Evidence-based practice confidence and behavior throughout the curriculum of four physical therapy education programs: a longitudinal study.

BACKGROUND: Evidence-based practice (EBP) is a foundational process taught in health professional education, yet it is unclear when EBP confidence and skills are obtained. Increases in EBP confidence and behaviors from the start of physical therapy programs to post graduation have been reported in studies that evaluated a single program or used non-valid questionnaires. This study aimed to describe changes in EBP confidence and behavior using validated questionnaires of students from four physical therapy education programs throughout their curriculum and one year post graduation. METHODS: One hundred and eighty-one students from a potential pool of 269 (67.3%) consented to participate. Students completed the Evidence-Based Practice Confidence (EPIC) Scale and the Evidence-Based Practice Implementation Scale (EBPIS) at 6 timepoints: start of the program, prior to first clinical experience, after first clinical experience, at the end of classroom instruction, graduation, and one year post. Medians (Mdn) and 25th and 75th percentiles (P25, P75) were calculated for 42 (23.2%) students with complete data across all timepoints. Change between timepoints was assessed using Friedman's test and Wilcoxon signed rank test with a Bonferroni correction for post hoc analysis. RESULTS: There were significant changes in EPIC scores (p < 0.001) from enrollment (Mdn 50.0, P25, P75 35.5, 65.9) to prior to first clinical experience (Mdn 65.5, P25, P75 57.3, 72.5) and after the first clinical experience (Mdn 67.3, P25, P75, 58.9, 73.2) to the end of classroom instruction (Mdn 78.6, P25, P75, 72.0, 84.1). Significant increases on the EBPIS (p < 0.01) were only seen from after the first year of training (Mdn 15, P25, P75, 10.0, 22.5) to end of the first clinical experience (Mdn 21.5, P25, P75 12.0, 32.0). CONCLUSIONS: EBP confidence increased significantly after classroom instruction but remained the same after clinical experiences and at one year post graduation. EBP behavior significantly increased only after the first clinical experience and remained the same through graduation. Confidence and behavior scores were higher than were previously reported in practicing professionals. Ongoing assessment of EBP confidence and behavior may help instructors build appropriate curricula to achieve their outlined EBP objectives.

Balance and Mobility Improvements During Inpatient Rehabilitation Are Similar in Young-Old, Mid-Old, and Old-Old Adults With Traumatic Brain Injury.

OBJECTIVE: To compare balance, mobility, and functional outcomes across 3 age groups of older adults with traumatic brain injury; to describe differences between those discharged to private residences versus institutional care. SETTING: Acute inpatient rehabilitation facility. PARTICIPANTS: One hundred adults, mean age of 78.6 ± 7.9 years (range = 65-95 years), with an admitting diagnosis of traumatic brain injury. DESIGN: Retrospective case series. MAIN MEASURES: Functional Independence Measure (FIM) for Cognition and Mobility; Berg Balance Scale; Timed Up and Go; and gait speed, at admission to and discharge from an inpatient rehabilitation facility. RESULTS: Statistically significant improvements (P < .01) were made on the Timed Up and Go, Berg Balance Scale, and gait speed for young-old, mid-old, and old-old adults, with no differences among the 3 age groups. Substantial balance and mobility deficits remained. The FIM cognition (P = .013), FIM Walk (P = .009), and FIM Transfer (P = .013) scores were significantly better in individuals discharged home or home with family versus those discharged to an institution. CONCLUSION: Preliminary outcome data for specific balance and mobility measures are reported in 3 subgroups of older adults following traumatic brain injury, each of which made significant and similar improvements. Some FIM item scores discriminated between those discharged to a private residence versus a higher level of care.

Supporting clinical practice behavior change among neurologic physical therapists: a case study in knowledge translation.

