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Physical therapy [journal]
- The Use of a Knowledge Translation Program to Increase Use of Standardized Outcome Measures in an Outpatient Pediatric Physical Therapy Clinic: An Administrative Case Report. [JOURNAL ARTICLE]
- Phys Ther 2014 Jul 17.
Pediatric physical therapists face many challenges related to the application of research evidence into clinical practice. A multi-component knowledge translation (KT) program may be an effective strategy to support practice change. The purpose of this project was to use a KT program to improve the knowledge and frequency of use of standardized outcome measures by pediatric physical therapists practicing in an outpatient clinic.This program occurred at a pediatric outpatient facility with 1 primary clinic and 3 additional satellite clinics, and a total of 17 physical therapists. The initial underlying problem was inconsistency across staff recommendations for frequency and duration of physical therapy services. Formal and informal discussion with the department administrator and staff identified a need for increased use of standardized outcome measures to inform these decisions. The KT program to address this need spanned 6 months and included identification of barriers, the use of a knowledge broker, multiple workshop and practice sessions, online and hard copy resources, and ongoing evaluation of the KT program with dissemination of results to staff. Outcome measures included pre and post knowledge assessment and self-report surveys, and chart review data on use of outcome measures.Participants (N = 17) gained knowledge and increased the frequency of use of standardized outcome measures, based on data from self-report surveys, a knowledge assessment, and chart reviews.Administrators and others interested in supporting practice change in physical therapy may consider implementing a systematic KT program that includes a knowledge broker, ongoing engagement with staff, and a variety of accessible resources.
- Introduction to the GRADE Approach for Guideline Development: Considerations for Physical Therapist Practice. [JOURNAL ARTICLE]
- Phys Ther 2014 Jul 17.
Practice guidelines (guidelines) have an increasing role in healthcare delivery and are increasingly published. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) is an approach for guideline development. The GRADE approach has been adopted by multiple national and international organizations producing guidelines related to physical therapist care.The purpose of this paper is to introduce physical therapists to the GRADE approach for guideline development.GRADE provides a consistent approach for guideline development, transparency in communication of how guidelines were developed and how the recommendations were reached leading to informed choices by patients, clinicians, and policymakers in healthcare. GRADE leads to a clear distinction between the strength of the evidence and the recommendation. The recommendation includes both the direction (for or against) and strength (weak or strong) of the recommendation. To determine the strength of the recommendation, GRADE considers: the quality of evidence, the balance of benefit and harm, the uncertainty or variability in patient values and preferences, and uncertainty if the intervention is a wise use of resources.The GRADE approach has primarily been used with interventions and clinical questions and less with questions related to diagnosis and prognosis.The publication of guidelines is increasing. To make informed choices in the healthcare system, physical therapists should understand how guidelines are developed. The GRADE approach has been adopted by national and international organizations that produce guidelines relevant to physical therapist practice. Understanding the GRADE approach will enable physical therapists to make informed clinical choices.
- Chronic Stress, Cortisol Dysfunction, and Pain: A Psychoneuroendocrine Rationale for Stress Management in Pain Rehabilitation. [JOURNAL ARTICLE]
- Phys Ther 2014 Jul 17.
Pain is a primary symptom driving patients to seek physical therapy and its attenuation commonly defines a successful outcome. A large body of evidence is dedicated to elucidating the relationship between chronic stress and pain. A physiologic stress response may be evoked by fear or perceived threat to safety, status, or well-being, and elicits the secretion of sympathetic catecholamines (epinephrine and norepinepherine) and neuroendocrine hormones (cortisol) to promote survival and motivate success. Cortisol is a potent anti-inflammatory that functions to mobilize glucose reserves for energy and modulate inflammation. Cortisol may also facilitate the consolidation of fear-based memories for future survival and avoidance of danger. While short-term stress may be adaptive, maladaptive responses (such as magnification, rumination, or helplessness) to pain or non-pain-related stressors may intensify cortisol secretion and condition a sensitized physiologic stress response that is readily recruited. Ultimately, a prolonged or exaggerated stress response may perpetuate cortisol dysfunction, widespread inflammation, and pain. While stress may be unavoidable in life and challenges are inherent to success, humans have the capability to modify what they perceive as stressful and how they respond to it. Exaggerated psychological responses (eg: catastrophizing) following maladaptive cognitive appraisals of potential stressors as threatening may exacerbate cortisol secretion by facilitating fear-based activation of the amygdala. Coping, cognitive re-appraisal, or confrontation of stressors may minimize cortisol secretion and prevent chronic, recurrent pain. Given the parallel mechanisms underlying the physiologic effects of a maladaptive response to pain and non-pain-related stressors, physical therapists should consider screening for non-pain-related stress to facilitate treatment, prevent chronic disability, and improve quality of life.
