Habit Formation Intervention to Improve Type 2 Diabetes Self-Management Behaviors: A Feasibility Study.

IMPORTANCE: Self-management of lifestyle behaviors is the recommended focus for interventions to address Type 2 diabetes. Habit formation is an effective approach to changing personal behaviors, but evidence of success for Type 2 diabetes is limited. OBJECTIVE: To examine the feasibility and preliminary effectiveness of occupation-based habit formation interventions for improving diabetes self-management behaviors. DESIGN: Single-subject design with multiple participants providing 4 wk of baseline data followed by 10 wk of intervention data. SETTING: Individual telehealth sessions. PARTICIPANTS: Eight adults (ages 29-75 yr) with Type 2 diabetes, who had access to a telephone and who were not involved in other diabetes-related education or interventions voluntarily, enrolled into the study. INTERVENTION: Participants engaged in 10 wk of habit formation intervention focused on four diabetes self-management domains: nutrition, blood glucose monitoring, medication management, and physical activity. OUTCOMES AND MEASURES: Data gathered included findings on measures of diabetes self-care behaviors and habit formation. RESULTS: There was a significant change in self-care behaviors for 6 of the 8 participants (p < .05 for 1 participant, and p < .01 for 5 participants). Group changes were statistically significant (p < .001). Habit strength significantly improved for all areas of diabetes self-management (p < .001 for nutrition, blood glucose monitoring, and medication management and p = .001 for physical activity). CONCLUSIONS AND RELEVANCE: Findings suggest that the occupation-based intervention was feasible and showed promise for developing self-management behaviors. What This Article Adds: Habits are considered foundational to occupations, yet application of the science of habit formation is often not well understood by occupational therapists. This study considered the theoretical components of habit formation that have been neglected by prior studies and demonstrates the feasibility and preliminary effect estimates of a habit formation intervention when used with people with Type 2 diabetes.

Attention-Deficit Hyperactivity Disorder Status Moderates Polysubstance Use Among Substance Using Populations: A Cross-Sectional Analysis.

INTRODUCTION: Attention-deficit hyperactivity disorder (ADHD) increases the risk for comorbid psychiatric and substance use disorders, which may increase the risk of adverse patient outcomes. This study examined the prevalence of ADHD in residential addiction treatment as well as the prevalence of mono-substance use, comorbid substance use, and polysubstance use disorders (PUD) as a function of ADHD status. METHODS: All participants were adults (18 years and older) admitted to a residential substance use disorder treatment center in Sioux Falls, SD. Participants were administered a Wender Utah ADHD rating scale to assess ADHD status using a cutoff score of 46. The participants were administered ADHD questionnaires developed to assess ADHD history, family history, and academic performance. RESULTS: Students showed a 17% increase in confidence in discussing substance use with patients and a 47% increase in confidence in applying MI techniques after the instructional session. At CC, 54.5% of patients reported substance use and 16.7% of those patients responded that they would consider quitting in the next month after the student interview. In the post-clinic survey, students rated an average of 4.21 out of 5 on comfort level in discussing excessive substance use. CONCLUSION: ADHD and substance use disorder have notable comorbidity. This study demonstrates a high prevalence of ADHD in populations with substance use disorder. The presence of ADHD may be a risk factor for PUD. Effective screening and treatment of ADHD may alleviate substance use burden among users.

Work-Life Balance in Women Physicians in South Dakota: Results of a State-Wide Assessment Survey.

