Medical Articles Physical Theraphy

Disability in Primary Health Care


Disability in primary health care is particularly important as understanding primary health care (PHC) access for people with disabilities can help inform policies, clinical practices, and future research in community settings.

What is a disability?

According to the Centers for Disease Control and Prevention, a disability is any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to take part in certain activities (activity limitation) and interact with the world around them (participation restrictions).


There are many types of disabilities, such as those that affect a person’s: Vision, Movement, Thinking, Remembering, Learning, Communicating, Hearing, Mental health, Social relationships


The physical or mental impairment experienced by a disabled person has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. 


According to the World Health Organization, disability has three dimensions:


Impairment in a person’s body structure or function, or mental functioning; examples of impairments include loss of a limb, loss of vision, or memory loss.


Activity limitation, such as difficulty seeing, hearing, walking, or problem-solving.


Participation restrictions in normal daily activities, such as working, engaging in social and recreational activities, and obtaining health care and preventive services.

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Disability and Primary Health Care


Primary health care is a whole-of-society approach that includes health promotion, seeks to prevent injuries and diseases, treatment, rehabilitation, and palliative care. It’s about more than delivering health care services. 


Primary health care is about creating the conditions that help people to become and stay healthy and well. It’s also about extending the reach of health care providers into communities.


Social Model of Disability


The Social Model of Disability states that the poverty, disadvantage, and social exclusion experienced by many disabled people is not the inevitable result of their impairments or medical conditions, but rather stems from attitudinal and environmental barriers within society. 


As highlighted by several studies, this view recognises that disabled people have impairments but, unlike the medical model of disability, maintains that the exclusion they experience is caused by not only their society but also the lack of relevant knowledge, education and the poor attitudes of students and health care professionals towards adults and children with disabilities (Kritsotakis G, 2017; Matziou V, 2009; Velonakis VS, 2015). 

Disability in primary health care is particularly important as understanding primary health care (PHC) access for people with disability can help inform policies, clinical practices and future research in community settings.

Barriers to accessing primary healthcare services for people with disabilities

Access to healthcare contributes to the attainment of health and is a right that is fundamental to humans. People with disabilities are believed to experience widespread poor access to healthcare services, due to the absence of implemented policy in the area of primary health and disability, inaccessible environments, discriminatory belief systems, and attitudes.


Three major barriers: 


  • Cultural beliefs or attitudinal barriers, 
  • Information barriers, and 
  • Practical or logistical barriers.


Role of Physiotherapy in supporting people with disability 


Physiotherapy uses evidence-based techniques to improve a person’s health and wellbeing. Physiotherapy is used to assess treat and prevent a wide range of health conditions and movement disorders.


It can be a common misconception that physiotherapy is useful only to people who are recovering from an illness or injury. However, physiotherapy is ideal for supporting people with disabilities to participate in physical activities that they’re interested in. Traditionally, physiotherapists have supported people with disabilities by helping them overcome their mobility challenges.


People diagnosed with Cerebral Palsy, Autism, or who have psychosocial or intellectual disabilities can benefit from physiotherapy. The possibilities are endless, but supporting a child with autism to ride a bike, for example, can positively impact their ability to socialise, make friends and set up healthy exercise practices for life and may mean they have a chance of meeting the World Health Organisation’s recommendation of 150 mins of moderate physical activity per week. 

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This then improves their health, while enabling them to make friends and increase their safety as people in their local community get to know and look out for them.




To achieve full health coverage at the acceptable quality for people with disabilities, and their inclusion in society, starting with primary healthcare, it is necessary for healthcare stakeholders, including rehabilitation professionals, to consider the combined and cumulative effects of the various barriers to healthcare on people with disabilities, their carers, and their families and develop an understanding of how healthcare decisions are made by people with disabilities at the personal, household and the society level. 


It is only then that more nuanced and effective interventions to improve access to primary healthcare, systematically addressing barriers, can be designed and effectively implemented.




Reformed policies, health information provided in accessible formats, and community health education are all important to aid the inclusiveness of persons with disabilities in society. 

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There is also the need to provide in-service and collaborative training to students, health care professionals, formal and informal supporters, and disabled people themselves on how to enhance approach, effective communication skills, and therapy models for persons with disabilities.


Medical Articles Physical Theraphy

Goal Attainment Scaling GAS As 1st and Most Popular Outcome Measure in Pediatric Therapy

Goal Attainment Scaling (GAS) in Pediatric Therapy

Goal Attainment Scaling GAS in Pediatric Therapy  has in recent times become a benchmark technique used in assessing the functional goal attainment of children in pediatric therapy practice. Setting goal between clients and physiotherapists is a fundamental part of rehabilitation. Goal setting is “the formal process whereby a rehabilitation professional or a multidisciplinary team, together with the patient and/or their family, negotiate attainment goals in the management of the patient.” Goal setting is used in directing the rehabilitation intervention to a focused outcome.

Goal setting can also be shared in order to co-ordinate members of the multidisciplinary team and ensure they are working together towards a common set goal and that nothing important is left out in the service delivery. Goal setting is also used to ascertain the success of rehabilitation interventions. There is no consensus on a gold standard for a method of goal setting, but it is widely held that it is a priority for guiding rehabilitation interventions toward achievable and meaningful outcomes.

This work is aimed at assisting potential pediatric therapists to decide whether or not to use GAS and also to provide information about how to implement GAS with a minimum of bias.

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Brief History of Goal Attainment Scaling GAS in Pediatric Therapy

GAS was first developed by Kiresuk & Sherman (1968) and used to evaluate mental health programs.

In 1979, GAS was considered the most popular outcome evaluation technique in the human sciences. GAS was initially used to measure the impact of intervention in the mental health field, with recent development and its efficiency, it has been adopted for use in other healthcare discipline. Currently GAS is widely used to evaluate health services, educational programs, and social services in many fields; rehabilitation, education, medicine, nursing, and social work.

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There are two main reasons for measuring outcomes in the field of pediatric therapy:

  1. To evaluate outcomes for a specific child (to improve services to that child), and
  2. To determine the effectiveness of a service or program as a whole.


GAS can be used for both purposes–to document therapeutic change in individual children or to examine change in groups of children.

Many questions need to be considered when designing outcome evaluation studies for children receiving occupational, physical, or speech-language therapy, either in the community or in a health care centre. One of the fundamental questions is whether to use a standardized or individualized measurement approach–or both.


Individualized methods indicate whether single individuals have achieved the goals of intervention. These methods also provide clear goals and priorities for intervention, ensure the ongoing relevance of the child’s goals, and reflect a client-centered perspective to service delivery.


One of the most widely-used individualized approaches is goal attainment scaling GAS, which provides an individualized, criterion referenced measure of change.

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Use of Goal Attainment Scaling GAS in Pediatric Therapy Services

GAS has been used in several studies of the effects of pediatric therapy services for children with developmental, physical, and communication needs (e.g., Brown, Effgen, & Palisano, 1998; Ekström, Johansson, Granat, & Carlberg, 2005; King et al., 1998; King, McDougall, Tucker et al., 1999; Palisano, Haley, & Brown, 1992; Palisano, 1993; Steenbeek, Meester-Delver, Becher, & Lankhorst, 2005; Stephens & Haley, 1991)

Brown et al. (1998)

  • Examined the effects of physical therapy intervention on attaining gross motor goals in 24 individuals aged 3 to 30 years with severely limited physical and cognitive abilities.
  • GAS was used to measure change in gross motor ability after 18 weeks of twice-weekly therapy intervention.
  • 3 goals were set for each participant, with one goal randomly selected as a control goal.
  • Participants’ improvement on goals was assessed during therapy, recess and at home.
  • GAS indicated that participants demonstrated improvement during therapy, which did not consistently transfer to the recess and home settings.
  • Participants showed greater improvement on treatment goals than on control goals during therapy, but there were no differences between treatment and control goals during recess and at home.


Ekström et al. (2005)

  • Evaluated functional training for children with cerebral palsy using GAS.
  • The intervention was carried out in the context of natural settings.
  • 14 children aged 6 months to 6 years participated in the 5-month intervention.
  • 77% of goals were attained King et al. (1998).
  • One objective of this feasibility study was to examine the utility of GAS for evaluating therapy services provided to children with special needs in the regular school setting.
  • 16 children receiving an average of 13 therapy sessions over 4 to 5 months had 1 to 3 functional goals set in one of 3 target areas: communication, productivity, or mobility.
  • Findings showed that all children made improvements on their goals.
  • Study concluded GAS was a responsive measure of children’s functional change in the 3 target areas and was appropriate for evaluating therapy outcomes in the school setting.


King, McDougall, Tucker et al. (1999)

  • One objective of this program evaluation study was to use Goal Attainment Scaling GAS to measure the extent to which children with special needs achieved their individual, functional goals in the school setting.
  • 50 children received an average of 17 therapy sessions throughout the school year.
  • Each child worked toward 1 to 2 goals set in one of the following target areas: communication, productivity, or mobility.
  • Findings showed that 98% of the children made improvement on their functional goals after receiving intervention, and maintained that improvement 5 to 6 months later.


