Volume 4 Issue 2 • February 2021

Editorial
Publishing Research Protocols
Ivan Neil Gomez, PJAHS Editor-in-Chief

Letter to the Editor

On why universal design must be considered the minimum in
the field of the built environment
Louie T. Navarro

Original Articles
Clinical Audit on Examination Tools Used by Physical Therapists in
Metro Manila in Examining Conditions with Neck Pain
Arlene Chiong Maya, Christopher Cruz, Hymn Nuntasomsaran, Pauline Alyssa Vega, John Ed
Kevin Tan, Jerome Rivera Jr., Vanessa Regina Guevarra

The Relevant Anatomy of the Biceps Tendon When Performing

Tenodesis in Filipino Cadaveric Specimens
Martin Louie Bangcoy , Charles Abraham Villamin, Chino Ervin Tayag, Patrick Henry Lorenzo

Short Reports
Impact of COVID-19 Pandemic in Filipino Occupational Therapy
Practice Across Regions
Rod Charlie Delos Reyes, Karla Czarina Tolentino, Wendy Sy

A Literature Review on the Facilitators and Barriers to the Uptake of

Interprofessional Collaboration in the Field of Assistive Technology
within Rehabilitation Medicine
Daryl Patrick Yao, Kenneth Matthew Beltran, Treisha Naedine Santos, Kaoru Inoue

A Rapid Literature Review on the Strategies for Collaboration

Between Occupational therapists and Speech-Language Therapists in
the Field of Augmentative and Alternative Communication
Daryl Patrick Yao, Kaoru Inoue, Ghislynne Dei-Anne
 PJAHS • Volume 4 Issue 2 2021

Table of Contents
Editorial Board
Preface
Ivan Neil Gomez
2 Preface to PJAHS Volume 4 Issue 2 Editor-in-Chief

Editorial Catherine Joy Escuadra

Kim Gerald Medallon
Publishing Research Protocols Managing Editors
3
Ivan Neil Gomez, PJAHS Editor-in-Chief
Donald Lipardo
Letter to the Editor Donald Manlapaz
Associate Editors

3 On why universal design must be considered the minimum in the field Valentin Dones III, Reil Vinard
of the built environment Espino, Paulin Grace Morato-
Louie Navarro Espino, Karen Leslie Pineda
PJAHS Review Board
Original Articles
Consuelo Suarez
Clinical Audit on Examination Tools Used by Physical Therapists in Anne Marie Aseron
7 Metro Manila in Examining Conditions with Neck Pain Editorial Advisory Board
Arlene Chiong Maya, Christopher Cruz, Hymn Nuntasomsaran, Pauline Alyssa
Vega, John Ed Kevin Tan, Jerome Rivera Jr., Vanessa Regina Guevarra Anna Lea Enriquez
Ethics Consultant
The Relevant Anatomy of the Biceps Tendon When Performing
13 Archelle Callejo, Zyra Villamor,
Tenodesis in Filipino Cadaveric Specimens Lyle Patrick Tancuangco,
Martin Louie Bangcoy , Charles Abraham Villamin, Chino Ervin Tayag, Patrick Jazzmine Gale Flores
Henry Lorenzo Editorial Staff

Short Reports Genejane Adarlo, Tsuyoshi Asai,

Alvin Atlas, Katerina Los Baños-
22 Impact of COVID-19 Pandemic in Filipino Occupational Therapy Atlas, Stephanie Balid-Attwell,
Practice Across Regions Rumpa Boonsinsukh, Umar
Rod Charlie Delos Reyes, Karla Czarina Tolentino, Wendy Sy Mohammad Bello, Mary Monica
Bueno, Ke-Vin Chang, Supat
A Literature Review on the Facilitators and Barriers to the Uptake of Chupradit, Jesus Alfonso Datu,
29 Interprofessional Collaboration in the Field of Assistive Technology Janine Margarita Dizon, Marian
within Rehabilitation Medicine Grace Gabor, Karen Grimmer,
Daryl Patrick Yao, Kenneth Matthew Beltran, Treisha Naedine Santos, Kaoru Joel Guerrero, Usa Karukunchit,
Inoue Masayoshi Kubo, Cynthia Lai,
Ritzmond Loa, Steve Milanese,
A Rapid Literature Review on the Strategies for Collaboration Davynn Tan, Jou Yin Teoh, Ruth
Segal, Sean Sullivan, Gian Carlo
Between Occupational therapists and Speech-Language Therapists in Torres, Atsuhiro Tsubaki, Jeric
35 the Field of Augmentative and Alternative Communication Uy, Jana Patricia Valdez, Les
Daryl Patrick Yao, Kaoru Inoue, Ghislynne Dei-Anne Paul Valdez, Candace Vickers,
Alexander Miles Yiu
42 Announcements International Academic Editors

PJAHS Call for Papers

44 Regular Issue
45 Special Section

The Philippine Journal of Allied health

Sciences [ISSN: 1908-5044] is an Open
Access, peer reviewed journal
published by the University of Santo
Tomas-College of Rehabilitation
Sciences, Manila, Philippines.

1
 PJAHS • Volume 4 Issue 2 2021 •

Preface to PJAHS Volume 4 Issue 2

Copyright © 2021 PJAHS. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.

To say that the past year has been challenging professionals. Three short reports are reported
for the everyone is an understatement. in this issue. The first short report looks at the
Disruptions in in academia, and in the scientific impact of the COVID-19 pandemic to Filipino
community in general, has been tough. occupational therapists across regions. The next
Nevertheless, here in PJAHS, we are grateful that two short reports are literature reviews. The
we still continue to receive article submissions. first literature review discusses experiences in
interprofessional collaboration in rehabilitation
In this issue’s editorial, PJAHS introduces a new
using assistive technology. The second literature
model of article type that will accepted from
review explores collaborative practices among
hereon. Study protocols represents an innovative
speech language pathologists and occupational
research article typology that has gained
therapists in the field of augmentative and
attention in the past decade among scientific
alternative communication.
journals. It serves several important functions in
improving scientific rigour and enhancing This issue of PJAHS presents an interesting mix
scientific publishing. Thus, the decision in of articles from different allied health
accepting study protocols will be enacted, with a professions, as well as types of articles. It is our
complete guide presented at the end of this issue, hope that the expansion of the types of articles
in the announcements section. discussed in the announcement section of this
issue opens new opportunities for authors to
We are happy to present to you six research
submit their work to us. It is with an optimistic
articles in the Volume 4 Issue 2 of the Philippine
mind that we look forward your future
Journal of Allied Health Sciences. Our letter to
submissions.
the editor explores the concept of universal
design on how we conceptualize the built We thank the editorial board and pool of
environments for people with disabilities. There international academic editors of PJAHS for their
are two original research articles included in this valuable contribution to making this issue of
issue. The first article audits the use of evidence- PJAHS possible and a reality.
based practice tools used by physical therapists.
This article challenges Filipino physical
therapists in reflecting how they use these
evidence-based outcome measures in their own
practice. The second article is a first for the
journal, which reports on a cadaveric study and
provides practice implications as to how we can
learn from their findings as allied health

2
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.001)

Editorial
Publishing Research Protocols
Ivan Neil Gomez, Editor-in-Chief
Article Received: December 31, 2020
Article Published: February 14, 2021 (online)
Copyright © 2021 Gomez. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.

Over the years, scientific journals have evolved some point in the future, this definition may
in their role from publishing research into a change in order to adapt to the constantly
more proactive role of improving the state of evolving state of the knowledge base.
research through supporting transparency and
The publication of research protocols has been
rigour.1 The scientific community has recognized
adopted by various local and international
that an important step towards transparency
scientific journals. This is an important
and rigour of the research process is the
innovation in the state of scientific publication as
reporting of research protocols.2 Various
it assists in addressing publication bias and
databases have been established offering
increases the internal validity of researches.
information on on-going research projects to
Among other things, it has also been suggested
inform patients and their family members,
that the publication of research reports is
researchers, practitioners, grant funders, and the
essential in: peer review of the protocol prior to
community in general (i.e., ClinicalTrials.gov,
implementation, highlighting quality research
PROSPERO, Philippine Health Research
studies in their early stages, reduces negative or
Registry(PHHR)). So much so, registry of
inconvenient findings, recruitment of possible
research protocols in these databases is slowly
participants, aids in funding, prevention of “data
becoming standard in some countries.
fishing” through a priori data analysis plans,
A research protocol is an empirical description of opens avenues for collaboration among
a study proposal. While various authors and researchers, reduces unnecessary duplication of
institutions may provide different definitions, research, facilitates subsequent publication of
the Philippine Journal of Allied Health Sciences the completed research project, and grounding of
(PJAHS) operationally define research protocols priority research areas among others.1,3,4
be a research article reporting the background,
It is for these reasons that PJAHS is excited to
study objectives, methods, and expected results
announce that starting with Volume 5, we are
of a proposed or ongoing research.2 This is a
now opening our submission system to Research
general definition that encompasses various
Protocols. PJAHS will consider publishing study
research paradigms, approaches, and study
protocols (i.e., primary studies, systematic
designs aimed towards answering relevant allied
reviews with or without meta-analysis) that have
health clinical and research problems. As the
been approved by a funding agency and/or an
state of healthcare research continuously
ethics approval body. Whenever appropriate,
evolves, PJAHS believes that such a definition
study protocols should be registered in
enables a classical description that can stand the
appropriate databases (i.e., ClinicalTrials.gov,
test of time. Nevertheless, we recognize that at
3
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.001)
PROSPERO, PHRR, etc.). Study protocols are
strongly recommended to follow relevant
reporting guidelines (i.e., SPIRIT, SPIROS,
PRSIMA-P, or consult the list by the EQUATOR
Network). Study protocols without current ethics
approval will not be considered. A more detailed
description of the submission guidelines can be
seen in our website,
https://pjahs.ust.edu.ph/submission/.2
We recognize that this model of publishing is an
experiment. There will be a need for PJAHS to
learn from our own experiences, as well as from
other journals in order to fine-tune a framework,
editorial and peer-review process, and even a
format that can best respond to the specific
needs of allied health research.5-7 Nonetheless,
we believe that this is an important step towards
improving not only the state of our journal but of
scientific research in the field of allied health.
Hence, from hereon, PJAHS joins the scientific
community in supporting the principle of
publishing peer-reviewed research protocols.
4
References:
1. Eysenbach G. Peer review and publication of
research protocols and proposals: a role for open
Access Journals. Journal of Medical Internet
Research. 2004;6(3):e37. DOI:
10.2196/jmir.6.3.e37.
2. Philippine Journal of Allied Health Sciences.
Guidelines for Submission (PJAHS). Submission
Guideline. PJAHS; 2021. Available from:
https://pjahs.ust.edu.ph/submission/.
3. Li T, Boutron I, Salman RA, Cobo E, Flemyng E,
Grimshaw JM, Altman DG. Review and publication
of protocol submissions to trials–what have we
learned in 10 years? Trials. 2017;18(1):34. DOI:
10.1186/s13063-016-1743-0.
4. Uppstad PH, McTigue E. A rationale for publishing
peer-reviewed study protocols in the Nordic
Journal of Literacy Research in order to increase
scientific rigour. Nordic Journal of Literacy
Research. 2020;6(1). DOI: 10.23865/njlr.v6.2010.
5. Gomez INB. The state of the journal. Philippine
Journal of Allied Health Sciences. 2020;3(1). DOI:
0.36413/pjahs.0301.002.
6. Gomez INB. Critical Reflection in Responding to
Reviewers’ Comments. Philippine Journal of Allied
Health Sciences. 2020;3(1). DOI:
36413/pjahs.0302.001.
7. Gomez INB. In peer review we trust. Philippine
Journal of Allied Health Sciences. 2020;4(1). DOI:
10.36413/pjahs.0401.001.
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.002)

Letter to the Editor

On why universal design must be considered the minimum in the field of the built
environment
Louie T. Navarro1,2,3
1loutaet al., Manila, Philippines; 2louta et al., Tokyo, Japan (www.loutaetal.com); 3Interior Design Department, College of Fine
Arts and Design, University of Santo Tomas, Manila, Philippines
Correspondence should be addressed to: Louie T. Navarro1; ltn@loutaetal.com
Article Received: November 5, 2020
Article Accepted: December 30, 2020
Article Published: February 14, 2021 (online)
Copyright © 2021 Navarro et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The notion of universal design had its roots in
the early US disability rights movement of the
1960s.1 Its widely credited ‘father,’ Ron Mace,
defined universal design as “the concept of
designing all products and the built environment
to be aesthetic and usable to the greatest extent
possible by everyone, regardless of their age,
ability, or status in life.”2
Wheelchair-bound himself because of Polio
acquired during childhood, Mace’s own
experiences—hindrances to social participation,
specifically physical (spatial) barriers that put
him at a disadvantage3—led to the establishment
in 1989 of the Center for Accessible Housing, at
North Carolina State University in Raleigh, US.2,3
Currently known as The Center for Universal
Design, this change in focus of the institute from
accessibility to universal design is representative
of a narrative arc that informs much of what
spatial designers use today in designing inclusive
spaces.
Albeit simplistic—as they say, there are more to
it than meets the eye—I’d like to simply narrow
in on the attitude that underpins this arc,
beginning with the challenges faced by early
proponents of accessible design.
As but just one of the many narratives of
humanity rising above adversity, we are almost
always inclined to highlighting such a triumph
5
but forget that for everyone story of success, our
humanity grounded in empathy is sidelined—as
if only through the trauma of experience can we
be human.
Not to be dismissive, the knowledge base
available to us now has been founded in such
documentations of human experiences such as
Mace’s, and indeed, there have been great design
innovations precisely because of this. One good
example of this is the now common access ramps
that allow access for all—exemplifying the
fundamental notion of accessibility: that what
many consider but another flight of steps is, in
fact, an insurmountable Everest to some.
Flowing from this ‘reactionary’ narrative, the
shift from accessible design to universal design
was not as direct as one might think—incidental
is more fitting. As Steinfeld and Maisel1 would
emphasize, designs that were intended to be for
the exclusive use of the disabled population is
slowly being revealed to be useful to all in fact:
“The result of the effort to eliminate
discrimination, to make the world accessible and
usable for all, is that unintended consequences
are becoming evident.” The authors’ example of
this is how elevators in subway stations
primarily meant to give access to the disabled
are now used by all ranging from travelers with
luggage and those who are simply too tired from
a day’s work.1
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.002)
Crucially, the learnings derived from these past
challenges are essential to educational
institutions that in turn play a vital role in paving
the way for a generation of ‘woke’ practitioners
of the built environment.4
Specific to the practice of interior design in the
country, the current curriculum has a provision
under the course Professional Practice and
Ethics that covers the study of B.P. 344 or The
Law to Enhance Mobility of Disabled Persons.
Beyond education, this is further reinforced in
the subject’s inclusion in the Board of Interior
Design examination administered by the
Philippine Regulatory Commission. In the
professional practice, R.A. 10350 or the
Philippine Interior Design Act of 2012 and its
emphasis on the Continuing Professional
Development (CPD) programs offered by the
Philippine Institute of Interior Designers (PIID),
ensures that designers are up to date with the
advancements in universal design.
Although much has been gained in this
evolutionary process, it is now imperative that
we continue moving forward in a direction that
is defined by empathy. Beyond these ideas of
‘reactionary’ and the ‘incidental,’ we must
continue to act and push for a truly inclusive
design language informed by empathy first and
foremost.
Foregrounding the Principles of Universal
Design5, designers must deepen their ties with
various professionals from other fields—with
Occupational and Physical Therapy at the
forefront—for us to create spaces that are for
use by all that accommodate the most vulnerable
members of society as a minimum.
Universal design must be considered the
baseline in the field of the built environment
because we are but at the cusp of its fulfillment,
and there is a lot to be done still.
Locally, we need to acknowledge that existing
frameworks and systems are long overdue for a
revisiting—only after then can we even begin to
tackle the bigger problem of raising awareness.
As designers of the built environment were once
accountable for discriminatory spatial practices
(i.e., physical barriers),1 we must now ensure
that our designs moving forward also speaks of
inclusivity. That the everyday spaces we live in
6
serve as a reminder to all that design is not
exclusive—with hopes of cultivating a mindset
by way of empathy by design.
From here, we will see that we have come full
circle in this brief history of universal design and
arrive at the core of what it really means to live
in an inclusive world: social justice.1,4 As
succinctly stated by Steinfeld and Maisel:
“Equality of access to the environment has
always been an issue in civil rights.”1
This is far from a polemic and is, in fact, but a
letter that parallels the trajectory of the history
of universal design beginning with a personal
account of my own: after all, I have a niece
diagnosed with Pervasive Developmental
Disorder-Not Otherwise Specified (PDD-NOS). It
can even be argued that this is but a reaction
based on the worry for this family member come
the time that she will have to be on her own—
only conveniently intersecting with my
professional practice.
Given this frame and still consistent with the
narratives that continue to drive the
improvements to universal design, this piece can
be taken as such: a letter imploring future
generations of practitioners in the built
environment to be more mindful of the impact of
our choices—and yes, critically, to be better than
I was.
References:
1. Steinfeld E, Maisel J. Universal design: designing inclusive
environments. New Jersey: John Wiley & Sons; 2012.
2. The Center for Universal Design. About the center: Ronald
L. Mace. Raleigh: NC State University; c2008. Available
from:
https://projects.ncsu.edu/ncsu/design/cud/about_us/usr
onmace.htm
3. Bringolf J. Who was Ron Mace. Centre for Universal Design
Australia; c2017. Available from:
http://universaldesignaustralia.net.au/who-was-ron-
mace/
4. Sirel A, Sirel O. “Universal Design” Approach for the
Participation of the Disabled in Urban Life. Journal of Civil
Engineering and Architecture. 2018; 12: 11-21. Available
from: doi:10.17265/1934-7359/2018.01.002
5. Centre for Excellence in Universal Design. The 7
Principles. Dublin: National Disability Authority; c2020.
Available from: http://universaldesign.ie/What-is
Universal-Design/The-7-Principles/
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.003)

