The Role of Movement in Physical Therapist Clinical Reasoning.

OBJECTIVE: The purpose of this study was to explore how physical therapists use movement as a component of their clinical reasoning. Additionally, this research explored whether movement as a component of clinical reasoning aligns with the proposed signature pedagogy for physical therapist education, human body as teacher. METHODS: The study utilized qualitative, descriptive methods in a multiple case studies design (each practice setting represented a different case for analysis purposes) with cross-case comparisons. Researchers conducted 8 focus groups across practice settings including acute care, inpatient neurological, outpatient orthopedics, and pediatrics. Each focus group had 4 to 6 participants. Through an iterative, interactive process of coding and discussion among all researchers, a final coding scheme was developed. RESULTS: Through exploration of the research aims, 3 themes emerged from the data. These primary themes are: (1) movement drives clinical reasoning to optimize function; (2) reasoning about movement is multisensory and embodied; and (3) reasoning about movement relies on communication. CONCLUSIONS: This research supports a description of movement as the lens used by physical therapists in clinical reasoning and the integral role of movement in clinical reasoning and in learning from and through movement of the human body while learning from clinical reasoning experiences in practice. IMPACT: As the understanding of the ways physical therapists use and learn from movement in clinical reasoning and practice continues to emerge, it is important to continue exploring ways to best make this expanded, embodied conception of clinical reasoning explicit in the education of future generations of physical therapists.

Clinical Reasoning in Physical Therapy: A Concept Analysis.

BACKGROUND: Physical therapy, along with most health professions, struggles to describe clinical reasoning, despite it being a vital skill in effective patient care. This lack of a unified conceptualization of clinical reasoning leads to variable and inconsistent teaching, assessment, and research. OBJECTIVE: The objective was to conceptualize a broad description of physical therapists' clinical reasoning grounded in the published literature and to unify understanding for future work related to teaching, assessment, and research. DESIGN/METHODS: The design included a systematic concept analysis using Rodgers' evolutionary methodology. A concept analysis is a research methodology in which a concept's characteristics and the relation between features of the concept are clarified. RESULTS: Based on findings in the literature, clinical reasoning in physical therapy was conceptualized as integrating cognitive, psychomotor, and affective skills. It is contextual in nature and involves both therapist and client perspectives. It is adaptive, iterative, and collaborative with the intended outcome being a biopsychosocial approach to patient/client management. LIMITATIONS: Although a comprehensive approach was intended, it is possible that the search methods or reduction of the literature were incomplete or key sources were mistakenly excluded. CONCLUSIONS: A description of clinical reasoning in physical therapy was conceptualized, as it currently exists in representative literature. The intent is for it to contribute to the unification of an understanding of how clinical reasoning has been conceptualized to date by practitioners, academicians, and clinical educators. Substantial work remains to further develop the concept of clinical reasoning for physical therapy, including the role of movement in our reasoning in practice.

Evaluating the effectiveness of a nutrition assistant role in a head and neck cancer clinic.

AIM: Acute toxicities secondary to (chemo)radiation for head and neck cancer can substantially impact nutritional intake. Nutrition is usually managed by dietitians, although time constraints may limit capacity to sufficiently deal with complex nutritional issues. The aim of the present study was to determine the effectiveness of a nutrition assistant performing screening and intervention of patients in a multidisciplinary head and neck clinic. METHODS: A model of care was developed to guide nutrition assistant practice within the clinic, with training provided to nutrition assistants prior to the clinic's implementation. Outcomes, including amount of dietitian time managing high risk patients, weight change over the duration of treatment, timing of initiation of enteral feeding and patient satisfaction were compared with pre- and post-implementation of the nutrition assistant role. RESULTS: Ninety-one patients were included, 43 pre-implementation and 48 post-implementation. Overall, (n = 21, 44%) of patients met criteria for nutrition assistant screening or intervention. Mean weight change between groups was comparable both during (-5.6% vs -4.7%, P = 0.3) and post-radiotherapy (-6.6% vs -6.49%, P = 0.9). Following implementation of the role significant improvement was found for overall patient satisfaction (4.0 ± 1.1 vs 4.6 ± 0.61, P = 0.03), and the dimensions: patient-perceived benefit (3.8 ± 0.69 vs 4.4 ± 0.62, P < 0.01) and dietitian/nutrition-assistant interpersonal skills (3.91 ± 1.1 vs 4.6 ± 0.55, P = 0.02). CONCLUSIONS: The nutrition assistant role resulted in improved patient satisfaction and maintenance of nutritional outcomes demonstrating the effectiveness of this role in supporting the management of head and neck cancer patients within a multidisciplinary treatment clinic.

Considering the Yin and Yang of Teaching and Learning: a Resource for the Novice Educator.

This paper introduces four key teaching and learning concepts that may be useful for novice educators new to the teaching and learning process. We have organized these concepts into the Chinese symbol of a yin-yang where one side captures what is needed for student learning to occur and, the other, what teachers need to do to prepare for teaching. This two-sided symbol brings together several practical ideas, such as cognitive load theory, co-construction of knowledge, and instructional design principles that may be useful for faculty new to teaching and learning.