INTRODUCTION/BACKGROUND: There is currently a high prevalence of burnout among women physicians. This is associated with factors related to job satisfaction and work-life balance. Female physicians are more likely to experience burnout and related negative consequences. Preventing burnout among physicians improves wellness in both doctors and patients. The goal of this study is to determine burnout among physicians in South Dakota and identify possible burnout prevention strategies to improve work-life balance. METHODS: South Dakota State Medical Association (SDSMA) physician members were emailed a survey with anonymous responses in November 2017 and January 2018. Survey questions were based on a 5-point Likert scale with two open-ended questions which were evaluated by qualitative measures. RESULTS: A total of 1,989 surveys were administered with 433 responses (21.8 percent). Of the 433 survey responses, 133 individuals provided additional comments regarding work-life balance. A slender majority of male and female physicians are satisfied with their work-life balance (54.7 and 55.4 percent, respectively). Both men and women physicians would choose the same specialty again (78.2 and 74.8 percent, respectively) as well as choose to be a physician again (79.4 and 78.7 percent respectively). Overall, women suggested more time for administrative tasks, more flexible hours, offering daycare at the hospital. CONCLUSIONS: Possible workplace interventions to prevent physician burnout include hiring scribes, allocating time for administrative work, and allowing less work hours. Personal strategies aiding in work-life balance include utilizing daycares, having supportive families, and hiring individuals to assist in daily home tasks.

Analysis of Gauntlet Test Performance and Injury Risk in Intercollegiate Division I Female Soccer (Football) Players: A Retrospective Study.

CONTEXT: Injury risk factors and relevant assessments have been identified in women's soccer athletes. Other tests assess fitness (eg, the Gauntlet Test [GT]). However, little empirical support exists for the utility of the GT to predict time loss injury. OBJECTIVES: To examine the GT as a predictor of injury in intercollegiate Division I female soccer athletes. DESIGN: Retrospective, nonexperimental descriptive cohort study. SETTING: College athletic facilities. PARTICIPANTS: 71 female Division I soccer athletes (age 19.6 ± 1.24 y, BMI 23.0 ± 2.19). MAIN OUTCOME MEASURES: GT, demographic, and injury data were collected over 3 consecutive seasons. GT trials were administered by coaching staff each preseason. Participation in team-based activities (practices, matches) was restricted until a successful GT trial. Soccer-related injuries that resulted in time loss from participation were recorded. RESULTS: 71 subjects met the inclusion criteria, with 12 lower body time loss injuries sustained. Logistic regression models indicated that with each unsuccessful GT attempt, the odds of sustaining an injury increased by a factor of 3.5 (P < .02). The Youden index was 2 GT trials for success, at which sensitivity = .92 and specificity = .46. For successive GT trials before success (1, 2, or 3), the predicted probabilities for injury were .063, .194, and .463, respectively. CONCLUSIONS: The GT appears to be a convenient and predictive screen for potential lowerbody injuries among female soccer athletes in this cohort. Further investigation into the appropriate application of the GT for injury prediction is warranted given the scope of this study.

Physician Assistant Training, Collaboration, and Practice Act Legislation: Perspectives From Practicing Physician Assistants.

INTRODUCTION: This study examines training, experience, and collaborative practices of physician assistants (PAs) with employment experience and their perspectives on practice act legislation. METHODS: Mixed method study with quantitative and qualitative data. RESULTS: One hundred eighty participants completed the survey. During clinical employment, 81.05% of respondents reported physicians participated in training. However, supervising physicians trained only 43.46%; 56.54% reported being trained by nurse practitioners (NPs), PAs, and/or other physicians. Onsite collaboration with physicians was reported by 87.2%. Supervising physician involvement was reported by 67.3%, and of these, 59% collaborated with PAs, NPs, and/or other physicians as well. One-third collaborated only with NPs, PAs, and/or other physicians. Daily/weekly collaboration with a supervising physician was reported by 78.89% in their first position and 54.87% in their current/most recent position; 77.22% collaborated with NPs, PAs, and/or other physicians in their first position and 71.68% in their current/most recent position. Most (64.44%) felt PAs should not be legally required to have physician supervision. Most (76.12%) felt care quality would not decrease if supervision were lifted. Most (74.44%) agreed that PAs are hired less frequently than NPs in states where physician supervision is required for PA but not NPs. DISCUSSION: Findings suggest that team-based practice is already the current structure of PA clinical training and collaboration with PAs receiving significant support from physicians who are not supervising physicians and other nonphysician practitioners. Establishing oversight at the practice level is supported by this practice structure. Determining effects of practice act legislation on employment training, collaboration, and hiring practices warrants further research.

