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Selected Topical Medications: Patterns, Knowledge and Preference in Clinical Practice among Nigerian Physiotherapists
Onigbinde Ayodele Teslim
,
Olatipe Christianah Folake
,
Tarimo Nesto
,
Mukoka Grace
Issue: Volume 2, Issue 5-1, October 2014
Pages: 22-28
Received: 2 September 2014
Accepted: 19 September 2014
Published: 29 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.15
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Abstract: Application of topical medication remains an essential component of clinical physiotherapy practice but previous reports have revealed poor knowledge of medications among Nigerian physiotherapists. Also, there are arrays of topical medications available but there is envelope of doubts on what determines the choice of Nigerian physiotherapists. The primary aims of this study were to investigate the pattern and preference of selected topical medications in clinical practice among physiotherapists. A structured self administered questionnaire was administered to 200 physiotherapists in purposively selected hospitals in Southwest, Nigeria. Descriptive statistics of mean, standard deviation and percentages were used to analyze the data. The results showed that most physiotherapists were familiar with diclofenac sodium (92.0%) and methyl salicilate (92.5%) while very few were familiar with dexamethasone, zinc oxide ,magnesium sulphate, capsaicin and naproxen (27.0%, 34.5%, 35.0%, 36.0% and 37.0%) respectively. The results also showed that 56.5% and 63.5% of physiotherapists were correct about functions of diclofenac sodium and glucosamine sulphate respectively. Only 8%, 20.5% and 2.5% physiotherapists knew the functions of magnesium sulphate as an analgesic and as a muscle relaxant; and lidocaine as an anesthetic agent. The results further revealed that 34.0% and 17.0% chose menthol and dexamethasone respectively as their least preferred topical medications and they based their choice mostly on efficacy, active ingredients in the drugs and reported efficacy by patients. Most physiotherapists (63.3%) were not correct about the dominant ions present in the selected topical medications. We concluded that physiotherapists in this study were mostly familiar with diclofenac sodium and methyl salicylate but diclofenac was the most preferred topical medication in clinical practice. There was general poor knowledge on functions and dominant ionic charges in the topical medications.
Abstract: Application of topical medication remains an essential component of clinical physiotherapy practice but previous reports have revealed poor knowledge of medications among Nigerian physiotherapists. Also, there are arrays of topical medications available but there is envelope of doubts on what determines the choice of Nigerian physiotherapists. The ...
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Relationship between Selected Anthropometric Variables, Cardiovascular Risk Factors and Endurance Walk in Non-Insulin Dependent Diabetic Participants
Oluwafemi Oluwasegun
,
Adeyanju Solomon Adekunle
,
Onigbinde Ayodele Teslim
Issue: Volume 2, Issue 5-1, October 2014
Pages: 61-66
Received: 2 September 2014
Accepted: 19 September 2014
Published: 27 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.22
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Abstract: There appears to be an increasing number of patients with cardiovascular disorders and diabetes but there is paucity of data on likely factors which are related to these disorders. The primary purpose of this study was to examine the relationship between selected anthropometric variables, cardiovascular disease risk factors and cardiovascular response to endurance walk in participants with diabetics. Sixty participants each, with non-insulin dependent and without diabetes were recruited for this study. The weight, height, Body Mass Index, Waist Circumference, Hip Circumference, Sagittal Abdominal Diameter, Waist to Hip Ratio, Waist to Height Ratio, %BF-Percent Body Fat, blood pressure, fasting blood sugar, and distance covered in 6-minute walk test; and other selected adipose tissue variables were measured for each participant while percentage body fat was computed. The descriptive statistics and student t-test were used to analyze the data. The result showed that the age, weight, BP, PR, BMI, WC, WTH, %BF and SAD of the diabetics were significantly higher than that of the non-diabetics (P < 0.05). There was no significant difference between all the selected cardiovascular risk factors between male and female but the distance covered by male was significantly higher than that of female (t = 1.89, p = 0.006). There was significant relationship between systolic BP and BMI (r = 0.27, p = 0.04) and similar trend was observed for between FBS and WHR (r = 0.26, p = 0.05). There was also significant relationship between distances covered during 6-minutes walk test, weight (r = -0.28, p = 0.03) and BMI (r = -0.29, p = 0.03). It was concluded that there was significant relationship between BMI, WHR, blood pressure and blood glucose. Similarly, there was significant difference in most of the anthropometric and adipose tissue variables of diabetics and non-diabetics.
