customers of these services, will be a basis for the customers to choose the exceptional education organization for these services offering because of more services offered in there and it will cause the case absorption problem in the centers Some of the suggestions were not result of mentioned comparison and just propounded as a suggestion to help service offering in private rehabilitation centers. Finally and based on what the managers present in the research said, interaction with welfare organization engrosses the uttermost volume of intellectual engagements of a private rehabilitation center's manager. What we can get from these statements is that this interaction and relation will

cause managers to face several problems and regarding can highly affect the private rehabilitations' activities and managers that because of the extent of this effect it looks necessary to find a good solution for this problem. It is sensible the missing of negotiation in a calm and safe environment without deflecting the private rehabilitation service managers or welfare organization responsible in province and township areas. Reducing the intellectual engagements and the worries caused by them which engage a private rehabilitation center's manager will definitely provide more comfortable conditions for managing and administrating the private rehabilitation center and regarding a better ground to offer the services to disabled people society (13). As the effect of the worry level for service offered in private institutes on quality of service offering to the target population has studied by Bilotta (10) on a issue of private personal care for disabled seniors and had same results. Acknowledgments: We would like to take this opportunity to appreciate all private rehabilitation center's managers and province and township welfare office experts who were present in our focus group interview meetings and helped us to execute this research and reach determined targets.

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Bank Institute (WBI) Working Papers, World Bank, Washington, DC. (1999, p.140)

2. International Classification of Impairments, Disabilities and Handicaps (ICIDH), World Health Organization, Geneva, 1980.

3. R GM. [Evaluation of the efficiency and quality of hospitals publicly owned with private management and hospitals of the public sector]. Acta Med Port. 2006 Dec;20(5):471–490.

4. Roman PM, Ducharme LJ, Knudsen HK. Patterns of organization and management in private and public substance abuse treatment programs. Journal of Substance Abuse Treatment. 2006;31(3):235–243.

5. Guerriere DN, Wong AY, Croxford R, Leong VW, McKeever P, Coyte PC. Costs and determinants of privately financed home-based health care in Ontario, Canada. Health & social care in the community. 2007;16(2):126–136.

6. Nadjafi A. [The study of nongovernmental rehabilitation centers cases' capitation cost in Tehran province(Persian)]. State welfare organization. 2001.

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Queensland: exploring Health Professional and Peer Leaders’ perceptions of working together. Health & Social Care in the Community. 2009;17(2):105–115.

8. Corbin J, Strauss A. Basics of qualitative research: Grounded theory procedures and techniques. Basics of qualitative research: Grounded Theory procedures and techniques. (1990, p. 41).

9. Qualitative research uses the natural setting as the source of data. The researcher attempts to observe, describe and interpret settings as they are, maintaining what Patton calls an "empathic neutrality" (1990, p. 55).

10. Bilotta C, Vergani C. Quality of private personal care for elderly people with a disability living at home: correlates and potential outcomes. Health & Social Care in the Community. 2008;16(4):354–362.

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of government's extent) . Legal relating office in Mashsad University of medical science. 2008. www.mums.ac.ir/shares/btom/btom1/amoozesh/powerpoint/%20tahavol/khiyabani.ppt



* All correspondences to: Mahdi Rahgozar, E-mail:<[email protected]>

Original Article

Identification of Genetic Polymorphism Interactions in Sporadic Alzheimer’s disease Using Logic Regression

Najimeh Tarkesh Esfehani, MSc; Mahdi Rahgozar*, PhD; Akbar Biglarian, PhD;

University of Social Welfare and Rehabilitation, Tehran, Iran

Hamidreza Khorram Khorshid, PhD; University of Social Welfare and Rehabilitation, Genetic Research Center, Tehran, Iran

Objectives: Genetic polymorphism interactions are among the important factors in affliction with complex diseases like Alzheimer’s disease. The important goal of genetic association studies is to identify a combination of polymorphisms and measure their importance in increasing the risk of occurrence of such diseases. In this study, feature selection approach of logic regression was used to identify the interactions among genetic polymorphisms influential in patients affected with Alzheimer’s disease.

Method and Materials: 101 Alzheimer’s cases and 109 control subjects from Iranian population were recruited in a case-control study. The evaluation of genes in two groups was performed using molecular technique methods; in particular, the PCR-RFLP technique was used to evaluate the intended polymorphisms in APOE, ABCA1, CALHM, CCR2, GSK3β, SAITOHIN, TAU, TNF-α and VDR genes, and then the feature selection approach was used to detect the significance polymorphisms and interactions between them.

Results: Based on feature selection approach, the two-way interaction between the polymorphisms of SAITOHIN and APOE genes were significant on occurrence of Alzheimer’s disease.

Conclusion: Logic regression approach is recommended to detect interaction in the genetic association studies.

Keywords: Logic regression, Feature selection, Interactions, Genetic Polymorphisms, Alzheimer’s disease

Submitted: 12 Dec 2010 Accepted: 04 Mar 2011

Introduction Single nucleotide polymorphism (SNP) is a minor genetic variation which can occur in DNA sequence. SNP occurs when a nucleotide is replaced by one of the other three nucleotides in nucleotide chain. On the average SNPs in human populations occurs more than %1 of the times. Individual SNP usually has small to medium effects in occurrence of diseases, particularly in complex or multi-factorial diseases. Therefore when dealing with complex diseases, the purpose of association studies is to specify the combined effects of SNPs and the interaction among them on the increase in risk of disease (1). Alzheimer’s disease (AD) is one of such diseases. AD is the most common cause of dementia in middle and old age in western societies; therefore, aging increases the risk of affliction with the disease. AD is the fourth important cause of death in the

United States (2), and is one of the most important factors of disability and health endangering in the world. In 2006, nearly 26.6 million people in the world were suffering from AD. With elevation of life expectancy, it is quite possibly anticipated that until 2050, more than 100 million people will suffer from AD, which shows that one per 85 people in the world will be affected with the disease (3). Due to the increasing trend in Alzheimer’s disease it is crucial paying more attention to its early diagnosis and detection. Over 95% of patients suffering from Alzheimer are sporadic and late-onset type, the diagnosis of which is based on clinical and neuropsychological evaluations and is time consuming and costly. Consequently, the diagnosis of disease by a genetic marker could be a good solution for this problem, so as to be used for quick diagnosis of disease in early stages or for treatment

Vol. 9, No. 14, Oct. 2011 46

aims (4). Alzheimer is a complex disease because it lacks any specific hereditary pattern and is heterogenic, since a variety of mutations and polymorphisms in several genes are responsible for the disease along with non-genetic factors. Individual SNPs have small to middle effects in the occurrence of such complex disease and it seems necessary to specify the combined effect of SNPs and the interactions between them in increasing of the risk of this disease (1). Thus far, many genes have been investigated as risk factor for Alzheimer’s disease, the most well-known of is the APOE on chromosome 19. This gene has been identified as the most important risk factor in 65% of sporadic Alzheimer cases (5). The APOE gene in human has the three allele e2, e3, e4. These alleles are differently influential in the risk of occurrence of Alzheimer’s disease (6). Also, there are evidences on the relationship between Alzheimer and SNPs from genes such as ABCA1, CALHM, CCR2, GSK3β, SAITOHIN, TAU, TNF-α, and VDR. Since the human genome is diploid, that means it has pairs of chromosomes, 2 bases explained each SNP. Thus, each SNP can have one of the following 3 forms: – “Homozygous reference (wild type) genotype”:

both explaining bases of the SNP are the variant which is more frequent.

– “Heterozygous variant genotype”: one of the bases is more frequent variant and the other is the less.

– “Homozygous variant genotype”: both bases are the less frequent variant.

Thus, in an association study concerned with SNPs data, it is thus of interest to construct classification rules of the following type:

“If SNP A is of the heterozygous variant genotype AND SNP B is of the homozygous variant genotype OR both SNP C AND D are NOT of the homozygous reference genotype, then a person has a higher risk for the disease of interest”.

Classic parametrical statistical methods such as logistic regression are unable to detect such interactions and in most problems a regression model can only investigate the relationship the main effects of predictors on the response and the interaction between variables, in case considered in the model, does not go beyond two-way and, at most, three-way. A procedure developed for solving exactly these types of problems is logic regression which was introduced by Ingo Ruczinski, and attempts to identify Boolean combinations of binary

variables for the prediction of case–control status in an observation (7). After the first introduction on logic regression model by Ruczinski, several models were proposed to improve the model, among which the Feature selection logic regression (logicFS) can be noted (8). Feature selection is a combination of bootstrap and logic regression that can be used for quantifying the importance of interactions for classification. In order to detect the interactions of genetic polymorphisms of the noted genes and genotypes of APOE gene in affliction with Alzheimer, the Feature selection approach of logic regression was used. Materials and methods This study was a case-control one in which the required samples for the case and control groups were received from the Genetic Research Center- university of Social Welfare and Rehabilitation Science, in which Alzheimer cases and control subjects were included if they were older than 65 years old and the informed consent was signed by them or their legal care takers. The criteria for inclusion as a case were existence of Alzheimer diagnosed by an expert psychiatrist based on DSM IV criteria and lacking any neurologic or psychiatric disorders for control group according to medical report or responsible physician statements. Subjects were excluded if they had any family history of dementia or neurologic diseases. Alzheimer and control subjects were recruited from Alzheimer’s society of Iran and Geriatric centers Mehrvarzan, Kahrizak, Shayestegan, Farzanegan,Hashemi nezhad and Rheumatism Center in Tehran, Iran from 2007 to 2008. The evaluation of genes in the two groups was performed using molecular techniques; The PCR-RFLP technique was used to particularly evaluate the intended polymorphisms in APOE, ABCA1, CALHM1, CCR2, GSK3B, SAITOHIN and TAU, TNF-α and VDR genes. Afterwards, the information related to 316 people were received from the lab. From these people 106 observations had one or more missing polymorphisms and with deletion of these observations 210 observations were analyzed by logic FS and the important interactions were specified by the calculation of the two indexes of VIMsingle and VIMmultiple. In order to find the best logic combination the algorithm Simulated Annealing was used (7). For this purpose the R statistical software version 2.13.2 was used.


Results Present study was conducted on data obtained from 210 participants above 65 years of age including 101 afflicted with Alzheimer’s disease in the case group and 109 in the control group. The primary information about the APOE genotypes and other polymorphisms investigated is given in table 1 and 2.

For fitting the logic regression model and using feature selection method, the input variables are changed into binary variables in the following form. Regarding the APOE gene, the information related to the six genotypes (e2e2, e2e3, e2e4, e3e3, e3e4, e4e4) is at hand and the binary variables of X1 to X6 are defined as follows:

Table1: The APOE genotype frequencies were compared between Alzheimer cases and control subjects

case control number (percent) number (percent) Genotype

1 (1.0) 1 (0.9) e2e2 5 (5.0) 14 (12.8) e2e3 1 (1.0) 1 (0.9) e2e4

78 (77.2) 81 (74.3) e3e3 15 (14.9) 11 (10.1) e3e4 1 (1.0) 1 (0.9) e4e4

Each SNP Si, is split into two variables as defined in below: Si1: “At least one of the bases explaining Si is the less frequent variant.”

Si2: “Both bases explaining Si are the less frequent variant.” These made variables are used instead of the SNPs themselves.

