Simulation-based clinical assessment identifies threshold competence to practise physiotherapy in Australia: a crossover trial.

BACKGROUND: Although evidence exists for the efficacy of high-fidelity simulation as an educational tool, there is limited evidence for its application in high-stakes professional threshold competency assessment. An alternative model of simulation-based assessment was developed by the Australian Physiotherapy Council (APC), using purpose-written standardised patients, mapped to the appropriate threshold level. The aim of this two-phase study was to investigate whether simulation-based clinical assessments resulted in equivalent outcomes to standard, real-life assessments for overseas-trained physiotherapists seeking registration to practice in Australia. METHODS: A randomised crossover trial comparing simulation-based assessment to real-life assessment was completed. Participants were internationally trained physiotherapists applying for registration to practice in Australia, voluntarily recruited from the Australian Physiotherapy Council (APC) assessment waiting list: study 1 n = 25, study 2 n = 144. Study 1 participants completed usual APC real-life assessments in 3 practice areas, completed on different days at APC partner healthcare facilities. Participants also underwent 3 practice area-matched simulation-based assessments, completed on the same day at purpose-designed simulation facilities. Study 2 participants completed 3 simulation-based assessments and 1 real-life assessment that was randomly allocated for order and practice area. Assessment of competency followed the standard APC procedure of 90-minute examinations using The Moderated Assessment Form (MAF). RESULTS: The overall pass rate was higher for real-life assessments in both studies: study 1, 50% versus 42.7%; study 2, 55.6% versus 44.4%. Chi-square analysis showed a high to moderate level of exact matching of pass/fail grades across all assessments: study 1, 73.4% (p < 0.001); study 2, 58.3% (p = 0.027). Binary logistic regression showed that the best predictors of real-life pass/fail grade were simulation-based MAF pass/fail grade (study 1, OR 7.86 p < 0.001; study 2, OR 2.037, p = 0.038) and simulation-based total MAF score (study 1, OR 1.464 p < 0.001; study 2, OR 1.234, p = 0.001). CONCLUSION: Simulation-based assessment is a significant predictor of clinical performance and can be used to successfully identify high stakes threshold competence to practice physiotherapy in Australia.

New graduate physiotherapists' perceptions and experiences working with people from culturally and linguistically diverse communities in Australia: a qualitative study.

INTRODUCTION: Upon entering the workforce, physiotherapists are required to provide safe and effective care toward people from culturally and linguistically diverse (CALD) communities. Objective: To explore new graduate physiotherapists' perceptions and experiences when working with people from CALD communities in Australia. METHODS: A phenomenological framework guided this qualitative study. Seventeen new graduate physiotherapists who had experience working with people from CALD communities were interviewed. Interviews were audio-recorded, transcribed verbatim, and then thematically analyzed. RESULTS: New graduate physiotherapists felt challenged when they encountered people from CALD communities. Although they had good intentions, their healthcare approach was limited. Their perceived approach to care was unidirectional and anchored in a western healthcare framework, and they used superficial strategies for cultural adaptation. Perceptions that people from CALD communities were passive recipients to healthcare also underpinned their practices. While participants described pockets of patient-centered care, their perceived healthcare approach lacked appropriate consideration and integration of their patients' cultural perspective. CONCLUSION: New graduate physiotherapists may need support with effectively integrating different cultural perspectives into their care and adapting their practices and interventions for people from CALD communities. Education and training at entry-level and after graduation should address these learning needs. However, there is limited research on how to culturally adapt physiotherapy practices and interventions that impact patient engagement outcomes. Thus, research is needed to understand how current evidence-based interventions can be culturally adapted to integrate patients' cultural perspectives into care.

'It's the ultimate observer role you're feeling and seeing what's happening to you': students' experiences of peer simulation.