BACKGROUND AND PURPOSE: Physical therapists tend to underuse research evidence in clinical practice. Emerging research on knowledge translation activities (KTAs) provides guidance to address this problem. We describe a yearlong effort to promote clinical practice behavior change in neurologic physical therapists. CASE DESCRIPTION: Physical therapy stroke and brain injury teams in an inpatient rehabilitation setting implemented a quality improvement project to encourage use of a novel, evidence-supported gait training method (nonsupported gait training [NSGT]) for patients with hemiparesis. INTERVENTION: The project consisted of multidimensional KTAs, including (1) quarterly staff meetings at which NSGT was introduced, reviewed, and discussed; (2) group and individual dialogue regarding successes, challenges, solutions, and clinical decision-making; (3) ongoing monitoring of and aggregate feedback about appropriate NSGT attempts via chart audit; and (4) ongoing reminders, role modeling, and clinical consultation. Specific staff perceptions about the approach, captured by a mid-year survey, further informed targeted problem-solving and clinical case presentations. OUTCOMES: In the first, second, and fourth quarter, 50%, 60%, and 73% of eligible patients were trained with NSGT, respectively. A mid-year survey showed that 19% of therapists were very/moderately familiar with NSGT before the quality improvement project, versus 78% at the 6-month point. Thirty-three percent stated that they used NSGT almost always/often before the project, versus 66% at the 6-month point. DISCUSSION: Extensive multidimensional KTAs were feasible in inpatient rehabilitation and were accompanied by a moderate increase in documented and self-reported frequency of NSGT attempts. Clinical teams may benefit from adopting KTAs that best support clinical practice change.

Relationships among measures of balance, gait, and community integration in people with brain injury.

OBJECTIVE: To examine the relationship among measures of gait, balance, and community integration in adults with brain injury. SETTING: Two rehabilitation hospitals. PARTICIPANTS: Thirty-four community-dwelling individuals with brain injury, aged 18 to 61 years (mean = 32 years), who were able to walk at least 12 m independently or with supervision. Mean time post-brain injury was 52 ± 44 months. DESIGN: Cross-sectional study. MAIN MEASURES: Community Balance and Mobility Scale, Dynamic Gait Index, Ten-Meter Walk Test for gait speed, and the Community Integration Questionnaire (CIQ). RESULTS: Mean balance and gait scores were as follows: 54 ± 26 of 96 on the Community Balance and Mobility Scale; 19 ± 5 of 24 on the Dynamic Gait Index; and gait speed of 1.36 ± 0.88 m/s. Mean score on the CIQ was 16 ± 5 of 29. Correlations between the balance/gait measures and the total CIQ score ranged from 0.21 to 0.30 and were not significant. All 3 balance/gait measures correlated significantly with the CIQ Productivity subscale (range = 0.38-0.52). CONCLUSIONS: The ability of people with brain injury to engage in work/school/volunteer activity may be reduced by impairments in balance and mobility. Future research should explore this relationship and determine whether interventions that improve balance and mobility result in improved community productivity.

Use of a fracture prevention screening algorithm predicts self-reported falls in postmenopausal women.

Background and Purpose: The prevention of falls and fall-related fractures following menopause is an important health initiative. The Fracture Prevention Screening Algorithm (FPSA) uniquely uses fracture risk to prompt fall risk assessment to classify both fall and fracture risk in individuals. The purpose of this study was to determine whether use of the FPSA accurately predicted self-reported falls in post-menopausal women over one year. Methods: 142 postmenopausal women were recruited. Based on Fracture Risk Assessment Tool (FRAX®) scores, women with a ≥3% 10-year probability of hip fracture (high risk), or who self-identified as having balance problems or a fall history, underwent the Functional Gait Assessment (FGA) to estimate fall risk (high risk = ≤22/30). This allowed classification on the FPSA into one of four risk categories: low fall/low fracture risk; low fall/high fracture risk; high fall/low fracture risk; high fall/high fracture risk. Participants were contacted monthly for one year to determine fall and injury occurrence. Results: Fall/injury surveillance was conducted with 136 subjects over one year. Compared to women in the low fall/low fracture risk group, both high fall risk groups demonstrated significantly greater fall rates. Falls were 81-89% more likely in women with FGA scores of 22/30 or less. All injuries were rare events across all risk strata and did not differ between risk groups. Conclusion: These findings support the use of fracture risk as a trigger for fall screening to comprehensively classify risk in post-menopausal women as proposed by the FPSA.

Screening postmenopausal women for fall and fracture prevention.