Figure1: VIMSingle (left panel) and VIMMultiple (right panel) of the interactions identified in analysis of Alzheimer

data set. Since the SNP names are too long for graphical representation, they are coded. Consequently, having six genotypes from APOE gene and eleven SNPs from other genes possibly related to Alzheimer, the 28 binary variables as predictors are available as input for the logic regression model. Of these variables all observations showing more than 5 missing values are removed from the analysis leading to a total of 22 variable and 210 observations.

Logic FS is applied to this data set twice using 10000 iterations in each run of simulated annealing and 200 bootstrap samples,—once with a single-tree and a maximum of 6 variables contained in this tree and the other time allowing 2 trees to grow with a maximum of 10 variables in all the 2 trees combined. In the single-tree case, this leads to the detection of 449 potentially interesting polymorphisms interactions, whereas in the

Vol. 9, No. 14, Oct. 2011 48

multiple-tree case, 562 SNPs and SNP interactions are identified. however, just one interaction, namely !X1&X20 or decoded e2e3&STH (HinfI(A/G))1, consisting of 2 polymorphisms from the gene APOE and SAITOHIN seems to be associated with the case–control status since in it both indexes VIMsingle and VIMmultiple have high values. If the STH (A/G) is not of homozygous reference genotype and there is no e2e3 genotype in the person, there will be a little higher risk of developing Alzheimer. STH (A/G) itself has the highest value of VIMmultiple and third highest VIMsingle. Therefore, the SAITOHIN gene may itself influence in Alzheimer and AG and GG genotypes of this gene are risk factors for the disease. Discussion Alzheimer’s disease is one of the complex diseases which lacks specific hereditary pattern and is heterogenic and mutations and polymorphisms existent in several genes along with environmental factors, are influential in it. Since there is no definite treatment for Alzheimer at the time, the identification of risk factors leading to this disease and prevention of their occurrence is of high significance. Based on the studies conducted, one-late Alzheimer occurs under the influence of a number of genetic and environmental factors. Controlling genetic factors is impossible but it is highly possible, through the identification of genetic factors influential in Alzheimer, to identify people at risk and trying to control the influential environmental factors in the occurrence of Alzheimer such as low level of mental activities, social-psychological stress, diet, smoking and drinking, pesticides environmental factors over use of some medicines,”. Also it is possible to use these genetic markers to detect diseases in elementary stages and reduce the speed and disabilities resulted from the disease by its early diagnosis of it. One of the important and common goals in genetic association studies in such diseases is the determination of SNPs and their interactions which are related to the occurrence of the disease. The

previous studies have shown the relationship between several single SNPs and Alzheimer (4, 9-15). Since the interaction between SNPs ore more influential than single SNPs in the occurrence of complex disease, it seems necessary to have some methods to identify these influences. Moreover, in order to have a suitable prediction and classification for the intended response, these methods should be able to quantify the significance of these interactions. In this article, feature selection which is a combination of bootstrap and logic regression methods was used to determine potential individual and interaction effects between genetic polymorphisms influential in affliction with one-late Alzheimer and then the two indexes of VIMsingle and VIMmultiple were used to quantify the importance of the specified effects and based on it, one interaction effect of the polymorphisms of APOE and SAITOHON genes was determined. The results revealed that if the polymorphism A/G in the SAITOHIN gene is not of homozygous reference type and in case of non-existence of e2e3 genotype in the person, the risk of Alzheimer increases. Based on the previous studies in non-Iranian populations, the e2 allele increases the age of onset of the disease and protects from it (16-18). In the studies conducted in Iran by Vaisi Reygani and et.al (19) and Gozalpour (20), the frequency of ε2 allele and ε2ε3 genotype in healthy people was reported to be more than in no significant the patients, but there was difference between the two groups. The only study investigating the SAITOHIN gene in Iranian population was conducted by Veisi (21); in his study the AA genotype was introduced as having a protective role and the AG genotype as being the risk factor in affliction with Alzheimer. Moreover, in the investigation of interaction of this gene in AG polymorphisms and minus APOEε2 subjects a significance difference was reported but the interaction of GG genotype and minus APOEε2 subjects was not meaningful. One of the advantages of this method is that unlike other regression models, in order to investigate the existence of an interaction,

Table2: The SNP frequencies were compared between Alzheimer’s cases and control subjects

case Control number (percent) number (percent)

genotype SNP Gene

34 (33.7) 41 (37.6) GG 48 (47.5) 50 (45.9) GA 19 (18.8) 18 (16.5) AA

R219K (G/A)

ABCA1

79 (78.2) 93 (85.3) CC 17 (16.8) 12 (11.0) CT

P86L CALHM1


case Control number (percent) number (percent)

genotype SNP Gene

5 (5.0) 4 (3.7) TT 86 (85.1) 91 (83.5) GG 14 (13.9) 16 (14.7) GA 1 (1.0) 2 (1.8) AA

)V64I (CCR2- )G/A(

CCR2

27 (26.7) 33 (30.3) TT 53 (52.5) 52 (47.7) TC 21 (20.8) 24 (22.0) CC

)T/C(AluI GSK3â

63 (62.4) 77 (70.6) GG 30 (29.7) 24 (22.0) GA 8 (7.9) 8 (7.3) AA

)G/A(ALuI

60 (59.4) 80 (73.4) CC 32 (31.7) 21 (19.3) CG 9 (8.9) 8 (7.3) GG

)C/G(Alw26I

66 (65.3) 77 (70.6) AA 31 (30.7) 27 (24.8) AG 4 (4.0) 5 (4.6) GG

)A/G( SepI

TAU

77 (76.2) 93 (85.3) GG 24 (23.8) 15 (13.8) GA

0 (0) 1 (0.9) AA )G/A(-308 TNF-α

67 (66.3) 89 (81.7) AA 34 (33.7) 17 (15.6) AG

0 (0) 3 (2.8) GG )A/G(HinfI SAITOHIN

45 (11.9) 50 (45.9) CC 46 (42.2) 46 (42.2) CT 10 (9.9) 13 (11.9) TT

)C/T(TaqI

19 (18.8) 23 (21.1) GG 46 (45.5) 52 (47.7) GT 36 (35.6) 34 (31.2) TT

)G/T(ApaI

VDR

Interactions do not need to be known in advance and used as input variables in the model, but the detection of important variable interactions is the main aim of logic regression; and this way it is possible to concentrate on the most important effects specified by this approach. Since in case-control studies, the goal is to make a classification rule based on the minimum possible number of variables, the identification of the interactions of SNPs influential in predicting the response is the first, and the same time a very important, stage. In the next stage, it is possible to, for example, consider K number of the most important interactions which are higher than specific level of significance and use the form of binary variables in logic regression or any other classification and prediction models. Therefore, conducting studies based on APOE and

SAITOHIN genes with a larger sample is recommended. Conclusion Feature selection approach is a new method for the detection of interaction in genetic association studies with many variables. In the present study, the two-way interaction between polymorphisms in APOE and SAITOHIN genes was detected using this method. Acknowledgement: We wish to express our special thanks to all colleagues at the Genetic Research Center -University of Social Welfare and Rehabilitation Sciences, especially Dr. Koorosh Kamali, for their helps in the data collection.

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20. Veisi K. Association study between MAPT, GSK3b and STH genes polymorphisms with sporadic Alzheimer disease in Iranian population. Tehran: University of social welfare and rehabilitation Sciences; 1388.



* All correspondences to Dr. Soleimani Email <[email protected]>

Original Article

Dental status and DMFT index in 12 year old children of public care Centers in Tehran

Nasim Shafiezadeh;

Islamic Azad University, Tehran, Iran

Farin Soleimani*; University of Social Welfare and Rehabilitation sciences, Pediatric Neurorehabilitation Research Center,

Tehran, Iran.

Saeedeh Mokhtari Shahid Beheshti University of Medical sciences, Tehran

Nahid Askarizadeh;Reza Fatehi Islamic Azad University, Tehran, Iran

Objectives: Dental caries is a public health problem that affects pre-school and school children throughout the world. Poor oral health profoundly affects a person’s quality of life. Information on caries prevalence and severity represents the basis for caries prevention programs and indicates treatment necessity in the population. The occurrence of permanent teeth caries particularly in non-industrial societies, seems to be high;The aim of this study was to present the prevalence of dental caries inunder supervision 12- years old children living in Tehran and to assess the influence of the factors which are related to their oral health.

Method and Materials: This cross-sectional study was carried out on 113 undersupervision children.The clinical examinations focused on dental status, expressed as DMFT (Decayed, Missed, Filled Permanent Teeth) index,following WHO standards methodologies. Clinical examinations and personal interviews to investigate the related factors to oral health were conducted by a single investigator.

Results: The level of DMFT was estimated at 1.32±0.86. Among the relevant factors, the reason for visiting the dentist (p‹0.0001) and duration of stay in the center (p‹0.04) had a meaningful relation to DMFT index of more than 2.

Conclusion: The community under the research has a good condition as compared with the WHO goal. Further studies are recommended due to meaningful relation between DMFT index and the reason for visiting dentists as well as the duration of stay in the center.

Keywords: DMFT index, Oral health, Governmental Round-The-Clock Centers, under-supervision children

Submitted: 10 Sep 2010 Accepted: 23 Dec 2010

Introduction Dental caries is a public health problem that affects pre-school and school children all around the world, leading to pain, chewing difficulties, general health disorders, speech and psychological problems, and poor quality of life (1-4). Insufficient oral health profoundly affects a person’s quality of life (5, 6).Information on caries prevalence and severity, shows the basis of caries preventive programs and indicates treatment necessity in the population (7).

Measures of caries prevalence are indexes of decayed (D), missed (M), and filled (F) permanent teeth (T) or surfaces (S), ie, DMFT or DMFSindex (8). For the first time at a national level in 1995, the mean DMFT of 12 year old Iranian children was 2.0, which indicated that the oral health status of this age group could be classified in the low range (mean DMFT 1.2-2.6) compared with other countries worldwide. In second national survey in 2004 the mean DMFT for 12 year old Iranian children was

Vol. 9, No. 14, Oct. 2011 52

1.9 and this was consistent with the oral health goals set by the World Health Organization (WHO) for 2010, albeit far from the goals set for 2020 (9).Considering the condition of special groups (such as under supervision children) in every society is essential to estimate the real health situation. The risk of caries significantly increases among adolescents with a high consumption of cariogenic snack and low oral hygiene. It is also influenced by maternal socio-economic background and educational level (10), as well as dietary, hygienic, and other socio-economic factors indicating the importance of preventive educational programs and a comprehensive caries prevention scheme for children (11). The aim of this study was to assess the caries prevalence in 12- years old under supervision healthychildren living in governmental round-the-clock centers in Tehran and to assess the influence of the factors which are related to their oral health by using the indexes for decayed, missed, and filled teeth (DMFT). Method This cross-sectional study was based on clinical data from clinical examinations and questionnaire. Study sample consisted of all the113 twelve year- old children (80 male,33 female) residing in the public round-the-clock centers of Social Welfare Organization because of having no headman, in Tehran province (consisting Tehran, Shahre-Ray, Shemiranat) in 2007-2008.By an interview with each child’s caregiver and using medical information records these data were collected in a questionnaire: sex ratio (male/female),duration of staying in the center (less than3 years/3years and more), frequency of tooth brushing (once a day or more/ never or occasionally) and time of tooth brushing (after each mealtime/before bed time), frequency of dental visits (sometimes/never or when he or she had pain), date of last dental visit (during last year/more than a year ago or not at all),cause of dental visit (checkup/pain), frequency of snack consumption (never/less than 3 times a day/more than 3 times a day), time of snack consumption (after main course/between meals), occlusion related factors (crowding/ spacing), oral hygiene instructor (parents/dentist/center’s caregivers). Before starting the examination process, there was a 20-30 minute communication to motivate the children, then each subject was examined separately with a trained examiner, in a room with adequate

light, using a disposable mirror (Atlas Co., Iran), a disposable explorer (Atlas Co., Iran),a torch (Philips co, Germany) and a sterile cloth (to remove material alba and debris from the teeth). The study protocols were approved by the Research Committee of Faculty Research Section. To determine the intra-examiner reliability, 10% of the total samples was reexamined during the data collection (Kappa=0.98). Then the level of DMFT measured among the subjects with 95% confidence interval. The effect of related factors on DMFT was studied with chi-square test, the significance level was considered as P Value <0.05. Results Of the 113 children examined, 35.4% were caries free and 16.8% had DMFT of 2 or more. Of total DMFT, 46.4% were due to decayed (D), 2.6% due to missed (M), and 51% due to filled (F). The mean level of DMFT was estimated at 1.32±0.86.Considering the normal variations, the studied community had normal distribution. Chart 1 shows the mean D,M,F and DMFT for each child.