Palisano et al. (1992)

  • Tested sensitivity of GAS to measure change and involved 65 infants 3 to 30 months old with motor delays as measured by the Peabody Developmental Motor Scale (PDMS).
  • Therapists set 2 motor goals per infant prior to a 6 month intervention period.
  • Findings showed that the infants scored higher than expected at the end of intervention.
  • Study results support the validity of GAS as a responsive measure of motor change in infants with motor delays.


Palisano (1993)

  • Study examined the validity and responsiveness of GAS; GAS was compared to the PDMS.
  • 2 goals were set for 2 consecutive 3 month periods for 21 infants with motor delay.
  • Study results support the content validity and the responsiveness of GAS, and provide evidence that GAS and the PDMS measure different aspects of motor development.


Steenbeek et al. (2005)

  • Evaluated the effect of botulinum toxin type A treatment for children with cerebral palsy using Goal Attainment Scaling GAS.
  • 11 children participated in the study.
  • Goals were recorded weekly for 14 weeks.
  • 9 of 11 children showed significant improvement on their goals Stephens & Haley (1991).
  • Study investigated the validity and sensitivity to change of the PDMS and GAS.
  • 54 children 0 to 3 years old and enrolled in early intervention programs were included.
  • 1 to 2 goals were set for each child prior to a 6 month therapy period.
  • PDMS and GAS correlations were low (Stevens and Haley suggest that GAS should not be highly correlated with developmental tests that apply the same standard to everyone).
  • Study concluded that GAS can be used to complement the results of standardized motor assessment (if using GAS alone, interpret with caution).

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Description of Goal Attainment Scaling GAS in Pediatric Therapy

GAS is an individualized, criterion-referenced measure of change. It involves:

  • Defining a unique set of goals for each child,
  • Specifying a range of possible outcomes for each goal (on a scale recommended to contain five levels, from -2 to +2), and
  • Using the scale to evaluate the child’s functional change after a specified intervention period.

Goal Attainment Scaling GAS is a 5-Point Rating Scale.

A score of,

-2        represents the child’s baseline level before intervention, Much less than expected.

-1        represents improvement that is less than the expected level of attainment after intervention.

0          represents the expected level of attainment after intervention.

+1       represent greater than expected outcome and

+2       represent levels of attainment that exceed expectations but represent outcomes that the child is thought to be capable of achieving     under favorable conditions.

Merits of Goal Attainment Scaling GAS

  • GAS is criterion-referenced, rather than norm-referenced, making it responsive to minimal clinically significant changes.
  • Useful for measuring individual goals.
  • Useful for evaluating functional goals.
  • Goals can be written for all levels of functional difficulty identified by the International Classification of Functioning, Disability, and Health (World Health Organization, 2001) (i.e., impairment, activity limitation, participation restriction).
  • Promotes cooperative goal setting.
  • Reflects a client-centred perspective to service delivery.
  • Yields a numeric score for analysing group performance Potential Benefits.
  • Improved conceptualization and delivery of intervention.
  • Improved clarity of therapy objectives for therapists and clients.
  • Realistic client and therapist expectations of therapy.
  • Increased client satisfaction.
  • Increased motivation of the client toward improvement, provided by the very existence of the goals.


Potential Limitations of Goal Attainment Scaling GAS

  • Reliability ±          The reliability of a therapist’s judgment of the impact of intervention.
  • Validity ±             Whether the GAS procedure is measuring what purports to measure (GAS has been criticized as being a way for                              therapists to set easy goals that are not clinically relevant)


How to Improve Reliability of Goal Attainment Scaling GAS

  • Involve experienced therapists (at least one year of experience in program).
  • Provide comprehensive training in GAS to therapists.
  • Ensure goals are well-written.
  • Use independent raters (i.e., raters who do not have a personal investment in outcome score) and provide training to raters


How to Improve Validity of Goal Attainment Scaling GAS

  • Kiresuk et al. (1994) strongly urge that GAS be supplemented with measures that provide more defensible estimates of post-treatment status (i.e., standardized measures) to provide a comprehensive assessment of outcome.
  • Employ randomly selected control goals (after Brown et al., 1998).

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Guidelines for Using Goal Attainment Scaling GAS

Number of Goals to Set:

  • Available resources, including time, will influence the number of goals set for a client within a certain intervention period.
  • For psychometric reasons, Kiresuk et al. (1994) recommend setting at least three goals per client.
  • For practical reasons, studies have set 1 or 2 goals per client (King et al., 1998; King, McDougall, Tucker et al., 1999; Palisano, Haley, & Brown, 1992; Palisano, 1993; Stephens & Haley, 1991).

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Determining Who Sets Goals:

  • According to strict research methodology (Cytrynbaum et al., 1979), the therapist who sets the goals should not be the same therapist who provides the treatment, as they have a vested interest in the client achieving the goals.
  • In actual clinical practice it is most realistic and cost-effective for the treating therapist to be involved in goal setting (Lewis, Spencer, Haas, & DiVittis, 1987; Kiresuk et al., 1994).


For example, in the King, McDougall, Tucker et al. (1999) study, it did not make sense from a clinical standpoint for one therapist to set the goals in conjunction with the teacher, parent, and child, and then have a different therapist provide treatment who had not established rapport with these individuals (such a procedure would be disruptive to the therapist/client relationship and would not be an accurate representation of the way school-based therapy services are provided).


Minimizing Bias in Goal Setting

  • Use collaborative goal setting, involving several individuals; this helps to ensure that the goals are clinically meaningful and relevant and not just easy goals that therapists set on their own and can be sure of attaining (Clark & Caudrey, 1986; Stollee et al., 1999).


As an example, in King, McDougall, Tucker et al. (1999), each child’s treating therapist, parents, teacher, and when appropriate, the child him/herself, determined the child’s baseline assessment level (-2) and the expected level of attainment at the end of intervention (0), then, the treating therapist and a research assistant determined the –1, +1, and +2 levels.


  • Involve “GAS” therapists (not involved in treatment) and a research assistant (or a person well-trained in GAS) in goal review.


In King, McDougall, Tucker et al. (1999), the research assistant and the “GAS” therapists of the same discipline as the child’s treating therapist reviewed the GAS scales and made suggestions for improvement.


  • Use a standardized procedure with set criteria [see GAS Checklist, APPENDIX B, used by King, McDougall, Tucker et al. (1999)].


Criteria for Writing Goals in Goal Attainment Scaling GAS Format

 Six Basic Requirements:

  • Relevant
  • Understandable
  • Measurable
  • Behavioural
  • Attainable
  • Time Frame.


As a whole, the scale should meet the following criteria:

  • Aim for clinically equal intervals between all scale levels e.g. The jump from +1 to +2 should not require a much larger change in attainment than the jump from -2 to -1.
  • Amount of change between levels needs to be clinically relevant.
  • Improvement should be measured using only one variable of change (as long as the goal remains meaningful), keeping other variables constant. e.g. -2 The child walks 100m with platform walker in 8 minutes with two hands on walker to assist with steering.

the above goal includes three variables: distance, time, and level of assistance.

Decide on one variable by which to measure change in performance, say time, and hold other variables constant e.g. 0 The child walks 100m with platform walker in 6 minutes with two hands on walker to assist with steering.

  • Specify a time period for achievement of a goal. Intervention should take place over a set time period, such as 4 to 5 months or a given number of therapy sessions.

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Each level on the scale should meet the following criteria:

  • All rating scale levels should be phrased in the present tense e.g. The child can……
  • All scale levels should be achievable or realistically possible.
  • All scale levels should be written as clearly as possible, in concrete behavioural terms.
  • All scale levels should specify an observable behaviour.


Rating Goals After Intervention

  • Each person’s performance is observed either naturalistically (in the classroom, hallway, etc.) or on a specific assigned task, depending on the nature of the goal.
  • For goals whose attainment cannot be observed under naturally occurring circumstances, the therapist interacts with the client and requests performance of the goal. The therapist orients the child to perform the goal. If prompting is required, the therapist starts with the expected (0)level of the scale and prompts performance up or down, depending on the client’s success.
  • The number of trials each client will be given when attempting his/her goal should be established.
  • Brown et al. (1998) allowed up to 3 trials per goal (for children with severely limited physical and cognitive abilities).
  • Consider the view of the person being rated (i.e., the person may be motivated to perform well for the visiting rater or may act out inappropriately).
  • In order to reduce “hype” regarding the rater’s visit, inform the client in advance of the visit and assure the client that regular performance is what is called for.
  • The rater should be unobtrusive (maintain a low profile).

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Demonstrating the Reliability of the GAS Rating Procedure


It is recommended that GAS scores be examined for inter-rater reliability to establish absence of bias.


Inter-rater reliability is determined by correlating the ratings of the original “ GAS” therapists” with a second “GAS” therapist on random sub-sample of goals [King, McDougall, Tucker et al. (1999) correlated the ratings of 30% of study goals].


