JRLJUL2007 Web SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 2 41 Effectiveness of Palliative Care Including Physiotherapy in HIV Patients A Review of the Literature L i t e r a t u r e R e v i e w ABSTRACT: It is estimated that 41 million people throughout the world are living with HIV/AIDS and of these 39 million are in sub-Saharan Africa (UNAIDS 2004). The HIV/AIDS epidemic is devastating the African continent. In Africa poorly resourced health care infrastructure further impairs the quality of life in HIV sufferers. Palliative care is an approach that aims to improve the quality of life of people living with threatening diseases such as cancer and HIV/AIDS. This review aimed to determine the efficacy of palliative care. Complementary therapies such as Cognitive Behavioural Therapy, peer/counselling group therapy, massage therapy, and exercise therapy constitute palliative care. Seventeen articles published in peer reviewed journals during the period 1990-2005 were reviewed. The findings of our review demonstrate that there are indications that palliative care can be effective in improving the quality of life in patients with life threatening diseases such HIV/AIDS. Research in this field is complicated by the heterogeneity of study samples, difficulty in patient recruitment, and death before the end of the intervention period. Future research in this area should aim to include larger study samples, using valid tools to assess quality of life and to employ qualitative methods in studies to assess the effectiveness of palliative care. KEY WORDS: PALLIATIVE CARE, COMPLEMENTARY THERAPY, PHYSIOTHERAPY, HIV/AIDS, TERMINALLY ILL, QUALITY OF LIFE. Uwimana J, MSc1; Louw Q, PhD2. 1 University of the Western Cape. 2 University of Stellenbosch. INTRODUCTION An estimated 41 million people world- wide are living with HIV/AIDS and of these 39 million are in sub-Saharan Africa (UNAIDS 2004). Ten million of these HIV/AIDS sufferers are signifi- cantly affected by the disease, which causes great suffering and economic hardship for them and their families (Sepulveda et al., 2002). Palliative care (PC) has been introduced with the aim of reducing suffering in HIV/AIDS patients. It is deemed crucial, since peo- ple with HIV infection can live 10 years and longer (Brecht et al., 2001, Singer 2002). Palliative care also offers a support system for carers to cope during the patient’s illness and in their own bereavement after the loss of a relative or friend (Addington-Hall & Higginson, 2001). The World Health Organisation (WHO) defines palliative care as an approach that should improve the quality of life in patients and their rela- tives who face problems associated with life-threatening diseases (WHO, 2002). Palliative care is multidisciplinary in nature and it involves nurses, physio- therapists, medical doctors, counsellors, social workers and religious leaders (Meldbrum, 2003; Addington-Hall & Higginson, 2001). Physiotherapy plays a central role in this multidisciplinary approach by assisting patients to make the most of their decreasing potential, encouraging them to set short-term goals and relieving discomfort (Boyce, 2004). Palliative care is considered to be a cost-effective method by which to man- age HIV/AIDS patients (Sepulveda et al., 2002). It is thus advisable to intro- duce palliative care in poverty-stricken regions where the infrastructure is poor and opioid drugs are unavailable (Sepulveda et al., 2002). However, many African countries have not yet consid- ered palliative care as a public health solution (Sepulveda et al., 2002). One explanation for this is that effectiveness of palliative care remains questionable and is mostly based on anecdotal reports. This review aims to ascertain the effectiveness of palliative care in the management of HIV/AIDS patients, and to contribute towards further understanding of published and future research into palliative care. METHODOLOGY This review is based on information obtained from peer-reviewed publica- tions in scientific journals over a period 15 years (1990-2005). In accordance with the aims of the review, studies that could provide insight into the