Original Article
Clinical Audit on Examination Tools Used by Physical Therapists in Metro Manila in
Examining Conditions with Neck Pain
Arlene Chiong Maya1, Christopher Cruz1, Hymn Nuntasomsaran1, Pauline Alyssa Vega1, John Ed Kevin Tan1, Jerome
Rivera Jr.1, Vanessa Regina Guevarra1
1Department of Physical Therapy, College of Rehabilitation Sciences, University of Santo Tomas
Correspondence should be addressed to: Arlene Chiong Maya1; acchiongmaya@ust.edu.ph
Article Received: September 7, 2020
Article Accepted: November 27,2020
Article Published: February 14, 2021 (online)
Copyright © 2021 Chiong Maya et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: Neck pain is considered the fourth leading cause of disability, with an annual prevalence rate of 15 to 30%. Using evidence-based
practice in neck pain examination is a vital part of the rehabilitation process as it serves as a basis for determining the best treatment. The objective
of the study is to determine the usage of recommended examination tool for neck pain among the physical therapists in selected hospitals and clinics
in Metro Manila. Methods: The study has three distinct phases wherein phase 1 was the development and validation of a data extraction sheet,
phase 2 was the assessment of interrater reliability among the investigators who will perform the chart review, and phase 3 was the chart review
process. Descriptive statistics were used for data analysis. Results: In phase 1, the contents of the data extraction sheet were found to be valid. In
phase 2, the inter-rater reliability was 96.7% percent. In phase 3, the visual analogue scale was the most commonly used examination tool, yielding
a 54% usage. This was followed by cervical range of motion & cervical manual muscle testing (22%), palpation (15%), sensory testing (7%), postural
assessment (6%), special test (4%), ocular inspection (2%), functional assessment (1%), Functional Index Measure (1%) and functional muscle
testing (1%). Neck Disability Index, which was one of the literature-recommended examination tools, was not used. Conclusion: Visual analogue
scale was the most commonly used examination tool in conditions with neck pain in selected hospitals and clinics in Metro Manila. Further
investigation can be done in order to know the reasons for the use or nonuse of examination tools.
Keywords: Clinical Audit, Neck Pain, Evidence-based Physical Therapy

INTRODUCTION

According to the Global Burden of Disease 2010
Study, neck pain is the fourth leading cause of
disability, with an annual prevalence rate
ranging from 15 to 30%.1 Proper examination of
neck pain should be done to have a clinical and
theoretical basis to determine the most suitable
treatment. The examination of conditions with
neck pain includes, but is not limited to, proper
history taking, measuring the range of motion,
muscle strength, functional analysis, and the use
of outcome measure tools and self-administered
questionnaires.2 The use of these standardized
tools will provide objective data of the patient’s
health status.3 Incorporating evidence-based
practice (EBP) in the examination will also aid in
the management and prescription of
interventions or medications for the patient.4
EBP is the conscientious, explicit, and judicious
use of current best evidence in making decisions
about the care of the individual patient. It entails
integrating individual clinical expertise with the
best available external clinical evidence from
systematic research.5,6 Use of recommended
examination tools from research is a form of
application of one of the aspects of EBP.
The actual utilization of the recommended
examination tools is translated into
documentation of the results in a patient’s chart.
To check for the documentation of the usage of
recommended examination tools, a clinical audit

7
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.003)
is recommended.3 Clinical audit is the process of
systematically reviewing, evaluating, and
assessing current practice methods against
research-based standards to improve clinical
care for service users.3 It aims to recommend or
support examination and treatment processes
being carried out in practice.
The objective of the study is to determine the
usage of recommended examination tools for
neck pain among physical therapists of selected
hospitals and clinics in Metro Manila.
METHODS
Ethical Consideration. The study was reviewed
and approved by the Ethics Research Committee
of the University of Santo Tomas- College of
Rehabilitation Sciences. The study was in
agreement with ethical principles set by the
Declaration of Helsinki. Number codes were
assigned to the reviewed physical therapy chart
to maintain anonymity of the patient, the
physical therapist, the doctor and the institution.
Study Design. The design of the study was
descriptive and observational. The study is
composed of three phases.
Phase I: Development and Validation of a
Data Extraction Sheet for Chart Review. A
literature search in five databases, Science
Direct, PubMed, Medline, CINAHL, and Google
Scholar, was done in May 2016 to develop the
data extraction sheet. The search formula
“examination tools AND neck pain AND physical
therapy” was used. Published articles between
the years 2006 and 2016 were included in the
study.
A panel of experts composed of three physical
therapists with at least five years of experience
in handling patients with neck pain7 was invited
to validate the developed data extraction sheet.
They were asked to rate the items in the
formulated data extraction sheet using a
validation form that contains a 4-point rating
scale: 1=not relevant, 2=somewhat relevant,
3=quite relevant, and 4=highly relevant. An
open-ended question of “what other examination
tools should be in the data extraction sheet” was
also asked from the experts. An item in the data
extraction sheet must be unanimously rated as 4
in order for it to be included in the final draft.
8
Phase II: Interrater Reliability. Inter-rater
reliability was done before the actual chart
review process to remove potential information
bias and maintain uniformity. Using the validated
data extraction sheet, the first ten physical
therapy charts were reviewed by all of the
researchers for interrater reliability. Using
interclass correlation, the results were analyzed,
and the kappa score should not be lower than 0.8
to show a strong agreement among the
assessors.8
Phase III: Chart Review Process. All physical
therapy charts of patients with neck pain in the
selected hospitals and centers of Metro Manila
who agreed to be part of the study were
reviewed. Neck pain was defined as any to be a
disorder that is reported above the shoulder
blades.9 Charts that contained a diagnosis of
headaches, temporomandibular joint disorder,
sprain/strain, tumors, fractures, various
infectious diseases, inflammatory arthropathies,
and fibromyalgia.10
The inclusion criteria for the clinical audit were
the charts that contained the following
information: (1) all physical therapy charts from
June 1, 2015 to June 30, 2016, (2) physical
therapy charts of patients who had complaints of
any kind of neck pain; and (3) all physical
therapy charts of patients with neck pain who
were referred by the physician for examination
or who were admitted in the hospital. Charts
without documentation of complaints of neck
pain were excluded. Charts with incomplete data
in the documentation were also excluded.
The charts were then labeled with number codes
to ensure confidentiality. The validated data
extraction sheet was used to determine the
examination tools used.
Statistical Methods. All data were entered in
Microsoft Excel. Descriptive statistics, using
frequency tables, was used to analyze the data in
Microsoft Excel.
RESULTS
Phase I: Development and Validation of a
Data Extraction Tool for Chart Review. Out of
the total of 82,304 hits in databases searched,
only 100 articles were found to be relevant. Out
of the 100 articles, title and abstract filter were
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.003)
done. The articles included were those that were Table 1. Demographics
categorized Level I (Systematic Review) or II n*(total:706) %
(Randomized Control Trial) in the National Gender
Health and Medical Research Council (NHMRC) Male 262 37%
Female 444 63%
Evidence Hierarchy.8 After the title and abstract
Age
filter, only 16 articles were found to be relevant 20-30 115 16%
in the study. (Supplement A). 31-40 136 19%
The panel of experts reviewed the first draft of 41-50 159 23%
the data extraction sheet, and only the items 51-60 184 26%
61-70 72 10%
visual analogue scale (VAS), cervical range of
>70 40 6%
motion (CROM), and neck disability index (NDI) Note: n is Number
were unanimously graded as 4. The panel
recommended the addition of the items cervical Table 2. Results Using the Data Extraction Sheet
manual muscle testing (CMMT) and special tests. n (total: %
The final draft (Supplement B) included the 706)
recommendations, and all the items were then VAS Yes 382 54%
given a grade of 4 by the experts. No 324 46%
CROM Yes 154 22%
Phase II: Interrater Reliability. The first ten No 552 78%
charts were collected to check for interrater CMMT Yes 152 22%
reliability. The interrater reliability result was No 554 78%
96.7% percent or a kappa score of 0.97, showing Special Test Yes 27 4%
strong agreement among the six assessors.25 No 679 96%
NDI Yes 0 0%
Phase III: Chart Review Process. Out of the 26 No 706 100%
selected hospitals and centers, eight agreed to be Others
part of the study. A total of 20,249 charts was PA 83 6%
gathered, and out of this number, 706 charts met Palpation 131 15%
the inclusion criteria. Table 1 contained the FMT 2 1%
demographics of patients from the charts FA 5 1%
OI 6 2%
collected. The diagnoses of the charts included
Sensory Testing 51 7%
the following: cervical strain (10%), cervical FIM 4 1%
impingement (3%), cervical radiculopathy (8%), Movement analysis 1 0%
cervical spondylosis (29%), cervical stenosis Note. n is Number; VAS is Visual Analogue Scale; CROM is
(1%), muscle strain (23%), cervical herniated Cervical Range of Motion; CMMT is Cervical Manual Muscle
nucleus pulposus (3%), torticollis (2%) and Testing; NDI is Neck Disability Index; PA is Postural Analysis;
FMT is Functional Muscle Testing; FA is Functional Analysis;
myofascial pain syndrome (27%). OI is Ocular Inspection; FIM is Functional Index Measure
Table 2 and Figure 1 showed that majority of the
charts in the selected hospitals and centers DISCUSSION
utilized VAS the most, followed by CROM, CMMT,
The study findings showed that VAS was the
and special tests. NDI was not used in all of the
most commonly used neck pain examination
charts reviewed. There are a few charts that
tool. Many health care professionals utilize the
showed the use of other examination tools such
examination of pain as a basis for their
as postural assessment, palpation, functional
evaluation and treatment approach.26 According
muscle test, functional assessment, Functional
to Petala et al., VAS has good reliability and
Index Measure, ocular inspection, and sensory
validity, suited to parametric analysis, and is
testing.
easy to use.27 The use of VAS can be further
improved by taking into

9
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.003)

Figure 1. Presence of Examination Tools in the Charts Reviewed (Note: Figure 1 depicts that the
Visual Analogue Scale (VAS) was utilized the most in the examination of neck pain followed by
Cervical Range of Motion (ROM), Cervical Manual Muscle Test (MMT), and Palpation. Other
examination tools used but with lesser frequency were Postural Analysis (PA), Sensory Testing,
Special test, Ocular Inspection (OI), Functional Index Measure (FIM), Functional Muscle Testing
(FMT), and Movement Analysis. Neck Disability Index (NDI) was not used during neck examination in
the audit period.)

context the patient’s experience of pain, attitude
towards pain, experience of psychologic distress,
exhibited illness behaviors, and social
environment.2 Other measures of pain, such as
questionnaires including the psychological and
social aspects, can be recommended to make the
examination of a patient more holistic.2
Misailidou et al. recommended the use of CROM,
CMMT, and palpation because patients with neck
pain present with a decrease in range of motion
and strength compared to those with individuals
without neck pain. Patients with neck pain were
found to present with trigger points; this
necessitates the inclusion of palpation in the
examination.2 Our study showed that there was
only less than 30% utilization of these literature-
recommended examination tools. The reason
behind the gap can be further investigated in
future researches. One of the factors contributing
to non-usage could be the absence of a clinical
practice guideline in neck pain in the Philippines.
Our results were consistent with the findings
from separate studies done by Swinkels et al.,
Jette et al., and Biering-Sørensen et al., wherein
they found out that only a limited number of
measurement instruments is being used by
physical therapists.28, 29,30 The studies
investigated on the barriers for the limited use,
and these were the lack of knowledge,
insufficient integration in practice, and lack of
time, and no instruments available in practice. 28
To improve and promote the use of examination
tools, a training program can be designed. A
study by Dizon et al. showed that the use of a
contextually designed EBP training program for
Filipino physical therapists showed significant
gains in knowledge and skills.31
Newton-Brown et al. stated that implementation
of clinical audit could contribute to the
improvement in the process of patient
examination. The study showed that there was
departmental change in the process of patient
examination after an audit. This process
produced new medical and nursing
documentation in the patients’ charts.32 The
conduct of this clinical audit should hopefully