The two “GAS” therapists should rate the goals on the same occasion (independently), or one of the raters could observe the therapy session and the other rater observe a video tape of the session.




Good number of organizational conditions are needed to be in place for the successful implementation of a program evaluation study using GAS.


They include:

  1. A motivated team whose members are committed to the evaluation and who share a common drive toward improvement of therapy services,
  2. Adequate orientation and training of therapists,
  3. The availability of people to coach therapists in the proper application of GAS, so that both technical and practical issues are addressed in an integrated fashion, and
  4. Sufficient resources allocated to do the


A primary strength of GAS is its ability to measure change in performance, whereas most standardized measures are discriminative tools designed to measure post-intervention status (based on norms for children without special needs) and have not been validated as responsive to clinically significant change. Clinical significance refers to the magnitude of an effect in real world terms.


GAS is criterion-referenced, rather than norm-referenced, making it potentially responsive to small changes that are perceived by children, families, and teachers as important for daily function.


GAS may be particularly useful for children with low cognitive functioning, since standardized measures may not be sensitive to the small but meaningful changes targeted for these individuals.


Relatively few standardized measures address functional outcomes that are appropriate for children with special needs within a context such as school (e.g., children’s ability to walk from the bus to the school classroom).


Standardized assessments of function often are designed to measure a broad range of abilities. Some of these areas may not reflect therapy goals and not be relevant to particular children. Pediatric studies provide a fair amount of evidence that GAS and parallel standardized measures provide scores that are only moderately correlated with one another. For formal program evaluation purposes, Goal Attainment Scaling (GAS) and standardized measures use are both recommended.

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In addition to the ability to measure change in the performance of individual children, GAS has other advantages: clinical utility, relevance, client involvement, and acceptability. GAS is ideally suited to collaborative goal setting between a therapist, child, parent, and other professionals (such as teachers). Its collaborative use reflects a client- or family-centered approach to service delivery.


Other potential advantages of Goal Attainment Scaling GAS include:

  1. Improved clarity of therapy objectives for both therapists and clients,
  2. Improved conceptualization and delivery of the intervention,
  3. More realistic client and therapist expectations of therapy,
  4. Increased client satisfaction, and
  5. Increased motivation of the client toward improvement, provided by the very existence of goals.



There are a number of potential limitations in using Goal Attainment Scaling GAS in a program evaluation study:

  1. Biases in goal scaling and rating can occur,
  2. Training and standardized implementation procedures are required, which are time-consuming (when therapists are unfamiliar with GAS), and
  3. GAS can interfere with day-to-day practice because, when conducting a program evaluation, therapists should not modify a goal in the course of the intervention.


There are two reasons for this:

First, the study intervention period may not be sufficiently long for change to be expected on a new or modified goal.

Secondly, therapists may elect to change goals they discover that they cannot meet, which undermines the utility of GAS.


The major drawback to GAS is the possibility of bias in the use of the tool, which can affect its validity.  Unintentional bias can occur in goal scaling (so goals are overly easy to attain) or in goal rating (showing children make improvements that are not in fact real).


Reliability and validity can be improved, however, by comprehensive training of raters, adequate definitions of the levels of goal attainment, and the use of multiple raters.


A collaborative goal setting model (a common feature of a multidisciplinary, family-centered approach to service delivery) helps to ensure that goal levels are meaningful and ratings are valid because both are based on a consensus involving several individuals who are knowledgeable about the child and invested in ensuring that

the child makes real gains.


Thus, collaborative goal setting helps to ensure that therapy goals are meaningful to the child and family and not simply easy goals that therapists set on their own and can be sure of attaining, which is a criticism raised by many.


From observations noted in Kings et al., 1999 work in respect to differences between the rehabilitation disciplines with respect to the ease of writing appropriate functional goals.


The GAS scaling format appears easiest to apply for speech therapy goals and harder to apply for physical therapy and occupational therapy goals. As well, in King et al., speech-language pathologists found it easier to set goals that could be integrated into the child’s function in the school setting. Speculations are that the established hierarchy of the development of speech sounds may assist speech-language pathologists in setting goals in the area of articulation.

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Physical and occupational therapists needed to give more thought to the process of writing the various goal attainment levels. For instance, physical therapists in the work found it hard to set equal intervals between goal levels for goals targeting unique mobility difficulties and found it hard to establish relevant goal levels for high functioning children.


Appendix A – Common Errors in Writing GAS Scales


Error Description Solution
Overly Generalized Goals If the expected level (i.e., 0 level) of a scale is written in very general terms (e.g., “the client walks a greater distance in a set period with assistance”), it will be difficult or impossible to create the remaining scale points The expected level of a scale should be written as clearly as possible (e.g., “the client walks with platform walker 100 metres in six minutes with two hands on walker to assist with steering”).
Overly Technical Goals A goal setter may use terms specific to his/her profession in creating a scale that the goal rater is not familiar with. Write goals in common terms, especially if the rater and goal setter differ in professional backgrounds.
Multiple Variables of Change A scale may include two or more variables of change. This could be problematic if the scale is written so that improvement is expected to occur simultaneously on these variables. Decide on one variable by which to measure change and hold others constant. If, in doing so, the goal does not remain clinically meaningful, two (or more) variables could change within in a single scale, provided that improvement is not expected to occur simultaneously on these variables.
Unequal Scale Intervals A scale may be created where the amount of clinical change is greater between, say, the +1 and +2 levels than the amount of change between the -2 and -1 levels. Aim for clinically equal intervals between all levels of the scale.





Clinically Irrelevant or Unrealistic Scale Levels A scale may be created where one or more of the levels represents an amount of change that would not be clinically relevant (i.e., amount of change is too small to matter) or amount of change is unrealistic for the client (i.e., amount of change is too great). The amount of change between all scale levels needs to be clinically relevant and all levels should be achievable for the client.




Using Different Tenses (i.e., Past, Present, Future) When Writing Scale Levels A GAS scale may be written with the -2 level written in one tense and all other levels in another tense, which could be confusing and bias the goal rater. All scale levels should be phrased in the present tense, in order for evaluation to make sense at different time points (i.e., “the client can …”).




Redundant or Incomplete Scale Levels A scale may be written where a client could be scored on two levels at the same time (e.g., the +1 level has walking distances specified between “40 and 50 metres” and the +2 level specifies distances between “50 and 60 metres”. If a client walks exactly 50 metres, both the +1 and the +2 level would be correct. On the other hand, a gap could be present in the scale where a client could not be scored on any level (e.g., the +1 specifies walking distances between “40 and 50 metres” and the +2 specifies distance between “60 and 70 metres”; if a client walks 55 metres, neither +1 nor +2 is correct). Be careful not to create scale levels that are redundant or incomplete. Careful wording (e.g., +1 would be “more than 40 metres and up to 50 metres” and +2 would be “more than 50 metres and up to 60 metres” or specific instructions to the rater (e.g., if a client obtains a midway point between two levels, score the client at the lower level) will be of benefit.




Baseline Level is Set at Inappropriate Level A scale may be written with -2 as the baseline when a client has a progressive, chronic condition. This scale would not capture any deterioration in condition. When no deterioration is expected in client’s performance, -2 can be defensibly used as the client’s baseline. When evaluating the performance of clients with progressive conditions who may deteriorate in function over time, it would make sense to set the baseline at -1, leaving room for deterioration over the intervention period.



Blank Scale Levels It may be difficult to write the more extreme levels of a scale, tempting the goal setter to leave these levels blank. If a client happens to achieve an upper or lower extreme, it would be impossible to rate the client’s performance. Be careful to set goals where it is possible to complete all scale levels.



Appendix B – Goal Attainment Scaling Checklist

Name of Participant: ……………………………………………………………………………..

  • Therapy Goal: Expected Outcome (i.e., a score of 0)



As a whole, the scale must meet the following criteria:

Criteria Criterion Met Criterion Not Met Comments
Amount of change between levels is clinically important      
There are approximately equal intervals between levels      
There is a set time period for goal achievement      
Scale reflects a single variable of change (or, if not feasible, each level reflects a single variable of change)      


Each level on the scale must meet the following criteria:

Criteria Criterion Met Criterion Not Met Comments
Be written in concrete behavioral terms      
Specify an observable behavior      
Be written in the present tense      
Be achievable or realistically possible      


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 Appendix C – Examples of Goals Written in GAS Format


Example 1 of GAS Scale for Physical Therapy

Therapy Discipline:                        Physical

Therapy Target Area:                    Movement Functions

Sub-category:                                 Control of Voluntary Movement Functions

Functional Level:                            Impairment

Time Line:                                         5 months


Goal Attainment Rating Scale:

-2        The client is able to lift his head and right arm when attempting to roll from supine to prone over his left side.

-1        The client is able to roll half way from supine to prone over his left side (and attain left-side lying).

0          The client is able to roll from supine to prone over his left side.

+1       The client is able to roll from supine to prone and half way back to supine over his left side (and attain left-side lying).