effective- ness of palliative care were reviewed. Research papers in English and French were included. Review articles were excluded. CORRESPONDENCE TO: Prof. Quinette Louw Department of Physiotherapy University of Stellenbosch PO Box 19063 Fax: (021) 930-8370 Tel: (021) 938-9300 Email: qalouw@sun.ac.za 42 SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 2 Formulation of search terms Four key search terms were formulated: effectiveness of palliative care in HIV/AIDS patients, effectiveness of alternative therapy care in HIV/AIDS patients, effectiveness of home-based care in HIV/AIDS patients and effec- tiveness of primary care in HIV/AIDS patients. Synonyms were then applied to formulate the 20 key search terms. The search terms are formulated in Table 1. Database search and results MEDLINE, CINAHL, African Healthline and SCIRUS were searched, as these databases are available at the University of the Western Cape library. The results of each search term were combined and results are presented in Table 2. Methodological quality of articles reviewed Studies were reviewed for methodolo- gical rigour by using validated quality scoring tools. The Crombie Scale was used to assess cohort studies, the Pedro Scale was use to assess the randomized controlled trials (RCTs) and survey studies were assessed by applying the National Health Medical Research Council Scale (NHMRC-Australia, 2003). RESULTS A total of 17 articles were reviewed. Table 3 indicates the four types of study design employed in the studies reviewed. Observational study The observational study aimed to assess the feasibility of quality of life (QoL) data in a palliative care setting and sug- gest practical ways of presenting QoL outcomes over a prospective period (Paci et al., 2001). The sample included terminal cancer patients aged 18 years and above. Patients experienced a reduc- tion of pain in the final weeks of life. It was not possible to ascertain whether this finding was due to the palliative care intervention, as the pain reduction may also attributed to effective pain control by drugs or under-reporting of pain in the last period of life. See Table 4 Surveys Five surveys (Butters & Higgison, 1993; Hardy, Edmonds, Turner, Rees & A’Hern, 1999; Brechtl, Breitbart, Galietta, Krivo & Rosenfeld, 2001; Lo et al., 2002; Goodwin, Higginson, Myers, Douglas & Normand, 2003) aimed to evaluate the quality of life in patients receiving palliative care. Only one study could not mention the type of patients involved in the study, but most of the patients suffered from HIV/AIDS and advanced cancer. Males and females aged 19-91 years were included. Tables 5 and 7 summarize the study aims and populations of the surveys. Forty per- cent (4) of the surveys (Butters & Search Search Term terms nr 1 Effectiveness of palliative care in HIV/AIDS patients 2 Efficiency of palliative care in HIV/AIDS patients 3 Efficacy of palliative care in HIV/AIDS patients 4 Success of palliative care in HIV/AIDS patients 5 Outcomes of palliative care in HIV/AIDS patients 6 Effectiveness of alternative therapy care in HIV/AIDS patients 7 Efficiency of alternative therapy care in HIV/AIDS patients 8 Efficacy of alternative therapy care in HIV/AIDS patients 9 Success of alternative therapy care in HIV/AIDS patients 10 Outcomes of alternative therapy care in HIV/AIDS patients 11 Effectiveness of home-based care in HIV/AIDS patients 12 Efficiency of home-based care in HIV/AIDS patients 13 Efficacy of home-based care in HIV/AIDS patients 14 Success of home-based care in HIV/AIDS patients 15 Outcomes of home-based care in HIV/AIDS patients 16 Effectiveness of Primary care in HIV/AIDS patients 17 Efficiency of Primary care in HIV/AIDS patients 18 Efficacy of Primary care in HIV/AIDS patients 19 Success of Primary care in HIV/AIDS patients 20 Outcomes of Primary care in HIV/AIDS patients Table 1: Search Terms. Database Hits Included Excluded Duplicate Retained Total MEDLINE 38 20 18 15 5 5 CINAHL 26 17 9 12 5 5 AFRICAN HEALTHLINE 68 18 50 16 2 2 SCIRUS (Science direct) 1826 80 1746 75 5 5 TOTAL = 17 Table 2: Search Results. SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 2 43 Author