012 0.61

0.030.67 1.32

Chart 1.Mean D,M,F and DMFT in the children

In 3 sections of Tehran province: Shemiranat, Shahre-ray, and Tehran DMFTswere: 1.66±1/02;1.33±0/17, and0/90±0/27 respectively as is showed in Table 1. Table 1. The mean DMFT in governmental round -the -clock centers children of social welfare organization in

cities of Tehran province Tehran

ProvinceTehran Shemiranat Rey Place of Study

1.32 1.33 1.66 0.9 DMFT The most common time of tooth brushing was before bedtime. Most subjects were learned oral hygiene instructions from a dentist. Data analysis indicated that there was no statistically significant relation between the level of DMFT and


frequency/time of tooth brushing, frequency of dental visits, date of last dental visit, occlusion related factors (crowding/ spacing) and oral hygiene instructor. But there was a statistically significant relation between DMFT and the duration of stay in the center (P< 0.001) and the cause of dental visit (p<0.04). Diet schedule in all centers were almost similar following three main course schedule. Snacks were not included in diet schedule in all centers, and the frequency of consuming snacks among the children was not exactly measurable. Because the children, may had snacks from the sources out of the centers as donations and also they were not reliable to talk about the frequency of use. Discussion In this study which was aimed to determine the DMFT status of 12 years old children, living in public round-the-clock centers of Social Welfare Organization of Tehran in 2008, the mean DMFT was estimated 1.32±0.86. In this study 35.4% of subjects were caries free and 16.8% had DMFT of 2 or more. So, according to goals of WHO in 2010 (that 12 Y/O children should have DMFT less than 2), it seems that the subjects were in desirable status. (12) Many studies as Island 1998 (DMFT=1.5) (13), Portugal (DMFT=1.85)(14), Spain (DMF T=1.12)(15), Algeria (DMFT=1.63)(16) have reached the same results as this study. But there are also some studies that have shown lesser level of DMFT as England (DMFT=0.86), Bangladesh (DMFT=0.97) and South Africa (DMFT=0.25). These differences may be due to difference in race and geographical region, research methodology sample size, sampling method, examination instruments or applying preventive dentistry for under supervision children in some countries. In this study about 51%of mean DMFT score of the surveyed children, was contributed by restored teeth (Filling/F), however in some studies as in England (17), Jordan (18), two studies on12 year old children in Gorgan in 2006 and in Robat-karim in 2001in Iran, DMFT score was most contributed by Decayed teeth (D)(19). This shows that the surveyed community has better oral care which leads to repairing and filling the decayed teeth. In this study there were no relations between DMFT and the variables of frequency and time of tooth brushing, frequency of dental visits, the date of last dental visit, occlusion related factors and oral

hygiene instruction. Other factor as duration of stay in the center and the cause of dental visit showed significant relation with DMFT score. The children, who had DMFT score more than 2, have been lived in the centers for 3 years and more and this correlation was statistically significant; It must be mentioned that the researchers did not have any access to the pre-admission medical and hygiene history of participants, including dental health status. But it should be assumed that access to carbohydrates was limited due to low income. Although they have yet better DMFT in comparing with 12 years school children in Tehran. Results also show those children in whom pain was the cause of dental visit had 6.2more time chance of having DMFT score more than 2 that is expectable. In a study on 13-18 year- old under supervision adolescents in Tehran in 1996, no relation was found between frequency and time of tooth brushing and the source of oral hygiene learning with DMFT. In another similar study in 1997-98 in Tehran, there was a significant relation between frequency of tooth brushing and frequency of dental visits and the DMFT score, but the oral hygiene instruction history and the time of living in the center had no significant relation with DMFT. V arasteh et al, showed the opposite finding in a research in 2003 (19). Our result indicated that the mean DMFT score in Shahr-e-Rey is higher than Tehran and in Tehran DMFT score is lower than Shemiranat. This is also indicated in a same study in 1997 (19). Because of a significant relationship between duration of living in the centers and DMFT scores, more surveys are recommended to investigate this correlation. Also, more attention to pay about oral health and care in these children is advisable. Conclusion As there was no relation between the variables of oral hygiene instructor, frequency and duration of tooth brushing, frequency of dental visits and DMFT, and according to high number of decayed teeth (D factor in DMFT) and also a positive relation between the duration of living in center and DMFT score more than 2 in surveyed children, we can conclude that the lower DMFT score of children living in Boarding Centers of Social Welfare Organization of Tehran in 2008 was due to their diet regimens and lack of snacks between meals in these centers, and not because of more preventive interventions.

Vol. 9, No. 14, Oct. 2011 54

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18. Albashaireh Z, Hamasha AH. Prevalence of dental caries in 12-13-year-old Jordanian students. SADJ. 2002 Mar;57(3):89–91.

19. Shafizade N, AskariZadeh N, Fatehi R. Assessing DMFT index and related factors in 12 year old children under-supervision of WelfareOrganization in Tehran during 1385-86. Islamic Azad University, Tehran, Iran 1386-87. (MSc. Thesis in Persian language).



* All correspondence to: Majumi M Noohu, Email: < [email protected]>

Original Article

Effects of Task Related Training and Hand Dominance on Upper Limb Motor Function in Subjects with Stroke

Mohammed Azam Khan; Fuzail Ahmad;

Jamia Hamadard. New Delhi. India

Jamal Ali Moiz, PhD.; Majumi M.Noohu*, PhD; Jamia Millia Islamia, New Delhi. India

Introduction: Recovery of upper limb motor function in stroke is limited. Different approaches are used to improve the upper limb function, but none has satisfactory results. The present study investigated the effect of task related training and role of hand dominance in upper limb motor function rehabilitation in stroke population.

Method an Material: A convenient sample of 32 subjects divided into 4 groups with 8 subjects each took part in the study with an experimental design. The group 1, experimental dominant hand group, consisted of subjects with dominant hand paresis, the group 2 consisted of subjects with non dominant, group 3 & 4 consisted of dominant (dominant hand control group) and non dominant hand paresis (non dominant hand control group) .The group 1 and 2 received task related training and conventional therapy, while group 3 & 4 received conventional physiotherapy. All patients were assessed prior to training 4 weeks & after the 4 weeks of training program by using Chedoke Arm & Hand activity Inventory Score form, this score were used to find the difference between and within groups.

Results: A within group analysis showed that there is a statistical significant difference for Chedoke Scores between pre training and post training in group 1, 2 and 3 but no significant difference in group4. There was no significant difference between group1 post training scores; there was a significant difference in post training scores group 1 and group 3. There was no significant difference in post training scores between group 3 and group 4. The comparison between group 2 and 4 group showed no significant difference in post training scores.

Conclusion: From this study it is evident that task related training and hand dominance play an important role in upper limb rehabilitation.

KeyWords: Task related training, hand dominance, stroke, upper limb function

Submitted: 10 Sep 2010 Accepted: 04 Nov 2010

Introduction Stroke has devastating consequences on individual’s physical and cognitive abilities.(1) The likelihood of improvement after stroke varies with nature and severity of the initial deficit. Approximately 35% of survivors with initial paralysis of the leg do not regain useful function. Six months after stroke, about 65% of patient cannot incorporate the affected hand into their usual activities.(2) Studies report that 45 to 50% of individuals sustain a left hemisphere lesion and therefore right-sided paresis. In as much as up to 80% of people are right side dominant, a significant proportion of individuals who experience a stroke will have their dominant

hand affected. It is not known whether these individuals will gain better outcome than those who had their non-dominant hand affected form stroke.(3) Recent trails emphasis the practice of task related movements. Many different task oriented practices strategies have shown significantly greater benefit from more intensive therapies that involve training in specific skills as compared with only several hours a week of general rehabilitation spread among many activities.(4) Recently Salbach et al reported benefits of task related practice on locomotion in people with stroke.(5) Bllehasset al support the use of additional task related practices of during rehabilitation.(6)

Vol. 9, No. 14, Oct. 2011 56

Task-specificity, practice, goal-setting, feedback and motivation are considered important elements in motor learning. In practice, it appears that repetition alone is less effective than repetition with variable practice (7) As we know that in motor learning the degree of performance improvement is dependent on the amount of practice. It is also known from the motor learning literature that variable practice is more effective than massed practice. Introducing task variability in any given session increases retention (8) Task related training provides variability during treatment session as different objects are used. Many different task oriented practice strategies have shown significantly greater benefits from more intensive therapies that involve training in specific skills, as compared with only general rehabilitation.(4) There are not many studies which have reported the effect of task related training and effect of hand dominance in functional regain in stroke survivors. The current study was done to find out the effect of task related training and to examine do hand dominance play a role in reaching activities in stroke survivors. Method A convenient sample of 32 subjects took part in the study with an experimental design. The group 1 consisted of subjects with dominant hand paresis and received task related training and conventional therapy (experimental dominant hand group). The group 2 consisted of subjects with non dominant hand paresis and received task related training and conventional therapy (experimental non dominant hand group). Group 3 & 4 consisted of dominant (dominant hand control group) and non dominant hand paresis (non dominant hand control group) respectively and they received conventional physiotherapy. All subjects were right hand dominant. Subjects were randomly assigned to different groups. The study was approved by research and ethics committee of Jamia Hamdard, New Delhi, India. The age, gender and duration of onset of hemiplegia were obtained from the patient’s history and medical records. Stroke location was identified by computed tomography or magnetic resonance imaging of the brain. The subjects were selected on the basis of following criteria, such as, 6 months post stroke, arm/hand paresis and subjects with aphasia and cognitive deficits were excluded. The consent of the subjects was obtained before enrollment into the

study and they were thoroughly explained about the study process. Subjects were matched by using two subsets of the Motor Assessment Scale (MAS).(9) On the upper arm subset, seated subjects were asked to hold their arm in 900 of the shoulder flexion for 2 seconds, while maintaining some external rotation. On the hand movement subset, subjects were asked to extend the wrist while holding a cup upright, with the forearm resting on the table. Subjects in group 1 and 2 received physiotherapy and task related training. For Task related training familiar objects were used that vary in size, shape & weight (50-500 gm) including coffee mugs, tea cups, plastic balls, books and writing and eating utensils. The objects were placed ipsilateral, contra lateral and midline on the table. Participants got an hour therapist-supervised reach-to-grasp training 5 times per week for 4 weeks (total 20 sessions)8 Progression criteria were established by increasing repetitions, increasing object size and weight, as well as increasing the distance at which objects were manipulated. The subjects in l group 3 and 4 received conventional physiotherapy program for upper limb. Trunk movements (sagital displacement, rotation) were prevented by verbal cues and therapist support. Rest periods of 1 to 2 minutes were permitted when necessary to avoid fatigue. All patients were assessed prior to training 4 weeks & after the 4 weeks of training program by using Chedoke Arm & Hand activity Inventory Score Form. Scoring is done on a 7-point ordinal scale (1=total assistance and 7=complete independence). Scoring is based on the percentage of contribution of each task by the paretic upper limb. For example the individual will score 7 on the jar opening task if he or she were able to hold the jar in the non paretic hand and open it with paretic hand. A score of 3 means that the individual is able to use the paretic hand to stabilize and manipulate the jar but requires hand over hand guidance (50%-75% contribution of the paretic upper limb). High internal consistency (Cronbach alpha=.98) and excellent inter rater reliability (ICC= .98), Construct validity (r=.81-.93) and face and content validity have been reported (10). Data Analysis Statistical analysis was performed using the SPSS Software (version 14). Demographic data of all subjects including age, sex, type of stroke, side of hemiplegia and hand dominance were descriptively summarized. The dependent variables for statistical


analysis were Chadoke hand inventory scale scores. Within group comparison was done by using Wilcoxon-Singed Ranks Test and for the between group analysis Mann-Whiteny test was used. A level of significance of p < 0.05 was used for all analysis to determine the statistical significance.