A comparison of the Sensory Profile scores of children with autism and an age- and gender-matched sample.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) reports that autism spectrum disorder (ASD) affects one in 88 children in the United States. The American Psychiatric Association's Diagnostic and Statistical Manual, Text Revision (DSM-IV-TR) defines ASD as a pervasive neurodevelopmental disorder characterized by qualitative impairment in communication and social interaction, and restricted, repetitive and stereotyped behavior patterns. The purpose of this study was to determine whether children with autism differ in their response to sensory input relative to typically developing age- and gender-matched peers. METHOD: The Sensory Profile (SP) is a 125-item caregiver questionnaire designed to measure a child's ability to process sensory information and to profile the effect of sensory processing on daily life activity. The results of the SP of 21 participants with autism ages 3 to 9 years were compared with an age- and gender-matched sample of typically developing children. RESULTS: Significant differences were found across all four SP quadrants (Registration, Seeking, Sensitivity, and Avoiding) as well as eight of the nine SP factor scores. This study adds to the evidence indicating that children with autism process and respond to sensory input differently than typically-developing peers. CONCLUSION: The findings from this study support previous research findings that sensory processing differences exist between children with ASD and their typically-developing peers, as measured by the SP.

US physical therapist practice patterns evaluating concussion and clinical practice guideline adherence.

OBJECTIVES: To assess the influence of contemporary physical therapy clinical practice guidelines (CPG) on concussion evaluation practice patterns and barriers/facilitators for CPG adherence. DESIGN: Electronic cross-sectional survey. SETTING: Online survey platform. PARTICIPANTS: US licensed physical therapists that manage concussion. MAIN OUTCOME MEASURES: 1) practice patterns 2) knowledge/use of CPG 3) barriers/facilitations to CPG adherence. RESULTS: Knowledge/use of CPG categories significantly predicted the model (χ2(1) = 10.966, p < .001) of total vignette scores/practice patterns with a statistically significant effect. A Kruskal-Wallis test indicated significant differences in total vignette score means based on knowledge/use between "not aware of the concussion CPG" and "integrated concussion CPG into practice" groups (p < .001, ES = .21). Knowledge/use of the CPG predicted the perceived barriers/facilitators model for three questions: investment in specialized concussion training (χ2(1) = 39.52, p < .001), necessary equipment to complete concussion evaluation (χ2(1) = 16.01, p < .001), and confidence around concussion evaluation knowledge (χ2(1) = 27.46, p < .001) with a significant effect. CONCLUSION: The results of this study provide support for guiding documents like the CPG to positively influence concussion practice patterns and insight into facilitators for guideline adherence.

DUAL-TASK ASSESSMENT IMPLICATIONS FOR ANTERIOR CRUCIATE LIGAMENT INJURY: A SYSTEMATIC REVIEW.

BACKGROUND: Several systematic reviews have evaluated the role of dual-task assessment in individuals with concussion. However, no systematic reviews to date have investigated dual-task protocols with implications for individuals with anterior cruciate ligament (ACL) injury or ACL reconstruction (ACLR). PURPOSE: To systematically review the evidence on dual-task assessment practices applicable to those with ACL deficiency/ACLR, specifically with the aim to identify motor-cognitive performance costs. STUDY DESIGN: Systematic review. METHODS: A systematic literature review was undertaken on those with ACL-deficient or ACL-reconstructed knees performing dual-task activities. The following databases were searched from inception to June 8, 2018 including CINAHL, PsychInfo, PubMed, SPORTDiscus, Web of Science, and gray literature. Three primary search categories (knee, cognition, and motor task) were included. Only one reviewer independently performed the database search, data extraction, and scored each article for quality. All studies were assessed for quality and pertinent data were extracted, examined and synthesized. RESULTS: Ten studies were included for analysis, all of which were published within the prior ten years. Performance deficits were identified in those with either ACL deficiency or ACLR while dual-tasking, such as prioritization of postural control at the expense of cognitive performance, impaired postural control in single limb stance, greater number of cognitive errors, and increased step width coefficient of variation while walking. No studies examined those with prior ACL injury or ACLR during tasks that mimicked ACL injury mechanisms such as jump-landing or single-leg cutting. CONCLUSION: The results of the current systematic review suggests that postural control, gait, and/or cognitive deficits exist when evaluated under a dual-task paradigm in those with ACL deficiency or ACLR. This systematic review highlights the need for future research on dual-task assessment for individuals who have sustained an ACL injury or undergone ACLR, specifically utilizing more difficult athletic movements. LEVEL OF EVIDENCE: Level 3a.