Abstract: There appears to be an increasing number of patients with cardiovascular disorders and diabetes but there is paucity of data on likely factors which are related to these disorders. The primary purpose of this study was to examine the relationship between selected anthropometric variables, cardiovascular disease risk factors and cardiovascular respo...
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Assessment of Work Related Musculoskeletal Pain among Professional Drivers in the Service of a Tertiary Institution
Ojoawo Adesola Ojo
,
Onaade Oluwaseun
,
Adedoyin Rufus
,
Okonji Adaobi
Issue: Volume 2, Issue 5-1, October 2014
Pages: 56-60
Received: 2 September 2014
Accepted: 19 September 2014
Published: 27 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.21
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Abstract: Musculoskeletal pain (MSP) is usually work related and it is a common phenomenon among several occupations. This study aimed at determining the prevalence and pattern of work related musculoskeletal pain (WRMSP) among drivers at a Nigerian tertiary institution. An adapted Nordic musculoskeletal pain questionnaire (NMSPQ,) was distributed to all the professional drivers who were staff of Obafemi Awolowo University, Ile Ife, Osun State, Nigeria. The response rate was 90.9%. The data were analyzed using descriptive and inferential statistics. The result showed that 77% of the professional drivers (PDs) reported WRMSP once or more in their routine duties. Low back (50.5%) was the most frequently sited location of WRMSP while shoulder (35%), knees (30.9%), neck (26.8%), ankle (26%), elbow; and hip (22.7%) were other regions. Prolonged driving was reported to be a major cause of musculoskeletal pain (61.2%). There was significant relationship between musculoskeletal pain intensity and duration of driving per week (r=0.348, p<0.05) and absenteeism from work (r=0.356, p<0.05). The study concluded that MSP was prevalent among drivers at the selected institution and low back was the most predisposed site.
Abstract: Musculoskeletal pain (MSP) is usually work related and it is a common phenomenon among several occupations. This study aimed at determining the prevalence and pattern of work related musculoskeletal pain (WRMSP) among drivers at a Nigerian tertiary institution. An adapted Nordic musculoskeletal pain questionnaire (NMSPQ,) was distributed to all the...
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An Assessment of Knowledge of Nigerian Female Undergraduates on Obesity as a Risk Factor for Cardiovascular Disease in Women
Taofeek Oluwole Awotidebe
,
Rufus Adesoji Adedoyin
,
Busola Fatoogun
,
Victor Adeyeye
,
Chidozie Emmanuel Mbada
,
Odunayo Theresa Akinola
,
Olubusola Esther Johnson
,
Nicole De Wet
Issue: Volume 2, Issue 5-1, October 2014
Pages: 50-55
Received: 2 September 2014
Accepted: 19 September 2014
Published: 27 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.20
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Abstract: There is an increasing predilection to obesity and consequent cardiovascular disease (CVD) among women. This study investigated knowledge of Nigerian female undergraduates on obesity as a risk factor for CVD in women. This cross-sectional study recruited 400 female undergraduate students at a tertiary institution in Nigeria. A validated questionnaire was used to assess respondents’ knowledge of obesity as a risk factor for CVD. Descriptive statistics of frequency, mean and standard deviation were used to summarize data while inferential statistics of Spearman Rank Correlation was used to determine the relationship between knowledge score and each of age, level of study, and source of information. Alpha level was set at 0.05. Excessive high calorie intake, 322(80.5%), fatty food intake, 393(98.3%) and physical inactivity, 360(90.0%) were the most implicated causative factors for obesity. Three hundred and thirty five (83.8%) respondents recognized obesity as a leading cause of CVD. The result of this study also showed that there were no significant relationships between knowledge of obesity as risk factor for CVD and each of age (r = -0.04; p = 0.37), level of study (r =0.04; p = 0.45) and source of information (r = -0.005; p = 0.92). We concluded that Nigerian female undergraduates demonstrated average to good knowledge on obesity as risk factor for cardiovascular disease in women. Socio-demographic variables and source of information did not influence Knowledge of obesity as a risk factor for CVD among Nigerian female undergraduates.