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 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.003)
improve the examination process of neck pain in
the selected hospitals and centers in Metro
Manila.
Limitations and Recommendations. To avoid
confirmation bias, the authors would like to
emphasize that the method of the study was
purely observational. It did not investigate the
possible reason for the usage or non-usage of
certain neck examination tools. It did consider
the current knowledge, skills, and attitudes of
the physical therapists towards EBP.
For future studies, it is recommended to identify
the reasons of the physical therapists as to how
and why they choose to use a certain
examination tool, the barriers from using these
tools, and if they are encouraged or given
training in using outcome-measure
tools. Training of physical therapists and an audit
is also recommended to check if training can
change physical therapists' behavior towards
EBP.
Since our study only included non-specific neck
pain conditions, it is also recommended to
determine the recommended examination tools
for specific conditions or diagnosis of neck pain.
CONCLUSION
VAS was the most commonly used literature-
recommended examination tool in the
examination of neck pain in selected hospitals
and clinics in Metro Manila. There was only less
than 30% utilization of the recommended
examination tools in neck pain.
Individual Author’s Contributions
Ms. Arlene C. Chiong Maya and Mr. Christopher
G. Cruz conceptualized the study design.
All authors performed data collection, analyzed
the data, drafted and revised the manuscript,
gave final approval of the version to be
submitted for publication and agreed to be
accountable in all aspects of the manuscript.
Disclosure Statement
The authors have nothing to disclose.
11
Conflicts of interest
The authors of this paper declare no conflicting
interest.
Supplementary Materials
Supplementary Material A. Results of the
Literature Search
Supplementary Material B. Data Extraction Sheet
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 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.004)

Original Article
The Relevant Anatomy of the Biceps Tendon When Performing Tenodesis in Filipino
Cadaveric Specimens
Martin Louie Bangcoy1, Charles Abraham Villamin1, Chino Ervin Tayag1, Patrick Henry Lorenzo1
1 Department of Orthopedics, University of Santo Tomas Hospital, Manila, Philippines

Correspondence should be addressed to: Martin Louie Bangcoy1; martinlouiebangcoy@gmail.com

Article Received: October 1, 2020
Article Accepted: December 2, 2020
Article Published: February 14, 2021 (online)
Copyright © 2021 Bangcoy et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: Biceps tenodesis is a technique frequently performed in shoulder surgeries. Various techniques have been described, but there is no
consensus on which technique restores the length-tension relationship. Restoration of the physiologic length-tension relationship has been
correlated to better functional outcomes, such as decreased incidence of residual pain or weakness of the biceps. The objective of this study was to
measure the anatomic relationship of the origin of the biceps tendon with its zones in the upper extremity. This would provide an anatomic guide
or an acceptable placement of the tenodesis to reestablish good biceps tension during surgery. Methods: The study used nine adult cadavers (five
males, four females) from the [withheld for blinded review]. Nine shoulder specimens were dissected and markers were placed at five points along
each biceps tendon: (1) Labral origin (LO) (2) Superior bicipital groove (SBG) (3) Superior border of the pectoralis tendon (SBPMT) (4)
Musculotendinous junction (MTJ) and (5) Inferior border of the pectoralis tendon (IBPMT). Using the origin of the tendon as the initial point of
reference, measurements were made to the four subsequent sites. The humeral length was recorded by measuring the distance between the greater
tuberosity and the lateral epicondyle as well as the tendon diameter at the articular surface. Results: The intraclass correlation coefficient was
excellent across all measures. A total of nine cadavers were included. Mean age of patients was 66.33 years old, ranging from 52-82 years old. These
were composed of five male and four female cadavers. The mean tendon length was 24.83mm ± 4.32 from the origin to the superior border of the
bicipital groove, 73.50mm ± 6.96 to the Superior Border Pectoralis Major Tendon, 100.89mm ± 6.88 to the Musculotendinous Junction, and
111.11mm ± 7.45 to the Inferior Border Pectoralis Major Tendon. The mean tendon diameter at the articular origin was 6.44mm ± 1.76. Conclusion:
This study provided measurement guidelines that could restore the natural length-tension relationship during biceps tenodesis using the
interference screw technique in Filipinos. A simple method of restoring a normal length-tension relationship is by doing tenodesis close to the
articular origin and creating a bone socket of approximately 25mm in depth, using the superior border of the bicipital groove as a landmark.
Keywords: long head of the biceps tendon, biceps tenotomy, biceps tenodesis

INTRODUCTION
Lesions of the long head of the biceps tendon
(LHBT) are common shoulder pathologies that
can result to persistent pain and functional
impairment. LHBT lesions can be isolated but are
frequently associated with complex shoulder
conditions, such as shoulder instability or rotator
cuff tears. The decision of whether to do
conservative or surgical management of LHBT
lesions might depend on the associated shoulder
pathology and the chronicity of symptoms.1
Surgery is indicated for isolated biceps
tendinitis, subluxation or tears, concomitant
subscapularis tendon repair, pain associated
with massive rotator cuff tears, and some
Superior Labrum Anterior and Posterior (SLAP)
lesions.2, 3 Treatment can be tenotomy or
tenodesis. Tenotomy is simpler but has been
associated with deformity due to distal
migration, fatigue with resisted elbow flexion,
and supination strength loss.4 Tenodesis, on the
other hand, is associated with improved
cosmesis, lower rates of deformity, weakness
with supination, and continued spasm requiring
reoperation.2

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 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.004)
Tenodesis of the biceps tendon is a common
procedure performed for shoulder pathology.
Multiple surgical tenodesis techniques have been
described. However, little consensus exists about
which technique best reproduces the physiologic
length-tension relationship found in the native
shoulder. There are few papers that studied the
anatomy of the biceps tendon and the optimal
tenodesis position to restore length-tension
relationship.
In one study, they recommended that for
arthroscopic suprapectoral tenodesis using
interference screws, the superior border of the
bicipital groove is an effective landmark for
tenodesis. They have recommendations
regarding the amount of tendon that can be
resected and the ideal location for tenodesis
(both arthroscopic and subpectoral) to restore
the normal length-tension relationship.7
However, no study has been done on
Asian/Filipino cadavers. Therefore, the
recommended measurement guidelines cannot
be applied in our setting. With this in mind, this
anatomic study specifically investigated the
length and possibly, the optimal location for
biceps tenodesis in Filipinos. The resting tension
produced by the tenodesis may lead to
unfavorable clinical outcomes that depend on
this said location. We hypothesized that the
length and diameter of the biceps tendon would
differ between male and female specimens.
METHODOLOGY
Upon approval from The University of Santo
Tomas – College of Rehabilitation Sciences Ethics
Review Committee, nine embalmed cadavers
were dissected for analysis. There were five male
and four female cadavers used in this study.
There were nine right-sided and nine left-sided
shoulders included.
All dissections were performed by one of two
examiners: a fellowship-trained shoulder
specialist or a fellowship-trained joint/tumor
specialist and a senior orthopedic resident.
Each specimen was composed of the shoulder
girdle, clavicle, scapula, and all accompanying
soft tissue structures, from the arm down to the
hand.
14
Dissection started with the excision of skin and
subcutaneous tissue from the anterior half of the
shoulder, distally to the elbow. A standard
deltopectoral approach was used. The insertion
of the pectoralis major tendon was left intact and
uninjured. The humeral insertion of the
pectoralis tendon was used as a landmark.
Removing the anterior half of the deltoid
exposed the rotator cuff. The cuff was ensured
intact and free of any pathology (e.g., rotator cuff
tears, evidence of prior arthroscopic surgery).
Next, the biceps tendon was identified and used
as a reference point to develop the rotator
interval. Some parts of the supraspinatus and
subscapularis tendon were released at their
insertions to permit enhanced visualization of
the biceps tendon and its course from the labral
origin to the intertubercular groove.
The measurement technique was adapted from
the study of Kovack, Idoine and Jacob.7 Figure 1a
showed the specific locations along the biceps
tendon where tagging sutures and pins were
placed to enable anatomic length measurements.
(1) Labral origin (LO) (2) Superior bicipital
groove (SBG) (3) Superior border of the
pectoralis tendon (SBPMT) (4)
Musculotendinous junction (MTJ) and (5)
Inferior border of the pectoralis tendon (IBPMT).
All measurements were done twice by two
examiners to determine similarity in
measurements. Measurements were taken based
on the corresponding landmarks as seen on
Figure 1a.
The total biceps tendon length (TTL) was
measured from the labral origin to the
musculotendinous junction (LO-MTJ). Next, the
distance from the labral origin to the superior
biceps groove (LO-SBG) was measured. This
measurement was taken laterally to the articular
margin of the humeral head at the superior
aspect of the bicipital groove, just before it
transitioned inferior and distal. Next, the
superior and inferior borders of the pectoralis
major tendon were identified. Measurements
from the labral origin (LO to the
musculotendinous junction (LO-MTJ), superior
border of the pectoralis major tendon (LO-
SBPMT), and inferior border of the pectoralis
major tendon (LO-IBPMT) were obtained. These
values were then gathered from the biceps MTJ
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.004)
Figure 1a. Location landmarks in relation to the long
head of the biceps tendon (LHBT). (A) Labral Origin (LO);
(B) Super Bicipital Groove (SBG); (C) Superior Border of
the Pectoralis Tendon (SBPMT); (D) Musculotendinous
Junction (MTJ); (E) Inferior border of the pectoralis
tendon (IBPMT).
Figure 1. Location landmarks in relation to the long head of the biceps tendon.
to the inferior (MTJ-I) and superior (MTJ-S)
borders of the pectoralis tendon by subtracting
the measurements gathered from above (MTJ –
SBPMT) (IBPMT – MTJ). The diameter of the long
head biceps tendon was also determined from its
articular origin accordingly. Lastly, the distance
between the greater tuberosity and the lateral
epicondyle measured the humeral length. All
measurements were tabulated as seen on Table 2
(Length of Biceps Tendon from Origin to
Anatomic Landmark and Tendon diameter at
labral origin).
Statistical Analysis. Data were encoded in MS
Excel 2016 by the researcher. Stata MP version
14 software was used for data processing and
analysis. The Intraclass correlation coefficient
(ICC) for absolute agreement was utilized to
assess the reliability between the two outcome
assessors. Depending on the ICC value, the
agreement was rated as excellent (>0.75), good
(0.60-0.74), moderate (0.40-0.59), or poor
(<0.40).5 The average measure of the two
15
Figure 1b. Cadaveric set up during dissection showing
the location landmarks in relation to the long head of the
biceps tendon as pinned. (Green) Labral Origin (LO);
(White) Super Bicipital Groove (SBG); (Red) Superior
Border of the Pectoralis Tendon (SBPMT); (Blue)
Musculotendinous Junction (MTJ); (Yellow) Inferior
border of the pectoralis tendon (IBPMT).
outcome assessors was used for the analysis.
Continuous variables were presented as mean/
standard deviation (SD) while categorical
variables were presented as
median/interquartile range (IQR) depending on
data distribution. An Independent t-test was
used to compare the continuous variables by sex.
Paired t-test was used to compare the
continuous variables by laterality (left/ right).
Correlation between humeral length and each
tendon length was determined using Pearson’s
correlation coefficient (r). Correlation coefficient
was interpreted as follows: 0.90-1.00: very high,
0.70-0.90: high; 0.50-0.70: moderate; 0.30-0.50:
low; 0-0.30: negligible. values ≤0.05 were
considered statistically significant.6
RESULTS
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.004)
The intraclass correlation coefficients were 111.11mm ± 7.45 to the Inferior Border
excellent across all measures (Table 1). Pectoralis Major Tendon. The mean tendon
diameter at the labral origin was 6.44mm ± 1.76
A total of nine cadavers were included. The mean
and did not show a difference between male and
age of patients was 66.33 years old, ranging from
female specimens. Moreover, measures across
52-82 years old. It composed of five male and
all borders showed no statistically significant
four female cadavers. The overall length of the
difference by sex and laterality as seen in Table 3
biceps tendon from the origin to every anatomic
(comparison of measures by sex) and Table 4
landmark was illustrated in Table 2.
(comparison of measures by laterality).
The mean tendon length was 24.83mm ± 4.32
Furthermore, the total length of the biceps
from the origin to the superior border of the
tendon had a high negative correlation to tendon
bicipital groove, 73.50mm ± 6.96 to the Superior
diameter as demonstrated on the scatterplot
Border Pectoralis Major Tendon, 100.89mm ±
matrix (Figure 4).
6.88 to the Musculo-tendinous Junction, and

Table 1. Intraclass correlation coefficient between two outcome assessors.