Results A total of 32 patients with 8 subjects in each group and (mean±SD) age of the subjects were 53.18 ±5.56 years who participated in this study. The duration of stroke (mean±SD) was 16.50±5.09 months. The mean +SD of age and duration of stroke, group wise is summarized in table 1.

Table 1. Demographic profile of the subjects

Group Age (years) (Mean±SD)

Duration of the stroke (months) (Mean±SD)

Group 1(n=8) 55.58 + 6.43 14.38 + 3.06 Group 2(n=8) 52.00 + 3.92 15.00 + 4.75 Group 3(n=8) 54.63 + 4.20 16.13 + 5.66 Group 4(n=8) 50.75 + 6.81 16.87 + 5.89

A within group analysis showed that in group 1 and group 2 there is a statistical significant difference for Chedoke Scores between pre training and post training scores, group 1 (z=2.54, p=0.005) and group

2 (z=1.84, p=0.033) . In the group, group 3 There was significant difference (z=2.00, p=0.023) but no significant difference in group 4 (z=1.63, p=0.051) (table 2).

Table 2. Within Group Comparison of Chadoke hand inventory scores

Group Pre training

Chadoke Hand Inventory Score (Median±SD)

Post training Chadoke Hand Inventory Score

(Median±SD) Z P

Group 1(n=8) 21.00±1.66 23.50±1.06 2.54 0.005 Group 2(n=8) 21.50±2.85 22.50±3.56 1.84 0.033 Group 3(n=8) 20.50±1.18 21.00±1.12 2.00 0.023 Group 4(n=8) 20.50±1.66 21.00±1.38 1.63 0.051

Using Mann-Whitney Test for Chedoke Post Score it was found that there was no significant difference between group1 and group 2 on both pre training (z=0.37, p=0.70)(table 3) as well as post training scores(z=0.96, p=0.33)(table 4). Between group comparison of group 1 and group 3 showed no significant difference in pre training scores (z=0.75, p=0.44) (table 3) but there was a significant difference in post training scores (z=2.88,

p=0.004) (table 4). There was no significant difference between the pre training (z=0.16, p=0.87) (table 3) and post training (z=0.32, p=0.74) (table 4) scores between group 3 and group 4. The comparison between group 2 and 4 group showed no significant difference in pre training (z=1.12, p=0.26) (table 3) and post training scores (z=1.34, p=0.17) (table 4).

Table 3. Comparison of pre training Chadoke hand inventory scores between groups

Group Comparison Chadoke Hand Inventory Score

(Median±SD) Chadoke Hand Inventory Score

(Median±SD) Z P

Group 1 vs Group 2 21.00±1.66

(Experimental dominant hand group-Group 1)

21.50±2.85 (Experimental non dominant hand group-

Group 2) 0.37 0.70

Group 1 vs Group 3 21.00±1.66

(Experimental dominant hand group-Group 1)

20.50±1.18 (Dominant hand control group- Group 3)

0.75 0.44

Group 3vs Group 4 21.50±2.85

(Dominant hand control group- Group 3)

20.50±1.18 (Non dominant hand control group-

Group 4) 0.16 0.87

Group 2 vs group 4 21.50±2.85

(Experimental non dominant hand group- Group 2)


Group 4) 1.12 0.26

Vol. 9, No. 14, Oct. 2011 58

Table 4. Comparison of post training Chadoke hand inventory scores between groups

Group Comparison Chadoke Hand Inventory Score

(Median±SD) Chadoke Hand Inventory Score

(Median±SD) Z P

Group 1 vs Group 2 23.50±1.06 (Experimental

dominant hand group- Group 1) 22.50±3.56 (Experimental non dominant

hand group- Group 2) 0.96 0.33

Group 1 vs group 3 23.50±1.06 (Experimental

dominant hand group-Group 1) 21.00±1.38

(Dominant hand control group- Group 3) 2.88 0.004

Group 3 vs Group 4 22.50±3.56 ±2.85

(Dominant hand control group- Group 3)


Group 4) 0.34 0.74

Group 2 vs group 4 22.50±356 (Experimental non

dominant hand group- Group2)


Group 4) 1.34 0.17

Discussion As hypothesized, subjects with dominant hand paresis improved significantly. Subjects in group 1 were given additional task related training. There was also significant improvement in subjects of group 2 and group 3 but this was lesser than experimental dominant hand group. These results support the use of task-related training during stroke rehabilitation and influence of hand dominance in rehabilitation. The result of the present study gets the support from the work done by Blennerhassett et al (6). There was significant improvement in their subjects in terms of functions after applying additional task related training but in their study hand dominance was not taken in to account. The subjects of the present study improved their reaching and grasping ability after four weeks of intervention. Again this was most significant in group 1 subjects. The reason behind this gain may be that during intervention familiar objects were given. It has been proved by Thielman et al that the stroke subjects may gain functional improvement when they are given familiar object and emphasis is given on functional goals (8). This can be due to that patient gets more encouragement and motivation when he can use objects of daily living. Another possible explanation of the results of this study may be “use dependent plasticity”. We know that in the chronic stages of a stroke, the brain is still “plastic” and can reorganize in response to appropriate stimulus (4). The gain in group 3 subjects were less but significant. In the present study the subjects in group 3 were given conventional physiotherapy including passive active movements and strengthening. It has been proved that repetitive passive active movement training can improve upper limb motor function and activities in patients with chronic stroke with all degrees of upper extremity paresis. Strength gain

and repetitive movements may be attributed to this significant difference. There are studies that have examined the role of hand dominance in stroke patients. In the present study task related training and the role of hand dominance in stroke rehabilitation was examined. Subjects in dominant hand paresis improved after the treatment session. Harris et al showed that the tendency to use the dominant hand may lead to a better pre stroke neuromuscular condition of the dominant hand (e.g., stronger muscles, more efficient motor unit recruitment) compared to the non dominant hand (3). However their study was unable to show any difference between dominant and non dominant hand scores for activities of daily livings. Its being suggested that the more use of the dominant hand may produce a training effect, giving it and benefit over the non dominant hand. The issue of handedness in healthy individuals using transcranial magnetic stimulation found that the threshold required to produce movement was higher in the non dominant hand. This suggests differences in motor cortical output for dominant and non dominant hand movement. Therefore, if the dominant hand is affected by the stroke, it may demonstrate less impairment immediately following the stroke owing to its protective effect (3).

Another factor that can be a cause of good improvement in dominant hand group is motivation. According to Harris et al if the dominant hand has been affected by the stroke, individuals may be more motivated to use their dominant hand during recovery because they are not used to using their non- dominant hand for daily tasks. In contrast, if the non-dominant hand is affected individual may have little motivation to use this hand in daily task making it difficult to promote the use of the non-dominant hand (3). Patients with dominant hand affection tend to show better course of recovery than


the patients with non dominant hand and this should be kept in mind while formulating and implementing treatment for stroke survivors. The study should be carried on larger sample for better understanding of task related training and effect of hand dominance in recovery process after stroke.

Conclusion The results of the study showed that task related training is effective in treatment of stroke patients and patients with dominant hand paresis may recover better than the subjects with paresis of non-dominant hand. However it cannot be neglected that the patients in later stage of stroke develops compensatory or adaptive behavior to accomplish the activities of daily living.

References 1. O'Connor RJ, Cassidy EM, Delargy MA. Late

multidisciplinary rehabilitation in young people after stroke. Disabil Rehabil. 2005;27:111-116.

2. Dobkin BH. Clinical practice. Rehabilitation after stroke. N Engl J Med. 2005; 352:1677-1684.

3. Harris JE, Eng JJ. Individuals with the dominant hand affected following stroke demonstrate less impairment than those with the nondominant hand affected. Neurorehabil Neural Repair. 2006;20:380-389.

4. Ward NS, Cohen LG. Mechanisms underlying recovery of motor function after stroke.Arch Neurol. 2004 ;61:1844-1848.

5. Salbach NM , Mayo NE ,Robichaud-Ekstrand S, Hanley JA, Richards CL,Wood-Dauphinee S,The Effect of a Task-Oriented Walking Intervention on Improving. Balance Self-Efficacy Poststroke: A Randomized, Controlled Trial.J Am Geriatr Soc 2005; 53:576–582.

6. Blennerhassett J, Dite W Additional task-related practice improves mobility and upper limb function early after stroke: a randomised controlled trial. Aust J Physiother. 2004;50:219-224.

7. Kollen B, Kwakkel G, Lindeman E. Functional recovery after stroke: a review of current developments in stroke rehabilitation research.Rev Recent Clin Trials. 2006;1:75-80.

8. Thielman GT, Dean CM.A.M. Gentile, PhD Rehabilitation of reaching after stroke: Task-related training versus progressive resistive exercise. Arch Phys Med and Rehabil. 2004:85;1613-1618.

9. Carr JH, Shepherd RB, Nordholm L,Lynne D. Investigation of a New Motor Assessment Scale for Stroke Patients. Phys Ther.1985; 65:175-180..

10. Barreca SR, Stratford PW, Lambert CL, Masters LM, Streiner DL. Test-retest reliability, validity, and sensitivity of the Chedoke arm and hand activity inventory: a new measure of upper-limb function for survivors of stroke.Arch Phys Med Rehabil. 2005 ;86:1616-1622.


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* All correspondances to: Mohammad Amouzadeh Khalili, Email: <[email protected]>

Review

Spasticity: a review of methods for assessment and treatment

Mohammad Amouzadeh Khalili*; Masoumeh Rasulzadeh Semnan University of medical sciences, Semnan, Iran

Spasticity is the condition resulting of corticispinal damage as occurs in some neurological diseases. The aim of the article is to review the literature on assessment and treatment of spasticity and spastic limbs. The assessment and treatment methods are studied the study involves different method of mangement of spastic limbs in depth. Different method of evaluation of spasticity, including biomechanical and clinical assessment are reviewed and also some of the most common treatment methods of spasticity are studied. A number of methods for assessment and treatment of spasticity are reviewed, some of methods commonly used for assessment or management of spasticity, depend on the condition of the patient and the aim of the therapist a method may empoyed.