Abstract: There is an increasing predilection to obesity and consequent cardiovascular disease (CVD) among women. This study investigated knowledge of Nigerian female undergraduates on obesity as a risk factor for CVD in women. This cross-sectional study recruited 400 female undergraduate students at a tertiary institution in Nigeria. A validated questionnai...
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Prevalence and Relationship between Analgesic and Alcohol Consumption, Smoking Habit and Occurrence of Lowback Pain amongst Craftsmen in a South-East Nigerian Community
Gabriel Omoniyi Ayeni
,
Oyewale Mayowa Morakinyo
,
Oladire Olaniyi
,
Ayodele Teslim Onigbinde
,
Oluwasegun AkindeleAyeni
Issue: Volume 2, Issue 5-1, October 2014
Pages: 45-49
Received: 2 September 2014
Accepted: 19 September 2014
Published: 27 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.19
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Abstract: Low back pain (LBP) is a major cause of disability with high economic and public health repercussions. The main objectives of this study were to determine the prevalence and relationship between analgesic and alcohol consumption, smoking and occurrence of lowback pain amongst craftsmen in Owerri, a South-East Nigerian community. A structured questionnaire was used to collect data on lifestyle and low back pain of 500 craftsmen. The data was analyzed using descriptive statistics of mean, percentage, frequency and inferential statistics of chi square; and multiple regressions. The result showed that the point prevalence for LBP was 34%. The 3-month, 12-month and life time prevalence of LBP were 35.4% 57.4% and 69.0% respectively. Habits of analgesic consumption (OR = 5.51; CI = 1.07 - 4.29; p = 0.048) and alcohol consumption (OR=2.53, CI=1.47-4.38, p<0.001) had significant association with low back pain. We concluded that the point prevalence for low back pain was 34%. Also, LBP was associated with some selected lifestyle factors
Abstract: Low back pain (LBP) is a major cause of disability with high economic and public health repercussions. The main objectives of this study were to determine the prevalence and relationship between analgesic and alcohol consumption, smoking and occurrence of lowback pain amongst craftsmen in Owerri, a South-East Nigerian community. A structured questi...
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Comparative Effects of a Single Treatment Session Using Glucosamine Sulphate and Methyl Salicylate on Pain and Hamstring Flexibility of Patients with Knee Osteoarthritis
Onigbinde Ayodele Teslim
,
Adesina Olawale Daniel
,
Tarimo Nesto
,
Ojoawo Adesola
Issue: Volume 2, Issue 5-1, October 2014
Pages: 40-44
Received: 2 September 2014
Accepted: 19 September 2014
Published: 27 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.18
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Abstract: Transdermal delivery of topical medications is commonly used for managing osteoarthritis (OA). Osteoarthritis of the knee joint impairs lower limb functions which contributes to poor gait patterns. There is insufficient empirical data to support the efficacy of glucosamine sulphate and methyl salicilate cream in the management of knee OA. The aims of this study were to compare the immediate effects of glucosamine sulphate and methyl salicylate cream on pain, flexibility and knee flexion. Forty one subjects with grade ll knee OA were recruited for the study. They were randomly assigned to 2 groups. One gram of each topical formulation was administered to the knee joint using massage. Pre and post-intervention pain intensities, hamstring flexibilities and active knee flexion were measured. Descriptive, paired and independent t-tests statistics were used to analyze the data. There were significant reduction in pain intensities within the groups (t = 9.08, p<0.001; t =6.29, p<0.001). However, there was no significant difference in the post treatments pain intensities across the two groups. There were significant increase in the flexibilities of groups 1 and 2 post treatment (t= 9.14, p<0.001) and (t= -5.67, p<0.001) respectively but there was insignificant difference in the flexibilities of the groups. Similarly, there was insignificant difference in the range of motion when the active knee flexions of the two groups were compared. We concluded that transdermal massage of glucosamine was as effective as methyl salicilate in alleviating pains, improving hamstring flexibility and increasing knee flexion range of motion in a single treatment session among knee OA participants in this study.