- Use of the Theoretical Domains Framework to Develop an Intervention to Improve Physical Therapist Management of Falls Risk on Discharge. [JOURNAL ARTICLE]
- Phys Ther 2014 Jul 17.
Older adults are at increased risk of falls following discharge from hospital. Guidelines to manage this falls risk are well documented but commonly not implemented. This paper aims to describe a novel approach using the Theoretical Domains Framework (TDF) to develop an intervention to change clinical behaviour of Physiotherapists.The study had 4 phases: (1) Identifying the evidence practice gap; (2) Identifying barriers and enablers that need to be overcome; (3) Identifying behaviour change techniques to overcome the barriers; and (4) Determining outcome measures to evaluate behaviour change.The evidence practice gap identified that few patients who had undergone surgery for hip fracture were recognised to have a falls risk or had a documented referral to a community agency for falls prevention follow up. Project aims aligned with best practice guidelines were established; twelve of the fourteen TDF domains were considered to be relevant to behaviours within this project and six behaviour change strategies were implemented; primary outcome measures included proportion of patients who have documentation of falls risk and are referred on for a comprehensive falls risk assessment following discharge from the hospital.The use of a systematic approach involving the TDF was useful in designing a multi-faceted intervention to improve management of discharge falls risk by Physiotherapists in an acute care setting in South Australia. This framework enabled targeted intervention strategies to be identified that were likely to influence healthcare professional behaviour. Early case note audit results reflect positive changes to reduce the evidence practice gap.
- A Comparison Study of KOOS-PS and KOOS Function and Sport Scores. [JOURNAL ARTICLE]
- Phys Ther 2014 Jul 17.
To compare the construct validity the Knee Injury and Osteoarthritis Outcome Score (KOOS) Function and Sport scales with a shorter version of the measure (KOOS-PS).Using a cross-sectional, observational design, consecutive consenting patients diagnosed with knee osteoarthritis were recruited at an assessment center visit to determine need for conservative or surgical management. Patients completed the Lower Extremity Functional Scale (LEFS), KOOS, timed up and go and 6-minute walk test. A single function-sport score (KOOS FunSportsum) and the KOOS-PS were abstracted from the KOOS. We compared Pearson's correlation coefficients between the reference standards' scores (performance measures and LEFS) and KOOS scores. KOOS-PS raw scores were compared to KOOS-PS Rasch scores.377 patients aged 64.4 (SD 10.5) years participated. The correlation between performance reference standard and KOOS-PS Rasch scores was significantly lower than with KOOS FunSportsum scores (mean difference in r [95% CI]: 0.08 [0.03, 0.11]; Z = 4.45, P1 < 0.001). A similar finding was observed with the LEFS comparison.For patients with knee osteoarthritis the KOOS-PS appears too restricted in item content to provide a comprehensive estimate of a patient's lower extremity functional status level relative to the KOOS Function and Sport scales. Pursuit of a computer-adapted test may be a productive direction for future inquiry.
- 45th Mary McMillan Lecture: If Greatness Is a Goal… [JOURNAL ARTICLE]
- Phys Ther 2014 Jul 10.