Introduction: Simulation-based education (SBE) benefits learners, but multiple barriers limit curriculum integration. Peer simulation, where students are formally educated to portray patient roles in simulated interactions with their peers, might maintain the educational benefits of SBE, be cost-effective, and enable additional learning. Our research question was: 'What are the perspectives and experiences of physiotherapy students who participated in peer simulation?'. Methods: Second-year physiotherapy students (n=16) participated in a blended peer simulation programme that included preparation for patient role portrayal and simulated clinical interactions with peers. Using an interpretivist approach, students' experiences and perspectives were explored in two focus groups. Inductive thematic analysis was completed by two researchers. Results: Three primary themes were identified that characterised the experiences and perspectives of physiotherapy students: peer simulation is a valuable learning experience, specific design features enable effective peer simulation, and portraying a patient provides unique insight. Peer simulation was unexpectedly realistic, revealed knowledge and skill deficits, and improved their clinical skills. Specific design features included consistent engagement, repetitive, individualised practice, multiple forms of feedback, and detailed role preparation. Being the patient in peer simulation gave students unique and valuable insight into patients' experiences of and feelings about health issues and healthcare interactions. Conclusion: Physiotherapy students acquire new insights during peer simulation that may enrich their capabilities for practice through understanding healthcare interactions from patients' perspectives. Physiotherapy students' learning in peer simulation appears to align with the powerful learning experiences of health professional students in other immersive simulation modalities.

Fostering cultural responsiveness in physiotherapy: curricula survey of Australian and Aotearoa New Zealand physiotherapy programs.

BACKGROUND: Developing cultural responsiveness among physiotherapists is considered essential to promote quality and equity in healthcare provision for our culturally diverse populations. The aim of this study was to evaluate how entry-level physiotherapy programs in Australia and Aotearoa New Zealand (NZ) design curricula to foster the development of cultural responsiveness in physiotherapy students. Further, the challenges of integrating educational content and approaches, and the perceptions of the effectiveness of these curricula were also explored. METHODS: A cross-sectional telephone survey with closed and open-ended questions, was conducted with 18 participants representing 24 entry-level physiotherapy programs (82% of all programs) in Australia and NZ between May and September 2017. Data were analysed descriptively in the form of frequencies, percentages or ratios as appropriate. Open-ended responses were thematically analysed. RESULTS: Results suggest variability in the structure, and teaching and assessment methods used across all programs. The majority of programs appeared to rely on didactic teaching methods, along with knowledge based and implicit assessment methods. The main challenges reported were that cultural responsiveness was thought to be perceived by academic staff as unimportant and that the curriculum was perceived to be 'overcrowded'. Participants also felt there was room for improvement despite perceiving the curriculum to be effective at fostering cultural responsiveness. CONCLUSION: Results provide insight into the educational content and approaches integrated in entry-level physiotherapy curricula in Australia and NZ, and suggest opportunities for further research and development to foster cultural responsiveness among physiotherapy students.

Predictors of self-perceived cultural responsiveness in entry-level physiotherapy students in Australia and Aotearoa New Zealand.

BACKGROUND: Ensuring physiotherapy students are well prepared to work safely and effectively in culturally diverse societies upon graduation is vital. Therefore, determining whether physiotherapy programs are effectively developing the cultural responsiveness of students is essential. This study aimed to evaluate the level of self-perceived cultural responsiveness of entry level physiotherapy students during their training, and explore the factors that might be associated with these levels. METHODS: A cross sectional study of physiotherapy students from nine universities across Australia and Aotearoa New Zealand was conducted using an online self-administered questionnaire containing three parts: The Cultural Competence Assessment tool, Altemeyer's Dogmatism scale, and the Marlowe-Crowne social desirability scale- short form. Demographic data relating to university, program, and level of study were also collected. Data was analysed using one-way ANOVA, t-tests and multiple regression analysis. RESULTS: A total of 817 (19% response rate) students participated in this study. Overall, students had a moderate level of self-perceived cultural responsiveness (Mean (SD) = 5.15 (0.67)). Fewer number of weeks of clinical placement attended, lower levels of dogmatism, and greater social desirability were related to greater self-perceived cultural responsiveness. Additionally, fourth year undergraduate students perceived themselves to be less culturally responsive than first and second year students (p < 0.05). CONCLUSIONS: These results provide educators with knowledge about the level of self-perceived cultural responsiveness in physiotherapy students, and the factors that may need to be assessed and addressed to support the development of culturally responsive practice.