VARIABLES ICC (95% CI)
Superior Border Bicipital Groove- Right 0.80 (0.25 – 0.95)
Superior Border Bicipital Groove- Left 0.79 (0.36 – 0.95)
Superior Border Pectoralis Major Tendon- Right 0.81 (0.03 – 0.96)
Superior Border Pectoralis Major Tendon- Left 0.91 (0.66 – 0.98)
Musculo-tendinous Junction- Right 0.82 (0.27 – 0.96)
Musculo-tendinous Junction- Left 0.76 (0.21 – 0.94)
Inferior Border Pectoralis Major Tendon- Right 0.79 (0.36 – 0.95)
Inferior Border Pectoralis Major Tendon- Left 0.76 (0.22 – 0.94)
Humeral Length- Right 1.00 (0.97 – 1.00)
Humeral Length- Left 0.99 (0.72 – 1.00)
Tendon Diameter at Articular surface- Right 0.96 (0.85 – 0.99)
Tendon Diameter at Articular surface- Left 0.96 (0.85 – 0.99)

Table 2. Length of Biceps Tendon from Origin to Anatomic Landmark and Tendon diameter at labral origin
(n=9)
VARIABLES Range
Mean ± SD
Superior Border Bicipital Groove 24.83 ± 4.32 24 – 30
Superior Border Pectoralis Major Tendon 73.50 ± 6.96 61.50 – 82.50
Musculo-tendinous Junction 100.89 ± 6.88 90 – 105.2
Inferior Border Pectoralis Major Tendon 111.11 ± 7.45 101.50 – 122.50
Tendon Diameter at Articular surface 6.44 ± 1.76 5 – 11
Humeral Length 267.22 ± 42.36 162.50 – 300

16
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.004)
Table 3. Comparison of measures by sex (n=9)
MALE FEMALE
VARIABLES (n=5) (n=4) P VALUEa
Mean ± SD Mean ± SD
Superior Border Bicipital Groove- Right 24.50 ± 2.74 22.25 ± 6.28 0.8150
Superior Border Bicipital Groove- Left 24.20 ± 3.88 22.25 ± 4.37 0.7138
Superior Border Pectoralis Major Tendon- Right 73.30 ± 5.73 72 ± 7.49 0.1944
Superior Border Pectoralis Major Tendon- Left 73.80 ± 7.55 72.50 ± 6.42 0.1492
Musculo-tendinous Junction- Right 100.20 ± 98.75 ± 5.92 0.7610
8.19
Musculo-tendinous Junction- Left 100.60 ± 99.75 ± 5.25 0.6009
4.87
Inferior Border Pectoralis Major Tendon- Right 111.20 ± 111 ± 7.95 0.9712
7.97
Inferior Border Pectoralis Major Tendon- Left 107 ± 5.39 108.38 ± 0.8144
11.24
Tendon Diameter at Articular surface- Right 6.10 ± 0.22 6.88 ± 2.78 0.5474
Tendon Diameter at Articular surface- Left 6.40 ± 0.42 7.00 ± 2.71 0.6346
Humeral Length- Right 288.50 ± 240.63 ± 0.0906
12.20 53.75
Humeral Length- Left 282.50 ± 240.63 ± 0.1240
8.10 53.75
aIndependent t-test was used
12

12
Tendon Diameter (left)
10

Tendon Diameter (right)10

8

8
6

6
4

150 200 250 300 150 200 250 300

Humeral length (left) Humeral length (right)

Figure 4a. Humeral length is significantly correlated with Figure 4b. Humeral length is significantly correlated with
tendon diameter in the left side (r = -0.8417; p value = tendon diameter in the right side (r = -0.8584; p value =
0.0044). A high negative correlation was observed between 0.0031). A high negative correlation was observed between
the two measures. the two measures.
Figure 4. Scatterplot matrix of Humeral length and Tendon Diameter (a) Left; (b) Right

DISCUSSION
The purpose of this study was to postulate However, restoring the length-tension
anatomically based values of the normal length relationship can be challenging when using this
of the biceps tendon and possibly, provide technique. The information gathered in this
surgical recommendations for LHBT tenodesis study could help restore the length-tension
based on the findings. relationship during biceps tenodesis using the
interference screw technique.
Biceps tenodesis using an interference screw has
been reported to be strongest biomechanically.7,8

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 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.004)
In performing biceps tenodesis using an Based on the mean tendon length at this area, no
interference screw, a bone tunnel or socket was tendon resection was needed because the
created to contain the length of the screw. The tendon's length remaining after tenotomy at this
tip of the tendon was contained at the bottom of level matched the length of the interference
the bone tunnel, adjacent to the interference screw. Hence, doing tenodesis at the articular
screw. Hence, to be able to restore the length- margin was the preferred choice by most
tension relationship of the biceps tendon, the surgeons.
length of the tendon and length of the screw was
However, restoring the length-tension
considered. Tendon length was attributed to its
relationship was more complex with a distal
anatomic location and the length of tendon
tenodesis because both tendon length and screw
resected. Screw length was flexible and
length changed. In performing subpectoral
established the depth of the bone tunnel, as well
tenodesis, the goal was to position the
as the depth of tendon insertion. In this paper,
musculotendinous junction of the biceps at the
the length of the biceps tendon from the articular
lower border of the pectoralis major. In an
origin of the proximal humerus to the bicipital
anatomic study by Jarrett, McClelland and
groove was at 24.83mm ± 4.32. Therefore, if
Xerogeanes,11 it was established that the
biceps tenotomy will be done at the level of the
musculotendinous junction of the biceps was at
glenoid margin for tenodesis, creating a 25mm
approximately 22mm distal to the upper border
bone tunnel at the superior border of the
of the pectoralis major tendon and 31mm
bicipital groove would restore the length-tension
proximal to the lower border of the pectoralis
relationship. With this in mind, a 23mm
major tendon. Moreover, in a paper by Denard et
interference screw was suitable to allow for
al.,10 the musculotendinous junction was
2mm of the tendon at the tip of the screw within
determined 25mm distal to the superior border
the bone tunnel. (Figure 2 Biceps tenodesis
of the pectoralis major tendon and
above the bicipital groove, adjacent to the
approximately 20mm proximal to the lower
articular margin of the humeral head).
border of the pectoralis major tendon.
This is in line with a study by Denard et al.,10,
In this study, the musculotendinous junction was
which used the superior border of the bicipital
approximately 27mm distal to the upper border
groove as an effective landmark in performing
of the pectoralis major tendon and 12mm
tenodesis. In reference to this paper, the mean
proximal to the lower border of the pectoralis
length of the biceps tendon from the labral origin
major tendon. The measurements obtained were
was at 25mm. Therefore, doing a tenotomy at the
different from the abovementioned studies since
level of the glenoid for tenodesis, which created a
the specimens used were amputated above the
25mm bone socket, restored length-tension
elbow that could have affected the values. For
relationship. As a result, a 23mm interference
this study, the cadaveric specimens included the
screw was used to allow for 2mm of the tendon
entire arm from the scapula to the hand. This
to remain at the tip of the screw. The authors
possibly helped us obtain more accurate
further stressed the advantage of doing
measurements. It showed that to restore the
tenodesis at this location. Based on the mean
normal biceps length-tension relation, a
tendon length at this area, no tendon resection
subpectoral tenodesis should be performed
was needed because the tendon's length from the
above the lower border of the pectoralis major
labral origin was at 25mm. Therefore, doing a
tendon, approximately 12mm proximal to the
tenotomy at the level of the glenoid for
lower border of the pectoralis major tendon. For
tenodesis, which created a 25mm bone socket,
example, if a 10-15mm interference screw will
restored length-tension relationship. As a result,
be utilized, 10 to 15mm of biceps tendon should
a 23mm interference screw was used to allow for
be removed, and the tendon should be 12mm
2mm of the tendon to remain at the tip of the
proximal to the lower border of the pectoralis
screw. The authors further stressed the
major tendon (Figure 3).
advantage of doing tenodesis at this location.

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 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.004)

Figure 2. Biceps tenodesis above the bicipital groove, adjacent to the articular margin of the humeral head. (A) The normal
biceps tendon averages 25mm in length from its origin to the humeral head. (B) The tenotomy site (arrow) at the level of the
glenoid. (C) a bone socket is created adjacent to the articular margin of humeral head, and the tendon is secured in this socket
with a interference screw. As shown in the inset, allowing for 2mm of tendon to be at the tip of the screw, a 23 mm long
interference screw at this location will maintain the length-tension relation of the biceps because the native tendon is 25mm long
from its origin to this location of tenodesis. (PMT pectoralis major tendon).

Figure 3. The proper location for a subpectoral tenodesis. (A) the musculotendinous junction (MTJ) of the long head of the biceps
tendon is located beneath the pectoralis major tendon (PMT). The MTJ is approximately 27mm below the upper border of the
PMT and 12mm above the lower border of the PMT. (B) The tenotomy site (arrow) at the level of the glenoid, and a proximal
portion of the tendon is resected until there is only 15mm of tendon remaining above the MTJ. (C) A bone socket is created 12mm
above the lower border of the PMT, and the tenodesis is performed at this location to maintain the normal position of the biceps
tendon. As shown in the inset, a 12mm long interference screw at this location will allow for a small amount of tendon at the base
of the screw and maintain the length-tension relation of the biceps

This study also provided anatomic diameters of to 7mm diameter interference screw would be
the biceps tendon at the labral origin measured appropriate at this level.
at 6.44mm ± 1.76 with no difference seen by sex
This study also demonstrated that there were no
and laterality. Biomechanically, the smallest
differences in tendon length and diameter at the
diameter screw was recommended.11 Taking into
labral origin across gender and laterality. This
mind the suture preparation of the biceps tendon
was consistent in a study by Hussain et al.15 and
(whipstitch placement) slightly increased its
Denard et al.10 that showed no difference in
diameter. In most cases, a 7 to 8mm diameter
mean length of the long head of the biceps
interference screw was suitable when doing
tendon between male and female specimens.
tenodesis at the proximal humerus. If no suture
Furthermore, this paper demonstrated a
preparation were done to the biceps tendon, a 6
negative correlation between humeral length

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 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.004)
and tendon diameter. A longer humeral length
resulted in a decreased tendon diameter.
The strength of this study was that it provided
guidelines for surgeons regarding the amount of
tendon to be resected. It also demonstrated the
ideal location for tenodesis, which would help in
restoring the anatomic relationship of the biceps
tendon. This would be theoretically appealing
since complications such as pain and fixation
failure were known complications after
tenodesis. These can be ideally minimized if the
length-tension relationship was regained. In
addition, using the specimens that included the
entire arm and scapula improved the
measurements obtained in this study. Since
Filipino cadaveric specimens were utilized, these
results were deemed applicable in the local
setting. Furthermore, this study will provide an
in-depth explanation of how to perform biceps
tenodesis. It can help further broaden the
knowledge of allied health professionals to help
in their practice.
This study presented several limitations. The
tendon measurements may not apply to all cases
since histopathology reports were
undetermined. Moreover, the study did not
consider tendon measurements after tendon
preparation that may affect the tendon diameter.
The small sample size is also a limitation. More
cadaveric specimens must be included if another
similar study will be conducted in the future.
CONCLUSION
This study provided measurement guidelines
that could restore the natural length-tension
relationship during biceps tenodesis in Filipinos.
A simple method to restore the normal length-
tension relationship is to do tenodesis close to
the articular origin and by creating a bone socket
25mm in depth. However, tenodesis at a more
distal location varies depending on the tendon
length and depth of the bone tunnel.
Individual Author’s Contribution
C.V., C.T., P.L.; conceptualized the study, helped in
drafting and revising study content, substantially
contributed to design of work and acquisition of
data, and helped in revision of content
20
Disclosure Statement
The authors have no disclosures for this paper.
Conflicts of Interest
The authors of this paper declare no conflicting
interest.
Acknowledgements
This paper was supported by the University of
Santo Tomas Hospital Department of
Orthopedics. We are thankful to Dr. Jeremy
James C. Munji who provided his expertise that
greatly contributed the research. We are also
grateful to the University of Santo Tomas College
of Rehabilitation Sciences for giving is the
opportunity to use their cadaveric specimens for
this research.
References
1. Galasso O, Gasparini G, De Benedetto M, Familiari F,
Castricini R. Tenotomy versus tenodesis in the
treatment of the long head of biceps brachii tendon
lesions. BMC Musculoskeletal Disorders. 2012;13: 205.
2. Boileau P, Baqué F, Valerio L, Ahrens P, Chuinard C,
Trojani C. Isolated arthroscopic biceps tenotomy or
tenodesis improves symptoms in pateints with massive
irreperable rotator cuff tears. The Journal of Bone &
Joint Surgery. 2007; 89:747-757.
3. Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D,
Bicknell R. Arthroscopic treatment of isolated type II
SLAP lesions: Biceps tenodesis as an alternative to
reinsertion. The American Journal of Sports Medicine.
2009; 37:929-936.
4. Kelly AM, Drakos MC, Fealy S. Taylor SA, O’Brien SJ.
Arthroscopic release of the long head of the biceps
tendon: Functional outcome and clinical results. The
American Journal of Sports Medicine. 2005; 33:208-
213.
5. Fleiss JL, Levin B, Paik MC. Statistical methods for rates
and proportions. 3rd ed.New Jersey: John Wiley &
Sons, Hoboken. 2013.
6. Mukaka MM. A guide to appropriate use of correlation
coefficient in medical research. Malawi Medical
Journal: The Journal of Medical Association of Malawi.
2012; 24(3): 69-71.
7. Kovack T J, Idoine JD, Jacob PB. Proximal biceps
tenodesis: An anatomic study and comparison of the
accuracy of arthroscopic and open techniques using
interference screws. Orthopaedic Journal of Sports
Medicine. 2014; 2(2): 2325967114522198.
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.004)
8. Ozalay M, Akpinar S, Karaeminogullari O, et al.
Mechanical strength of four different biceps tenodesis
techniques. Arthroscopy. 2005; 21:861-866.
9. Richards DP, Burkhart SS. A biomechanical analysis of
two biceps tenodesis fixation techniques. Arthroscopy.
2005; 21:861-866.
10. Denard, PJ, Dai X, Hanypsiak B T, Burkhart SS. Anatomy
of the biceps tendon: implications for restoring
physiological length-tension relation during biceps
tenodesis with interference screw fixation.
Arthroscopy. 2012; 28(10), 1352-1358.
11. Jarrett CD, McClelland WB Jr, Xerogeanes JW. Minimally
invasive proximal biceps tenodesis: An anatomical
study for optimal placement and safe surgical
technique. Journal of Shoulder and Elbow Surgery.
2011; 20:477-480.
12. Slabaugh MA, Frank RM, Van Thiel GS, et al. Biceps
tenodesis with interference screw fixation: A
biomechanical comparison of screw length and
diameter. Arthroscopy. 2011; 27:161-166.
13. Brasseur JL. The biceps tendons: From the top and
from the bottom. Journal of Ultrasound. 2012; 15(1),
29-38.
14. Elser F, Braun S, Dewing CB, Giphart JE, Millet OJ.
Anatomy, function injuries and treatment of the long
head of the biceps brachii tendon. Arthroscopy. 2011;
27(4), 581592.
15. Hussain WM, Reddy D, Atanda A, Jones M,
Schickendantz M, Terry MA. The longitudinal anatomy
of the long head of the biceps tendon and implications
on tenodesis. Knee Surgery Sports Traumatology
Arthroscopy. 2015; 23(5),1518-1523.
16. Lafrance R, Madsen W, Yaseen Z, Giordano B, Maloney
M, Voloshin, I. Relevant anatomic landmarks and
measurements for biceps tenodesis. The American
Journal of Sports Medicine. 2013; 41(6), 1395-1399.

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Short Report
Impact of COVID-19 Pandemic in Filipino Occupational Therapy Practice Across Regions
Rod Charlie Delos Reyes1, Karla Czarina Tolentino1, Wendy Sy2
1 Philippine Academy of Occupational Therapists, Inc., Philippines; 2University of Perpetual Help System JONELTA - Biñan, Philippines

Correspondence should be addressed to: Rod Charlie Delos Reyes1; delosreyes.rodcharlie@yahoo.com

Article Received: October 3, 2020
Article Accepted: November 30, 2020
Article Published: February 14, 2021 (online)
Copyright © 2021 Delos Reyes et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
The Philippine Government has implemented community quarantine throughout the country to respond to the COVID-19 pandemic that has since
profoundly affected the lives, health, and well-being of individuals, families, and communities. This has also created an impact on the practice of
occupational therapy in the country as the pandemic presents occupational disruptions in the new normal. This paper summarizes the current
conditions of the practice of occupational therapy in times of the unprecedented disaster highlighted by the COVID-19 crisis and the situation of
practitioners and recipients of service across the regions of the country. Findings conclude that there are: (1) emerging delivery service patterns,
(2) consequences of COVID-19 to therapists, and (3) insights moving forward.