Abstract: Transdermal delivery of topical medications is commonly used for managing osteoarthritis (OA). Osteoarthritis of the knee joint impairs lower limb functions which contributes to poor gait patterns. There is insufficient empirical data to support the efficacy of glucosamine sulphate and methyl salicilate cream in the management of knee OA. The aims ...
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Electromotive Administration of Topical Medications in Clinical Physiotherapy Practice: A Review
Odeyemi Emmanuel
,
Oyedemi Jerremiah
,
Okonji Adaobi
Issue: Volume 2, Issue 5-1, October 2014
Pages: 34-39
Received: 2 September 2014
Accepted: 19 September 2014
Published: 27 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.17
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Abstract: Oral and injection routes of drug administration has adverse effect in the body system, hence, there is paradigm shift in route of drug administration to the use of electromotive force via the skin where applicable; and this by passes the first pass effect metabolism. Both iontophoresis and ultra-sonophoresis are examples of procedures for the electromotive administration of drugs. Potential serious side-effects are eliminated because transdermal routes of drug administration are known to possess little or no side effects. Iontophoresis is the introduction of medicinal ions into the body using Direct Current. It is a painless, sterile and non invasive technique with minimal adverse reactions in the gastro-intestinal system. The dose depends on current and time of treatment and a typical dosage is 40 mA-min. This review revealed that Iontophoresis is being used to subdue inflammation using topical Non-steroidal anti-inflammatory drugs, administer antibiotics to combat infection, manage bicep brachii spasticity of stroke survivours, promote wound healing, reduce bacteria colonization, combat fungal infection; and has produced analgesic effects in several studies. Also, the reviewed showed that ultrasonophoresis is relevant in clinical physiotherapy practice.
Abstract: Oral and injection routes of drug administration has adverse effect in the body system, hence, there is paradigm shift in route of drug administration to the use of electromotive force via the skin where applicable; and this by passes the first pass effect metabolism. Both iontophoresis and ultra-sonophoresis are examples of procedures for the elec...
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Opinion of Nigerian Pharmacists on Enlistment of Physiotherapists as Supplementary Prescribers of Relevant Medications
Onigbinde Ayodele Teslim
,
Ojo Mojisola Ayodele
Issue: Volume 2, Issue 5-1, October 2014
Pages: 29-33
Received: 2 September 2014
Accepted: 19 September 2014
Published: 27 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.16
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Abstract: There is increasing evidence that combining pharmacotherapy and physiotherapy is an effective tool towards effective management different pathologies. Physiotherapists in some countries have had prescription rights for more than a decade but this appears not to be the trend in Nigeria. In these countries, pharmacists played key roles in the change of policy which allowed allied health professionals to prescribe drugs. The primary aim of this study was to determine the opinion of pharmacists on the enlistment and legislation of physiotherapists as supplementary prescribers. A self administered questionnaire was used to obtain information from 110 pharmacists. Purposive sampling technique was used to select the hospitals and institutions. A descriptive statistics of frequency, percentages, standard deviation and Chi-square test were used to analyze the data. This study found that 70 respondents (70%) supported the enlistment of Physiotherapists as Supplementary Prescribers in Nigeria. The result of the Chi-square test showed that the number of respondents who supported the formulation of policy to allow physiotherapists to prescribe was significantly higher than the number of respondents who opposed it (X²= 16.00; P< 0.001). Also, 60 respondents (63.8%) are aware that physiotherapists are supplementary prescribers in some foreign countries. Also, 79 respondents (71.8%) opined that physiotherapists should be allowed to prescribe NSAIDs while 73 (66.4%) respondents opined physiotherapists should be allowed to prescribe analgesics. Most Pharmacists (71.9%) are unaware that cardiopulmonary physiotherapists can prescribe inhaler for patients requiring the use in some foreign countries. This study concluded that most pharmacists are of the opinion that Physiotherapists should be enlisted as supplementary prescribers and that a policy should be formulated to guide prescription by them.
Abstract: There is increasing evidence that combining pharmacotherapy and physiotherapy is an effective tool towards effective management different pathologies. Physiotherapists in some countries have had prescription rights for more than a decade but this appears not to be the trend in Nigeria. In these countries, pharmacists played key roles in the change ...