+2       The client is able to roll from supine to prone and back to supine over his left side.


Example 2 of GAS Scale for Physical Therapy

Therapy Discipline:                        Physical Therapy

Target Area:                                     Mobility

Sub-category:                                 Moving Around Using Equipment

Functional Level:                            Activity Limitation

Time Line:                                         5 months


Goal Attainment Rating Scale:

-2        The client walks with walker from library to classroom in 6 minutes, with supervision and verbal cueing.

-1        The client walks with walker from library to classroom within 4 to 5 minutes, with supervision and verbal cueing.

0          The client walks with walker from library to classroom in 3 minutes or less, with supervision and verbal cueing.

+1       The client walks with walker from library to classroom in 3 minutes or less, with supervision and no verbal cueing.

+2       The client walks with walker from library to classroom in 3 minutes or less independently (no supervision and no verbal cueing.


Note: if client walks a distance that falls between scale levels (e.g., 5.5 minutes), the client will be rated at the lower scale level.

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Inferring from this work therapists should make informed decisions about whether or not to use Goal Attainment Scaling (GAS) in Pediatric Therapy, based on an understanding of the questions they need to ask and the requirements for using GAS appropriately and effectively in pediatric therapy practices.


Goal Attainment Scaling (GAS)  has been criticized due to its potential for bias when implemented without thought and care. A more hopeful or let’s say a balanced perspective have been provided in this work. GAS can be implemented appropriately when guidelines and standard procedures are used.


Under these conditions, it is well worth the effort to use GAS to evaluate pediatric therapy practice. Service providers, parents, and children themselves benefit from the knowledge provided by goal attainment scaling, pediatric therapists are therefore encouraged to adopt the use of Goal Attainment Scaling (GAS) in pediatric therapy practice.



Brown, D. A., Effgen, S. K., & Palisano, R. J. (1998). Performance following abilityfocused physical therapy intervention in individuals with severely limited physical and cognitive abilities. Physical Therapy, 78, 934-947.


Cardillo, J.E, & Smith A. (1994). Psychometric issues. In T. Kiresuk, A. Smith, & J.


Cardillo (Eds.), Goal attainment scaling: Applications, theory, and measurement (pp. 173-212). Hillsdale, NJ: Lawrence Erlbaum Associates.

Cytrynbaum, S., Ginath, Y., Birdwell, J., & Brandt, L. (1979). Goal attainment scaling: A critical review. Evaluation Quarterly, 3, 5-40.


King, G., Tucker, M., Alambets, P., Gritzan, J., McDougall, J., Ogilvie, A., Husted, K., O’Grady, S., Malloy-Miller, T., & Brine, M. (1998). The evaluation of functional, school-based therapy services for children with special needs: A feasibility study. Physical and Occupational Therapy in Pediatrics, 18, 1-27.


King, G., McDougall, J., Tucker, M., Gritzan, J., Malloy-Miller, T., Alambets, P., Gregory, K., Thomas, K., & Cunning, D. (1999). An evaluation of functional, school-based therapy services for children with special needs. Physical and Occupational Therapy in Pediatrics, 19, 5-29.


King, G., McDougall, J., Palisano, R. J., Gritzan, J., Tucker, M. (1999). Goal attainment scaling: Its use in evaluating pediatric therapy programs. Physical and Occupational Therapy in Pediatrics, 19, 30-52.


Kiresuk, T. J., & Sherman, R. E. (1968). Goal attainment scaling: A general method for evaluating comprehensive community mental health programs. Community Mental Health Journal, 4, 443-453.


Kiresuk, T. J., Smith, A., & Cardillo, J. E. (1994). Goal attainment scaling: Applications, theory, and measurement. Hillsdale, NJ: Lawrence Erlbaum Associates.


Palisano, R. J., Haley, S. M., & Brown, D. A. (1992). Goal attainment scaling as a measure of change in infants with motor delays. Physical Therapy, 72, 432-437.


Palisano, R. J. (1993). Validity of goal attainment scaling with infants with motor delays. Physical Therapy, 73, 651-658.


Steenbeek, D., Meester-Delver, A., Becher, J., & lankhorst, G. (2005). The effect of botulinum toxin type A treatment of the lower extremity on the level of functional abilities in children with cerebral palsy: evaluation with goal attainment scaling. Clinical Rehabilitation, 19, 274-282.


Stephens, T. E., & Haley, S.M. (1991). Comparison of two methods for determining change in motorically handicapped children. Physical and Occupational Therapy in Pediatrics, 11, 1-17.


Stollee, P., Zaza, C., Pedlar, A., & Myers, A. M. (1999) Clinical experience with goal attainment scaling in geriatric care. Journal of Aging and Health, 11, 96-124.


World Health Organization. (2001) ICF. International Classification of Functioning, Disability and Health. Geneva: World Health Organization.

Exercise and Fitness Medical Articles Physical Theraphy

6 Abdominal Separation Risk Factors: How To Fix Diastasis Recti Post Pregnancy

Abdominal Separation: Diastasis Recti Post Pregnancy Effect, Health Risk and Physiotherapy

Rectus Divarication commonly known as diastasis recti post pregnancy is an abdominal separation, a gap of 2.7cm and above between the two recti muscles. “Six pack muscles”( recti abdominus) is a paired vertical muscle located on at belly region. This muscle lie closely on the left and right side of your belly and are connected and separated by a layer of connective tissue called the linea alba in the midline of your belly. Transversely, these muscles are anchored by the rectus sheath at three tendinous insertion dividing the muscle into three or more.

When this muscle is tensed in muscular people, the areas of muscles between the tendinous attachments bulge. This bulge has resemblance of a six beverage cans hence the name “six packs”.

This muscle together with other muscles located on the belly functions to move the trunk and help maintain posture. It helps support and protect abdominal organs, compress the structures in your belly to increase the intra-abdominal pressure. This is to aid expulsion of air during respiration, coughing, sneezing, nose blowing, screaming, defecation, urination, vomiting and child birth.


Rectus Divarication commonly known as DIASTASIS RECTI is a Pregnancy predisposed abdominal separation, gap of 2.7cm and above between two recti muscles at the linea alba.

During pregnancy, the expanding uterus stretches out the six pack muscle so as to accommodate the growing baby. Hormones released during pregnancy such as relaxin and estrogen softens and makes the connective tissue between this muscle lax. The delivery of the baby can also cause abdominal separation ‘diastasis recti’ of the so called “Six pack muscles”(recti abdominus).

As nature would have its way, all women experience this muscle abdominal separation during pregnancy but what determines who gets this condition after delivery is the extent of the separation. Hence the definition of rectus divarication as a gap of 2.7cm and above or more than two finger length between the two recti muscles. The distance between the right and left rectus abdominis muscles is created by the stretching of the linea alba, a connective collagen sheath.

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For better and understanding of the focus topic diastasis recti, it is imperative that you have the knowledge of the difference that exist between rectus divarication, an abdominal separation and rectus sheath hernia.

Hernia is an abnormal protrusion of an organ or tissue through a defect in the structure by which it is normally contained. It can be congenital or acquired and is classified according to its anatomical location. A posterior rectus sheath hernia is a very rare type of abdominal wall hernia, described only in a few published cases.

These hernias are considered interparietal because the sac lies between the layers of the abdominal wall. The majority of these hernias are postsurgical or posttraumatic, with limited spontaneous cases being reported in the literature. “Journal of Surgical Case Report”


This question is often asked by a lot of women mostly those with diastasis recti pain during pregnancy. Quite unfortunate that majority of moms might have heard about this condition but they don’t know what it actually means. Perhaps, it is not discussed or made known to them as part of what to expect in pregnancy and child birth by their physicians and midwives.

The best time to check for rectus divarication is after delivery. The funny thing about diastasis recti is that it makes one have a pregnancy look after several months of delivery.  This is because of the bulge or ridge on your abdomen “mummy tommy” which is more pronounced when the abdominal muscles are tensed like during coughing, sneezing etc.

Diastasis Recti Post Pregnancy is better diagnosed by a physiotherapist or a physician as they will give you an accurate measurement of the extent of the separation using a caliper.

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Diastasis Recti Post Pregnancy
Healed Diastasis Recti Post Pregnancy


Yes, you can examine yourself for abdominal separation.

These are outlined steps to self examine yourself for Diastasis Recti Post Pregnancy:

  • Step1: lie on your back, with your knees bent and feet flat on the ground.
  • Step2: place your one hand under your head and the Fingers of the other hand placed Across the mid line of your belly on the umbilicus.
  • Step3: Push down the fingers deeper while lifting the head and shoulder off the ground with the hand placed under the head.
  • Step4: move your fingers back and forth and observe how many finger lengths can fits into the gap. Look out for Rectus Divarication above and below the umbilicus.


Having a diastasis recti or abdominal separation does not mean that you should panic. Although, sometimes the worries are inevitable. During my internship programme, I once had a woman who came to me with a complaint that she doesn’t look attractive anymore to her husband. Her husband now laments that her tommy is out of shape.