Key words: spasticity, spastic limb, assessment of spasticity, management of spasticity

Submitted: 19 Aug 2010 Accepted: 02 Nov 2010

Introduction Spasticity, derived from the greek word spastikos (to tug or draw) is characterised by resistance to passive movement of a joint, usually in a variable manner so that there is a velocity dependent increase in resistance often associated with a sudden giving way (so called claps-knife effect) (1). Patients with brain lesions often display hypertonia, or spasticity; spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex (2) The prevalence of cerebral palsy was reported to be 3.6 per 1000 in 8-years-old children and the majority of children with cerebral palsy are affected by spasticity(3). More than 80% of people with spinal cord injury have spasticity, and many have greater disability because of Spasticity develops gradually over several months after injury (4). In spasticity the normal reciprocal innervation is disturbed and during movements undesirable co-contraction of different muscle groups occures and prevents skillful movements causing loss of function in patients Colin and Daly(5) stated that movements disorders as a result of upper motor neuron damage are known as either positive or negative symptoms. They

described that the positive and negative symptoms of spasticity are independent symptoms and depend on the place and amount of lesion and spontaneous improvements. that positive symptoms (dynamic assessment) are abnormal behaviour including all exaggeration of normal phenomena, ie; hyperreflexia. The negative symptoms (static assessment) are motor control or preference deficits including weakness, loss of function and dexterity . Spasticity occurs in many neurological condition, depending on the nervous system involvement the characteristic of the spasticity is variable, spasticity not only limits function but may lead to existing flexion contractture (6). Spasticity is present in a group of muscles rather than a particular muscle. When spasticity is present, all muscles of the related limb are adopted to the pattern of spasticity (flexion or extension), in the case of the patient with spasticity in extensor muscles of the lower limb, spasticity will present in extensors, adductors and medial rotators of the hip, extensors of the knee and plantar flexor of the foot (7). Khalili and Yadegary described that manual dexterity affected by spasticity and dependent on coordination between the central nervous system, peripheral nerves and the upper limb muscles (8).


Various stimuli may affect spasticity. Spasticity may be changed by various factors, there may be a fluctuation in the spasticity during the day and this seems more pronounced in persons with spinal cord injury (9) Therefore, to avoid variation of experimental results, the conditions of the patient and the experimental results, the conditions of the patient and the experiment must be the same(10). Lesion of the corticospinal pathways at different levels of the brain (cerebrum and the spinal cord) cause spasticity, Some important factors and diseases causing spasticity are; multiple sclerosis, head and/or spinal cord injury, cerebral palsy, cerebral vascular accident and other neurological conditions(11). Assessments Clinical assessment may affect management programme of spasaticity. During decades many methods for assessment of spastic limbs, have been applied depending on the aims and treatment programme of investigators, to assess the spastic limb recovery. However, there is no total agreement among investigators as to what method of assessment is the most suitable for evaluation of spasticity. Ashworth scale and modified Ashwoth scale are the most common scales for assessment of spasticity. However, those are not suitable methods of spasticity assessment(12). A number of the other tools have been proposed for measurement of tone, these tools are motor assessment scale, Oswestry scale of spasticity. Some of investigators employed electrodignostic technique for meaurement of spasticity, but this technique can be used only for individual muscle or local measurements (13). Also an assessment method has been suggested for disabled people with spastic limbs(14), this method is used for sport and functional classification. The mejority of the spasticity scales are based on assessment of resistance during passive movement(11). Investigators widely employed this assessment methods for spastic limbs, eg; Nuyens and colleages used the Ashworth Scale for measurement of spasticity (15) and Khalili and Hajhassanie employed Modified Ashworth Scale for evaluation of spastic limbs in children with cerebral palsy(10). However, in a study Fleuren and co-workers proposed that the validity and reliability of the Ashworth scale is insufficient to be used as a measure of spasticity(12). The other assessment methods have been used for evaluation of spastic

limbs. Josien and co-workers in 2009 used goniometry in estimating the joint angle of the catch in spasticity assessment of the medial hamstrings, soleus and gastroenemius in twenty children with Cerebral palsy(16). Also they used modified Ashworth scale for assessment of children with spasticity on their lower limbs. Deglado and colleages in 2010 proposed a number of tools for assessment of spasticity including Tardieu scale and recommended that Tardieu scale is a proper tool for evaluation of spasticity(3). Some of investigators assessed reliability and validity of the measurements and they reported a variety of the results, modified ashworth scale(15), pendulum test( 17), range of motion (18). Khalili assessed goniometric measurement on 16 healthy subjects and reported that it is necessary to standardize the method of goniometric measurement in different parts of the body (18). Isokinetic dynamometers have frequently been used for evaluation of spasticity. Biering and co-workers (9) stated the great advantage of Isokinetic dynamometers is standardization of the applied stretch velocity-dependent and amplitude possible, and thereby can measure the velocity-dependent resistance in the muscle to passive movement. Biering and co-workers suggested that, a combination of electrophysiological and biomechanical techniques shows some promise for a full chartacterization of spastic syndrome, there is a need of simple, standardized instrument, which provide a reliable quantitative measure with a low interrater variability. Treatment There is no model based evidence agreed and available for the management of spasticity and much of what is done is based on a logical and pragmatic approach(19). The key to succeed the management of spasticity is education of the patient and carers with both verbal and written information. This allows them to understand, appreciate and be fully involved in the management plan(20). Doctors, physiotherapists, occupational therapists, and nurses across primary and secondary care can play key roles in working with the individual and their carers to assess the degree and impact of spasticity, identify the treatment goals, initiate referring to the specialist, implement management programmes, and monitor the effects of all the mentioned interventions. Effective spasticity management requires clear communication and

Vol. 9, No. 14, Oct. 2011 62

documentation between the individual and all the services involved in their care (19) . "Theorically, the best chance for full functional recovery would be total anatomical restoration of the lost neurons and axonal corrections. This would require replacement of the lost neurons, regeneration of injured axons and restoration of synaptic contacts that were lost(20). Current clinical management of spasticity involves a wide variety of therapies ranging from noninvasive (eg, oral administration of antispastic drugs, physiotherapy) to invasive procedures (eg, surgical rhizotomy). The type and rate of treatment depend on the levels of spread (diffuse versus focal) and disability caused by spasticity. Bavikatte and Gabe in 2009 proposed the following aims for management of spasticity(20); 1. Improve function- mobility , dexterity 2. Symptom relief (Ease pain- muscle shortening,

tendon pain, postural effects, decrease spasms, orthotic wearing)

3. Postural- Body image 4. Decrease carer burden- care and hygiene,

changing position, dressing 5. Optimise service responses- to avoid unnecessary

treatments, facilitate other therapy, delay/ prevent surgery

Shaw and Rodgers(22) described that pharmacological, Physical and surgical treatments are currently employed in spasticity management. Pharmacological: The most commonly used antispastic drugs are Baclofen, Benzodiazepine, Clonidine, and Ttizanidine. Each of these drugs could be used alone or in combination with the others to obtain a desired effect and are administered orally or intrathecally(4) . Physical modalities: Simple physical treatments such as correct positioning, stretching and exercise therapy are recommended for use in the first stage of treatment (22). Collin and Daly stated that rehabilitation techniques, positioning, splinting, and stretching have a large part to play(5). DeSouza and colleages proposed that an approach to rehabilitation that views the in the individual in his or her social, family, work and cultural roles, informs the therapist about the impact of disability on the individual lifestyle(23). A number of investigators studied to determine a suitable method for the treatment of patients with neurological conditions, ie; stretching, cooling muscle and heat, Bobath technique, Brunnstrome technique, proprioceeptive neuromuscular

facilitation, and nerve block The aim of such techniques would be to help patients to obtain as much normal active movements as much as possible, but the therapist must be trained in each method(20, 24). Stretching in spasticity can improve muscle flexibility, reduce muscle stiffness, and improve function. Clinically, a number of stretching techniques is used including static, dynamic, Proprioceptive Neuromuscular Facilitation (PNF) for improvement of spastic limbs (25). Electrical stimulation of muscles and nerves has been used in the rehabilitation of patients with neurological problem to reduce spasticity and improve limb functions, this method can be applied for children and adults with spasticity(10), Vodvonik and co-workers suggested that about one-half of randomly selected spinal cord injury patients with knee joint spasticity might benefit electrical stimulation(26). Khalili and Hajhassanie applied electrical stimulation on spastic limb of children with cerebral palsy and reported that electrical stimulation may contributing improvement of spasticity in children(10). Various electrical stimulation modalities have been used to reduce the level of spasticity. These conditions vary from surface electrical stimulation of muscles to electrical stimulation of the peripheral and central nerves. Electrical stimulation of peripheral nerves would block sensory and motor muscle activity and may prevent the transmission of residual voluntary activation of muscles that might remain after incomplete spinal cord injury(4). It has been reported that the load that is applied to paralyzed muscle during an electrical stimulation training program is an important factor in determining the amount of muscle adaptation that can be achieved(27). Davis and co-workers (28) explained some of the advantages of electrical stimulation leg exercise include augmented “cardiorespiratory fitness, promotion of blood circulation in the leg, increased activity of specific metabolic enzymes or hormones, greater muscle volume and fiber size, enhanced functional exercise capacity like strength and endurance, and altered bone mineral density.” Positive psychosocial adaptations have also been reported among SCI individuals who undergo FES exercise. Peripheral nerve block in control of spasticity: Nerve block can be used in the treatment of spasticity. Nerve block refers to the application of a chemical agent to a nerve to either temporarily or permanently


impair the function of the nerve. The agents most frequently used are phenol, alchol and local anesthethetics(29). Khalili and co-workers used the technique by the application of phenol for peripheral nerve to block electrical stimulation of the motor nerve innervate to the related (spastic) muscles(30). Since then the technique has been widely developed (24, 30). Rekand proposed that Botulinum toxin combined with physiotherapy and orthopedic surgery is effective treatment of localized spasticity(11). Viel and colleages proposed that regional blocks have a threefold use in patients with painful spasticity including diagnostioc, prognostic, and therapeutic, peripheral neurotic blocks are easy to perform, effective, and inexpensive(30). Spasticity in agonist (spastic) muscles resists antagonist movements and prevents limb function. If spasticity in agonists can be relieved by using nerve block, strengthening of antagonist muscles will be possible and limb function will improve (29). It has been claimed that phenol nerve block can prevent surgery(30). Petrillo and Knoploch(31) employed nerve block on the tibial nerve on 92 patients with severe spasticity of plantar flexors and ankle invertors. Nineteen of patients had had indication for surgery. The authors reported that after nerve block, the range of movements improved in all of them and surgery was prevented. However, this study did not accurately investigate nerve block effects in preventingsurgery, and further research required. Sciatic nerve block: Injection to the sciatic nerve can reduce spasticity in the hamstring muscles. Injection facilitates it, positioning and standing transfer, also range of motion of the knee is improved and contracture and pressure sores are prevented. Injection facilitates heel strike during walking(30). Musculocutaneous nerve block: Injection of the musculocutaneous nerve may reduce spasticity in the biceps and improve flexion contracture of the elbow(30). If there is a severe hypertone in the brachioradialis muscle and elbow movement is limited, motor point block of the brachioradialis muscle is useful to reduce spasticity of the brachioradialis muscle(31). Advantages of nerve block: Nerve block may be a useful technique to reduce spasticity and obtain hand function and gait improvement. Range of motion and activities of daily living are improved by using nerve block(24). Further more, it has been suggested that application of nerve block is a valuable treatment between the period of short