Keywords: COVID-19, occupational therapy, Philippines, chapters

INTRODUCTION
In light of the worldwide spread of the
coronavirus disease (COVID-19), the Philippine
government has aimed to mitigate its
socioeconomic and health impacts by declaring
different levels of community quarantine
throughout the country, all of which have
significant consequences on the lives, health, and
well-being of Filipinos.1,2 The country’s
community quarantine measures, which are
among the longest-lasting in the world,3
consisted of social distancing, cessation of the
operations of non-essential institutions and
entities, restrictions of any form of travel, among
others.
For occupational therapists in many parts of the
world, this is an unprecedented time that
evolves every day, and this may significantly
affect how people participate in their
occupations, or the activities that they do—as an
individual, in families, and with communities—
to occupy time and bring purpose and meaning
to life.4 This is important because the core of
occupational therapy practice is the task of
ensuring that everyone, from all walks of life
with different levels of ability and independence,
is able to perform and participate in meaningful
activities in the environment where they are in.
In the Philippines, the wide-scale impact of the
pandemic becomes even more complex for
persons with disabilities because of prevailing
attitudinal, institutional, and environmental
barriers. This prompted the Philippine Academy
of Occupational Therapists, Inc. (PAOT), as the
professional organization of occupational
therapists in the country, to release in May 2020
the Board Resolution 2020-003 (or the Interim
Guidelines on the practice of Occupational
Therapy amidst the Coronavirus Disease (COVID-
19) situation in the Philippines) to provide
guidance and recommendations to its members

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 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.005)
and recipients of service to ensure the safety of
all while providing or receiving quality
occupational therapy services.5 In support of
this, the chapters of the organization have been
instrumental in disseminating information,
upholding, enforcing, and monitoring practice
standards and ethics, as well as serving as
linkages to regions outside Metro Manila,
especially during these difficult times.6
This paper aims to synthesize all the
information that has been gathered from the
recognized and potential chapters across the
country in an effort to understand the overall
impact of the COVID-19 pandemic with regards
to the occupational therapy practice in the
Philippines.
PARTICIPANTS AND SETTING
Currently, there are four recognized chapters
and three potential chapters (organized groups
of occupational therapists in a region applying
for official recognition from PAOT). In this paper,
both recognized and potential chapters are
considered as PAOT chapters. Information
gathering was done during July 2020, four
months after the implementation of community
quarantine in different areas of the country.
More than a third of the participants are
practicing in pediatrics based on the data
analyzed.
APPROACH
Upon the approval of the PAOT Board of
Directors, the Committee on Chaptership tasked
each PAOT chapter to assess its members on the
impact of COVID19 through remote surveys and
online discussions. Questions such as, but not
limited to, “What are the impact of COVID-19 on
their lives and service recipients?”, “How was the
experience of service delivery during the
pandemic?” and “How do they see their future
after the pandemic?” guided their surveys. It was
ensured that all participants were asked for
verbal or written consent before participating in
each survey as it was assured that participation
is voluntary and would not affect standing with
PAOT. Each chapter was asked to submit reports
with no strict format or template, which included
summarized narratives of their surveys,
23
anecdotes from some participants, and raw
survey results. Because all findings are based
only on the submissions of each chapter, the data
analyzed may not necessarily indicate the
prevailing situation across the entire nation and,
as such, should be taken with caution.
In this paper, a secondary analysis was utilized
to synthesize the overall impact of the COVID-19
pandemic with regards to the occupational
therapy practice in the Philippines across
regions. To wit, secondary analysis is a cost-
effective and useful method when there is
already available data, such as summarized
reports.7 All these reports were compiled by the
first author, and only the number of participants
was clarified with each chapter. The compilation
was the sole set of data analyzed through
thematic analysis following the six-step process
proposed by Caulfield: familiarization, coding,
generating themes, reviewing themes, defining
and naming themes, and writing up.8 The first
and last authors conducted independent coding
and the generation of preliminary themes. All
participated in the finalization of the themes to
ensure rigor.
Table 1. Participants of the Remote Surveys and Online
Discussions
Online Online
Chapter
Survey Discussions
Central Luzon 35 *
Central Visayas 3 *
Mindanao 7 *
National Capital Region 18 19
Southern Tagalog 17 15
Western Visayas 3 8
*No discussion was done
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.005)
FINDINGS
Three themes emerged: (1) Emerging service
delivery service patterns, (2) Consequences of
COVID-19, and (3) Moving forward (see Table 2).
Emerging Service Delivery Patterns
Shift to Teletherapy. The ongoing worldwide
crisis has made Filipino occupational therapists
abruptly shift to teletherapy, an action made by
necessity and not by choice. Teletherapy is a
service model that has been utilized in other
countries since the late 1990s but was an
unpopular mode of service delivery in the
Philippines even before the pandemic. For many
Filipino occupational therapists, teletherapy has
its appeal (subtheme 1.1) and drawbacks
(subtheme 1.2) (see Table 3).
New Normal in the Clinical Setting. For some
participants who resumed face-to-face therapy
sessions in clinics, hospitals, and other facilities,
they also had to make adjustments with their
practice delivery. Health sectors and companies
had to look into the redesign and construction of
facilities to encourage air circulation, training of
healthcare workers on infection prevention and
control, sourcing of personal protective
equipment (PPE), and the optimal settings for
care delivery and how it is reimbursed (e.g.
online and mobile payments).9 But even with
these precautions, a majority of the participants
expressed anxiety and uncertainty on the levels
of safety at work, especially for those who have
children or elderly parents at home and are also
burdened with other responsibilities outside of
direct patient care.
Another major source of worry for many
participants is the risks associated with in-
person therapy services. Although rehabilitation
professionals are considered as essential
healthcare workers or front-liners,10 therapists
who are working in private clinics are not
compensated with hazard pay. In addition, there
are still no definitive guidelines published by
PAOT or any government agency for a safe
return to private therapy centers, which left
many clinic owners and managers scrambling to
come up with their own protocols to support
clinic-based practice. Adding to the confusion is
the unclear standards for therapy centers to re-
open, as local government units have
implemented varying policies when it comes to
health and safety protocols. This makes it
difficult for clinic owners and managers to find
and utilize a model to help comply with these
standards.
Threats to Practice. Before the pandemic, there
were some individuals that can be identified as
pseudo-professionals, who have represented
themselves as legitimate therapists without the
necessary educational background and clinical
training required to practice occupational
therapy. Unfortunately, there have been more
reports of pseudo-professionals surfacing in the
provinces and rural areas during these times,
where the public may not have access to
information that can protect them from

Table 2. Impact of COVID19 in Philippine Occupational Therapy Practice

Theme 1: Emerging Service Delivery Patterns

1.1 Shift to Teletherapy 1.2 New Normal in the Clinical 1.3 Threats to Practice
Setting
1.1.1 Benefits
1.1.2 Obstacles

Theme 2: Consequences of COVID-19 to Therapists

2.1 Decreased Financial 2.2 Rising Mental Health 2.3 Activity Engagement as a Coping
Security Concerns Mechanism

Theme 3: Moving Forward

3.1 Challenges and Opportunities 3.2 Professionals in the Future

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Table 3. Benefits and Obstacles of Utilizing Teletherapy in the Philippines
1.1 Benefits
• An ideal way to deliver care without
endangering patients and their caregivers
• Allows for treatment within a service
recipient’s natural environment
• Increases parental or caregiver satisfaction
• Increases family involvement
• Effective therapy option for specific
populations
fraudulent practices. They have become a more
common choice for service recipients because
they offer cheaper rates. However, they do not
guarantee effective and evidence-based
intervention and only pose an alarm to the
health and safety of the public that they attempt
to serve.
Consequences of COVID-19 to Therapists
Decreased Financial Security. The majority, if
not all, participants shared that they were
eventually forced to downsize their lifestyles and
re-evaluate their financial priorities, or to go
back to being dependent on their families
because of lack of work. Most of the participants
were consultants before the pandemic who were
paid per therapy session, and many of them do
not have the same financial benefits that
employees enjoy, such as health insurance and
fixed monthly income. This meant additional
financial burden when it comes to COVID-19
testing and possible hospitalizations if they
contract the virus, special transportation
expenses (because cheaper public transportation
is limited), and purchasing the needed PPE for
work.11 To augment their income, some
participants have gone into other ventures, such
as opening home-based and retail businesses,
creating therapy and educational materials for
sale, or even entering an unrelated industry
altogether.
Rising Mental Health Concerns. Because not
much is known about the novel coronavirus
25
1.2 Obstacles
• Described as hectic, draining, and a struggle
• The lack of available and skilled caregivers
at home
• Increased demand to plan and create or
search for all activity materials needed for a
session ahead of time
• Preparations before sessions are
challenging and time-consuming
• Concerns on of internet connection and
availability of gadgets
• Additional costs for some clients and their
families
causing COVID-19 and how it affects the body, it
is common for everyone to experience increased
levels of distress and anxiety12,13 Occupational
disruptions are inevitable, causing added
anxiety, stress, and strain physically as well as
mentally.14 A number of participants have
experienced, and are still experiencing, various
degrees of emotional distress over the transition
from in-person therapy to teletherapy. Aside
from the exhaustion and screen fatigue, which is
very common for health practitioners offering
online services,15,16 some have experienced
difficulty in accepting or adjusting to the
transition because they believed that the
community restrictions, and the pandemic itself,
were temporary. This, in itself, is also already a
traumatizing event for service recipients as the
transition to the new normal was not anticipated
at all.16
There are also concerns about the inevitably
delayed career and life plans, which may cause
what is called a career shock or loss in direction
when it comes to a career.14,18 Generally,
disruption to an early career path have
significant career consequences for the next
several years.17,18 Nevertheless, the sudden
change in employment (including
unemployment) coupled with the broader
societal and political changes that are currently
happening in the country have made the
participants re-examine either their career
trajectories or life aspirations.
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.005)
Finally, while some participants praise the
Philippine government’s efforts to contain the
COVID-19 outbreak, a number of participants
have grown dissatisfied with the heavy-handed
approach and contradicting statements from the
country’s leaders. News reports of systemic
corruption in different government agencies,19
the apparent lack of transparency from the
health sector,20 and the lack of active response
other than to wait for a vaccine have culminated
into a general sense of hopelessness for the
coming months.
Activity Engagement as a Coping Mechanism.
Without a doubt, the direct and indirect
psychological and social effects of the COVID-19
pandemic are pervasive and could have lasting
effects on a person’s mental health now and in
the future. For some participants, this is a time
for them to take a break and spend more time
with their family due to the decreased workload
and to explore new hobbies and interests. There
are several participants who shared that they
have turned to their faith — by participating in
online religious services, among others — to
cope with the trauma and distress brought about
by the pandemic, which research has shown to
be an important coping mechanism.21 As
occupational therapists, they are aware that
even when confined and isolated, people still
need to engage in a routine that includes being
physically active, having fun, staying in contact
with other people, and limiting media
consumption in order to reduce stress and
nourish emotional well-being.20,21
Moving Forward
Challenges and Opportunities. Being at the
forefront of the profession in the country, PAOT
has been called to act on the current situation by
strengthening its stand on teletherapy and
developing guidelines to enable standardization
and assurance of safe and quality service
delivery. Aside from this, participants have
appealed to PAOT to promote teletherapy more
as a valid and effective mode of service delivery
in order to address the demand for accessible
therapy services. Many participants have also
expressed that continuing education
opportunities be given online. However, some
have suggested that more comprehensive
workshops be given, rather than lectures, to
facilitate skill-building; and to get experts from
26
other regions to provide a more enriching and
contextualized experience.
Furthermore, the rising mental health issues of
practitioners should be addressed promptly
since it can affect their service delivery and
overall well-being. Creating a platform that can
provide mental health response and support to
members, and a concrete plan to solve the
growing number of employment changes are two
windows of opportunities that the organization
can look into to alleviate the burdens that
therapists are currently facing.
Finally, while one of PAOT’s mandates is to serve
its members and stakeholders, non-members
and newly licensed occupational therapists
should also be included in the discussions
because the pandemic experience is universal
and social connections are all the more
important at this time. It has been suggested that
PAOT revitalize its membership campaigns and
to make membership to the organization more
approachable and inclusive.
Professionals in the Future. As the Philippines
continues on its eight-month community
quarantine, Filipino occupational therapists face
a daunting task to rise above obstacles and
explore unfamiliar and potential roles that do
not only involve direct patient care. Because of
the physical restrictions, the COVID-19 pandemic
has opened up opportunities for practitioners to
navigate the virtual environment, so some
participants continue to view the situation as a
challenge to learn something new, rediscover
their strengths, and reflect on their passions. One
participant shared that the true value of an
occupational therapist—rooted in creative
thinking and problem-solving—is being tested
during a prolonged crisis such as this ongoing
pandemic, and they are hopeful that a new breed
of occupational therapists will emerge.
REFLECTIONS AND CONCLUSIONS
This paper explored the limited data from
Filipino occupational therapists who are
practicing in different regions of the country.
Because of the pandemic, changes in care
delivery appear to have significant effects on
both the practitioners and the recipients of
service—from its service delivery and the
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.005)
providers in varied aspects of their engagement
in daily life to the future direction of the practice.
The first theme discusses teletherapy as the
emerging mode of service delivery in lieu of
traditional face-to-face therapy. Despite the
guidelines released by PAOT, teletherapy has
been received with hesitation and uncertainty.
This suggests that there is still room for further
development of this delivery model, through
research and contextual analysis, to better suit
the context of Philippine healthcare. Likewise,
with the transition to the new normal,
traditional therapy practice must also undergo
adjustments in order to better fit the new
environment. This introduces a challenge to
adjust and improve already established aspects
of the healthcare practice, such as the
educational or training process, the licensure
process, and the monitoring of care, just to name
a few.
The second theme discusses the consequences of
the pandemic on occupational therapy practice
and its practitioners. While practitioners and the
general populace alike are both similarly
affected by the pandemic, practitioners have the
added obligations to provide frontline services at
the cost of their physical and mental health.
Emphasis was placed by the participants on the
mental health strain they have experienced due
to the stress of adaptation to the new
environment, as well as of overall job security.
This prompts PAOT to create and prioritize plans
that address these concerns to protect and care
for its members and their recipients of care.
The third theme describes the windows of
opportunities from the perspective of the
participants that may guide the organization in
responding to the changes brought about by the
new normal. Occupational therapy is still a
growing profession, and it continues to develop
according to the needs of the populations that it
serves while staying true to its foundation: to
promote health and well-being through
meaningful engagement for everyone from all
walks of life.
Individual Author’s Contributions
R.C.D.: conception of work, acquisition, analysis,
and interpretation of work, drafting the work
27
and revising critically, approval of the version to
be submitted for publication, and accountable
for most aspects of the work; K.C.T.: acquisition,
analysis, and interpretation of work, drafting the
work and revising critically, approval of the
version to be submitted for publication, and
accountable for most aspects of the work; W.S.:
analysis, and interpretation of work, drafting the
work and revising critically, approval of the
version to be submitted for publication, and
accountable for most aspects of the work.
Disclosure Statement
The first two authors are members of PAOT’s
Committee on Chaptership, while the last author
is a regular member of PAOT. The views
expressed in this paper do not reflect the general
position or opinion of the organization.
Funding
No funding agency supported the completion of
this paper.
References
1. World Federation of Occupational Therapists. Public
Statement - Occupational Therapy Response to the
COVID-19… | WFOT. 2020. Available from:
https://wfot.link/covidpublic
2. World Health Organization. 100 days of COVID-19 in
the Philippines: How WHO supported the Philippine
response. 2020. Available from:
https://www.who.int/philippines/news /feature-
stories /detail/100-days-of-covid-19-in-the-
philippines-how-who-supported-the-philippine-
response
3. The Economist. The Philippines’ fierce lockdown drags
on, despite uncertain benefits. 2020. Available from:
https://www.economist.com/asia/2020/07/11/the-
philippines-fierce-lockdown-drags-on-despite-
uncertain-benefits
4. American Occupational Therapy Association. The Role
of Occupational Therapy: Providing Care in a
Pandemic. Aota.org. 2020. Available from:
https://www.aota.org/Advocacy-Policy/Federal-Reg-
Affairs /News/2020/OT-Pandemic.aspx
5. Carandang K, Medallon K, Mallari J, Tan-Ibanes V,
Roderos K, Luib D et al. Interim Guidelines on the
Practice of Occupational Therapy amidst the
Coronavirus Disease (COVID-19) situation in the
Philippines. Wfot.org. 2020. Available from:
https://www.wfot.org/assets/resources/PAOT-
Interim-Guidelines-on-the-Practice-of-OT-amidst-the-
COVID-19-situation.pdf
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.005)
6. Isaac C. Guidelines on the institution and governance of 19. Malindog-Uy A. Corruption Amid A Pandemic
OTAP Chapters. PAOT; 2005. [Internet]. The ASEAN Post. 2020 [cited 18 September
7. Cheng H, Phillips M. Secondary analysis of existing 2020]. Available from:
data: opportunities and implementation. https://theaseanpost.com/article/corruption-amid-
2014;26(6):371-375. pandemic
8. Claulfield J. How to Do Thematic Analysis | A Step-by- 20. Bayod R. Ethics of care and Philippine politics during
Step Guide & Examples. Scribbr. 2020. Available from: the COVID-19 outbreak. Eubios Journal of Asian and
https://www.scribbr.com/methodology/thematic- International Bioethics. 2020;30:69-76. Available from:
analysis/ https://www.eubios.info/EJAIB42020.pdf
9. Baur A, Georgiev P, Munshi I. Preparing for the next 21. Goodman B. Faith in a time of crisis.
normal after COVID-19. McKinsey & Company. 2020. https://www.apa.org. 2020. Available from:
Available from: https://www.apa.org/topics/covid-19/faith-crisis
https://www.mckinsey.com/industries/healthcare-
systems-and-services/our-insights/healthcare-
providers-preparing-for-the-next-normal-after-covid-
19#
10. Keiser University. COVID-19: The Forgotten Frontline
Workers - Keiser University. Keiser University. 2020.
Available from:
https://www.keiseruniversity.edu/covid-19-the-
forgotten-frontline-workers/
11. American Hospital Association. Hospitals and Health
Systems Face Unprecedented Financial Pressures Due
to COVID-19. 2020. Available from:
https://www.aha.org/system/files/media/file/2020/
05/aha-covid19-financial-impact-0520-FINAL.pdf
12. Malindog-Uy A. COVID-19 Impact On Mental Health Of
Filipinos. The ASEAN Post. 2020. Available from:
https://theaseanpost.com/article/covid-19-impact-
mental-health-filipinos
13. Hu Z, Lin X, Chiwanda Kaminga A, Xu H. Impact of the
COVID-19 Epidemic on Lifestyle Behaviors and Their
Association With Subjective Well-Being Among the
General Population in Mainland China: Cross-Sectional
Study. Journal of Medical Internet Research.
2020;22(8):e21176. Available from:
https://www.jmir.org/2020/8/e21176/
14. American Psychiatric Association Foundation. Working
Remotely During COVID-19: Your Mental Health &
Well-Being. Workplacementalhealth.org. 2020.
Available from:
http://www.workplacementalhealth.org/getmedia/fd
8a9b98-b491-4666-8f27-2bf59b00e475/Working-
Remotely-During-COVID-19-CWMH-Guide
15. Wilser J. The New York Times. 2020. Available from:
https://www.nytimes.com/2020/07/09/well/mind/t
eletherapy-mental-health-coronavirus.html
16. Zeavin H. Therapists Are Doing Sessions in Locked
Bathrooms While Patients Call in From Their Cars.
Slate Magazine. 2020. Available from:
https://slate.com/technology/2020/04/therapy-
coronavirus-telemedicine.html
17. Akkermans J, Richardson J, Kraimer M. The Covid-19
crisis as a career shock: Implications for careers and
vocational behavior. Journal of Vocational Behavior.
2020;119(103434). Available from:
https://www.sciencedirect.com/science/article/pii/S0
001879120300592?via%3Dihub
18. Rudolph C, Zacher H. COVID-19 and careers: On the
futility of generational explanations. Journal of
Vocational Behavior. 2020;119(103433). Available
from:
https://www.sciencedirect.com/science/article/abs/p
ii/S0001879120300580?via%3Dihub