The painful part of the story being that she has done virtually everything within her power to fix the diastasis recti but to no avail.

To be frank, this woman was really looking depressed becaused she had an obvious bulge on the abdomen that gives her the look of a 5months pregnant woman, though she is not. Find out here best ways to manage depression. Once you are diagnosed of diastasis recti, do not prescribe exercises or treatments on your own. Talk to your physiotherapist, he or she knows the best abdominis corrective exercises that could help manage the diastasis recti.

Rectus Divarication: Diastasis Recti Post Pregnancy Risk Factors

Studies has shown that the following can be risk factors to diastasis recti.

  1. Maternal body mass index above 35kg/m2: Having a body mas index of greater than 35 means that you are overweight. During pregnancy, the mother is more likely to gain an additional weight which will put so much stress on the belly muscles.
  2. Over weight babies: The trending thing now is giving birth to babies that weigh up to 5kg. Yes, there are fewer good sides to this. Pregnancy has it’s pros and cons and it does not encourage for over weight babiers. The more the weight, the more the pressure it puts on the belly muscles. Causing Rectus Divarication on the long run.
  3. Primiparous mothers: primiparous mothers are moms that are in their first child birth. That first pregnancy has already stretched the muscles, It may not lead to diastasis but it will stand as a risk factor for diastasis in subsequent pregnancies.
  4. Maternal age above 35: Aging comes with a lot of changes and muscular changes are not exempted. Aging could lead to changes in collagen formation and deposition. This could result to a more laxed muscle fibres predisposing one to diastasis recti post pregnancy.
  5. Multiple birth: Women that give birth to twin or triplets stand a chance of having abdominal separation.
  6. Women that had complication of diastasis in their first pregnancy are also predisposed to the risk of rectus divarication.

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Separation of rectus abdominus muscle during pregnancy is unavoidable but you can actually engage in the following to prevent diastasis recti.

  • Avoid heavy lifting or any exercise that increases abdominal pressure during pregancy.
  • Watch your weight before and during pregnancy.
  • Constantly go for abdominal diastasis check after delivery.
  • Constantly engage in exercises that builds abdominal strength after delivery strictly prescribed by a physiotherapist.


No, there are other causes of diastasis recti like too much abdominal fat (obesity), improper abdominal exercises , genetics, lack of exercises, premature birth in children etc. For the sake of this article, we are concentrating on diastasis recti post pregnancy.

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  • Chronic back pain: weak abdominal muscles often result in back pain after pregnancy.
  • Urinary incontinence: weak abdominal muscles cause pelvic floor dysfunction and this often leads to urinary leakage after birth.
  • Constipation: abdominal muscles contract to produce the force needed in defecation. Weakness of the muscles can cause constipation.
  • Poor support to abdominal organs.
  • Pelvic tilt, instability and poor posture.
  • Abdominal hernia.
  • Poor body image.


It is not advisable. I will tell you why. back to my story about the woman with diastasis recti post pregnancy. During my assesment she told me that she was diagnosed with this diastasis after her first child birth and she was advised to see a women’s health physiotherapist by her physician and to use a tummy belt by her friends but she didn’t listen to them.

She went on and became pregnant for the second time and her condition worsened. Pregnancy with yet to be fixed diastasis recti worsens the condition and can predispose you to the above mentioned health risks.


Yes, in minor cases without any intervention diastasis recti can heal on its own. But in most cases, it requires treatment. Diastasis Recti Physiotherapy has been found to be the best management form for abdominal separation.

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No. Thanks to our grandmothers that always advice their daughters or daughter in-laws to tie wrapper, piece of cloth or tummy belt on their abdomen after child birth especially during “omugwo” to treat diastasis recti post pregnancy. All these are good ideas but not sufficient enough to treat abdominal separation.

What diastasis recti belt does for you it to close the gap between the two muscles and help you suck your tommy and support your back thereby reducing the symptom of your belly bulging.

This is synonymous with giving someone having malaria tepid sponging to reduce his or her high body temperature in place of an effective anti-malaria drugs. Tummy belt or abdominal binders helps reduce diastasis recti symptoms but does not address the underlying issue which is the separated weak abdominal muscles that requires Strengthening. If you base your treatment on belly binders, then be prepared to wear it for long. An electronic abs Toning Flat Tummy Device Could be of help in diastasis recti exercises.

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Using Muscle Stimulator Belt will help in Diastasis recti exercises

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Read Also: Cerebral Palsy Symptoms and It’s Early Signs


Physical therapy remains the most effective treatment for rectus divarication. The treatment protocol is on diastasis recti abdominis corrective exercise prescribed by a women’s health physiotherapist.

Some women, when they hear that exercises helps diastasis recti abdominis correction, they begin to engage in all form of corrective exercises which eventually worsens the situation.

Not all corrective exercises helps abdominal separation. Infact, any exercise that makes your stomach bulge more when performing it will not help and can worsen it. Such exercises are sit ups, crunches, planks, twists, jumping out of bed etc.

Exercises prescribed by a physiotherapist strengthens the abdominal muscles and helps you boost your self esteem and confidence. Book an appointment with a women’s health physiotherapist here.


These four basic core exercises according to L. Augustyn, (Physical Therapist) of Fitness Blender is best self exercise protocol for treating rectus divarication.

Diastasis Recti Abdominis Corrective Exercise One

The first exercise is activating the deep abdominal muscles in a side lying position. Start by lying on your side and then use your fingers to feel your abdominal wall just inside your pelvic bone. Activate your lower abdominal wall by gently drawing inward the lower abdominal muscles.  Maintain this abdominal activation or contraction for up to 10 seconds.

You can start with a 5 second hold and then progress to 10 seconds as tolerated.  Make sure you breathe normally throughout the diastasis recti abdominis corrective exercise and then relax your abdominal wall back to a resting position in between repetitions.  Your upper abdomen should remain relaxed throughout the exercise. To progress this corrective exercise extend the duration of this hold for up to 10 seconds at a time as long as you are correctly able to activate the lower abdominal muscles.

Diastasis Recti Abdominis Corrective Exercise Two

The second exercise is to activate the deep abdominal muscles when lying flat.  Start by lying on your back with your knees bent and feet flat. Keep the normal curve of your lower back throughout the time.  Place your fingers on your lower abdominal wall just inside your pelvic bones.  Gently activate your deep abdominal muscles (the same technique as exercise one.

Maintain this abdominal activation/contraction for up to 10 seconds and continue to breathe normally throughout the exercise and then relax your abdominal wall back to resting.  Just like the previous exercise your upper abdomen should remain relaxed throughout the corrective exercise. Make sure you learn to correctly activate your deep abdominal muscles before extending the duration of this hold for up to 10 seconds at a time.

Diastasis Recti Abdominis Corrective Exercise Three

The third exercise is bent knee fall outs. This is a progression of the first two exercises. You want to start by lying on your back with your knees bent and feet flat while again keeping the normal curve in your lower back.  Activate your abdominal muscles like in exercises one and two and then gently lower one leg out the side while keeping the other leg bent and pointing upwards towards the ceiling.

Keep your pelvis stable throughout this exercise and try to avoid trunk rotation.  Return your leg to the starting position as soon as you feel you compensate with trunk movement. Relax your deep abdominal muscles and then repeat 2-3 repetitions on each side and progress to increased reps as tolerated.  Increase the challenge by increasing the number of repetitions without releasing your abdominal contraction.

Diastasis Recti Abdominis Corrective Exercise Four

The fourth exercise is heel slides.  This will also further progress the challenge for your core muscles.  Start in the same position as the last exercise.  Place your fingers to feel your abdominal muscles just inside your pelvis.  Gently activate your deep abdominal muscles as you extend your right leg (sliding your foot until your knee is straight).

When you feel your low back begin to arch bring your leg back to the starting position by bending your knee. Relax your deep abdominal muscles. Repeat 2-3 repetitions on each side when just staring out and you can progress by doing a number of repeated exercises in a row without releasing the abdominal contraction.

These are the first four basic exercises to start out with and then you can continue to progress to more challenging exercises including straight leg raise with an abdominal contraction and seated heel slides with abdominal contraction.  Further progressions are available but just remember to avoid intense core exercises. Always involve your physical therapist in progress of your exercise sessions.

Remember we always encourage you before enacting any exercises, self diagnosis or treatment plan, always talk to your personal healthcare provider who has all of your healthcare information. You can also reach out to our expert team by booking an appointment with us.


Enweluzor, Onyinye k

Anthony Maximilian

Medical Articles Physical Theraphy

Cerebral Palsy Physiotherapy: Causes, Symptoms, Risk Factors

Cerebral Palsy Physiotherapy – Causes, Symptoms, Risk Factors

Cerebral palsy is a group of disorders that occurs due to damage to the developing or immature brain. This brain damage can occur before birth, during birth or 3-5 years after birth. This condition is the leading cause of physical disabilities in young children, affecting 2-4 children in every 1000 live births globally. Half of these children affected achieve independent walking in life.