Study aims Butters et al. (1993) To compare the views of palliative care reported by patients, informal carers and the community care team, a multidisciplinary team caring for people with late stage HIV/AIDS illness. Galantino et al. (1999) To evaluate the effect of electroacupuncture in improving the condition of neuropathic HIV/AIDS patients Hardy et al. (1999) To assess the quality of life of patients in palliative care by using the Rotterdam Symptom Checklist Sparber et al. (2000) T o determine the extent at which Complementary Medicine or alternative therapy CAM) is used by adults patients participating in HIV/AIDS clinical trials and investigate issues of communication between patients and clinical investigators Brechtl et al. (2001) To address the impact of Highly Active Antiretroviral Therapy (HAART) on medical, palliative care, and quality of life of patients with advanced HIV infection Lo et al. (2002) To evaluate the quality of life of palliative care patients in the last two weeks of life De Visser et al. (2002) To estimate the prevalence of Complementary Medicine or alternative therapy (CAM) use in a nation-wide sample of Australian people living with HIV/AIDS, and to identify sociodemographic and attitudinal variables associated with CAM Virik et al. (2002) To qualify and quantify the nature of palliative Medicine Liaison Consultation service in a large teaching hospital and the utility of a simple scoring system in the assessment of the impact of the service on direct patient care Radbruch et al. (2002) To evaluate information about the variability in the documentation and the services among the palliative care units and on factors influencing this variability Goodwin et al. (2003) To evaluate the effectiveness of palliative day care in improving pain, symptom control, and quality of life Table 5: Study Aims of Surveys. Higgison, 1993; Hardy, Edmonds, Turner, Rees & A’Hern, 1999; Lo et al., 2002; Goodwin, Higginson, Myers, Douglas & Normand, 2003) investigated different research tools/instruments to assess the quality of life, since this is the main outcome of palliative care. The McGill quality of life questionnaire and Support Team Assessment Schedule questionnaire were found to be appro- priate validated tools to evaluate the effectiveness of palliative care for com- munity and in-patient units for terminal illnesses such as Aids and cancer. The Rotterdam Symptom Check List ques- tionnaire was used as a symptom control assessment tool and not as a measure of quality of life (Butters & Higginson, 1993; Hardy, Edmonds, Turner, Rees & A’Hern, 1999). The average methodological score of all surveys (N=10) was good (74.8%). The lowest score was 50% (De Visser & Grierson, 2002). Methodological sound- ness of these surveys implies that the results may be valid and reliable. Table 6 illustrates the NHMRC score results. Randomized Controlled Trials Studies (RCT) Out of five randomized controlled trials, one study aimed to evaluate a palliative home care service. Four studies focused on evaluating the effectiveness of complementary or alternative therapies including massage therapy, Chinese Authors Criterion Total 1 2 3 4 5 6 7 8 9 10 Paci et al. (2001) 1 0 1 1 1 1 1 1 1 1 9(90%) Table 4: Crombie Scale: Observational Studies. Authors No of studies Study design Butters et al. (1993), Galantino 10 Surveys: et al. (1999), Hardy et al.(1999), 3 cross-sectional surveys, Sparber et al. ( 2000), Brechtl 5 prospective surveys, et al. (2001), Lo et al. (2002), 1 retrospective survey De Visser et al. (2002), Virikt 1 longitudinal study et al. (2002), Radbruch et al. (2002), Goodwin et al. (2003) McWhinney et al. (1994), 5 Randomised controlled Birk et al. (2000), Cohen et al. trials (2000), Diego et al. (2001), Molassiotis et al. (2002) Paci et al. ( 2001) 1 Cohort study Armes and Higginson (1999) 1 Qualitative study Table 3: Types of study designs. 