Patterns of Clinical Reasoning in Physical Therapist Students.

BACKGROUND AND PURPOSE: Clinical reasoning is a complex, nonlinear problem-solving process that is influenced by models of practice. The development of physical therapists' clinical reasoning abilities is a crucial yet underresearched aspect of entry-level (professional) physical therapist education. OBJECTIVES: The purpose of this qualitative study was to examine the types of clinical reasoning strategies physical therapist students engage in during a patient encounter. METHODS: A qualitative descriptive case study design involving within and across case analysis was used. Eight second-year, professional physical therapist students from 2 different programs completed an evaluation and initial intervention for a standardized patient followed by a retrospective think-aloud interview to explicate their reasoning processes. Participants' clinical reasoning strategies were examined using a 2-stage qualitative method of thematic analysis. RESULTS: Participants demonstrated consistent signs of development of physical therapy-specific reasoning processes, yet varied in their approach to the case and use of reflection. Participants who gave greater attention to patient education and empowerment also demonstrated greater use of reflection-in-action during the patient encounter. One negative case illustrates the variability in the rate at which students may develop these abilities. CONCLUSIONS: Participants demonstrated development toward physical therapist--specific clinical reasoning, yet demonstrated qualitatively different approaches to the patient encounter. Multiple factors, including the use of reflection-in-action, may enable students to develop greater flexibility in their reasoning processes.

Vaccine-related mumps infections in Thailand and the identification of a novel mutation in the mumps fusion protein.

An outbreak of nine cases of mumps was reported from a total of 97 vaccinated nursing students at two medical colleges in Thailand in 2010, 16-26 days after administration of MMR vaccine containing the L-Zagreb mumps strain. Symptoms ranged in severity from fever and parotid swelling to orchitis. Clinical samples were obtained from seven patients and three were suitable for further study. Sequencing confirmed that the SH gene of the mumps virus in the unpassaged clinical specimens was identical to the L-Zagreb SH gene in the vaccine. Further analysis of the viral genome identified nucleotide position 5170 as a novel mutation which corresponds to an amino acid change in the fusion protein. This study provides another virologically confirmed example of mumps resulting from the L-Zagreb vaccine strain.

Investigation of porcine circovirus contamination in human vaccines.

DNA from porcine circovirus type 1 (PCV1) and 2 (PCV2) has recently been detected in two vaccines against rotaviral gastroenteritis from manufacturers A and B. We investigated if PCV1 sequences are present in other viral vaccines. We screened seeds, bulks and final vaccine preparations from ten manufacturers using qRT-PCR. We detected 3.8 × 10³ to 1.9 × 107 PCV1 DNA copies/milliliter in live poliovirus seeds for inactivated polio vaccine (IPV) from manufacturer A, however, following inactivation and purification, the finished IPV was PCV1-negative. PCV1 DNA was not detectable in live polio preparations from other vaccine producers. There was no detectable PCV1 DNA in the measles, mumps, rubella and influenza vaccines analysed including material supplied by manufacturer A. We confirmed that the PCV1 genome in the rotavirus vaccine from manufacturer A is near full-length. It contains two mutations in the PCV cap gene, which may result from viral adaptation to Vero cells. Bulks of this vaccine contained 9.8 × 10¹° to 1.8 × 10¹¹ PCV1 DNA copies/millilitre and between 4.1 × 107 and 5.5 × 108 DNA copies were in the final doses. We found traces of PCV1 and PCV2 DNA in the rotavirus vaccine from manufacturer B. This highlights the issue of vaccine contamination and may impact on vaccine quality control.

The translocated Salmonella effector proteins SseF and SseG interact and are required to establish an intracellular replication niche.

The facultative intracellular pathogen Salmonella enterica causes a variety of diseases, including gastroenteritis and typhoid fever. Inside epithelial cells, Salmonella replicates in vacuoles, which localize in the perinuclear area in close proximity to the Golgi apparatus. Among the effector proteins translocated by the Salmonella pathogenicity island 2-encoded type III secretion system, SifA and SseG have been shown necessary but not sufficient to ensure the intracellular positioning of Salmonella vacuoles. Hence, we have investigated the involvement of other secreted effector proteins in this process. Here we show that SseF interacts functionally and physically with SseG but not SifA and is also required for the perinuclear localization of Salmonella vacuoles. The observations show that the intracellular positioning of Salmonella vacuoles is a complex phenomenon resulting from the combined action of several effector proteins.

phgABC, a three-gene operon required for growth of Streptococcus pneumoniae in hyperosmotic medium and in vivo.