10 percent of them may walk with walking aids, the rest remained crippled for life. Cerebral Palsy Physiotherapy treatment is the use of physical activities in the management protocols of patients with such conditions. Physiotherapy for cerebral palsy babies and cerebral palsy adults physical therapy is an effective regimen proven to be efficient in the management of evaluated symptoms in a Cerebral Palsy CP patient.

Physical activities enhances functional efficiency in a Cerebral Palsy patient.

Cerebral Palsy Definition

Cerebral palsy meaning to many differ depending on the presenting features but for better understanding of what cerebral palsy is. We simplified definition of cerebral palsy here so that you can understand the term better. Cerebral Palsy abbreviated in some literature CP is a condition origination from the neurological system ‘the brain’ at an immature and its developing stage.

Mostly Symptoms of Cerebral Palsy presents with movement disorder and also causes coordination deficit. Some may have in the past asked us questions like Can adults get Cerebral Palsy? The answer is capital NO. As earlier said cerebral palsy causes damage to the brain at an immature development stage. This is usually below five years of age. So to say that the condition cannot develop in adults.

Can Cerebral Palsy be cured?

To comfortably answer this, you need to clearly understand that Individuals living with cerebral palsy experience different signs and symptoms depending on the areas of the brain affected but over 70 percent of them have the spastic type of cerebral palsy which may pose motor problems like jerky movements, stiff muscles and joints, abnormal reflexes due to damage to the motor cortex.

In most cases, this condition remain undiagnosed until after the first two years of life. Perhaps, at this stage, the child is expected to have started walking but he or she may not be making any significant progress. At this time their parents or caregivers starts getting worried and in search for solutions.

Physiotherapy for cerebral palsy will do lots of positive good in helping the functional improvement of a baby with the condition. Cerebral Palsy Physiotherapy doesn’t at any point render a complete cure for CP. A child with the condition enters with it into adulthood but without cerebral palsy physiotherapy, activities of daily living will be difficult for such a patient.

Cerebral Palsy Physiotherapy is the use of physical activities in the management protocols of patients with risk factors cerebral palsy and Developmental delay.

Cerebral Palsy Physiotherapy Case Sample

During a rural outreach program by Healthcare Consulting Team. There was this 8months child who had undiagnosed cerebral palsy. Most likely a result of negligence and parents inability to seek for medical consultation. Why did I say so? The parents looked refined and literate. Who would have imagined that they could pay no attention to such serious situation.

Well, the deed has been done. After series of assessment and evaluation, the child’s parents were offered treatment appointment and was lectured about their babies condition by our Physiotherapists. We would continue with the story, lets get back to literature. Next in line is symptoms of cerebral palsy.

Read Also: Goal Attainment Scaling GAS As 1st and Most Popular Outcome Measure in Pediatric Therapy

Cerebral Palsy Symptoms and it’s Early Signs

Some of the early signs of this condition include:

  1. Developmental delay termed as Delayed Developmental Milestone DDM: The child may find it difficult to control or carry his or her neck at 3 months, roll from side to side at three months, sit unsupported at 6months, crawl at 7 months, stand with support at 9-11 months and walk independently at one year.
  2. Abnormal muscle tone: This is another notable symptom in which the child may have stiffness and tightness or floppy of muscles, joints in one part of the body or sometimes the whole body.
  3. Abnormal posture: The child may prefer to use one part of the body more than the others or might as well prefer a particular position such as keeping the neck and trunk bent.

Other significant symptoms of cerebral palsy includes

  • Tremors.
  • Coordination and balance problems.
  • Vision impairment.
  • Communication issues.
  • Auditory impairment.
  • Gait disturbances.
  • Mental retardation.

Cerebral Palsy Causes

Some of the most common causes of cerebral palsy are outlined in this literature. It is advisable for you to note this causes and ensure you mitigate its occurrence.

  • Maternal infection during pregnancy such as rubella (German measles), Cytomegalo virus infection etc.
  • Oxygen deficiency also known as Hypoxemia. Insufficient oxygen reaching the baby when the placenta is not functioning or when it tears away from the wall of the uterus before delivery.
  • Premature babies.
  • Low birth weight babies less than 2.5kg.
  • Seizures after birth.
  • Severe or Untreated jaundice.
  • Reduced supply of oxygen to the baby during a prolonged or difficult delivery.
  • Meningitis and head injuries after few years of life.
  • Substance abuse during pregnancy such as alcohol abuse, cocaine, Methamphetamine etc.
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7 Acupuncture Therapy Benefits and 9 Risks You Must Know

Acupuncture Therapy Benefits and risks that may interest you to note before trying Acupuncture for the first time.

Acupuncture eases everything ranging from stress, to pain to allergies. Research have also shown how acupuncture therapy benefits in reducing inflammation, increases blood flow and help in general body relaxation

Acupuncture therapy benefits ranges from relieve of pain, stress reduction and many more, it is a type of Chinese traditional medicine that dates back thousands of years. Acupuncturists use fine needles in pressure points in various parts of the body. This treatment is said to:

  • reduce inflammation
  • relax the body
  • increase blood flow

It’s also believed to release endorphins. These are natural hormones that reduce the feeling of pain.

In Chinese tradition, good energy flows through “qi” (pronounced “chee”). It can be blocked by obstructions called “bi.” The needles open up the qi and remove the bi.

Most people either don’t feel the needles, or feel a very small prick when the needles are inserted. The needles are said to be thinner than a strand of hair.

Some people use Acupuncture Therapy Benefits to treat joint pain, as well as headaches, back pain, and anxiety.

Everybody in our today’s society has turned to western medicine for treatment and forgetting some of the old ones that works like magic.

Today we are going to be looking at all the steps, precautions and what to expect when going for your first acupuncture therapy.

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Expect your acupuncturist to be really prying

During the acupuncture session, your acupuncturist is gonna want to know almost everything about you from your stress level to how many times you eat or even how many times you poop.

But don’t take all of this as an invasion of privacy, as the acupuncturist is doing this to know what and which energy channel to block in your body. Don’t try to understand that energy channel stuff, it on a whole different topic of it own.

By the way, just a heads up, if your acupuncturist does not ask you to fill any form or does not ask you a bunch of questions, advisable you find a better therapist.


I know most of you are gonna be like, needles going through my skin? isn’t that going to hurt?

But not to worry, it only going to feel like a little pinch. Although it not going to be as comfortable as you think but at the same time it doesn’t hurt badly either.

Once all the needles the size of a cat’s whisk are on place, you’re going to be asked to do absolutely nothing, no pressing of phone, no looking at anything, and even no thinking of anything. You just sit and let the spirit of serenity, joy and life pass through you.

Read Also: How To Lose Weight Fast And Easy In 30 Days: 6 Effective Ways


You are supposed to go for an acupuncture therapy at least once a week for a month. Some people go once every month, some book a series of acupuncture sessions when there is something specific they want treated.

7 Acupuncture Therapy Benefits You Must Know

  1. Reduce stress: This is like 70% of the reason why people go for acupuncture in the first place. Although work is the major trigger for this stress, acupuncture has been proven to reduce stress level.
  2. Reduce pains: Whether it is back pain or poor posture attributed pain, Acupuncture can always fix all of those anomalies. Acupuncture serves like a drug-free pain relief therapy.
  3. Relieve of Migraines and Headaches.
  4. Reduce Eye Strain: You could treat that eye strain you got from neck tensions, it is said to even treat other sorts of eye ailments.
  5. Improved immune System and Reduce Sick Days: Acupuncture Therapy can be used to treat virtually all ailments. It is used to fight off pathogens by increasing the efficiency of the immune system.
  6. Reduce Cigarette Craving: Yes that right, addicted to smoking? acupuncture benefits might also be for you as it helps in curbing cravings and promote lung tissue.
  7. Treat Arthritis: Arthritis is a debilitating disease that affects tens of millions of people around the world. Acupuncture benefits offers an option for reducing the painful and debilitating effects of arthritis.

Read Also: Depression: Symptoms, Causes, Treatment

Medical Articles Physical Theraphy

11 Painful Intercourse Causes (Dyspareunia): How to Completely Remove Pain

Painful Intercourse Causes (Dyspareunia) – The Menace of women’s health

Painful Intercourse Causes in most individual are as a result of vaginal dryness, genital injury, menopause, infection and many others. Dyspareunia also called Painful Intercourse is a general term used to describe all types of sexual pain upon penetration, during or after intercourse. It can exist anywhere in the genital area – the clitoris, labia, or vagina, etc. The pain may be described as sharp, stinging, burning, bumping, cramping or may be described in other ways.

Dyspareunia Causes

Causes of painful sexual intercourse are varied and include physical factors, psychological factors, or both. The location of the pain may help identify a specific physical cause.