term and long term rehabilitation programmes by reduction of spasticity in a particular muscle group(32). Side effects and complications: A number of investigators reported that following nerve block tenderness and swelling occurred in the injection area(32). Some other investigators have reported that more complications occur using nerve block, they reported development of paresthesia in a number of patients (31). Choi and co-workers pointed out that it is possible to cause allergic reaction, hematoma, pain, burning sensation, paresthesia, trismus, infection, and edema in the injection site of the limb(33). Glenn stated that a burning sensation may be felt by the patient, following motor point nerve block but no serious side effects occur particularly if injection is carried out by an experienced person who is aware of the nerve block complications(29). Contracture and surgery: One of the most common complications of spasticity is contracture, When there is imbalance between agonist and antagonist muscles, and if the limb is kept in a static position, spasticity may start during a short time (31) proposed that for treatment of the flexion contracture using surgery, 50% of recovery can be expected without a major complication. However, after surgery serial casting is recommended for further correction. Occasionally orthopaedic or neurosurgical procedures may be recommended. These can include myelotomy (severing of tracts in the spinal cord) and rhizotomy (resection of posterior roots)(34). Conclusion A number of methods for assessment and treatment of spasticity are reviewed, some of the common methods of spasticity assessment or management, depend on the patient’s condition and the therapist’s goal of treatment, in prefering a method. So developing, standardizing, and validating clinically relevant spasticity scales is necessary. Also it is noted that studies to establish efficacy of the current therapies and to find effective treatments to help people with spasticity. Acknowledgment: In preparation for this article we wish to acknowledge from the School of Rehabilitation, Semnan University of Medical Sciences, and all the staff of the School.

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References 1. Losseff N, Thompson A. The medical management of

increased tone. Physiotherapy. 1995;81(8):480-484. 2. Lamy JC ; Wargon I; Mazevet D; Ghanim Z; Pradat-Diehl P

and Rose Katz R, Impaired Efficacy of Spinal Presynaptic Mechanisms in Spastic Stroke Patients, Brain. 2009;132(3):734-748.

3. Delgado MR, Hirtz D, Aisen M, Ashwal S, Fehlings DL, McLaughlin J, Morrison LA, Shrader MW, Tilton A, Vargus-Adams J. Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2010, 26;74(4):336-43

4. Elbasiouny SM, Moroz D, Bakr MM, MD, and Mushahwar VK, Management of Spasticity after Spinal Cord Injury: Current Techniques and Future Directions, Neurorehabil Neural Repair. 2010, 24 (1); 23-33.

5. Collin C and Daly G., Brain injury, In; Stokes M, Neurological Physiotherapy, 1998; Mosby, UK, P. 91-103.

6. Thornton H and Kilbride C (1998) Physical management of abnormal tone and movement , In; Stokes M, Neurological Physiotherapy, Mosby, UK, P. 313-325.

7. Atkinson HW, Aspects of neuro-anatomy and physiology. In Downie, PA. ed. Cash’s textbook of neurology for physiotherapists, 1995; 4th ed. London: Mosby, Chapter 4.

8. Khalili MA and Yadegary H, Comparison of the level of fine movements development in children of rural and urban nersury in Semnan, Koomesh, Persian, 2004; 5(1&2), P. 53-61.

9. Biering-S_rensen F, Nielsen JB and K Klinge K, Spasticity-assessment: a review, Spinal Cord, 2006; 44: 1–15

10. Khalili MA and Hajihassanie A, Electrical simulation in combination with passive stretch has small effects on knee range of motion and spasticity in children with cerebral palsy: a randomised controlled trial, Australian J of Physiotherapy, 2008; 54: P. h85-9.

11. Rekand T, Clinical assessment and management of spasticity: a review, Acta Neurol Scand: 2010, 122 (Suppl. 190): 62–66.

12. Fleuren, JFM, Voerman GE, Erren-Wolters1 CV, Snoek, GJ, Rietman, JS, Hermens, HJ, and Nene, AV, Stop using the Ashworth Scale for the assessment of spasticity, J. Neurol. Neurosurg. Psychiatry. 2010; 81:2.

13. Khalili MA, Assessment in movements and functional rehabilitation of children, Koomesh, Persian, 2007, Vol. 8, (4); P. 205-210.

14. Khalili MA. Quantitative sports and functional classification (QSFC) for disabled people with spasticity. Br J Sports Med 2004;38:310–13.

15. Nuyens G, De Weerdt W, Ketalaer P, et al. Interrater reliability of the Ashworth scale in multiple sclerosis. Clinical Rehabilitation.1994; 8:286–292.

16. Josien C. van den Noorta , Vanessa A. Scholtesb, Jaap Harlaara, Evaluation of clinical spasticity assessment in Cerebral palsy using inertial sensors, Gait and Posture, 2009; 30(2); P. 138-143.

17. 17)White H, Uhl TL, Augsburger S, Tylkowski C. Reliability of the three-dimensional pendulum test for able-bodied children and children diagnosed with cerebral palsy. Gait Posture. 2007;26:97–105 .

18. Khalili MA, Inter-rater and intra-rater reliability of A angle measurements, Saudi J Disabil Rehabil, 2003, Vol.9(1), 12-15.

19. Thompson, Jarrett L, LockleyL, Lockley L Stevenson VL, Clinical management of spasticity, J Neurol Neurosurg Psychiatry 2005;76:459-463

20. Bavikatte G and Gaber T, Approach to spasticity in general prctice, British Journal of Medical Practitionres, 2009; 2(3): P. 29-34.

21. Selzer ME, Mechanisms of Functional Recovery in Traumatic Brain Injury, Neurorehabil Neural Repair 1995; 9: 73-82,

22. Shaw L and Rodgers H, Botulinum Toxin Type A for Upper Limb Spasticity after Stroke, Expert Rev Neurother. 2009; 9(12): 1713-1725

23. DeSouza L, Bates D, and Moran G., Multiple sclerosis, , In; Stokes M, Neurological Physiotherapy, 1998; Mosby, UK, P. 133-148.

24. Jeong-Yi K., Ji Hye H., Joon-Sung K ., Botulinum toxin a injection into calf muscles for treatment of spastic equinus in cerebral palsy: a controlled trial comparing sonography and electronic stimulation-guided injection techniques: a preliminary report, American Journal of Physical Medicine & Rehabilitation, 2010; Vol. 89 (4) P. 279-286.

25. Nordez A, Gennisson JL, Casari P, et al. Characterization of muscle belly elastic properties during passive stretching using transient elastography J Biomech, 2008; 6: 2305–2311.

26. Vodovnik L, Bowman B, Hufford P. Effects of electrical stimulation on spinal spasticity. Scand J Rehabil Med. 1984;16:29–34.

27. Crameri RM, Cooper P, Sinclair PJ, Bryant G, Weston A., Effect of load during electrical stimulation training in spinal cord injury. Muscle Nerve. 2004; 29(1):104-11.

28. Davis GM, Hamzaid NA, Fornusek C. Cardiorespiratory, metabolic, and biomechanical responses during functional electrical stimulation leg exercise: health and fitness benefits. Artif Organs. 2008; 32(8): 625-9.

29. Glenn MB. Nerve blocks for the treatment of spasticity. In: Katz RTPhysical medicine and rehabilitation: state of the art reviews. Philadelphia: Hanley & Belfus; 1994; pp. 481-505.

30. Khalili AA, Harmel MH, Forster S, Benton JG. Management of spasticity by selective peripheral nerve block with dilute phenol solutions in clinical rehabilitation. Archives of Physical Medicine & Rehabilitation 1964; 45: 513-518.

31. Petrillo CR and Knoploch S, Phenol block of the tibial nerve for spasticity: A long-term follow-up study, Disability & Rehabilitation, 1988, Vol. 10(3) , P. 97 - 100

32. Viel E, Pellas F, Ripart J, Pélissier J, Eledjam JJ., Peripheral nerve blocks and spasticity. Why and how should we use regional blocks? Presse Med. 2008; 37(12):1793-801.

33. Skeil DA, Barnes MP. The local treatment of spasticity. Clin Rehabil 1994; 8: 240-6.

34. Keenan MA. Management of the spastic upper extremity in the neurologically impaired adult. Clin Orthop Relat Res 1988;233:116–125.

35. Garland D.E. Lilling M and Keenan MA, Percutaneous phenol blocks to motor points of spastic forearm muscles in head-injured adults, Arch Phys Med Rehabil, 1984; 65: pp. 243–245

36. Choi EH, Seo J Y, Jung BY, and Park W, Diplopia after inferior alveolar nerve block anesthesia: Report of 2 cases and literature review, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2009; 107(6): P. e21-e24

37. Ko Ko C, and Ward AB. Management of spasticity. Br J Hosp Med 1997;58(8):400-405.



* All correspondences to: Alwin Robert, Email: <[email protected]>

Short communication

Patient Centered Model of Care - A Positive Impact on Treatment Outcome in a Rehabilitation Hospital in Saudi Arabia

Rana Siddiqui; Asirvatham A. Robert*; Shaiza Irfan, PhD. Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia

Patient-centered model of care (PCMC) is a philosophy and mindset that requires a high level of commitment and significant adjustments in organizational structures. The patient-centered care (PCC) concept is based upon communication and involvement of both patients and their families in the treatment options and the potential outcome, thus empowering the patient and family. The PCC is a quality benchmark that is multidimensional and entails all aspect of how services are delivered to patients. The objective of this study was to study the effectiveness of PCC on the treatment outcome of a Rehabilitation Hospital in the Kingdom of Saudi Arabia. The survey was conducted during the January 2009 to July 2010 at Sultan Bin Abdulaziz Humanitarian City (SBAHC), Riyadh, Saudi Arabia. A total number of 1125 patients participated in the questionnaire and surveys. This paper provides an in-depth discussion of the concepts and evidence regarding PCC, a comprehensive review of approaches, action plan and an examination of activities at SBAHC, Riyadh, Saudi Arabia.

Keywords: Patient centered model, Rehabilitation, patient satisfaction, Saudi Arabia

Submitted: 25 Aug. 2010 Accepted: 22 Nov 2010

Introduction Patient-centered model of care (PCMC) is a promising approach in improving patient treatment outcome and decreasing burden of care for person and family served and other stakeholders. This paper provides an in-depth discussion of the concepts and evidence regarding patient-centered care (PCC), a comprehensive review of approaches, action plan and an examination of activities at Sultan Bin Abdulaziz Humanitarian City (SBAHC), Riyadh, Saudi Arabia. The paper focuses on strategies that can be used by health care organizations by implementing patient-centered care approach. The PCC includes but not limited to patient and family involvement in plan of care, family and caregiver education, achieving optimal patient satisfaction and ensuring patient privacy and respect. The objective of this study was to study the effectiveness of PCC on the treatment outcome of a Rehabilitation Hospital in the Kingdom of Saudi Arabia. The survey was conducted during the January 2009 to July 2010 at Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia. A total number of 1125

patients participated in the questionnaire and surveys. Patient and Family Involvement in Plan of Care: In PCC, patients become active participants in their own care and receive services designed to focus on their individual needs and preferences, in addition to advice and counsel from health professionals 1. Patient or patients’ advocate voices patients’ needs and expectations. Every member of the treating team is an advocate of the patient. Patient and family participate with goal setting and active involvement of patients and family help us to change the manner and focus of the communication with our patients. Treatment team comes up with a patient-driven interdisciplinary collaborated and coordinated care plan. Accepting patients as partners led us to a problem-solving environment leading to an increased patient satisfaction. In this study we found that 80% of our inpatients said that family conferences were beneficial and 83% of our inpatients said that they were able to decide their goals in their plan of care2.