THE INFLUENCE OF VISUAL FIXATION ON HOP TEST PERFORMANCE.

BACKGROUND: It has been recognized that anterior cruciate ligament (ACL) injuries typically occur when athletes are attending to a secondary task or object, including teammates, opponents, and/or a goal. Commonly applied tests after ACL injury include a series of hop tests to determine functional status, yet do not control for visual fixation. PURPOSE: To examine the influence of visual fixation during two functional hop tests in healthy individuals. STUDY DESIGN: Repeated measures. METHODS: Participants performed the crossover triple hop for distance (XHOP) on the left lower limb, and the medial triple hop for distance (MHOP) on the right. For the hop test only conditions, participants were not instructed where to fix their vision while performing the hop test. The visual fixation condition required participants to fix their vision on an alternating plus/minus sign at the center of a display monitor located in front of the participant while performing each hop test, respectively. A retest session occurred 48-72 hours after the initial test session in order to examine reliability. RESULTS: Thirty-four healthy adults (age: 24.0 ± 3.9 years) completed testing procedures, performing the XHOP and MHOP under standard and visual fixation conditions. Of those participants, twelve completed a retest session for reliability analysis. Hop distance was not altered by the addition of visual fixation (p = 0.27), with trivial effect sizes found across conditions (d = 0.02 - 0.07); however, the addition of visual fixation slightly improved within- and between-session intrarater reliability, standard error of measurement, and minimal detectable change of the MHOP. CONCLUSION: Hop distance during the XHOP and MHOP was not influenced by visual fixation. Measurement of both the XHOP and MHOP was reliable, but lacked precision. Measurement properties for the MHOP including within- and between-session reliability, standard error of measurement, and minimal detectable change improved slightly with the addition of visual fixation compared to normal MHOP procedures. LEVEL OF EVIDENCE: 2b.

INCORPORATING A DUAL-TASK ASSESSMENT PROTOCOL WITH FUNCTIONAL HOP TESTING.

BACKGROUND: Hop tests are commonly used within a testing battery to assess readiness for return to sport after anterior cruciate ligament (ACL) injury, yet athletes still experience a high rate of re-injury. Simultaneous performance of a secondary task requiring cognitive processing or decision-making may test the athlete under more realistic contexts. PURPOSE: To examine a clinically feasible, dual-task assessment paradigm applied during functional hop tests in healthy individuals. STUDY DESIGN: Repeated measures. METHODS: Participants performed the crossover triple hop for distance (XHOP) and medial triple hop for distance test (MHOP) under three separate conditions: standard procedures and two dual-task protocols including the backward digit span memory task and a visuospatial recognition task. The visuospatial task involved briefly displaying an image consisting of 18 randomly placed red and blue circles on a screen, where the participant was asked to identify the number of red circles in each image. The backward digit span task was applied by introducing a sequence of random numbers to the participants, who were required to repeat the sequence in reverse order. Each motor and cognitive task was performed independently and simultaneously, in accordance with the dual-task paradigm. RESULTS: Thirty-four healthy participants (age: 24.0 ± 3.9 years) completed testing procedures. No differences in hop distance were observed with the simultaneous application of a cognitive task, with the exception of the backward digit span memory task resulting in decreased hop distance (p = 0.04, d = 0.14). There were no differences in cognitive accuracy according to hop test type, although the effect size was greater for the XHOP (p = 0.08, d = 0.49) compared to the MHOP (p = 1.0, d = 0.07). The dual-task protocol revealed good-excellent within- (ICC3,1 = 0.85 - 0.99) and between-session (ICC3,k = 0.94 - 0.99) intrarater reliability for hop distance across all dual-task conditions. The addition of a cognitive task to the XHOP and MHOP resulted in a lower standard error of measurement and decreased minimal detectable change, as compared to standard testing procedures. CONCLUSION: The simultaneous application of a cognitive task did not alter hop distance, with the exception of the backward digit span memory task resulting in decreased hop distance with a trivial effect size. There were no differences in cognitive accuracy according to task type (sitting, XHOP, MHOP). All combinations of dual-task assessment demonstrated good-excellent within- and between-session intrarater reliability among healthy individuals, but measurement precision was deficient. LEVEL OF EVIDENCE: 2b.