  1. Menopause
  2. Vaginal dryness
  3. Vaginismus
  4. Genital injury
  5. Inflammation or infection
  6. Skin disorders or irritation
  7. Abnormalities at birth
  8. Physical causes
  9. Medical treatments
  10. Medical conditions
  11. Psychological causes

Vaginal dryness:

During sexual arousal, glands at the entrance of the vagina secrete fluids to aid intercourse. Too little fluid can lead to painful intercourse. Inadequate lubrication can arise from, a lack of foreplay, a reduction in estrogen particularly after menopause or childbirth, medications, including some antidepressants, antihistamines, and birth control pills.


The involuntary contraction of the pelvic floor muscles causes vaginismus, leading to painful sexual intercourse. Women with vaginismus may also experience difficulty with gynecological examinations and tampon insertion. There are several forms of vaginismus. Symptoms vary between individuals and range from mild to severe. It can be caused by medical factors, emotional factors, or both.

Genital injury:

Any trauma to the genital region can lead to painful sexual intercourse. Examples include female genital mutilation (FGM), pelvic surgery, or injury arising from an accident. Painful intercourse is also common after childbirth. A research suggested 45 percent of its participants experienced postpartum dyspareunia.

Inflammation or infection:

Inflammation around the vaginal opening is called vulvar vestibulitis. This can cause painful sexual intercourse. Vaginal yeast infections, urinary tract infections, or sexually transmitted infections(STIs) can also lead to painful intercourse.

Skin disorders or irritation:

Painful sexual intercourse may arise from eczema, lichen planus, lichen sclerosus, or other skin problems in the genital area. Irritation or allergic reactions to clothing, laundry detergents, or personal hygiene products may also cause pain.

Abnormalities at birth:

Less common underlying causes of painful sexual intercourse include vaginal agenesis. When the vagina does not develop fully, or imperforate hymen, in which the hymen blocks the vaginal opening.

Physical Dyspareunia Causes:

  • Entry pain: Entry pain may be associated with vaginal dryness, vaginismus, genital injury, and others.
  • Deep pain: If pain occurs during deep penetration or is more acute in particular positions. It may be the result of a medical treatment or a medical condition.

Medical treatments

Medical treatments that can lead to painful sexual intercourse include

  • pelvic surgery,
  • hysterectomy, and
  • some cancer treatments.

Medical conditions that causes painful sexual intercourse include:

  • Cystitis: An inflammation of the bladder wall, usually caused by bacterial infection.
  • Endometriosis: A condition arising from the presence of tissue from the uterus in other areas of the body.
  • Fibroids: Non-cancerous tumors that grow on the wall of the uterus.
  • Interstitial cystitis: A chronic painful bladder condition.
  • Irritable bowel syndrome (IBS): A functional disorder of the digestive tract.
  • Ovarian cysts: A build-up of fluid within an ovary.
  • Pelvic inflammatory disease (PID): Inflammation of the female reproductive organs, usually caused by infection uterine prolapse. One or more pelvic organs extend into the vagina.

Read Also: How to keep your vag clean and smelling good daily

Psychological Dyspareunia causes

Common emotional and psychological factors can play a role in painful intercourse. Anxiety, fear, and depression can inhibit sexual arousal and contribute to vaginal dryness or vaginismus. Stress can trigger a tightening of the pelvic floor muscles, resulting in pain. A history of sexual abuse or sexual violence may contribute to dyspareunia.

Excerpt: Dyspareunia simply means Painful Intercourse. It is a general term used to describe all types of sexual pain. Painful sexual intercourse may occur upon penetration, during intercourse, and/or following intercourse. Dyspareunia causes in most individual are resultant of vaginal dryness, genital injury, menopause, infection and many others as rightly detailed in this work.

How to Prevent (Painful Sexual Intercourse)

In an attempt to prevent painful intercourse, a woman might avoid or discontinue use of the following:

  • Perfumed soaps
  • Douching
  • Vaginal perfumes
  • Bubble baths
  • Scented or tinted toilet papers
  • Panty liners or tight synthetic undergarments such as panty hose

Dyspareunia (Painful Intercourse) Treatment

Since the underlying cause of painful sexual intercourse is often elusive, the clinician acts to ease the pain for the affected patient. It is also helpful to keep tab and make diary of the pain symptoms, its time of onset, pain intensity and duration as it brings clues of what exactly caused the painful sexual intercourse and best treatment approach.

Non-steroidal anti-inflammatory drugs (NSAIDs) are usually used to relieve the pain, exercises, massages, sleep, and baths are also recommended. Topical anesthetics are also used to alleviate genital pain. The clinician creates a “pain prescription” together with the patient, they jointly decide what the woman should do when the pain kicks in, and when next she should consult with her medical personnel.

Read Also: Women’s hypnotherapy cure for alcohol addiction

Natural Home Remedies To Help Relieve Dyspareunia

Applying lubricating gels to the outer sexual organs, the vulva and labia, as well as using lubricating products in the vagina may be helpful to some women and ease pain during intercourse. Sex toys, such as vibrators or dildos, may also be useful. A woman should talk with her health care professional before attempting to use a vaginal dilator.

Specialties Doctors To Treat Painful Intercourse

These are the specialist healthcare professionals you need to meet for dyspareunia treatment:

  • Gynecologist: Will do a thorough pelvic examination and testing
  • Urologist: will evaluate your bladder and urethra condition
  • Behavioral health specialist: Evaluation of possible social or psychological contributors to the painful intercourse.

Read Also: Sudden increase in body odor female “fishy smell”

General  Advice

If relationship difficulties are considered a fundamental factor in the development of painful sexual intercourse, couples should be encouraged  to talk.  The lack of improvement in this step usually means that the couple should seek professional help from a couple’s counselor.

In any case, treatment are specific to couples and their desires. A combination of behavioral and penetration desensitization exercises, where  the affected woman is encouraged to insert one finger into her vagina, followed by two and three fingers (while at the same time relaxing the  lower muscles)  has been shown to be quite effective for dyspareunia (painful intercourse) treatment.

Graded vaginal trainers in women’s health physiotherapy is also used,  but clear instructions are vital for the success of this approach. If psychological problems persevere, the  patient is to be referred to a psycho sexual therapist. Often the basis of the treatment is enabling the  women to become more comfortable with her genitals in order to overcome the fear of penetration.  Education is also central, and sometimes  there is a need for exploration of fantasies.


Both the patient and the clinician should agree to accept partial improvement and partial gains, as this condition is often a combination of different pathophysiological factors.  Clinicians who have all the necessary information about the causes and potential therapies are in the  position to effectively and comfortably start a conversation about this frequently neglected issue.

In need of consultation and more Information contact Healthcare Consultings

Okaku Martins

Anthony Maximilian

Physical Theraphy Vision care

How to care for your Health: 5 Best Practices

Care For Your Health

Care for your health is paramount for healthy lifestyle practices such as eating healthy foods, regular engagement in exercises, avoiding drugs and alcohol, getting enough sleep, practicing good hygiene, managing stress and regular medical check-ups.

Having poor overall health can make recovery harder.  Finding ways to take care for your health can aid your recovery and help you feel better. Get routine check-ups and visit your doctor when you’re not feeling well. Sometimes, it is hard to tell whether not feeling well is due to a side-effect of your medicine, a symptom of your mental health disorder or a different health problem. Your doctor can help you sort this out. Taking good care of yourself is very important and needed for quality living, reason why Healthcare Constings have decided to put together this effective 5 best practices on how to care for your Health.

Once you have practiced healthy living you should make a list of things that work for you to stay healthy; for instance walk my neighbor’s dog, eat more apples and get enough sleep. It is also a good idea to make a list of things that you know from experience trigger unhappy moods and make symptoms worse. Making a list of the ways to live well and triggers to avoid will help you live the healthiest life possible and avoid some unnecessary health (mental and physical) complications.

How to Care for Your Health

  1. Eat Right
  2. Be Active and Exercise
  3. Get Enough Rest
  4. Manage Stress
  5. Get the Care You Need

Eat Right

Eating right is really good, effective in improving your health performance and help you stay healthy. Sometimes, medicine can cause you to gain weight. Other times, eating unhealthy foods can be a cause for weight gain. Foods high in calories and saturated or “bad” fats can raise your blood pressure and cholesterol. This can increase your chances of gaining weight and having other health problems, such as heart disease and diabetes.

Following some basic suggestions ones energy, mood and overall wellness can be boosted:

  • Don’t skip meals: Eating consistently throughout the day provides your brain and body with a steady supply of fuel. It also prevents your blood sugar from dropping, which can cause nervousness, irritability, and other problems.
  • Snack well: Sustain your energy by eating healthy snacks. Try to eat some nuts, whole or dried fruit or other portable food.
  • Work on your balance: Maybe you know that your body needs a varied diet. But have you thought about your brain? Your brain needs a healthy supply of carbohydrates, fats, and proteins, or it can’t perform functions that affect your mood and thinking.
  • Don’t over-diet: Eat to be healthy and fit not to compare to anyone else. Strict food rules usually backfire, and excessive dieting can be dangerous. If you or someone you know seems at risk of an eating disorder, professional counseling can help.