44 SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 2 Authors Study Aims Type of Patients Gender Age McWhinney et al. (1994) To evaluate a palliative care home support Advanced cancer Not Not team based on an inpatient unit patients mentioned mentioned Birk et al. (2000) To determine the effects of massage therapy HIV/AIDS Male (95%) alone and massage combined with exercise patients Female (5%) 27-50 yrs or immune system measures and quality of life in HIV Cohen et al. (2000) To evaluate the effectiveness and safety of Advanced Males Above 17 Chinese herbal formulation for HIV-associated HIV/AIDS years pathogen-negative diarrhoea patients Diego et al. (2001) To assess the effect of massage therapy on HIV/AIDS Females 13-19 yrs patients with HIV/AIDS patients Molassiotis et al. (2002) To assess the effectiveness of cognitive HIV/AIDS Male (91.4%) behavioural group therapyc(CBT) and peer patients Female (8.6%) 20-62 yrs support/counselling group therapy (PSC) in relation to improving the mood and QoL and decreasing uncertainty in illness Table 8: Study Aims and Population. Authors Criterion Total 1a 1b 2 3 4 5 6 7a 7b 8 9 10 11 12 Butters et al. (1993) 1 0 1 1 0 1 1 1 1 0 1 0 1 1 10(71%) Galantino et al. (1999) 1 1 1 1 1 1 1 1 1 1 0 1 0 1 12(85%) Hardy et al. (1999) 0 0 1 1 0 0 1 1 1 1 1 1 0 1 9(64%) Sparber et al. (2000) 1 0 1 1 1 0 1 1 1 1 1 1 1 1 12(85%) Brechtl et al. (2001) 1 1 1 1 1 1 1 1 1 1 0 1 0 1 12(85%) Lo et al. (2002) 1 1 1 1 1 0 1 1 1 1 0 1 1 1 12(85%) De Visser et al. (2002) 1 0 1 1 0 0 1 0 1 0 0 1 0 1 7(50%) Virik et al. (2002) 1 1 1 0 0 1 0 1 1 1 1 1 1 1 11(76%) Radbruch et al. (2002) 1 0 0 1 1 0 1 1 1 1 0 1 0 1 10(71%) Goodwin et al. (2003) 1 1 1 1 1 0 1 1 1 1 0 1 0 1 11(76%) Table 6: Quality of Surveys. Authors Type of patients Gender Age Butters et al. (1993) HIV/AIDS Not mentioned 25-55 yrs, 27-57 yrs Galantino et al. (1999) HIV/AIDS Male (82%), Female (18%) 24-58 yrs Hardy et al. (1999) Cancer Not mentioned 36-83 yrs Sparber et al. (2000) HIV/AIDS Male (98%), Female (2%) 31-50 yrs Brechtl et al. (2001) Advanced HIV Male (77%), Female (23%) 25-78 yrs Lo et al. (2002) HIV/AIDS Male (91%), Female (9%) 18-72 yrs De Visser et al. (2002) Advanced cancer Male (62%), Female (38%) 17-86 yrs Virik et al. (2002) Not mentioned Male (46%), Female (54%) 19-95 years Radbruch et al. (2002) HIV and Cancer Male (50%), Female (50%) 30-91 yrs Goodwin et al. (2003) Cancer and HIV Male (49%), Female (52%) 35-87 yrs Table 7: Study Population. SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 2 45 herbal formulation, cognitive behavioural group therapy (CBT) and peer support/ counselling group therapy (PSC) used in palliative care in improving the quality of life of patients. The findings demon- strate that complementary or alternative therapies such as massage therapy, CBT and PSC were effective in palliative care. This is evidenced by improvement in the patients’ quality of life. Table 8 summarizes the aims of the studies and the population of RCTs. The Pedro scale was used to score the quality of randomized controlled trials. The average score was 50.8%. One study by McWhinney, Bass & Allan (1994) was excluded because patients were terminally ill and died before the study ended. Table 9 presents the Pedro score results. Description of interventions Out of five randomized controlled trial studies, only one study used palliative home care as an intervention to evaluate the effectiveness of palliative care while others evaluated the effectiveness of complementary/alternative therapies used by HIV/AIDS patients in conjunc- tion with quality of life assessment. Table 10 summarizes the interventions and main findings of palliative care and complementary/alternative therapies in HIV/AIDS and cancer patients. Qualitative study The main aims of the qualitative study (Armes & Higginson, 1999) were to assess the quality of HIV palliative care services and to qualitatively assess the needs of those with advanced HIV/AIDS. The components of high-quality HIV palliative care were assessed by using the multidimensional model developed by Maxwell (Armes & Higginson, 1999). Maxwell’s model (Armes & Higginson, 1999) identifies the components of high-quality HIV palliative care as: • Effectiveness • Acceptability • Efficiency • Access • Equity • Relevance Authors Criterion Total 1 2 3 4 5 6 7 8 9 10 11 McWhinney et al. (1994) 1 1 0 0 1 0 0 0 0 0 0 3 (27%) Birk et al. (2000) 1 1 