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 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.006)

Short Report
A Literature Review on the Facilitators and Barriers to the Uptake of Interprofessional
Collaboration in the Field of Assistive Technology within Rehabilitation Medicine
Daryl Patrick G. Yao1, Kenneth Matthew B. Beltran2, Treisha Naedine H. Santos3, Dr. Kaoru Inoue1
Department of Occupational Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan; 2Skill Builders
Therapy Services Corp., Manila, Philippines; 3College of Allied Medical Professions, University of the Philippines - Manila, Manila, Philippines

Correspondence should be addressed to: Daryl Patrick G. Yao 1; dgyao.ot@gmail.com

Article Received: October 20, 2020
Article Accepted: December 12, 2020
Article Published: February 14, 2021 (online)
Copyright © 2021 Yao et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Assistive technology (AT) enables an optimized life for persons with disability through the scaffolding of functional capabilities. However, AT
provision faces challenges such as long approval processes, funding inadequacies, and difficulties integrating evidence into practice. A means to
address these issues is through interprofessional collaboration (IPC), the process by which health professionals efficiently coordinate and work
with each other towards a common goal to maximize limited resources. To promote its effective implementation, there is a need to know the
facilitators and barriers that affect its implementation. Thus, this paper aims to review the facilitators and barriers to the uptake of IPC in the field
of AT within rehabilitation medicine identified by existing literature. This literature review followed the steps outlined by The Model Systems
Knowledge Translation Center. Articles published between January 2000 until September 2019 were retrieved from four electronic databases
(Cochrane Library, PubMed, Scopus, Science Direct). Three studies were included in the study. Facilitators identified were: (1) optimal work culture,
(2) professional competence, and (3) associating with team members. Barriers to effective IPC in the field of AT were identified as: (1) presence of
professional silos, (2) lack of unified language, and (3) gaps in bureaucratic support. The mechanisms and factors in implementing interprofessional
collaboration identified by the World Health Organization are vital in the field of AT. However, the barriers identified above need to be addressed
to promote the uptake of IPC within this specialized field.

Keywords: Collaborative practice; clinical setting; assistive product, service delivery

INTRODUCTION
Assistive technology (AT) is any product used to
prevent, replace, or improve the functional
capabilities of persons with disabilities (PWDs)
to enable participation in daily life.1 AT
facilitates one’s ability to achieve well-being and
allows for an equitable life.2,3 The World Health
Organization has supported the positive impact
of AT on the health and well-being of a person
and their family, as well as broader
socioeconomic benefits.4 Despite these positive
outcomes, AT provision is hindered by numerous
factors. In Germany, AT providers and PWDs
experienced difficulty due to bureaucratic
burden and long AT approval processes.5
Additionally, there are instances where health
professionals recommend numerous and
conflicting types of AT to end-users. This greatly
impacts AT users in developing countries, where
AT acquisition is typically an out-of-pocket
expense by the user and their family.6
Stakeholders need to decide and prioritize what
they perceive to be the most necessary of AT,
often with conflicting priorities or without the
guidance of the health professionals, thereby
limiting ideal performance.
A means to address these issues is through the
practice of interprofessional collaboration (IPC).
IPC occurs when health professions from various

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 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.006)
backgrounds and specializations, together with Science Direct). Search combinations were
stakeholders, work together as a team to deliver connected by Boolean operators and were
the highest level of quality care.7 A greater formulated by using alternative terms and
understanding of IPC will contribute towards wildcards of the following key terms: Assistive
developing “flexible health workforces that Technology, Collaboration, and Rehabilitation
enable local health needs to be met while (see Table 1).
maximizing limited resources”.7
AT selection should be done with a team of Table 1. Alternate Terms
professionals and consultants trained to match
an AT to specific needs.8 Moreover, IPC has been Assistive Collaborat* Rehabili*
found to optimize the AT prescription process.9 Technolog*
Thus, there is a need to know the facilitators and
Assistive Product Cooperat*
barriers that affect the implementation of IPC.
Knowing these facilitators and barriers will Assistive Device Partnership
guide clinicians and organizations towards the Alliance
first step to effectively implement an IPC-ready
program within an institution. This paper aims
to review the facilitators and barriers to the Data Collection. The search yielded 270 articles
uptake of IPC in the field of AT within for screening (see figure 1). When there were
rehabilitation medicine identified by existing concerns about whether an article met the
literature. inclusion criteria, the team convened for
deliberation. Data extracted from the articles
that met the inclusion criteria were the title,
METHODOLOGY authors, year published, country, research design,
This literature review was conducted using the team members, facilitators, and barriers.
process outlined by The Model Systems
Knowledge Translation Center.10 Steps include
(a) selection criteria, (b) search strategy, (c) data
collection, (d) displaying data, and (e) analysis
and synthesis.
Selection Criteria. Inclusion criteria are as
follows: (1) IPC done by a health professional
with health or non-health professional/s or
organization to create, select, acquire, train, or
maintain an AT device used by a client, (2) all
types of studies that discuss the actual process
done in collaboration with other professionals,
(3) published studies with electronic copy
accessible from the internet, (4) studies
published between January 2000 to September
2019, and (5) are published in the English
Language. Exclusion criteria are as follows: (1)
the use of rehabilitative devices which are used
only as part of clinical treatment, (2)
collaboration done in the process of formal
education on a hypothetical client, and (3)
editorials and commentaries.
Search Strategy. Articles were independently
searched and retrieved from four electronic Figure 1. Search Process
databases (Cochrane Library, PubMed, Scopus,

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 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.006)
Displaying Data. Three studies, which
documented both facilitators and barriers to
collaboration, were included in the study. Four
studies were excluded due to the inability to
obtain full-text articles. The data gathered are
summarized in Table 2.
Analysis and Synthesis. Identified facilitators
and barriers along with the features documented
in Table 2 were clustered according to their
common features via a free spreadsheet
program. Themes were then formulated from the
clustered codes.
RESULTS
Facilitators. Three clusters from six codes were
identified as facilitators towards IPC in the field
of AT within the rehabilitation medicine (see
Table 3 for an overview). Notably, all facilitators
identified were congruent to that of the
mechanisms and competencies necessary in
IPC.7,13 Findings are expounded in the
subsequent sections.
Optimal Work Culture. Effective communication
strategies and shared decision-making were
identified as facilitators9, which are in line with
the mechanisms identified by WHO to stimulate
IPC.7 As many professionals are involved,
conflicting goals and differing perspectives are
often observed.14 To address this issue, there is a
need to optimize the work culture through
practicing effective, consistent, and clear
communication strategies between
professionals, to share each professional’s
perspective on the necessary characteristics
needed from the AT by the user as determined
by their specific needs, and to conglomerate to
decide on a singular goal in relation to AT
provision.9
Professional Competence. As AT is a specialized
field with constant development, high
expectations are embedded among
professionals, necessitating the advancement of
new knowledge geared towards both AT and IPC.
This knowledge is vital if one is to share
information and collaborate with other
professionals.9,11-12 An understanding of the
practical use and applicability of an AT, as well
as the role of other stakeholders involved, may
impact a health professional’s inclination to
31
engage in IPC. In a study by Malinowsky and
colleagues, the collaboration between
occupational therapists and assistant nurses
were influenced by their varying understanding
of PWDs, which cascaded to their respective
approach to supporting the use of ATs.11
Additionally, possessing preliminary
comprehension of ATs also assisted
professionals in clarifying the use of ATs to
PWDs and their significant others, as well as
justifying the practical usability and necessity of
ATs to other professionals11. Awareness of one’s
role and other professions’ role in assessing and
addressing a patient’s healthcare needs is a core
competency for effective collaboration.13
The use of a model for knowledge translation
can help professionals share a common
understanding and language, not just among
professionals but also with the end-users of AT
devices11. Providing practitioners with “a way of
thinking” can help them deliberate about ways to
translate their knowledge into practical use in
terms of designing interventions that support
the use of AT.11
Sense of Team Membership. An opportunity for
health workers to interact with other
professions and capacitate each other in their
respective professions lays the foundation for
IPC.7 IPC entails incorporating multiple
perspectives across different professions to yield
novel and holistic solutions to address complex
healthcare needs.11-2 Thus, recognizing the
knowledge and experience of another health
professional is beneficial in identifying and
providing the ideal AT device and to the end-
users.9,11
Barriers. Three clusters from five codes were
identified as barriers towards IPC in the field of
AT within rehabilitation medicine. The barriers
identified below possess a compounding effect
wherein issues affecting AT service delivery, and
challenges on the application of IPC in general
may influence one another; leading to complex
problems.15-18 Findings are expounded in the
subsequent sections.
Silo mentality. The study by Malinowsky and
colleagues captured the compartmentalization
and the lack of shared accountability among
professionals, as exemplified by one participant
pointing out that AT prescription and follow-up
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.006)
Table 2. Summary of Included Studies

Title Advantages and disadvantages of An approach to facilitate healthcare Interdisciplinary development of manual and
interdisciplinary consultation in the professionals readiness to support automated product usability assessments for
prescription of assistive technologies for technology use in everyday life for older adults with dementia: lessons learned12
mobility limitations9 persons with dementia11

Authors de Laat FA, van Heerebeek B, van Netten JJ. Malinowsky C, Rosenberg L, Nygård L. Boger J, Taati B, Mihailidis A.