Promoting Student Interest in Family Medicine Through National Conference Attendance.

INTRODUCTION: The University of South Dakota Sanford School of Medicine (USDSSOM) had success in preparing students to enter family medicine. A sharp decline in students choosing the specialty became noticeable in 2004. In 2005, only 10.2% of the graduating class entered family medicine residency programs. To reverse this trend, the Department of Family Medicine partnered with the South Dakota Academy of Family Physicians (SDAFP) chapter that year to send students to the American Academy of Family Physicians (AAFP) National Conference of Family Medicine Residents and Medical Students. This report examines the influence of national conference attendance on career choice. While many factors influence student choice, conference attendance served as an additive method for recruitment. METHODS: Internal departmental records on national conference attendance and subsequent National Resident Matching Program (NRMP) data were reviewed retrospectively, to determine if a correlation existed between conference attendance and choice of family medicine as a specialty. Chi-squared analysis was utilized to further examine this relationship. RESULTS: The association between conference attendance and number of times attending is significant (χ2 =6.78, P<.05). The recent data show that this intervention has resurrected student interest in family medicine, with USDSSOM now exceeding the NRMP average for family medicine. CONCLUSIONS: A positive correlation exists between national conference attendance and medical student choice to enter family medicine residency programs. This intervention may be used by more medical schools wishing to promote family medicine in order to help meet our nation's primary care workforce needs.

CHANGES IN DYNAMIC BALANCE AND HIP STRENGTH AFTER AN EIGHT-WEEK CONDITIONING PROGRAM IN NCAA DIVISION I FEMALE SOCCER (FOOTBALL) ATHLETES.

BACKGROUND: Lower extremity injury commonly affects female soccer athletes. Decreased dynamic balance and hip strength are identified risk factors for lower extremity injury. Little is known about how these factors adapt to a training stimulus in this population. PURPOSE: To retrospectively investigate changes in lower extremity dynamic balance and isometric hip strength in Division I collegiate female soccer athletes after participating in an eight-week strength and conditioning program. STUDY DESIGN: Retrospective, non-experimental cohort study. METHODS: As part of a standard testing battery, soccer athletes completed athletic performance pre- and post-testing separated by an eight-week off-season conditioning program consisting of overall strength and technical skill development. Testing included lower extremity dynamic balance assessment through the Star Excursion Balance Test (SEBT) and isometric hip abduction and external rotation (ER) strength testing, normalized to limb length and percent body mass, respectively. Athletes rested for one week prior to post-testing. RESULTS: Seventeen healthy Division I female soccer athletes (age: 18.8 ± 0.9 years, height: 1.7 ± 0.06 m, mass: 68.0 ± 8.2 kg) completed the protocol. Significant improvements in SEBT composite reach distance were observed in the dominant (DOM) (3.6 ± 4.8%, 95% CI: 1.1 to 6.0) and nondominant (NDOM) (4.8 ± 6.1%, 95% CI: 1.7 to 7.9) limbs. Significant improvements in DOM hip ER strength (2.4 ± 2.3%, 95% CI: 1.3 to 3.6) and DOM SEBT anterior reach (2.1 ± 2.8%, 95% CI: 0.6 to 3.5) were observed. Large effect sizes were observed for DOM and NDOM hip ER strength gains (0.87 - 1.0), while small-moderate effect sizes were noted for the anterior reach direction (0.40 - 0.66). Further, DOM hip ER strength gains were significantly associated with DOM anterior reach performance improvements (r2 = 0.37, p<.01). CONCLUSION: DOM hip ER strength gains appear to be associated with improved lower extremity dynamic balance on the ipsilateral limb for the SEBT anterior reach direction in collegiate, Division I female soccer athletes after an eight-week conditioning program. Future investigations should prospectively investigate intervention strategies to modify lower extremity injury risk factors in this population. LEVEL OF EVIDENCE: 2b.