0 1 0 0 0 0 1 1 1 6 (54%) Cohen et al. (2000) 1 1 1 1 0 0 0 1 0 1 1 7 (64%) Diego et al. (2001) 1 1 0 1 0 0 0 1 0 0 1 5 (45%) Molassiotis et al. (2002) 1 1 1 1 0 0 0 1 0 1 1 7 (64%) Table 9: Pedro Scale Results. Authors Interventions Main findings McWhinney et al. (1994) Palliative care home for a period of 18 months Negative outcome: Problems with recruitment, death before comparison point, failure to complete questionnaire Birk et al. (2000) 45-minute overall body massage once/week, similar Positive outcome: massage and supervised aerobic exercises 2 other Massage in combination with days/week, similar massage and biofeedback stress stress management favourably management once /week. alters health perceptions and leads to less utilization of health care resources. Cohen et al. (2000) Source QiTM (Chinese herbal formulation) in an Positive outcome: 8- week, open label study Reduction in diarrhoea in patients with advanced HIV, pathogen-negative diarrhoea. Diego et al. (2001) Massage therapy in a period of 2 times/week for Positive outcome: 12 weeks Patients feeling less anxious and depressed. Enhanced immune function. Molassiotis et al. (2002) Cognitive-behavioural group therapy (CBT) and Positive outcome peer support/counselling (PSC) for 12 weekly Improved psychological distress sessions over 3 months in terms of mood, anger, tension-anxiety, depression and confusion and the quality of life improved significantly compared to the PSC group. Table 10: Description of interventions Studied in Palliative Care. 46 SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 2 Author(s) and years Assessment tools Outcome measures Butters et al.1993 Support team assessment schedule (STAS) Pain, and symptom control, questionnaire anxiety and service needs McWhinney et al. 1994 McGill pain questionnaire and Melzack nausea Pain and nausea questionnaire Hardy et al.1999 Rotterdam symptom check list Psychological and physiological questionnaire (RSCL) aspects of quality of life such as depression, anxiety, pain, nausea, etc Galantino et al.1999 MOS-HIV : 30 – item instrument questionnaire and Pain tibial reflex index Armes and Higginson, 1999 Individual interviews and focus groups Components of high-quality HIV palliative care: effectiveness, acceptability, efficiency, flexible and responsive care, equity. Birk et al.2000 Questionnaires (General Health Self-Assessment) Change in Peripheral blood levels of CD cells, CD8 cells, CD4/CD8 cells ratio and natural killer cells, 6 dimension of quality of life. Cohen et al.2000 The Thygeson Stool Tool (daily diary) Diarrhoea Sparber et al. 2000 Questionnaire CAM and HIV related problems: nausea, dermatological, depression, insomnia, and weakness Paci et al.2001 Therapy impact questionnaire (TIQ) Physical symptoms, function Quality of life questionnaire (QoL) condition, psychosocial aspects Brechtl et al.2001 Karnofsky Performance rating Scale (KPRS), CD4 cells counts and Physical Brain Pain Inventory (BPI), Memorial Symptom and psychological factors (pain, Assessment scale (MSAS), Hamilton Depression symptom distress, depression, Rating Scale (HDRS), Edmonton Functional psychological well-being) Assessment Tool (EFAT) Diego et al.2001 Demographic questionnaire, CES-D and the CD4 and CD8 cells counts, State Anxiety Inventory depression and anxiety De Visser et al.2002 Questionnaire CAM Lo et al.2002 McGill QoL scale for Hog Kong Chinese (MQOL-HK) Physical symptoms, psychological, existential, support and sex domains Virik et al.2002 Questionnaire Pain Molassiotis et al. 2002 Questionnaires (The profile mood states,BREF-HK Psychological distress and quality scale, and Mishel uncertainty in illness scale of life Radbruch et al.2002 Questionnaire Pain control Goodwin et al. 2003 McGill Quality of Life Questionnaire (MOQL) and Pain and symptom control, and Palliative care outcome scale (POS) quality of life aspects Table 11: Assessment Tools and Outcome Measures. The main findings illuminated the complex nature of the needs of people with HIV/AIDS. Clients’ needs and personal circumstances seemed to influ- ence the criteria used to judge the six dimensions of high-quality HIV pallia- tive