Year 2018 2013 2015

Published

Country Netherlands Sweden Canada

Research Cross-sectional study Grounded Theory with Constant Reflection

Design Comparative Analysis

Team Technician: Occupational Therapists ⚫ Engineers

composition prosthetist, orthotist, pedorthist or Assistant Nurses ⚫ Computer Scientists,
orthopedic (shoe) technician Nurse ⚫ Human Factors Expert
Prescriber: Assistant Officer ⚫ Rehabilitation Scientist
Rehabilitation specialists, orthopedic ⚫ Statistician
surgeons, vascular surgeons, others. ⚫ Clinical Research Assistants

Facilitators ⚫ Clear communication rules
identified ⚫ Shared decision-making
⚫ Shared knowledge of diagnosis and
device
⚫ Recognizing the knowledge and
experience of the AT prescriber
and AT technician
⚫ Shared knowledge and information
⚫ Obtaining new knowledge and tools
⚫ Different funds of knowledge about
PWDs, which together could
support the use of AT…
⚫ Careful Planning
⚫ Familiarity with team members
⚫ Development of a shared understanding
⚫ Appreciation of significant outcomes
from multiple perspectives

Barriers ⚫ Poor Chemistry among professionals
identified ⚫ Planning problem (time efficiency)
⚫ Reimbursement issues
⚫ Non-adequate location for try-outs
⚫ Problems in understanding each None mentioned
other
⚫ Different focuses of technology
among professions
⚫ Differing views about who is
responsible for solving the client’s
problems

32
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.006)
is not a part of their responsibilities11. The
participant, however, claimed that although AT
prescription is not within their immediate
responsibility, they still communicate problems
surrounding AT with the occupational therapist.
This sense of unequal accountability on the
stakeholder’s optimal health can negatively
affect service delivery as it perceives the patient
according to the different problems rather than
holistically.
Lack of a Unified Language. The lack of a
standardized and shared language can greatly
affect collaboration between professionals.9
Interpretation of professional language poses a
challenge to the other members of the team,
affecting the efficiency and interaction among
professionals and collaboration on goal setting.14
Additionally, terminologies for AT are
inconsistent, leading to further difficulties in
communication and translating evidence into
practice.20
Gaps in Bureaucratic Support. There are
notable difficulties arising from IPC within AT
provision, such as logistical, administrative, and
financial impairments, exemplified by the need
for adequate reimbursement processes and
redundancy, among others.9 De Laat and
colleagues proposed performing shared
evaluation procedures and improving record
storage and retrieval system by using digital
means to address the challenges they identified 9.
However, reimbursement issues are harder to
address, as these involve policy changes.
DISCUSSION
The studies provided a glimpse of the facilitators
and barriers that influence the uptake of IPC in
the field of AT within rehabilitation medicine.
These facilitators must be utilized, while barriers
must be minimized in order to pursue ideal AT
service provision.
A means to achieve this is by establishing a
mindset early on by integrating interprofessional
education (IPE) into existing curricula. IPE
prepares professionals to collaborate and
interact with colleagues while maintaining their
identity during service delivery. This is in line
with the recommendations of Frenk and
colleagues, who suggest that a reformation of
33
education will promote more effective and
efficient collaborative relationships.16 Attitudinal
and administrative changes through the pursuit
of professional development in terms of AT and
IPE, as well as equipping future professionals
with core competencies of IPC is recommended.
As a lack of unified language impedes IPC in AT
provision, the International Organization for
Standardization (ISO) released a classification
and terminology of AT and products. At present,
the most updated version is ISO 2016:9999.1
However, contrary to its intention to unify the
language, it is a paid document, thereby limiting
its accessibility. To strengthen IPC in AT
provision, there is a need for professionals to
have opportunities to be educated on a shared
language. It is recommended for organizations to
exert further initiative to implement this on an
institutional scale through primer courses.
In relation to a unified language, there is also a
need for an internationally recognized standard
in AT provision. de Witte and colleagues
recommended the establishment of such to
promote high-quality, accessible, and affordable
AT.21 They propose that a standardized method
provides data that can be used to assess policy
impact and assessment. With an internationally
recognized process, the AT provision process is
optimized, leading to the promotion of
professional cooperation, client-centeredness,
and the use of pre-intervention strategies, which
can potentially impact the AT service needed.
Additionally, it is recommended to enact
organizational changes by utilizing the virtual
context in data management and communication
and optimizing service by removing redundant
procedures to maximize limited resources.
Recommendation for further research.
Further research regarding IPC in the context of
AT is recommended to explore the extent of
influence of each factor. Subjective accounts on
the experiences of major stakeholders, especially
from differing cultures without established
medical and social insurance schemes, also
necessitates exploration.
Limitations. As the alternative terms were
unilaterally agreed upon by the authors, there
may have been some lapses in identifying key
terms. Furthermore, critical appraisal of
retrieved articles was not done as it is beyond
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.006)
the established scope of the review. Articles that
were irretrievable due to limited resources
might have also provided more information. A
list of such articles is provided in the Appendix.
CONCLUSION
AT is a major healthcare component hindered by
multiple factors, remediable with the application
of effective IPC. Optimal work culture,
professional competence, and a sense of
membership will facilitate and optimize the
synergy of AT and IPC. Efforts should be made to
limit the influence of barriers, such as the lack of
unified language, a silo mentality, and the gaps in
bureaucratic support. Nonetheless, the retrieved
studies have shown that the influence of IPC in
the field of AT justifies the need for further
research to identify ideal systems for efficient AT
service delivery.
Individual author’s contributions
DPGY searched, analyzed, and wrote the paper;
KMBB searched, analyzed, and co-wrote the
paper; TNHS searched, analyzed, and co-wrote
the paper; KI Supervised the research providing
critical discourse and arguments during analysis
process.
Disclosure Statement
The authors have nothing to disclose. This work
was not funded by any agencies/ organizations
Conflicts of interest
All authors declare no conflict of interest.
Acknowledgment
We would like to acknowledge the 2nd Asia-
Pacific Interprofessional Education and
Collaboration Conference and its organizers for
providing us the venue to share the results of
this endeavor.
Supplementary Material
Supplementary Material A. Appendix
34
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lessons learned. Disability and Rehabilitation: Assistive
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technology-2. Italy: Association for the Advancement of
Assistive Technology in Europe; 2015
16. Frenk J, Chen L, Bhutta ZA, Cohen J. Crisp N, Evans T, et
al. Health professionals for a new century:
Transforming education to strengthen health systems
in an interdependent world. Lancet.
2010;376(9756):1923-58
17. Paul S, Peterson CQ. Interprofessional collaboration:
Issues for practice and research. Occupational Therapy
in Health Care. 2002;15(3-4):1-12.
18. Supper I, Catala O, Lustman M, Chemla C, Bourgueil Y,
Letrilliart L. Interprofessional collaboration in primary
health care: A review of facilitators and barriers
perceived by involved actors. Journal of Public Health
(Oxford). 2015;37(4):716-27
19. Clark KM. Interprofessional education: Making our way
out of silos. Respiratory Care. 2018;63(5):637-9.
20. Friesen EL, Theodoros D, Russell TG. Assistive
technology devices for toileting and showering used in
spinal cord injury rehabilitation – A comment on
terminology. Disability and Rehabilitation: Assistive
Technology. 2014;11(1):1-2
21. De Witte L, Steel E, Gupta S, Ramos VD, Roentgen U.
Assistive technology provision: towards an
international framework for assuring availability and
accessibility of affordable high-quality assistive
technology. Disability and Rehabilitation: Assistive
Technology. 2018;13(5):467-472

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 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.007)

Short Report
A Rapid Literature Review on the Strategies for Collaboration Between Occupational
therapists and Speech-Language Therapists in the Field of Augmentative and Alternative
Communication
Daryl Patrick Yao1, Ghislynne Dei-Anne Andaya2, Kaoru Inoue1
1Department of Occupational Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan; 2 Able Center,
Inc., Makati, Philippines

Correspondence should be addressed to: Daryl Patrick Yao1; dgyao.ot@gmail.com

Article Received: December 4, 2020
Article Accepted: December 28, 2020
Article Published: February 14, 2021 (online)
Copyright © 2021 Yao et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
An alternative and augmentative communication (AAC) device replaces or supplements a person’s natural speech. Speech-Language Pathologists
(SLPs) collaborate with a team of healthcare professionals in the process of identification and use of the right AAC device for a person with complex
communication needs (CCN). In the Philippines, occupational therapists (OTs) and SLPs are more likely to collaborate in the treatment of their
clients due to their interprofessional education (IPE) experience. However, most Filipino SLPs do not engage in interprofessional collaboration
(IPC) when rendering AAC services. Thus, there is a need to identify existing literature that tackles collaborative practices to raise the quality of
service and care. Hence, this study aimed to identify and discuss existing literature that documented IPE and IPC strategies between OTs and SLPs
in the field of AAC. The structure of this literature review was guided and adapted from the topics outlined in the preferred reporting items for
systematic reviews and meta-analyses (PRISMA). Literature archived in two databases (Pubmed and Scopus) were reviewed. Two articles out of
five studies were included in this review. Strategies found were “case based learning approach” for post-graduate students and the “Beyond Access
model” in supporting practitioners. In conclusion, there is a dearth of literature on IPC practices among OTs and SLPs in the field of AAC. There is a
need to report IPE and IPC efforts in the Philippines to provide applicable strategies to the local healthcare landscape.

Keywords: Interprofessional collaboration, interprofessional education, assistive technology, occupational therapy, speech-language pathology,
Philippines

INTRODUCTION
An alternative and augmentative communication provide an appropriate AAC device, SLPs
(AAC) device is a type of assistive product that collaborate with a team of healthcare
aids an individual with complex communication professionals.2
needs (CCN) to converse and interact with
Interprofessional collaboration (IPC) happens
others through replacing or supplementing a
when one works with a team of health
person’s natural speech.1 The use of AAC devices
professionals toward a common goal to improve
are well-identified within the domain of practice
learning, quality services, team support, and
of the speech-language pathology (SLP)
decision-making.3,4 One of the many health
profession as speech-language pathologists
professional SLPs can collaborate with are
(SLPs) possess adequate knowledge in terms of
occupational therapists (OTs). Occupational
language development, communication patterns,
therapy (OT) is a client-centered health
bodily structures and functions necessary for
profession concerned with promoting health and
speech, and AAC devices.2 To identify and
35
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.007)
wellbeing through meaningful everyday
activities.5 It has been asserted that OTs possess
the competence to adequately provide assistive
products by looking at the interplay among
person-activity-environment.6
In the Philippines, OTs and SLPs tend to have
more opportunities to collaborate in rendering
intervention primarily due to the mandatory
exposure of most OTs and SLPs to
interprofessional education (IPE) over a longer
period.7 However, when it comes to assessing
and providing AAC for individuals with CCN to
achieve communication-related goals, 80-90% of
Filipino SLPs rarely or never collaborated with
other health professionals due to difficulties in
identifying the role of others in the assessment
process.8,9
SLPs specializing in AAC-related services
observe four communicative competencies
namely: linguistic competence, operational
competence, strategic competence, and social
competence.10 All these competencies entail
collaborative effort. For instance, operational
competence requires the need for OTs in
providing a professional appraisal of the AAC
user’s performance skills. Additionally, SLPs and
OTs could collaboratively assess an individual’s
social interaction skills needed for developing
strategic and social competence.
Concretizing the collaborative practice done
between both professions is a viable first step
towards raising the quality of service and care.
At present, there is a need to identify literature
that examines the collaboration between the two
professions on a global scale to jumpstart such
collaboration in the Philippines. Hence, this
study aimed to identify and discuss existing
literature that documented IPE and IPC
strategies between OTs and SLPs in the field of
AAC.
METHODOLOGY
The structure of this rapid literature review was
guided and adapted from the topics outlined in
the preferred reporting items for systematic
reviews and meta-analyses (PRISMA). Several
steps were omitted to access information
promptly and without compromising clinical
decision-making despite the limited resources.11
36
Eligibility Criteria. Included articles are those
that discuss strategies for collaboration in the
field of AAC. The team should include at least an
OT and an SLP practitioner. Only articles
published from January 2000 to September 2019
written in the English language were gathered.
Search Strategy. An electronic search was done
in the final week of October 2019. Articles
archived in PubMed and Scopus were reviewed.
The following keywords were used for the
search: alternative or augmentative
communication, collaboration, occupational
therapy, and speech or speech-language
pathology. The use of wild cards to include other
associated variants and alternative terms, which
are connected via Boolean operations, was done.
Study Selection. A total of five articles were
obtained and screened. Of the five articles, only
two articles were included in this study (see
Figure 1). The articles were excluded for the
following reasons: a book chapter tackling AAC
in general (n=1) and articles focusing on AAC
without discussing strategies for IPC (n=2).
Data Collection and Synthesis. The following
information was extracted and tabulated: title,
author(s), year published, country, type of
research, IPC strategy used, and features of the
strategy. The finding was then summarized and
described in the next section. The finding was
then appraised using the Critical Appraisal of a
Case Study checklist.12 Studies were summarized
and synthesized through the critical analysis of
the tabulated information.
RESULTS
In this review, we discussed the retrieved
literature used to enable an interprofessional
collaborative practice between OTs and SLPs in
the field of AAC. A summary of the included
articles can be found in Table 1.
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.007)
Figure 1. Search Process
Case Based Learning (CBL) Approach. CBL is
defined as a form of learning through solving
authentic clinical scenarios geared towards
attaining a stated set of learning objectives and
outcomes.15 Not all information was initially
provided to facilitate inquiry and discovery. The
CBL approach was utilized by Wallace and
Benson.13 The formulated case scenarios were
discussed by post-graduate OT and SLP students
as part of formal coursework between the OT
and SLP departments. Participants were
arranged to communicate through face-to-face
team meetings and online interactions spanning
25 to 45 minutes.
The strategy brought about an increase in one’s
understanding of the role and importance of
others. The approach identified the value of
professional communication in successful
collaboration. Professional communication
facilitated mutual respect and increased
cooperation and collaboration among team
members.

Table 1. Summary of included studies

Title Bringing Interprofessional Case-Based
Learning into the Classroom for
Occupational Therapy and Speech-
Language Pathology Students13
Author(s) Wallace SE, Benson JD
Year Published 2018
Country USA
Type of Research one group pretest posttest
Critical Appraisal 6/10
IPC Strategy used Case based Learning Approach
Features of the strategy two-part IPE activity with out-of-class
online meeting and a 2-hour class was
done among graduate students of the OT
and SLP departments. Worksheets and
instructions were provided to structure
the meetings.
A Case Study of Team Supports for a
Student with Autism’s Communication and
Engagement within the General Education
Curriculum: Preliminary Report of the
Beyond Access Model14
Sonnenmeier RM, McSheehan M,
Jorgensen CM
2005
USA
Case Study (observational)
8/10
Beyond Access Model
Four-phase model provided a framework
to the team to enhance their capacity in
planning, evaluating, and implementing
student and team support for an inclusive
classroom setting.