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Patient, Family and Caregiver Education: In Saudi Arabia a paid care giver is generally involved with patient care. We have an interdisciplinary patient, family and caregivers education program in place. It starts right from the pre-admission phase and continues through booking, admission, length of stay and discharge process. Education is provided for post discharge, continuum of care in home or work set up through various modes according to patients’ needs

and preference. Provided education is documented and checked for understanding and accuracy at the receiver’s end through teach-back method. 3 Patient education documentation is one of our service delivery efficiency outcome measures. It documents discussion of patient treatment, home exercise program and use of equipment/devices. Data shows not only high patient education documentation compliance but also increased compliance (Figure 1 ).

Figure 1. Patient Education Documentation

Patient Satisfaction: The World Health Report emphasizes responsiveness of health systems as a crucial component of their overall performance defining responsiveness as the way the system responds to non-health aspects, and whether it was meeting or not meeting patient expectations 4. In this study patient satisfaction survey is conducted monthly for all service areas. It shows to our patients and their families that we value their input and are interested in quality, and continuously looking for ways to improve. We get a lot of positive reinforcement about the many

things that we are doing well. Patient satisfaction and infection control reporting emphasized the need of hot and cold tray line that was implemented as proposed by the team. In the past the SBAHC has organized improvement projects around areas of patient dissatisfaction that resulted in improved satisfaction results. As per Jan 2010 – Sep 2010 patient satisfaction results shows that 96 % of our inpatients and 93 % of our outpatients said that they would recommend our services to family and friends (Figure 2 & 3).

Figure 2. Inpatient Satisfaction


Figure 3. Outpatient Satisfaction

Patient Privacy: Respecting privacy and patients' satisfaction are amongst the main indicators of quality of care and one of the basic goals of health services 5. In this study we ensure that patients are treated with dignity and respect, in environments that meet their needs for personal privacy. Demonstration of preservation of

patient dignity, privacy and confidentiality is a component of the job description of all staff. The results indicated that, during Jan 2009 - Aug 2010, our inpatient satisfaction results showed 96% satisfaction towards patient privacy (Figure 4).

Figure 4. Inpatient Privacy Respected

Information Sharing with Patient and Family: Sharing health information with patients and family through accessibility to medical record upon request is yet another adjunct to patient empowered care. Based

on the 'Patient and Family Information Needs Assessment Analysis', it is evident that our inpatient population prefers paper based information (Figure 5).

Figure 5. Information provided to patient rights and responsibilities

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Patient Outcome Analysis: Research shows that orienting the health system around the preferences and needs of patients has the potential to improve patients' satisfaction with care as well as their clinical outcomes. We regularly and systematically reviews data from outcomes of the person served that is related to goals achieved and their satisfaction with services delivered. 99% of our patients returned to their home/community after their discharge. Conclusion The SBAHC identified and implemented new tools and ways towards PCC culture and philosophy. A PCC campaign was launched to educate and

empower staff with tools for delivering services with PCC approach. Although our work is in process, we believe we have made significant progress in coming up with a model of care: one that places the patient and family in the centre of our service delivery. A patient and family centered model of care is a journey not a destination. As we go forward, we are planning to study more thoroughly to measure the impact of our PCMC on our patients and staff. We hope that others will benefit from our experience, and will join us in finding new ways to integrate the voices of patients and families into the pattern and delivery of healthcare.

References 1. Agency for Healthcare Research and Quality, "Expanding

Patient-Centered Care To Empower Patients and Assist Providers," Research in Action, issue 5 (2002), under subtitle, "Health Care Evolves Toward a Patient-Centered Model," http://www.ahrq.gov/qual/ptcareria.htm.</P< a>> (6) Institute of Medicine, Crossing the Quality Chasm, 6.

2. Marchland, Lucille; Kushner, Kenneth. Getting to the heart of the family conference: The residents' perspective. Families, Systems, & Health, Vol 15(3), Fal 1997, 305-319.

3. Shepperd S, Parkes J, McClaran J, Phillips C. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD000313. DOI: 10.1002/14651858.CD000313.pub2.

4. World Health Organization. The World Health Report 2000. Health Systems. Improving Performance. World Health Organization Geneva, Switzerland 2000.

5. Nayeri ND, Aghajani M. Patients' privacy and satisfaction in the emergency department: a descriptive analytical study. Nurs Ethics. 2010 17:167-77.



* All correspondence to: Jalal Younesi, Email: <[email protected]>

Case report

Efficacy of Mindfulness-Based Cognitive Therapy on Depressed Mothers with Cerebral Palsy Children

Zahra Sedaghati Barogh; Jalal Younesi, PhD*; Fateme Shoaei, MSc.; Siyamak Tahmasebi ,PhD

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Objectives: Findings Demonstrated that Parent of Children With Cerebral Palsy Experience Elevated Level of Distress, Depression, Anxiety, Posttraumatic Stress Symptom and Subjective Symptom of Stress. Depression is a common condition that typically has a relapsing course. Effective interventions targeting relapse have the potential to dramatically reduce the point prevalence of the condition. Many of studies have shown that Mindfulness based cognitive therapy (MBCT) is an intervention that has shown efficacy in reducing Depression syndrome and depressive relapse. In This Study, Effectiveness of Mindfulness –Based Cognitive Therapy (MBCT) on Reduction of Depression in Mothers of Children with Cerebral Palsy was examined.

Method and Material: Three Mothers Whose Children Had Cerebral Palsy Were Diagnosed to Have Depression Symptoms, Using Beck Depression Inventory II, Structured Clinical in This Experimental Signal - Case Study .After The Baseline was Determined, Subject Attended on Eight –Session Program of Mindfulness - Based Cognitive Therapy .

Results: The Comparison of Baseline and Post - Test was Showed That Depression Symptom has decreased through MBCT. Improvement Quotient for Depression of each Subject was good.

Conclusion: Data Showed that MBCT Reduced Depression Symptoms in Mothers of Children With Cerebral Palsy.

Keywords: Mindfulness Based cognitive therapy, Mindfulness, Depression, Cerebral Palsy.

Submitted: 18 Jan 2011 Accepted: 28 Feb 2011

Introduction Cerebral palsy (CP) is a disorder of posture and movement as a consequence of non-progressive injury to the immature brain. The estimated incidence of CP is 2.0 to 2.5 per 1000 live births in developed countries (1). Children with CP have significant limitations in the activities of daily living such as feeding, dressing, bathing, and mobility (2). Although motor dysfunction is the defining clinical feature of CP, sensory, cognitive, and verbal impairment in addition to learning difficulties and behavioral problems can also be seen in this condition (3). Limitations can result in requirements for long-term care that far exceed the usual needs of children as they develop (1). Care giving is a normal part of being the parent of a young child whereas this role takes on an entirely different significance

when child experiences functional limitations and possible long term dependence (4). Mothers of children with different level of disability tolerate high level of stress. Children with chronic medical conditions cause depression (5), emotional and behavioral problem in their mothers (6). In the study of Ones and his colleagues (3) mothers having CP children had depressive symptoms and lower quality of life, in addition Manual(7) reported 30% of mothers having CP Children had the symptom of depression above cut off on center for Epidemiologic Studied- Depression (CES-D) Scale Short Form and the other study by Chey (8) and et al (2009) showed that the prevalence of depression in mother with cerebral palsy 84% and in mothers group of control 33%.In general ,Many studies have shown that depression in mothers of children with

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cerebral palsy is more than common in mothers of normal children. (9-15) Like other mothers, mothers suffering from depression want the best for their children. But common symptoms of depression, such as anxiety, sadness, fatigue, and poor concentration, can affect parenting ability and the relationship between a mother and her both normal child and child with disabilities.(65-70) As a result, maternal depression is associated with a range of poor outcomes for children, including difficulties in mastering age-appropriate developmental tasks, reduced language ability (16), problems in social and emotional adjustment, and deficits in cognitive functioning (17). For example, infants with depressed mothers may have difficulties forming emotional bonds with caregivers and may be less responsive to others, less active, fussier, and slower to walk or vocalize (18). Toddlers with depressed mothers may exhibit attention problems and poor self-control, while for school-age children and adolescents, maternal depression is associated with school problems and low self-esteem. Children of depressed mothers are also at higher risk of developing mental disorders themselves (19). .In general, Depression affects almost all aspects of life and can eventually make

normal life impossible. (20) .It appeared that there is a relationship between child's disability and the maternal mental health problems that may affect each other. Many of intervention on depressed mothers with cerebral palsy child are child- centered, another words, In this case, using approaches to rehabilitation of children with cerebral palsy for improved motor function and its effect on the improvement of maternal depression were examined (3, 9). Despite , no or little positive results in this style of type of intervention on maternal depression; (3,9,10) other interventions, including psychotherapy intervention on these mothers has been used very little or not at all. Depression is serious health problem. The usual treatment offered is antidepressant medication, which often yields unwanted side effects, compromising patient compliance (21,22) .Cognitive therapy (CT) and psychopharmacology have been the mainstays of treatment for depression and relapse prevention, yet relapse remains a significant risk for this mental illness (23-26) .Consequently, the development of effective strategies to prevent relapse is very important.

Table1. Characteristics of mothers and their children

Participant A Participant B Participant C Age of child (years) 6 4 4

Gender Boy Boy Boy Type of cerebral palsy Spastic (Hemiplegia) Spastic (Diplegia) Spastic (Hemiplegia)

Age of mother 35 41 39 Occupation of mother Housewife Typist at home Housewife Number of children 2 1 2

Mindfulness-based cognitive therapy (MBCT) is an alternative, psychological intervention designed for prevention of relapse in recurrent depression. (27) MBCT1, can reduce depression and anxiety symptoms. More recently, MBCT was shown to help individuals discontinue antidepressants after recovering from depression.(28) Overall, Apart from the studies (29,30,31) that showed relapse preventing effect of MBCT in previously depressed patients, there are now a number of reports demonstrating that MBCT can successfully reduce symptoms in currently depressed patients.(32,33) MBCT includes mindfulness practice designed to cultivate nonjudgmental observation and acceptance of bodily sensation, cognition, and emotions.

1 -Mindfulness based cognitive therapy

Participations learn to engage in sustained observation of these phenomena, with the tendency of interest and curiosity, and to accept them as they are, without trying to change or escape them. The present study aimed to evaluate the effectiveness of MBCT on reduction of depression symptoms in mothers of children with cerebral palsy. The present study is an effectiveness study and not efficacy study. Efficacy studies examine the effects of treatment in randomized controlled trials, involving participants, using a highly structured treatment manual for a narrow problem focus. Effectiveness studies examine the consequences of treatment conducted in non-research based clinical setting and purposive sampling. The aim of such research is to maximize the external validity or generalization of results to various settings.