James Gordon, PT, EdD, FAPTA, is professor as well as associate dean and chair of the Division of Biokinesiology and Physical Therapy at the University of Southern California. He received his BS in Physical Therapy from the State University of New York-Downstate Medical Center. He then worked for 6 years as a physical therapist in acute care, rehabilitation, and home care settings before entering graduate school with the goal of becoming a researcher in the science underlying neurologic rehabilitation. In 1985, he was awarded an EdD in Movement Science at Teachers College, Columbia University. After graduation, Dr Gordon worked as a researcher with a focus on the neural control of movement, especially the roles of proprioceptive information in control of reaching movements. He has held full-time faculty positions in the physical therapy departments at Columbia University, New York Medical College, and University of Southern California. As a researcher and educator, he is recognized for his lectures and writings on applying research in motor control and motor learning to neurological rehabilitation. He has also taught courses in professional practice and co-authored a text on documentation in physical therapy. Long active in APTA, Dr Gordon is a member of the Education Section, Neurology Section, and Section on Research. Among many other accomplishments, he co-directed PTClinResNet, a groundbreaking Foundation of Physical Therapy-funded clinical research network. He has been an advocate for excellence in academic physical therapy, and most recently he played a leading role in the formation of the American Council of Academic Physical Therapy. Dr Gordon became a Catherine Worthingham Fellow of APTA in 2005 and was chosen to deliver the Education Section's Pauline Cerasoli Lecture in 2011.
- Predicting Response to Motor Control Exercises and Graded Activity for Low Back Pain Patients: Preplanned Secondary Analysis of a Randomized Controlled Trial. [JOURNAL ARTICLE]
- Phys Ther 2014 Jul 10.
Current treatments for low back pain have small effects. A research priority is to identify patient characteristics associated with larger effects for specific interventions.To identify simple clinical characteristics of patients with chronic low back pain who would benefit more from either motor control exercises or graded activity.Randomized controlled trial.Australian physiotherapy clinics.172 patients presenting with chronic low back pain were enrolled in the trial.The treatment consisted of 12 initial exercise sessions over an 8-week period and booster sessions at 4 and 10 months following randomization.The putative effect modifiers (psychosocial features, physical activity level, walking tolerance and self-reported signs of clinical instability) were measured at baseline. Measures of pain and function (both measured on a 0-10 scale) were taken at baseline, 2, 6 and 12 months by a blinded assessor.We found self-reported clinical instability was a statistically significant and clinically important modifier of treatment response for 12 month function (interaction: 2.72; 95% CI 1.39 to 4.06). People with high scores on the clinical instability questionnaire (≥9) did 0.85 points better with motor control whereas people who had low scores (<9) did 1.93 points better with graded activity. Most other effect modifiers investigated did not appear to be useful in identifying preferential response to exercise type.The psychometric properties of the instability questionnaire have not been fully tested.A simple 15-item questionnaire of features considered indicative of clinical instability can identify patients who respond best to either motor control exercise or graded activity.
- Task-Specific Training in Huntington Disease: A Randomized Controlled Feasibility Trial. [JOURNAL ARTICLE]
- Phys Ther 2014 Jul 10.
Task-specific training may be a suitable intervention to address mobility limitations in people with Huntington's disease (HD).We aimed to assess feasibility and safety of goal-directed, task-specific mobility training for individuals with mid-stage HD.This study was a randomized, blinded, feasibility trial; participants were randomized into control (usual care) or intervention groups.This multi-site study was conducted in 6 U.K. sites.Thirty individuals with mid-stage HD (13 male; mean (SD) age: 57.0 (10.1) years) were enrolled and randomized.Task-specific training was conducted by physical therapists in participant's homes, focusing on walking, sit-to-stand and standing, twice a week for eight weeks. Goal attainment scaling was used to individualize the intervention and monitor achievement of personal goals.Adherence and adverse events were recorded. Adjusted between-group comparisons on standardized outcome measures were conducted at 8 and 16 weeks to determine effect sizes.Loss to follow up was minimal (2); adherence in the intervention group was excellent (96.9%). Ninety-two percent (92%) of goals were achieved at the end of the intervention; 46% achieved much better than expected outcome. Effect sizes on all measures were small.Measurements of walking endurance were lacking.The safety and excellent adherence to a home-based, task-specific training program, in which most participants exceeded goal expectation is encouraging given the range of motivational, behavioral and mobility issues in people with HD. The design of the intervention, in terms of frequency (dose), intensity (aerobic versus anaerobic) and specificity (focused training on individual tasks) may not have been sufficient to elicit any systematic effects, and thus a larger scale trial of this specific intervention does not seem warranted.
- Author response. [Comment, Letter]
- Phys Ther 2014 Jun; 94(6):891.
- Global identity. [Letter]
- Phys Ther 2014 Jul; 94(7):1055.