Fragility fracture prevention has been historically associated with the diagnosis and treatment of osteoporosis. Given that the strongest determinant of fracture is falls, it is critical to add fall risk into clinical decision-making guidelines for fracture prevention. This special interest paper proposes an algorithm based on 2 validated tools: (1) World Health Organization's Fracture Risk Assessment Tool, which evaluates probability of fracture and (2) Functional Gait Assessment, which evaluates fall risk. Physical therapists can use this algorithm to better identify patients at greatest risk for fracture in order to customize interventions designed to promote bone health, minimize falls, and ultimately prevent fractures. Recommendations for referral, patient education, and exercise are provided for categories of varying fall and fracture risk.

Fracture risk and prevention: a multidimensional approach.

Although physical therapists commonly manage neuromusculoskeletal disorders and injuries, their scope of practice also includes prevention and wellness. In particular, this perspective article proposes that physical therapists are well positioned to address the client's skeletal health by incorporating fracture prevention into clinical practice with all adults. Fracture prevention consists primarily of maximizing bone strength and preventing falls. Both of these initiatives require an evidence-based, multidimensional approach that customizes interventions based on an individual's medical history, risk factors, and personal goals. The purposes of this perspective article are: (1) to review the role of exercise and nutrition in bone health and disease; (2) to introduce the use of the Fracture Risk Assessment Tool (FRAX®) into physical therapist practice; (3) to review the causes and prevention of falls; and (4) to propose a role for the physical therapist in promotion of bone health for all adult clients, ideally to help prevent fractures and their potentially devastating sequelae.

Competency-based validation of neurologic specialty practice.

INTRODUCTION: This paper describes a recent practice analysis of neurologic physical therapy. The purpose of the analysis was to describe the knowledge, skills, and abilities of a neurologic physical therapist and to distinguish elements that the neurologic specialist may perform differently from a nonspecialist. The analysis was done to revalidate and revise the Description of Specialty Practice used by the American Board of Physical Therapy Specialties (ABPTS). This Description supports the test plan for the neurologic certification examination. METHODS: A survey was developed by a subject matter expert group and was finalized by analysis of pilot survey data. The final survey consisted of 303 items about the duties, roles, procedures, and knowledge of neurologic physical therapists. Respondents were asked to rate items on frequency, importance, level of criticality, and level of judgment. Respondents were also asked to provide input about examination content percentages and their own clinical practice and demographics. RESULTS: The survey was sent to 590 members of the APTA's Neurology Section. The responses of 187 (32% return rate) physical therapists were combined with 30 responses to the pilot survey for analysis. The data yielded a new neurologic certification examination test plan and description of neurologic specialty practice. This description emphasizes the professional practice expectations, tests and measures, and intervention skills that characterize a neurologic specialist. SUMMARY: The results of this survey represent a summary of current neurologic specialty practice and therefore support an outline for the neurologic board certification examination.

Predicting caregiver assistance required for sit-to-stand following rehabilitation for acute stroke.

OBJECTIVE/METHODS: The objective of this case series was to determine the relationship between impairments identified at hospital admission and a reduced need for sit-to-stand (STS) assistance during an inpatient rehabilitation hospital stay. Fifty- five inpatients with a diagnosis of acute stroke were retrospectively studied. Demographic information and the following admission and discharge measures were collected from a chart review: bilateral dorsiflexion PROM, strength of the unaffected leg, Motricity Index (MI), presence of hemi-neglect, gait velocity, and Functional Independence Measure (FIM) scores for STS, ambulation, and cognition. Sit to stand improvement was determined by a change of at least one Caregiver Assistance Level (CAL) in STS performance between hospital admission and discharge. CAL 1 = STS FIM score of 7 or 6; CAL 2 = STS FIM score of 5; CAL 3 = STS FIM score of 4, 3, 2, or 1. RESULTS: Unaffected knee extension strength, Motricity Index (MI) score, FIM cognition scores, and bilateral ankle dorsiflexion PROM were each univariate, age-adjusted predictors of improvement in STS CAL. A multivariate, 3 main-effect model that included admission FIM cognitive scores and ankle PROM correctly predicted 90.6% (48 out of 53) of the possible sit to stand improvement outcomes. Admission gait velocity and MI differentiated extent of functional change in those who improved. CONCLUSIONS: Cognition and bilateral ankle dorsiflexion PROM most strongly predicted STS CAL improvement during an inpatient rehabilitation stay. Caregivers of patients with significant impairments may benefit from early and intensive training on how to assist their family member in the STS task.