A study of empathy decline in physician assistant students at completion of first didactic year.

PURPOSE: This research investigated empathy trends among physician assistant (PA) students through their education and included gender differences and specialty job interest. This research partially replicates similar studies of medical and other health professions students. METHODS: The Jefferson Scale on Physician Empathy (SPE) was administered to PA students three times: (1) during matriculation, (2) near the end of their didactic training and (3) during their clinical education phase. Data were analyzed using both parametric (ANOVA) and nonparametric (binomial) methods. RESULTS: A total of 328 survey responses (270 females, 57 males, and one nonindicator) from the graduating classes of 2009 through 2014 at a northeastern university were collected and analyzed. Reliability for the JSPE was .80 (Cronbach) in this sample. Sixty-two percent had lower median JSPE empathy scores toward the end of their didactic training than at the time of matriculation (P = .0001), while the difference between empathy scores from years two and three was not significant (P = .37). Women were significantly more empathetic (mean = 5.05) at the time of matriculation than men (mean = 4.70, P = .0003), while both genders appeared to lose empathy in a parallel fashion during didactic training (P = .76). There was no association between empathy scores and prospective job category interest. CONCLUSION: These findings illustrate a decline in empathy among both genders during PA training, similar to other health care providers' educations, and support the need for further conversation regarding a role for empathy assessment and curricula in PA education.

A novel technique for determining scapulohumeral translation: a case-control and inter-rater reliability study.

BACKGROUND: Alterations in scapular and glenohumeral kinematics in patients with shoulder dysfunction have been recognized by this studies authors' and described in multiple other studies available in the literature. A reliability study was developed to assess a new technique for measuring scapulohumeral kinematics. Previous scapular position measuring techniques may require expensive equipment which decreases clinical utility. Other techniques require identification of multiple anatomic landmarks that may decrease accuracy, precision, and reliability. METHODS: A sample of asymptomatic controls and symptomatic study subjects were recruited. Each subject had markers placed on each acromion and stood at a standardized distance in front of a light. The shadow projected from the acromial marker onto a standardized, data collection board was measured during the resting, flexion, and scaption positions for bilateral shoulders. The horizontal and vertical translations of the shadows were measured compared to the resting point for both flexion and scaption. RESULTS: The scapula translated superiorly and medially during both flexion and scaption movements in all subjects and controls. There was good inter-rater reliability for measuring scapular translation with scaption (ICC= 0.81) and moderate reliability for measuring scapular translation with flexion (ICC = 0.62). There was increased superior and medial scapular translation in the subjects with flexion (p= 0.004 and p=0.002) and scaption (p= 0.01 and p=0.007) in the symptomatic shoulder compared to the asymptomatic shoulder. Superior scapular translation with flexion (p=0.0003) and scaption (p=0.006) and medial scapular translation with flexion (p<0.0001) and scaption (p<0.0001) was greater in the symptomatic subjects compared to controls. CONCLUSIONS: The scapula translates both superiorly and medially with flexion and scaption in asymptomatic and symptomatic subjects. After shoulder surgery, patients have increased superior and medial translation of the scapula compared to 1) their asymptomatic shoulder and 2) an asymptomatic control group. The current technique has good inter-rater reliability (ICC=0.81) when measuring scaption and moderate reliability when measuring flexion (ICC=0.62). LEVEL OF EVIDENCE: III Diagnostic Case-Control Study.