Talk to your doctor to learn more about how to care for your health through a healthy diet plan.


Some evidence links depression and nutrition, although some of the research is still under debate. But in a bid to properly care for your health, these nutrients may play a role in combating depression:

  • Vitamin B-12 and folate: Good sources of B-12 are fish like salmon and trout and breakfast cereals that indicate in the nutrition information that they are fortified. Folate is found in dark leafy vegetables, almonds, dairy products, and fortified whole-grain breakfast cereals. Examples of fortified food include milk, salt, and certain cereals such as Special K, Cheerios, Total, Wheaties, and Kellogg’s Frosted Flakes.
  • Omega-3 fatty acids: The best source of omega-3 fatty acids are fatty fish like salmon, catfish, and trout. Other sources include ground flaxseeds, walnuts, and egg yolks.

If you’re feeling depressed, diet alone is likely not the answer. Consider contacting a mental health professional to get help.


Along with a healthy diet, healthcare consultings suggests that in order to effectively care for your health, exercise must be routinely incorporated. Exercises can improve your health and well-being. Exercising regularly can increase your self-esteem and confidence, reduce your feelings of stress, anxiety, and depression, improve your sleep, and help you maintain a healthy weight. Living with a mental health condition can lead to isolation and loneliness. Getting active is the antidote.

There are lots of ways to start getting more active. Go to the library or get out to the mall. Pursue your favorite hobby or take one up. Go to a musical event, while some cost money, others are free. Check for free or low-cost activities at public recreation centers, parks and adult education programs. If there is a tuition charge or admission fee, there may be discounts for people with disabilities or seniors.

For your overall health, the American Heart Association recommends:

  • At least 30 minutes of moderate aerobic activity (think walking or a leisurely bike ride) five days a week PLUS strength training twice a week.


  • At least 20 minutes of vigorous aerobic activity (like jogging or a challenging bike ride) three days a week PLUS strength training twice a week.

Find a type of exercise that you enjoy and talk to your doctor. You might enjoy walking, jogging, or even dancing. You don’t have to go to a gym or spend money to exercise. Some suggestions include:

  • Check out your local community center for free, fun activities.
  • Take a short walk around the block with family, friends, or coworkers.
  • Take the stairs instead of the elevator. First making sure the stairs are well lit.
  • Turn on some music and dance. Dance along to your favorite television shows.
  • Exercise to a workout video (public libraries offer a great variety and are free) or even a Wii fitness game.


Sleep can affect your mood as well as your body and is important to your recovery. Not getting the right amount of sleep can make day-to-day functioning and recovery harder.

According to the National Institute of Mental Health Epidemiological Catchment Area study, “the risk of developing new major depression was much higher compared to those without insomnia”. Furthermore in their study of about 8,000 participants, 40% of those with insomnia and 46.5% of those with hypersomnia (sleeping too much) had a mental illness. The relationship between getting enough rest and reducing the risk of depression, anxiety, and other mental illnesses is strong.

Tips for Improving Your Sleep

To sleep longer and better, healthcare consultings suggests:

  • Set a regular bedtime. Your body craves consistency, plus you’re more likely to get enough sleep if you schedule rest like your other important tasks.
  • De-caffeinate yourself. Drinking caffeine to stay awake during the day can keep you up at night. Try resisting coffee and sodas starting at six to eight hours before bed.
  • De-stress yourself. Relax by taking a hot bath, meditating, or envisioning a soothing scene while lying in bed. Turn off daytime worries by finishing any next-day preparations about an hour before bed.
  • Exercise. Working out can improve sleep in lots of ways, including relieving muscle tension. Don’t work out right before bed, though, since exercise may make you more alert. If you like, try gentle upper-body stretches to help transition into sleep.
  • Make your bed a sleep haven. No paying bills or writing reports in bed. Also, if you can’t fall asleep after 15 minutes you can try some soothing music, but if you remain alert it is recommend that you get up until you feel more tired.

MANAGE STRESS – Effective Practice in taking care for your health

Everyone has stress. It is a normal part of life. You can feel stress in your body when you have too much to do or when you haven’t slept well. You can also feel stress when you worry about your job, money, relationships, or a friend or family member who is ill or in crisis. Stress can make you feel run down. It can also cause your mind to race and make it hard to focus on the things you need to do. If you have a mental illness, lots of stress can make you feel worse and make it harder to function.

There has been considerable research done that proves that stress exacerbates mental health conditions. Studies indicate that work and family stress are associated with mental health conditions and loss of productivity at work and in normal day-to-day functions. A study by Australian researcher found work stress to be a significant risk factor for developing mental health conditions and decreased work productivity.

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How do I know if I am suffering from stress?

  • Each person handles stress differently. Some people actually seek out situations which may appear stressful to others. A major life decision, such as changing careers or buying a house, might be overwhelming for some people, while others may welcome the change. Some find sitting in traffic too much to tolerate, while others take it in stride. The key is determining your personal tolerance levels for stressful situations.
  • Stress can cause physical, emotional, and behavioral disorders that can affect your health, vitality, and peace-of-mind, as well as personal and professional relationships. Too much stress can cause relatively minor illnesses such as insomnia, backaches, or headaches as well as such potentially life-threatening diseases as high blood pressure and heart disease.

If you are feeling stressed, there are steps you can take to feel better:

  • Take one thing at a time. For people under tension or stress, an ordinary workload can sometimes seem unbearable. The best way to cope with this feeling of being overwhelmed is to take one task at a time. Pick one urgent task and work on it. Once you accomplish that task, choose the next one.
  • Know your limits. Let others know them too. If you’re overwhelmed at home or work, or with friends, learn how to say “no.” It may be hard at first, so practice saying “no” with the people you trust most.
  • Practice stress reduction techniques. There are a lot of things you can do to make your life more peaceful and calm. Do something you enjoy, exercise, connect with others or meditate.
  • Know your triggers. What causes stress in your life? If you know where stress is coming from, you will be able to manage it better.
  • Talk to someone. You don’t have to deal with stress on your own. Talking to a trusted friend, family member, support group or counselor can make you feel better. They may help you figure out how to better manage stress in your life and also help you care for your health better.
  • Shed the “superman/woman” urge. No one is perfect, so don’t expect perfection from yourself or others. Ask yourself, “What really needs to be done? How much can I do? Is the deadline realistic? What adjustments can I make?” Don’t hesitate to ask for help if you need it.


Healthcare Consultings also believe that Negative thinking can often drag you and others around you down. There are many different types of negative thinking and you may not even realize that you are doing it. It is an important part of living well and taking care of your health to overcome and change negative thought pattern.

Read Also: Coping with depression: 8 Sure Lifestyle Strategies

How to overcome negative thought pattern include:

Replacing the negative thought with a positive one: repeating positive statements and seeking professional therapy from a cognitive-behavioral therapist. Common types of negative thinking are:

  • Magnification and Minimization – this is placing a bigger importance on the negative events while ignoring the positive ones. When you start thinking in always, never, everyone, nobody, et cetera, then you are thinking too much about the negatives and using those to over-generalize. This is also called “all or nothing” thinking. An example of this would be: I always embarrass myself, nobody likes me.
  • Emotional Reasoning – this is drawing conclusions based on emotions and ignoring the facts. An example of this would be: I am angry with you so you must be wrong and the source of my problems.
  • Should Statements – this is relying on the absoluteness of “should” statements. “Should” statements cause the thinker to create rigid rules for themselves and others that need to be followed without flexibility. An example of this would be: I should always avoid talking about my personal issues with others. Or even: I should always wear black shoes after Labor Day.
  • Labeling and Mislabeling – this is the constant applying of labels on people. Often the labels are inaccurate or negative as you never know all the information. An example of this would be: She is promiscuous because she flirts a lot. Or even: He must be an alcoholic because he has had three glasses of beer to drink.
  • Personalization – this is blaming yourself for things you do not have control over, causing unnecessary stress. This could be thinking that it is your fault that the train came late or that it is your fault that your teenager likes suggestive rap music. An example of this would be: I am the reason that my insurance denied payment for medication.

If you find yourself caught in the loop of negative thinking ask yourself is this favorable enough for me following the principles of care for your health. Sit down and identify three strengths or things you do well. For instance you could be a good listener, in good physical shape, good with animals, or remember names easily. Convert thoughts of these into your strength.

Read Also: 12 Natural Home Remedies To Lose Weight On Tummy And Hips

Get the Care You Need

Care for your health is not complete without getting a routine check-ups. Visit your doctor when you’re not feeling well. It may be due to your medicine or a symptom of your mental illness. But it could also be a different health problem. Create a Family Health Portrait of the diseases and illnesses your family has faced and take it to your doctor to discuss your risks and what you should be looking out for.

Of course you don’t have to be in crisis to seek help. Why wait until you’re really in pain? Even if you’re not sure you’d benefit from help, it can’t hurt to explore the possibility.

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