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An Assessment of Inter-Professional Knowledge of Nigerian Pharmacists on Topical Dosage Specificity; and the Effects of Electro-Physical Agents on Drugs
Onigbinde Ayodele Teslim
,
Ojo Ayodele Mojisola
,
Bamitale Kayode Dominion
,
Wiesener Trond
Issue: Volume 2, Issue 5-1, October 2014
Pages: 17-21
Received: 2 September 2014
Accepted: 19 September 2014
Published: 27 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.14
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Abstract: There is need for Inter-professional education and collaboration among health professionals in order to avoid misconceptions and under-utilization. The primary aims of this study were to investigate the familiarity of Nigerian pharmacists with Finger Tip Unit (FTU) as a means of quantifying dose for topical medications; and also assess their knowledge on the effects of electro-physical modalities on drugs. A structured questionnaire was used to obtain information from 110 pharmacists. Descriptive statistics and Non- parametric inferential statistics were used to analyze the data. The result showed that only 48 respondents (43.6%) were familiar with Finger Tip unit (FTU). There was no significant difference in the number of respondents who were familiar and those unfamiliar with FTU. Among 84 respondents who answered questions on active ingredients, a total of 60.7% were rated between good and excellent in knowledge. The result of the Chi-square test showed that a significant number of respondents agreed that exercise can increase kinetic molecular movement of drugs, and that the effect of exercise depends on the type of drugs while drug absorption can also be increased by external massage (P < 0.001). This study concluded that pharmacists have good knowledge of active ingredients in the selected drugs. Also, about half the respondents knew the effects of physiotherapy agents on drugs and a moderate number were familiar with the use of FTU as a means of quantifying dose for topical medications.
Abstract: There is need for Inter-professional education and collaboration among health professionals in order to avoid misconceptions and under-utilization. The primary aims of this study were to investigate the familiarity of Nigerian pharmacists with Finger Tip Unit (FTU) as a means of quantifying dose for topical medications; and also assess their knowle...
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Physiotherapists as Supplementary Prescribers: Opinion of Nigerian Doctors
Onigbinde Ayodele Teslim
,
Oyeniran Tolulope Olaoluwa
,
Mukoka Grace
,
Nondwe Bongokazi Mlenzana
,
Manie Shamilar
,
Tarimo Nesto
Issue: Volume 2, Issue 5-1, October 2014
Pages: 12-16
Received: 2 September 2014
Accepted: 19 September 2014
Published: 27 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.13
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Abstract: In Nigeria, doctors have the sole primary responsibility of prescribing medications for patients, contrarily, in the United Kingdom (UK), physiotherapists have advanced from being supplementary prescribers in 2005 to independent prescribers in 2012; and this was aimed at improving patient’s accessibility to medications. The primary aim of this study was to investigate the opinion of Nigerian medical doctors on physiotherapists assuming the roles of supplementary prescribers. A self-administered questionnaire was used to seek opinion of 372 medical doctors in purposively selected hospitals. Descriptive statistics of frequency, percentages, mean, standard deviation and chi-square were used to analyze the data. Two hundred and twenty-two doctors (59.7%) were unaware that physiotherapists are supplementary prescribers in UK. The number of respondents (55.1%) who objected to physiotherapists becoming supplementary prescribers was significantly higher than those who supported it (X² -3.88, p = 0.05). Amongst to that supported supplementary (44.9%) prescription for physiotherapists, 98.2%, 72.5% and 58.7% opined that physiotherapists should be allowed prescribe analgesics, NSAIDs and muscle relaxants respectively. Only 4 doctors (1.1%) supported the prescription of anti-hypertensive drugs. We concluded that most medical doctors are unaware that physiotherapists as supplementary prescribers in UK and majority of them objected to Nigerian physiotherapists being recognized as supplementary prescribers.
Abstract: In Nigeria, doctors have the sole primary responsibility of prescribing medications for patients, contrarily, in the United Kingdom (UK), physiotherapists have advanced from being supplementary prescribers in 2005 to independent prescribers in 2012; and this was aimed at improving patient’s accessibility to medications. The primary aim of this stud...