The effect of implicit theories of pain on pain and disability in people with chronic low back pain.

BACKGROUND: Implicit theories of pain represent a socio-cognitive mechanism linked to important coping, emotional, and expressive reactions to chronic pain. Evidence suggests that chronic low back pain (CLBP) patients who hold an incremental theory of pain (i.e., view pain as a malleable) use more active coping strategies, display less pain behavior, and report lower levels of depression than those with an entity theory of pain (i.e., view pain as a fixed). However, a link between implicit theories of pain and symptoms of pain and disability in people with CLBP has not been established. OBJECTIVES: This study investigated the relationship between implicit theories of pain and the level of pain and disability reported by people with CLBP. DESIGN: Cross-sectional observational study. METHODS: One hundred and two participants with CLBP completed an online survey distributed through social media channels. The online survey assessed pain intensity and pain-related disability (Chronic Pain Grade Scale), implicit theories of pain (Implicit Theory of Pain Scale), and perceived control over pain (Survey of Pain Attitudes control scale). RESULTS: Participants with an incremental theory of pain reported significantly less pain and disability compared to those with an entity theory of pain (p < 0.001). CONCLUSIONS: These findings suggest that implicit theories of pain may guide self-reported symptoms of pain and disability in a CLBP population. Prospective studies are required to confirm the relevance of these findings for risk of future low back pain, and to confirm whether this relationship changes with and without treatment.

Fisioterapia guiada por EMT reduz a dor e induz a plasticidade no córtex motor na osteoartrose crônica do joelho / TMS-guided physiotherapy reduces pain and induces plasticity in the motor cortex in chronic knee osteoarthritis

INTRODUÇÃO: A osteoartrite do joelho (OA) está associada à dor crônica, comprometimento da função e perda da qualidade de vida. A plasticidade mal-adaptativa do cérebro pode estar envolvida, impedindo efeitos benéficos de exercícios e outras intervenções. A neuromodulação com estimulação elétrica periférica guiada pelo mapeamento da TMS pode influenciar especificamente as modificações mal-adaptativas. OBJETIVO: Comparar a organização cortical e excitabilidade de três músculos (reto femuris, vasto lateral e vasto medial) em um sujeito com OA joelho. MÉTODOS: Este estudo de caso único envolveu uma mulher de 66 anos com OA de joelho que estava considerando se submeter a uma artroplastia. Ela foi avaliada para dor (VAS), função (WOMAC e ICOAP) e força do quadríceps uma vez por semana, durante 10 semanas - ABA (A - avaliação de quatro semanas; B - avaliação de duas semanas e intervenção; A - avaliação de quatro semanas). O mapeamento de TMS foi realizado no início do estudo, após o período de intervenção de duas semanas e no final do estudo. Esse exame inicialmente revelou uma diminuição proeminente no volume da porção do músculo quadríceps do vasto medial sobre o córtex motor primário (M1), que determinou um protocolo de estimulação elétrica periférica projetado especificamente para aumentar a excitabilidade desse músculo. Durante o período de intervenção, o participante também realizou exercícios específicos diariamente. RESULTADOS: Os escores do WOMAC e a força do quadríceps não foram alterados durante o período do estudo. Melhoras foram observadas nas três subescalas do ICOAP após a intervenção. Esta alteração clínica foi associada a um aumento do vasto medial e também do vasto lateral, e uma diminuição nos volumes do mapa da TMS do músculo reto femoral, que foram mantidos até a última avaliação. CONCLUSÃO: O mapeamento do TMS pode guiar intervenções específicas para contrabalançar a plasticidade mal-adaptativa do córtex motor e influenciar positivamente a dor e a função na OA do joelho. [AU]