37
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.007)
Beyond Access (BA) Model. The BA model was
created as an attempt to include students with
disabilities in the general education system
through the provision of support like AAC. The
model was devised by Jorgensen and colleagues
to provide an intervention with an appropriate
and individualized set of goals that were
designed collaboratively by the intervention
team.16 The case study was done within a general
education classroom to meet the communication
needs of a child with Autism.14 The team
comprised of the following: the student’s
parents, an SLP practitioner, an OT practitioner,
an AAC consultant, a classroom teacher, an
instructional assistant, and a special educator.
The BA model identified four phases. The first
phase is a “comprehensive assessment of the
student and team supports,” which includes
determining the goal, the student’s strengths and
weaknesses, and the team’s perspective on their
overall functioning. The second phase explores
and describes the student’s support needs for
learning the general education content through a
trial-and-error-like approach. The third phase
involves observing and documenting
performance. The last phase entails reviewing
and reflecting on student and team performance
data. The educational team established a 45-
minute meeting on a weekly basis with a mentor,
skilled with the BA model, guiding the team
throughout the process.14 These phases
juxtapose the process done by health
professionals, which include: evaluation,
planning, intervention, and revaluation.
The intervention team deemed that the use of
the BA model was able to improve the student’s
participation through communication, as well as
increase the quality of the team’s service
delivery. This model may be considered for
evidence-based practice IPC on AAC provision
and intervention in the school setting.
Furthermore, a model that considers both
student and team factors in intervention
planning provides a wider view for appropriate
goal setting on both parties.14
DISCUSSION
This rapid literature review sought strategies for
incorporating IPC into AAC practice. However,
38
limited literature exists to tackle strategies
applicable to a clinician’s busy day. Regardless,
both analyzed studies can be adapted and
applied to the Philippine setting to create a
better model for AAC service delivery. Adapting
the models can provide a structure to promote
competency, especially for practitioners new to
the concept of collaboration.
IPE as a Springboard to an AAC-Ready IPC.
The general concept of having a collaboration
ready workforce is through starting in the
classroom IPE.17 Engaging in IPE increases the
likelihood and advancement of IPC in the
Philippines.9,18 Discussing AAC-related cases in
the classroom may address the lack of
understanding and importance of the non-AAC
specialist’s role in the AAC service delivery
process.9 Wallace and Benson explored the use
of a CBL approach with OT and SLP students to
establish a sense of collaboration in the field of
AAC.13 This approach provided a clear
delineation of roles in AAC assessment and
intervention as it required the SLP and OT
students to have a professional discourse,
encouraging the students to know and define
their specific roles within the team. While both
professionals can address the social competency,
OTs have a clear role when relating to
operational competency (access and positioning)
and SLPs have a distinct role in relating to
linguistic competency. However, there is much to
know as to whether the participants were able to
translate this learning experience into AAC
practice as educational and practice demands
differ when it comes to overall logistics. It would
be interesting to see the application of CBL in
actual practice. Moreover, there is a need to
explore the transference of learning from the
classroom to the workplace in terms of IPC
within the AAC practice. This could bridge or
identify the gaps in the disparity between pre-
professional training and professional practice
necessary to strengthen IPE programs within the
country.
Regardless, the study of Sonnenmeier and
associates suggest that establishing a clear
understanding of one’s professional role, as well
as the others, paved the way for IPC within
clinical practice.14 In fact, they asserted that the
BA model is an effective tool in IPC due to the
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.007)
effective communication and understanding of
the professionals’ role within the intervention
team.14 The use of a BA model revealed
significant progress in the four AAC
competencies and participation in the general
curriculum, suggesting an improved interaction
with the AAC user’s environment. Hence, the BA
model allows for effective IPC that may impact
an AAC user’s participation in daily life.
Having said this, structuring the CBL approach
through the BA model can be adapted by SLPs
and OTs in the Philippine setting to discuss AAC-
related cases during educational activities to
springboard a better quality of service and a
more effective service delivery model to
individuals with CCN. The CBL approach allows
the OTs and SLPs to address typical concerns of
an AAC user to achieve specific AAC-related
goals. It also paved the way for increased
awareness of the OTs’ and SLPs’ roles in AAC
service provision and theoretical discussions
during IPE. The BA model may be used for
theoretical intervention planning and goal-
setting. Furthermore, as there are few
opportunities for IPC during laboratory classes
and practical clinic exercises, including the BA
model in clinical experience during IPE may be a
beneficial framework for effective collaboration
for AAC-related cases.19
Barriers for AAC Collaborative Practice in the
Philippines. In the application of the strategies
identified to prepare and exercise IPE and IPC,
logistics issues such as schedule and time
allotment proved to be a problem. The issue of
logistics is a common challenge, especially in the
Philippines, wherein health professionals are
scarce.20 Less than 10% of the total registered
SLPs in the Philippines are certified to provide a
comprehensive evaluation and in-depth
intervention for individuals with CCN.21,22 This
implies a shortage of manpower needed for the
provision, assessment, and intervention for
Filipinos with CCN. Hence, the adaptation of such
strategies to the Philippine context may be a
challenge as the integration of the identified IPC
strategies into everyday practice may mean
allocating time for collaborative meetings.
Precious time that can instead be used to work
with other clients in need of professional
services.12 This perspective has been well
39
reflected in the survey conducted by Sy wherein
while OTs and SLPs agree to IPC fostering a
better quality of service to clients, they are
surprisingly neutral to the statements that
describe IPC as “time-consuming,”
“unnecessarily complicating things,” and “using
time that is better spent for other case-related
matters.”18 Furthermore, difficulties in
identifying the roles of the OTs in direct AAC
service provision may discourage SLPs from
having case discussions with OTs specific to AAC,
rationalizing why SLPs do not consult OTs and
other professionals in AAC assessment.9 These
attitudes may be credited to a lack of a context-
based intervention-focused collaboration model
or framework in the Philippines.
The inclusion of approaches, models, and
frameworks of AAC into the IPE curriculum can
provide OTs and SLPs a guide on how to
collaborate in clinical practice. Effective IPC
comes from a strong IPE foundation, as OTs and
SLPs who have had mandatory and/or voluntary
IPE are more likely to collaborate.18 Students
apply what they learn in their educational
experience; hence, introducing collaborative
practices specific to AAC may inspire them to
adopt these practices in clinical cases. Adapting
the BA model to be more logistically feasible or
creating one inspired by it can guide the
collaborative practice in AAC-related cases. This
will be extremely beneficial for individuals with
CCN, as well as for the advancement of the OT-
SLP collaborative practice in the Philippine
setting.
Recommendation for Research. Due to the
scarcity of data, there is a need to report
practices and strategies employed in other
settings. As there are no studies in the
Philippines that reports the benefits and
translation of IPE into IPC, there is a need to
document and create evidence-based
approaches and models in AAC collaboration.
Additionally, there is a need to create a context-
specific strategy/ protocol for promoting IPC in
AAC practice. Lastly, conducting a review with a
broadened search, such as the use of more
databases and including more health
professionals, may yield more information and
models, which may be more adaptable and
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.007)
applicable to the Philippine healthcare
landscape.
Limitations. Due to temporal constraints and
limited manpower and resources, only two
databases were searched. Broadening the search
to more databases and broadening the search
terms, as well as considering collaboration done
with other health professionals, may yield more
studies.
CONCLUSION
Existing literature on the IPE and IPC between
OTs and SLPs in the field of AAC exists but
remains scarce. Two specific strategies to
facilitate collaboration namely: “case based
learning approach” and “beyond access model”
were identified. There is a need to report IPE and
IPC efforts in the Philippines to provide
applicable strategies to the local healthcare
landscape and to create a context-specific
strategy/ protocol for promoting IPC in AAC
practice.
Individual author’s contributions
DPG Yao; conceptualized, searched, analyzed,
and wrote the paper.
GD Andaya; conceptualized, searched, analyzed,
and co-wrote the paper.
K Inoue; Supervised the research by providing
critical discourse and arguments during analysis
process.
Disclosure Statement
The authors have nothing to disclose. This work
was not funded by any agencies/ organizations.
Conflicts of interest
All authors declare no conflict of interest.
Acknowledgment
We would like to acknowledge the 2nd Asia-
Pacific Interprofessional Education and
Collaboration Conference and its organizers for
40
providing us the venue to share the results of
this endeavor. We would also like to thank Ms.
Hana Hanifah for providing an external review of
this manuscript.
References:
1. American Speech-Language-Hearing Association.
Augmentative and alternative communication. USA:
American Speech-Language-Hearing Association; nd.
Available from:
https://www.asha.org/public/speech/disorders/AAC/
#working
2. Frailey C. Augmentative and alternative
communication: The role of the AAC team. USA: Super
Duper Publications; 2005. Available from:
https://www.superduperinc.com/handouts/pdf/89_A
ugmentativeComm.pdf
3. DePaepe PA, Wood LA. Collaborative practices related
to augmentative and alternative communication:
Current personnel preparation programs.
Communication Disorders Quarterly. 2001;22(2):77-
86.
4. Batorowicz B, Shepherd TA. Teamwork in AAC:
Examining clinical perceptions. Augmentative and
Alternative Communication. 2011;27(1):16-25.
5. World Federation of Occupational Therapists.
Statement on occupational therapy. UK: World
Federation of Occupational Therapists; 2010. Available
from: https://www.wfot.org/resources/statement-on-
occupational-therapy
6. American Occupational Therapy Association. Assistive
technology and occupational performance. American
Journal of Occupational Therapy. 2016;70(suppl. 2):1-
10.
7. Sy MP, Martinez PGV. The status of interprofessional
education and collaboration within occupational
therapy, physical therapy, and speech therapy
professions in the Philippines. 2017 Association of
Medical Education in Europe Conference; 2017 Aug 26-
30; Helsinki, Finland
8. Paul S, Peterson CQ. Interprofessional collaboration:
Issues for practice and research. Occupational Therapy
in Health Care. 2002;15(3-4):1-12.
9. Chua ECK, Gorgon EJR. Augmentative and alternative
communication in the Philippines: A survey of speech-
language pathologist competence, training, and
practice. Augmentative and Alternative
Communication. 2019;35(2):156-66.
10. Light J, McNaughton D. Communicative competence for
individuals who require augmentative and alternative
communication: A new definition for a new era of
communication. Augmentative and Alternative
Communication. 2014;30(1):1-18.
 PJAHS • Volume 4 Issue 2 2021 • (doi:10.36413/pjahs.0402.007)
11. Triccio AC, Antony J, Zarin W, Striffler L, Ghassemi M,
Ivory J, et al. A scoping review of rapid review
methods. BMC Medicine, 2015;13:224.
12. Center for Evidence-Based Management. Critical
appraisal of a case study. Netherlands: Center for
Evidence-Based Management; nd. Available from
https://www.cebma.org/wp-content/uploads/Critical-
Appraisal-Questions-for-a-Case-Study.pdf
13. Wallace SE, Benson JD. Bringing interprofessional case-
based learning into the classroom for occupational
therapy and speech-language pathology students.
Occupational Therapy in Health Care. 2018;32(2):1-12.
14. Sonnenmeier RM, McSheehan M, Jorgensen CM. A case
study of team supports for a student with autism’s
communication and engagement within the general
education curriculum: preliminary report of the
beyond access model. Augmentative and Alternative
Communication. 2005;21(2):101-15.
15. McLean SF. Case-based learning and its application in
medical and health-care fields: A review of worldwide
literature. Journal of Medical Education and Curricular
Development. 2016;3:39-49.
16. Jorgensen CM, McSheehan M, Sonnenmeier R. The
beyond access model: Promoting membership,
participation, and learning for students with
disabilities in the general education classroom.
Maryland: Brookes Publishing; 2009.
17. World Health Organization. Framework for action on
interprofessional education and collaborative practice
[Internet]. Switzerland: World Health Organization;
2010 [cited 2019 Sep 25]. Available from
https://www.who.int/hrh/resources/framework_actio
n/en/
18. Sy MP. Filipino therapists’ experiences and attitudes of
interprofessional education and collaboration: A cross-
sectional survey. Journal of Interprofessional Care.
2007;31(6):761-70.
19. Costigan FA, Light J. A review of preservice training in
augmentative and alternative communication for
speech-language pathologists, special education
teachers, and occupational therapists. Assistive
Technology. 2010;22(4):200-12.
20. Cheng MH. The Philippines’ health worker exodus.
Lancet. 2009;373(9658):111-2.
21. Philippine Association of Speech Pathologists.
Directory. Philippines: Philippine Association of Speech
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22. Tinig AAC. List of affiliates. Philippines: Tinig AAC
Project; nd . Available from
https://www.tinigaacproject.com/list-of-affiliate

41
 Announcements
In response to continuously changing landscape
of scientific publishing, the Philippine Journal of
Allied Health Sciences announces the expansion
on the type of articles that we will be accepting
from henceforth. As mentioned in this issue’s
editorial, we will start to accept research study
protocols. The specific guidelines are explained
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A study protocol is a research article the
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42
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43
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 CALL FOR PAPERS
(Regular Issue)

The Philippine Journal of Allied Health Sciences (PJAHS), the official academic journal of
the College of Rehabilitation Sciences- University of Santo Tomas is now accepting
manuscripts to be reviewed for its upcoming Volume 5 Issue 1.

PJAHS is an online Open Access peer-reviewed scholarly journal which encourages authors
to publish original scholarly articles in the fields of physical therapy, occupational therapy,
sports science, speech-language pathology, nursing, psychology, biomedical engineering,
pharmacy, nutrition, education and other allied health sciences. PJAHS will consider
submissions on the following topics: human biomechanics, exercise physiology, physical
activity in pediatrics and geriatrics, ergonomics, physiologic profiling of athletes, sports
injury monitoring and clinical practice patterns in the allied health sciences. PJAHS publishes
original research, systematic reviews and meta-synthesis, short reports, and letters to the
editor.

Authors who wish to submit manuscripts for review can view the relevant information by
visiting our journal website at https://pjahs.ust.edu.ph/. The deadline for submission for the
upcoming regular issue is on April 30, 2021. Accepted manuscripts will be published by
August 2021.

For any inquiries, email us at pjahs@ust.edu.ph.

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 CALL FOR PAPERS
(Special Section on “Health-Related Outcome Measures for the Filipino Population”)

The Philippine Journal of Allied Health Sciences (PJAHS), the official academic journal of
the College of Rehabilitation Sciences- University of Santo Tomas is now accepting
manuscripts to be reviewed for the Special Section of its upcoming Volume 5 Issue 1.

The Special Section shall be dedicated to “Health-Related Outcome Measures for the Filipino
Population.” We will be accepting manuscripts with psychometric research study designs that
reports on the development, reliability testing, validity testing and/or diagnostic testing of
well-established health-related outcome measures (i.e. checklists, questionnaires,
assessments, evaluation tools and methods, etc.) and its contextualization for the Filipino
clientele. The author guidelines for submission shall be similar to that our regular issue.

Authors who wish to submit manuscripts for review can view the relevant information by
visiting our journal website at https://pjahs.ust.edu.ph/. The deadline for submission for the
upcoming regular issue is on April 30, 2021. Accepted manuscripts will be published by
August 2021.

For any inquiries, email us at pjahs@ust.edu.ph.

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