Materials and methods Participants Participants in this study consisted of three mothers who were selected from among mothers who were referred to University of Social Welfare and Rehabilitation Centers for the rehabilitation of their children. Facilitator screened interested subjects for inclusion and exclusion criteria. Inclusion criteria were (A) Diagnosed with depression by a psychiatrist and Possessing 19 score and above in Beck Depression Inventory-II (BDI-II) ;( B) Meeting criteria for depression determined by the modified version of the structured clinical interview for DSM IV (34) ;( C) Medically stable patients with current associated major depression, substance abuse and /or dependence and psychosis and disabled were excluded from the study because of low concentration and orientation. All the children were boys with cerebral palsy spastic type. (Ages 4-6).All the children lived with their parents. Procedure The method used in this study the single- case experimental design. In analyzing the data in the single case study, the dependent variable for the possible changes resulting from the independent variable can be read in two ways. (35) The first criterion is to draw the graphs of subjects’ functions of the baseline and the intervention phase, and then compare them; and the second criterion is to consider the slopes in each of the two –step graph-line during the intervention. Thus, any trends or slopes in each stage are examined. In this study, the Improvement quotient was used to show treatment effect clearly. We subtracted the pretest scores from the post-test score and then divided the attained number by the pretest score. (36) The Baseline included three measures of maternal depression using the Beck Depression Inventory, before the intervention. The measurements were performed at the end of second, forth, sixth and eighth sessions to monitor the changes. Participants attended in treatment for eighth consecutive weeks for tow hour individually. Intervention Mindfulness-based cognitive therapy (MBCT) is a synthesis of mindfulness-based stress reduction, mindfulness meditation, and traditional cognitive behavioral therapy. MBCT strategies help individuals recognize and understand the automatic patterns of sensation, cognition, behavior, and emotion which ultimately lead one to a depressive

episode. (27)Instead of trying to eliminate or fix the negative thoughts and emotions which precede depressive episodes, mindfulness-based cognitive therapy teaches the person to allow them to occur and become aware of what he or she is experiencing during their onset. (37) Ideally, in understanding these processes, one would be able to recognize the onset of symptoms and prevent them from developing into a depressive episode. MBCT is an eight week program which uses mindfulness exercises and homework to engage clients in experiencing the present and to avoid worrying about its relation to the past or future .(38) How does the intervention work? Individuals who are depressed tend to interpret their life experiences in a negative and biased way. These opinions lead to be universal, self-critical, and involve the past and future. Over time, these individuals develop automatic, habitual patterns based on associated thoughts and moods. As these patterns develop and become automatic, the negative thoughts may easily perpetuate the sad moods previously associated with the same or similar thoughts, thus it becomes easier for the individual to fall into a downward spiral of depression. (29) As this process progresses, even mild changes in mood may lead to major changes in thinking, a concept termed cognitive reactivity. Using MBCT strategies, these individuals learn to recognize and welcome these patterns in order to understand them. This means that MBCT elements of cognitive therapy that is consistent with nonjudgmental acceptance of the experience and living in the moment. A decentered view of thoughts is emphasized, in which participants are encouraged to view their thought as transient mental events rather than as aspects of themselves or as necessarily accurate reflections of reality or truth. (39) Mindfulness based intervention consists of the development of a particular kind of attention, characterized by a nonjudgmental awareness, openness, curiosity, and acceptance of internal and external present experiences, which allows practitioners to act more reflectively rather than impulsively.(40-42)

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Eventually, the individual would be able to recognize the onset of these patterns, and disrupt the automatic processes (feedback loops) thus, is believed, by modifying the neural circuits in their brain that are involved with emotion (e.g. amygdala, hippocampus. (43) Essentially MBCT is thought to alter the emotional/cognitive and physiological experiences of the present in order to treatment and prevent depressive relapse in the future (38). Research shows that such cognitive behavioral strategies may actually modify similar brain circuits which are targeted by medications. (44) Therapeutic Package In this study, the intervention include in our manual were provided in eight sessions. Goals and techniques in the first session included building a rapport with the client, obtaining information from the client, providing psycho education on mindfulness, CBT, depression, identifying automatics thoughts and leading the client through a guided mindfulness meditation. In the second Session, goals and techniques included ‘stepping out of automatic pilot’ (acting without conscious awareness), having a childlike Curiosity and Mindful eating Body scan (intentionally bringing awareness to bodily sensations) In the third session, goal and technique included dealing with barriers (Awareness of how the chatter of the mind influences feelings and behaviors), Being compassionate with yourself and short breathing meditation Goals and techniques in the fourth session helping the client recognize that most of her thought are not facts, teaching the client to use the thought record, educating client about cognitive distortion. Goals and techniques in the fifth session included educating staying present with awareness of attachment and aversion, being patient; then, diaphragmatic breathing and sleep hygiene; next, teaching the client a brief body scans exercise to reduce muscle tension. In the sixth session, goal and techniques included acceptance of thoughts and emotions as fleeting events; next, introducing mindful daily activity,

teaching mindful eating and mindful labeling on thoughts, feelings and behaviors. In the seventh session, goals and techniques included symptom of depression and rumination thinking.we educated accept your rumination thinking without judgment and used diffusion technique for reduction of it. In the eighth session, goal and technique included how can I best take care of myself? And using what you have learned to deal with future mood and reviewing the insights and found the most useful techniques of mindfulness by the client, identifying obstacle to practice mindfulness, providing a checklist of techniques included in the program. Instrument Beck Depression Inventory-II (BDI-II) The Beck Depression Inventory-Second Edition (BDI-II)(45) is a 21 –item scale and one of the most widely used self –report measures of depression . Beck mentioned the alphas of 0.93 for college students and 0.92 for outpatients, in Steer et al study; an alpha of 0.92 for the BDI-II was reported. Beck reviewed 11 studies that showed the BDI is capable of discriminating between groups that differ in level of depression. 35 synchronic validation studies compared BDI with other depression ratings. Fourteen other studies indicated the correlations between the clinical scales and BDI; coefficients of psychiatric patients ranged from 0.55 to 0.96 with a mean of 0.72. The correlation between the earlier version of BDI and (BDI-II) was 0/93 and kappa agreement was 0.70. (46) Result Participant A Diagram1 shows that the participant’s depression level is 20-24 in BDI-II approximately at the baseline statement. These scores are moderate rates of depression in BDI-II. She obtained a score of 19 in BDI-II at end of session 2; and this reduction continued until the end of the intervention.as in last session, her score in posttest measurement was 11 in BDI-II. That indicates reduction in symptoms of depression. Her Percent of recovery was %50.74 for depression. (See Figure 1)


Fig. 1 Participant A Percent of recovery

Participant B Diagram 2 shows that participant's depression levels were 32-41 in BDI-II approximately at the baseline statement. These scores are severe range of depression in BDI-II. She obtained a score of 23 in

BDI-II and at end of session 2. Her scores in last post-test measurement were 12 in BDI-II that indicate reduction in symptoms of depression. Her Improvement quotient was %66.67 for depression. (See Figure 2)

Fig. 2 Participant B Improvement quotient

Participant C Diagram 3 shows that participant's depression levels are 34-38 in BDI-II approximately at the baseline statement. These scores are severe rate of depression in BDI-II. She got the score of 24 in BDI-II at the

end of session 2. Her scores in last post-test measurement were ١٣ in BDI-II that indicate reduction in symptoms of depression. Her Improvement quotient was %63.55 for depression. (See Figure 3)

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Fig. 3 Participant C Improvement quotient

All participants showed scores of 20-41 at the baseline statement that indicated Moderate (20-28) and severe depression (29-62) in BDI-II. Visual observation of diagrams demonstrates the decline of scores. Post- test of three participants (A, B and C) is in low or no depression remains. Discussion This current study, According to the Ingram, Hayes, and Scott theory (2000), explains the result on the effects of MBCT on depressed mothers with cerebral palsy child in four areas to evaluate the performance of Cognitive Therapy. (46) Universality of change (what is the percentage of the improvement?) Differences between base line and post-test scores demonstrated that examinees show positive improvement on Beck depression scales. The percentages of recovery on depression were: participant A: %50.74; participant B: %66.67; and participant C: %63.55 These results are consistent with recent studies investigating the relationship between mindfulness and predictors of depression (47,48)which have shown that mindfulness functions as a protective factor against known correlates of depression Symptoms (e.g., rumination, negative cognitions). Generality of change (what are the changes in relation to critical situations and jobs?) The more complex the form of cerebral palsy, the less favorable the prognosis for the child's psychomotor development and a potentially greater risk of disturbances in the quality of communication and interaction with the parents (49, 50). The situation of parents of children with cerebral palsy is considered so stressful that it can be compared with the situation of parents of children with cancer (51) .The difficult and constant struggle to improve the child's health and development is accompanied by

doubt, guilt and shame, which contributes to the deterioration of the quality of life of parents. (52) Experiencing severe anxiety (e.g. before making a crucial decision) often times leads to feelings of helplessness and lack of control, and this in turn may contribute to feelings of parental incompetence .(3, 53)Fatigue and frequent loneliness lower resistance to stress and disturb the normal regulation of emotions(53) Moreover, Brehaut et al(54) found that over the year’s parents of children with cerebral palsy, compared with parents of healthy children, more frequently complain of experiencing severe and chronic stress, emotional and cognitive problems, as well as report numerous somatic complaints. In this study, participants also had many problems, including difficulty eating (part A), lack of concentration, decreased libido (part B), sleep disturbances (55) (part c), fatigue, lack of energy, social isolation, problems with spouse. At the end of the final sessions, the participant had a better solution for their problems and relationship with their spouse and children. Baer (56) argues that in mindfulness, several mechanisms can reduce the symptoms, including: • Cognitive change • improved self-management • Exposure to painful experiences leading to reduced emotional reactivity. Cognitive change—also called metacognitive awareness—is the development of a “distanced “or “decentered” perspective in which patients experience their thoughts and feelings as “mental events” rather than as true, accurate versions of reality. This is thought to introduce a “space” between perception and response that enables patients to have a reflective—rather than a reflexive or reactive—response to situations, which in turn reduces vulnerability to psychological processes that contribute to emotional suffering. Some preliminary


evidence suggests that MBCT-associated increases in metacognitive awareness reduce risk of depressive relapse. (57) Safety Comparing the participants’ scores at base line, post-test, and follow up in depression showed a great deal of improvement on the scales, and led to a full recovery. However, the recovery rate was different from patient to patient. This treatment approach did not show any side effects. Stability (Treatment Achievements) Follow up result (30 days after the last therapy session) indicated that depression of participants A and C maintained in the score of less than 13 which indicates the state of no depression or least depression. Participant B with the score of 14 was categorized in a range of 14-19 with a diagnosis of mild depression; and it can be stated that MBCT provided them with a relative stability.

Conclusion In summary, the current study demonstrated that Mindfulness-Based Cognitive Therapy has a significant effect on depression and on our samples. The depression changed in different ways. Due to the psychological interviews which the Facilitator carried out with mothers, this treatment approach significantly improved the relationship of these mothers with themselves, and their families, and also improved their social functions. The outcomes are coherent with the results of the studies which emphasize the Effectiveness of MBCT for treatment of depression, anxiety and stress and to improve psychosocial adjustment of people. (31, 58-64) Acknowledgment We would like to thanks research section of University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. We also would like to appreciate the mothers of children with cerebral palsy who have given us their valuable time and they trust us.

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