care and also their rating of their relative importance. These six dimen- sions of high-quality HIV palliative care appear to be inextricably linked from the client’s point of view. Thus, service commissioners and providers need to assess the quality of HIV services in palliative care in all six dimensions, namely effectiveness, acceptability, effi- ciency, access, equity and relevance. Description of outcome measures The most common outcome tool used in all 17 studies reviewed was the McGill pain and quality of life questionnaire. The McGill pain and quality of life questionnaire describes physical symp- toms, psychological aspects, existential, support and sex domains. Assessment of SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 2 47 pain was the most common outcome measure assessed in all studies. Quality of life evaluation is the main outcome of the effectiveness of palliative care although it is often difficult in the termi- nal stage to evaluate quality of life, since patients sometimes die before the end of intervention. Table 11 illustrates how quality of life was assessed as well as the different tools utilized in the studies that were reviewed. SUMMARY OF REVIEW Complementary alternative therapies (CAM), peer/counselling group therapy (PSC), as well as physiotherapy tech- niques including massage and exercise therapy, are included in palliative care and may be effective in improving QoL of HIV/Aids patients (Diego et al., 2001; Molassiotis et al., 2002). However, many patients do not communicate with their healthcare provider about their use of alternative therapies, nor do the providers ask patients about their use of such therapies. This results in a chance for interaction with the anti-retroviral drugs medications, adverse reactions of alternative therapies, or other unfore- seen problems. It is therefore critical for HIV/AIDS patients and their providers to openly communicate about the use of alternative therapies. There is an increasing trend of alternative therapies usage among patients and this trend is likely to continue until a cure for HIV/AIDS is developed (Friedenreich & Orenstein, 2002). Quality of life is the primary outcome measure of palliative care in terminally ill HIV/AIDS patients. This review highlighted that the McGill quality of life questionnaire/scale and Support Team Assessment Schedule question- naire are valid tools to provide informa- tion on quality of life in HIV/AIDS patients (Butters & Higgison 1993; Hardy, Edmonds, Turner, Rees & A’Hern, 1999; Lo et al 2002; Goodwin, Higginson, Myers, Douglas & Normand 2003). CONCLUSION Conclusive evidence regarding the effi- cacy of palliative care for HIV/AIDS patients is lacking since very few studies have been conducted in this field. Furthermore, published studies lack methodological rigour. Research in this area is complicated by the variety in the package of palliative care, diffi- culties in patient recruitment, hetero- geneity of study samples, death of a patient before the end of the project, and heterogeneity of study samples. Randomised controlled trials may be a suitable research design to assess the effectiveness of palliative care. However, this design may be inappropriate in the terminal stages of life due to the death of patients before the end of the inter- vention. Qualitative study designs should be considered in assessing the quality of HIV palliative care services since the quality of HIV palliative care appears to be inextricably linked to the client’s point of view. Despite the high incidence of HIV/AIDS in Africa, palliative care is not yet a priority on the health agenda in most African countries (Sepulveda et al., 2003). Considering the cost efficacy, research on HIV/AIDS and palliative care in Africa is of paramount impor- tance in order to meet the needs of peo- ple with HIV/AIDS and their families (Addington-Hall & Higginson, 2001). REFERENCES Abdu-Saad H H 2000. Palliative care: An international view. Patient Education and Counselling, 41, 15-22. Addington-Hall M J & Higginson J I. 2001. Palliative care for non-cancer patients. London: Oxford University Press. Armes J P & Higginson I J 1999. What consti- tutes high-quality of HIV/AIDS palliative care? Journal of Palliative Care, 15(41), 5-12. Birk T J, McGrady A, MacArthur R D & Khuder S 2000. The effects of Massage therapy alone and in combination with other comple- mentary therapies on immune system measures and quality of life in Human Immuno- deficiency virus. 