To cause disease, bacterial pathogens need to be able to adapt to the physiological conditions found within the host, including an osmolality of approximately 290 mosmol kg(-1). While investigating Streptococcus pneumoniae genes contained within pneumococcal pathogenicity island 1, we identified a three-gene operon of unknown function termed phgABC. PhgC has a domain with similarity to diacylglycerol kinases of eukaryotes and is the first described member of a family of related proteins found in many gram-positive bacteria. phgA and phgC mutant strains were constructed by insertional duplication mutagenesis and found to have impaired growth under conditions of high osmotic and oxidative stress. The compatible solutes proline and glycine betaine improved growth of the wild-type and the phgA mutant strains in hyperosmolar medium, and when analyzed by electron microscopy, the cellular morphology of the phgA mutant strain was unaffected by osmotic stress. The phgA and phgC mutant strains were reduced in virulence in models of both systemic and pulmonary infection. As the virulence of the phgA mutant strain was not restored in gp91phox(-/-) mice and the phgA and phgC mutant strains had reduced growth in both blood and serum, the reduced virulence of these strains is unlikely to be due to increased sensitivity to the respiratory burst of phagocytes but is, instead, due to impaired growth at physiological osmolality.

A locus contained within a variable region of pneumococcal pathogenicity island 1 contributes to virulence in mice.

We have previously described a 27-kb pathogenicity island of Streptococcus pneumoniae, termed pneumococcal pathogenicity island 1 (PPI1), which contains iron uptake locus piaABCD, required for full virulence in mice, and a further 28 previously uncharacterized genes. We have investigated one of these, Sp1051, which encodes a protein of unknown function. Disruption of Sp1051 does not affect growth in laboratory broth, serum, or blood but impairs virulence in mouse models of infection. When S. pneumoniae capsular serotypes were analyzed by PCR and Southern hybridization, it was found that 33% did not contain Sp1051. Analysis of other genes within PPI1 demonstrated that, compared to the serotype 4 genome published by The Institute for Genome Research (TIGR), the genomes of many strains contain deletions of a variable number of genes between Sp1046 and Sp1064, conforming to one of six different patterns. Amplification by PCR of this PPI1 variable region from a capsular serotype 17 strain and comparison of the sequence to TIGR serotype 4 strain sequence showed that Sp1051 is contained within an 11.3-kb segment of DNA flanked by 7-bp direct repeats within the serotype 4 strain which is not present in the serotype 17 strain. Further comparison of the sequences of this region between the three published S. pneumoniae genomes demonstrated that serotype 19F and strain R6 contain novel complements of genes not present in the serotype 4 strain. These data indicate that there is striking variation in gene content and structure of the 3' region of PPI1 among strains and that this region includes at least one virulence determinant. Gene variation within horizontally acquired DNA such as that of PPI1 may be one factor modulating differences in virulence among strains.

The classical pathway is the dominant complement pathway required for innate immunity to Streptococcus pneumoniae infection in mice.

The complement system is an important component of the innate immune response to bacterial pathogens, including Streptococcus pneumoniae. The classical complement pathway is activated by antibody-antigen complexes on the bacterial surface and has been considered predominately to be an effector of the adaptive immune response, whereas the alternative and mannose-binding lectin pathways are activated directly by bacterial cell surface components and are considered effectors of the innate immune response. Recently, a role has been suggested for the classical pathway during innate immunity that is activated by natural IgM or components of the acute-phase response bound to bacterial pathogens. However, the functional importance of the classical pathway for innate immunity to S. pneumoniae and other bacterial pathogens, and its relative contribution compared with the alternative and mannose-binding lectin pathways has not been defined. By using strains of mice with genetic deficiencies of complement components and secretory IgM we have investigated the role of each complement pathway and natural IgM for innate immunity to S. pneumoniae. Our results show that the proportion of a population of S. pneumoniae bound by C3 depends mainly on the classical pathway, whereas the intensity of C3 binding depends on the alternative pathway. Furthermore, the classical pathway, partially targeted by the binding of natural IgM to bacteria, is the dominant pathway for activation of the complement system during innate immunity to S. pneumoniae, loss of which results in rapidly progressing septicemia and impaired macrophage activation. These data demonstrate the vital role of the classical pathway for innate immunity to a bacterial pathogen.

Characterization of pit, a Streptococcus pneumoniae iron uptake ABC transporter.

Bacteria frequently have multiple mechanisms for acquiring iron, an essential micronutrient, from the environment. We have identified a four-gene Streptococcus pneumoniae operon, named pit, encoding proteins with similarity to components of a putative Brachyspira hyodysenteriae iron uptake ABC transporter, Bit. An S. pneumoniae strain containing a defined mutation in pit has impaired growth in medium containing the iron chelator ethylenediamine di-o-hydroxyphenylacetic acid, reduced sensitivity to the iron-dependent antibiotic streptonigrin, and impaired virulence in a mouse model of S. pneumoniae systemic infection. Furthermore, addition of a mutation in pit to a strain containing mutations in the two previously described S. pneumoniae iron uptake ABC transporters, piu and pia, resulted in a strain with impaired growth in two types of iron-deficient medium, a high degree of resistance to streptonigrin, and a reduced rate of iron uptake. Comparison of the susceptibilities to streptonigrin of the individual pit, piu, and pia mutant strains and comparison of the growth in iron-deficient medium and virulence of single and double mutant strains suggest that pia is the dominant iron transporter during in vitro and in vivo growth.