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Patient’s Perception of Nigerian Physiotherapists as Supplementary Prescribers
Onigbinde Ayodele Teslim
,
Oyedemi Oluwapelumi Jeremiah
,
Tarimo Nesto
,
Mukoka Grace
Issue: Volume 2, Issue 5-1, October 2014
Pages: 6-11
Received: 2 September 2014
Accepted: 19 September 2014
Published: 27 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.12
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Abstract: In supplementary prescription (SP) of drugs; patient must consent and ascent to clinical management plans (CMP) and this is the principle of shared decision making (SDM). Shared decision making is a modern care ideology being used to promote effective treatment of patients. If physiotherapists are to become supplementary prescribers (SPs) it is important to seek patient’s opinion as they are also expected to be involved in drawing the CMP. The primary aim of this study was to investigate the opinion of Nigerian patients on enlistment and legislation of physiotherapists as supplementary prescribers. A structured and self-administered questionnaire was used to seek the opinion of 240 patients. They were selected from purposively selected health institutions in Nigeria. The data were analyzed using descriptive statistics of frequency, percentage and non-parametric inferential statistics (chi-square). A significant number of patients opined that prescription of drugs should not be restricted to medical doctors alone (X2 =193.67, P<0.001). One hundred and ninety four (81.17%) participants supported the enactment of policies that will recognize physiotherapists as SPs. Similarly, a significant number of patients opined that physiotherapist should only prescribe oral drugs at the chronic stage of diseases (X2 =35.53, P<0.001). Majority opined that supplementary prescribing will reduce waiting time in hospital (92.89%), reduce burden on medical doctors (94.48%); and increase accessibility and timely intervention of medical care (94.15%). In conclusion, most patients opined that Nigeria physiotherapists should be allowed to become supplementary prescribers of relevant oral drugs because of the enormous benefits to patient care. Also, an enactment should be made to protect them against litigations.
Abstract: In supplementary prescription (SP) of drugs; patient must consent and ascent to clinical management plans (CMP) and this is the principle of shared decision making (SDM). Shared decision making is a modern care ideology being used to promote effective treatment of patients. If physiotherapists are to become supplementary prescribers (SPs) it is imp...
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Perception of Nigerian Physiotherapists on Enlistment, Legislation and Benefits of Supplementary Prescribing
Onigbinde Ayodele Teslim
,
Tijani Aishat Idowu
Issue: Volume 2, Issue 5-1, October 2014
Pages: 1-5
Received: 2 September 2014
Accepted: 19 September 2014
Published: 27 September 2014
DOI:
10.11648/j.ajhr.s.2014020501.11
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Abstract: Supplementary prescribing is a modern clinical practice of utilizing allied health professionals to make drug administration easier and more accessible for patients. In the UK, physiotherapists have advanced from being supplementary to independent prescribers. Nigerian physiotherapists are still restricted to the traditional roles of clinical practice. This study aimed at determining the perception of Nigerian physiotherapists on being enlisted and legislated as supplementary prescribers. A self-administered questionnaire was administered to 313 licensed physiotherapists from 35 selected health institutions in Nigeria. The data were analyzed using descriptive statistics and non parametric inferential statistics (chi square). Results showed that a significant number of respondents (85.3%) would like to be supplementary prescribers (X2 =407.08, P < 0.001) and would also want a legislation that would protect them against litigations. They would also like to prescribe analgesics (84.3%), Non-steroidal anti-inflammatory drugs (79.2%) and muscle relaxants (78.9%). Very few (5.8%) would like to prescribe all classes of drugs. Almost all respondents (90.4%) desired to improve their pharmacotherapy knowledge in order to meet requirements that would be needed for supplementary prescribing. The perceived benefits included effectiveness of combined therapy (83.4%) and timely drug intervention (61.0%). In conclusion, most physiotherapists would like to be supplementary prescribers, and would like to prescribe analgesics, muscle relaxants and Non-steroidal anti-inflammatory drugs. They were also willing to gain more pharmacology knowledge.
Abstract: Supplementary prescribing is a modern clinical practice of utilizing allied health professionals to make drug administration easier and more accessible for patients. In the UK, physiotherapists have advanced from being supplementary to independent prescribers. Nigerian physiotherapists are still restricted to the traditional roles of clinical pract...
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