BACKGROUND: Knee osteoarthritis (OA) is associated with chronic pain, impaired function and loss of quality of life. Brain maladaptive plasticity may be involved and prevent beneficial effects of exercises and other interventions. Neuromodulation with peripheral electrical stimulation guided by TMS mapping may specifically influence those maladaptive modifications. OBJECTIVE: To compare the cortical organization and excitability of three muscles (straight femuris, vastus lateralis and vastus medialis) in a subject with OA knee. METHODS: This single case ABA study involved a 66 yo woman with knee OA that was considering an arthroplasty. She was assessed for pain (VAS), function (WOMAC, ICOAP), and quadriceps strength one time a week, for 10 weeks (A ­ four weeks assessment; B ­ two weeks assessment and intervention; A ­ four weeks assessment). TMS mapping was performed at baseline, after the two-week intervention period and at the end of the study. This examination initially revealed a prominent decrease in the volume of vastus medialis portion of the quadriceps muscle over the primary motor cortex (M1), which determined a peripheral electrical stimulation protocol specifically designed to increase this muscle's excitability. During the intervention period the participant also carried over specific exercises daily. RESULTS: WOMAC scores, and quadriceps strength were not changed during the study period. Improvements were seen in the three subscales of the ICOAP following the intervention. This clinical change was associated with an increase in vastus medialis and also Vastus lateralis, and a decrease in rectus femuris TMS map volumes, which were maintained until the last evaluation. CONCLUSION: TMS mapping may guide specific interventions to counteract motor cortex maladaptive plasticity and positively influence pain and function in knee OA. [AU]

Primary Motor Cortex Organization Is Altered in Persistent Patellofemoral Pain.

OBJECTIVE: Reorganization of the primary motor cortex (M1) may be a feature of persistent patellofemoral pain (PFP), but no studies have investigated M1 organization in this condition. Here we aimed to examine the organization of the M1 representation of the quadriceps muscles in people with PFP and healthy controls. DESIGN: Using a cross-sectional design, the M1 representation of the rectus femoris, vastus lateralis, and vastus medialis was mapped using transcranial magnetic stimulation in 11 individuals with PFP and 11 controls. Measures of pain severity were also made. RESULTS: Individuals with PFP had reduced map volumes (P < 0.001) and an anterior shift in the M1 representation (P = 0.03) across all three quadriceps muscles compared with controls. Greater overlap of the M1 representation (P = 0.02) and a reduction in the number of discrete cortical peaks (P = 0.009) across all three quadriceps muscles were also observed in individuals with PFP compared with controls. There was no relationship between altered M1 organization and pain in PFP. CONCLUSIONS: These findings provide evidence of altered M1 organization in individuals with PFP compared with healthy controls. Notably, no difference in M1 organization was observed for the medial and lateral heads of the quadriceps in PFP. These data have relevance for our understanding of the pathophysiology of PFP and for the design of future treatments that aim to target M1 in this condition.

Hand therapy versus corticosteroid injections in the treatment of de Quervain's disease: A systematic review and meta-analysis.

STUDY DESIGN: Systematic review with meta-analysis. INTRODUCTION: Although corticosteroid injections are often cited as best practice in the treatment of de Quervain's disease, no reviews have compared their effectiveness to a multimodal definition of hand therapy. PURPOSE: To compare the effectiveness of corticosteroid injections with that of i) hand therapy alone and ii) combined hand therapy/corticosteroid injection approaches in the treatment of de Quervain's disease. METHODS: Searches of key databases were performed to identify experimental studies published between January 1950 and November 2014. Outcome measures included treatment success, pain, quality of life, and function. RESULTS: Both corticosteroid injections and hand therapy improved pain and function from baseline, but between-group differences were not significant (across 6 studies). However, significantly more participants were treated successfully when combined orthosis/corticosteroid injection approaches were compared to i) orthoses (RR 0.53, 95% CI 0.35-0.80) and ii) injections alone (RR 0.76, 95% CI 0.64-0.89). CONCLUSION: Combined orthosis/corticosteroid injection approaches are more effective than either intervention alone in the treatment of de Quervain's disease. LEVEL OF EVIDENCE: 1a.