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Diego M A, Field T, Hernandez-Reif M, Shaw K, Friedman L & Ironson G 2001. HIV adolescents show improved immune function following massage therapy. International Journal Neuroscience, 106, 35-45. Field D, Clark D, Corner J, & Davis C 2001. Research in Palliative care. (1st ed.). Phila- delphia: St Edmundsbury Press. Friedenreich C & Orenstein M 2002. Physical Activity and Cancer Prevention: Etiologic Evidence and Biological Mechanisms. Journal of Nutrition, 132, 3456-3464. Galantino M L A, Eke-okoro Sunday T, Findley T W & Condoluci D O 1999. Use of Noninvasive electroacupuncture for treatment of HI-related peripheral neuropathy: A pilot study. Journal of Alternative and Comple- mentary Medicine, 5(2), 135-142. Goodwin D M, Higginson I J, Myers K, Douglas H R & Normand C E 2003. Effectiveness of palliative day care in improv- ing pain, symptom control and quality of life. Journal of Pain and Symptom Management, 25(3), 202-212. Hagen N A 2003. Research methodology in palliative care. 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[Online] Available: [6/30/04]: 8.30 p.m. WHO 2002. National cancer control pro- grammes: Policies and management guidelines. Geneva. [Online] Available: [6/30/04]: 8.30 p.m. His effectiveness of physio- therapy in the palliative care of older people C O N G R E S S SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 2 49 FULL NAME: SASP MEMBERSHIP NO.: HPCSA PT NO.: ✁ 1. Complete questionnaire & insert the correct answers on the spaces provided. 2. Ensure that you have included your full details as requested. 3. Only original questionnaires will be considered therefor please cut out and submit to the SASP Head Office at: SASP CPD Questionnaire, P.O. Box 92125 Norwood 2117 by 15 August 2007. 4. In order to capture your CPD points at the HPCSA your submission must be accompanied by a cheque/postal order to the value of R20.00 (no cash), made out to the South African Society of Physiotherapy. For any queries regarding the submission of questionnaires, contact Gloria at the SASP Head Office on (011) 485-1467. Question 1 List two implications of the finding that Black children in Cape Town are performing 10% below their American peers on the BSIDII. Question 2 What is the name of the brain area that processes positive emotions? Question 3 What is the body’s first defence line? Question 4 Which four areas were highlighted as areas that impacted on the lives of youths with SCI? Please turn over. CPD Questions (Vol 63 no 2 - July 2007) How to Submit your Answers: ✁50 SA JOURNAL OF PHYSIOTHERAPY 2007 VOL 63 NO 2 Question 5 Which alternative therapies interventions are effective in enhancing quality of life in HIV/AIDS and cancer patients? Question 6 Which physiotherapy interventions may be effective in improving the immune function and quality of life? Question 7 What is the evidence available to warrant physiotherapy intervention in HIV/AIDS prevention treatment and care? Question 8 What role do physiotherapists play in establishing their contribution to HIV prevention treatment and care? Question 9 (Identify the correct option) To determine the psychometric properties of the Roland-Morris Disability Questionnaire for people with chronic mechanical low back pain, a) it was measured against a gold standard b) content and construct validity were determined c) a gold standard was not applicable as it is a self-report measure d) inter-rater reliability was established. Question 10 (Identify the incorrect option) The results of a study of patients with chronic mechanical low back pain showed that the Roland-Morris Disability Questionnaire a) has a very high internal consistency b) measures two distinct dimensions of function c) has a good ability to predict the need for surgery d) is easy to administer and score