A knowledge broker facilitated intervention to improve the use of standardized assessment tools by physical therapists: A cluster randomized trial.

OBJECTIVE: To compare two methods of knowledge broker support to improve standardized assessment use. DESIGN: Two-site cluster randomized trial. SETTING: Acute rehabilitation hospital. PARTICIPANTS: 18 physical therapists. INTERVENTION: A 10-month intervention was collaboratively designed with an external knowledge broker and physical therapists to compare full and partial implementation support. The knowledge broker provided education and strategies for implementation to the fully supported group and recommended strategies to the partially supported group that they self-implemented. MEASUREMENT: Chart audit data documenting frequency of use was extracted at four timepoints. Ten focus groups were conducted to describe factors that influenced use. Focus group data were coded using the Consolidated Framework for Implementation Research and rated as barriers and facilitators for standardized assessment use. RESULTS: For the fully supported group, standardized assessment use at initial examination increased from 0% to 58.3% at month 2 and decreased to 17.6% and 11.8% at months 4 and 8-10. For the partially supported group, standardized assessment use increased from 0% to 46% and 50% at month 2 and 4 and decreased to 2.8% at months 8-10. For both groups, early use was seen multiple facilitators. At month 10, barriers included organizational changes that impacted intervention fit. In addition, the fully supported group didn't value the selected standardized assessment and the partially supported group lacked space. CONCLUSIONS: Knowledge broker support improved both groups standardized assessment use early on, but it was not sustained. The amount of support could not be isolated as factors that influenced use varied by groups.

Exploring factors influencing physiotherapists' perceptions of measuring reactive balance following a theory-based multi-component intervention: a qualitative descriptive study.

Purpose: Reactive balance is a critical consideration for mobility and fall avoidance, but is under-assessed among physiotherapists. The objective of this study was to explore factors influencing physiotherapist perceptions about measuring reactive balance upon completion of a 12-month theory-based, multi-component intervention to increase use of a measure of reactive balance.Methods: A qualitative descriptive approach was used. Semi-structured interviews were conducted with 28 physiotherapists treating adults with balance impairment in three urban Canadian rehabilitation hospitals that participated in the intervention. Interviews explored perceptions of reactive balance measurement and perceived changes in clinical behavior. Thematic analysis involved multiple rounds of coding, review and discussion, theme generation, and interpretation of findings through individual analysis and team meetings.Findings: Participants expressed contrasting views about integrating reactive balance measurement in their practice, despite consistent acknowledgement of the importance of reactive balance for function. Three themes were identified highlighting factors that mediated perceptions about measuring reactive balance: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Conclusions: The findings highlight that decision making for measuring reactive balance in rehabilitation settings is complex. There is a need for additional work to facilitate long-term implementation of clinical reactive balance measurement, such as refining patient criteria for administration, ensuring sufficient time to establish a trusting relationship, and developing and testing strategies to address physiotherapist fear.IMPLICATIONS FOR REHABILITATIONReactive balance is important for falls prevention and mobility, but is under-assessed among physiotherapists.This study identified three factors that influenced uptake of reactive balance measurement among physiotherapists in rehabilitation settings: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Knowledge of the identified factors may assist with design and use of reactive and other balance measurements.Strategies aimed at developing trusting relationships between physiotherapist and patient along with addressing physiotherapist fear could facilitate the uptake of clinical reactive balance measurement.

Reliability and validity of the acquired brain injury challenge assessment (ABI-CA) in children.

PRIMARY OBJECTIVE: The Acquired Brain Injury Challenge Assessment (ABI-CA) was created to fill a measurement gap and evaluate deficits in advanced motor skills in children with acquired brain injury (ABI). Study objectives were to refine ABI-CA response options and evaluate (i) inter-/intra-rater reliability, (ii) concurrent validity and difficulty level in relation to the Community Balance & Mobility Scale (CB&M) and (iii) administration efficiency of the refined ABI-CA. RESEARCH DESIGN: Measurement study. METHODS: Phase I involved ABI-CA revisions. Phase 2 consisted of live-/video-scoring of the ABI-CA with 15 typically-developing (TD) children and 15 with ABI (7-17 years) to assess reliability/validity. RESULTS: The revised 20-item ABI-CA displayed excellent reliability for the entire sample (ICCs > 0.90; 95% CI = 0.92-1.00; SEM ≤ 3.60) and within ABI and TD sub-groups. The ABI-CA and CB&M correlated strongly (r = 0.75, p < 0.0001). The ABI-CA mean score (/100) was 11.3 points lower (p < 0.0001) than the CB&M's mean score (/100). CONCLUSION: The ABI-CA demonstrated excellent reliability and initial evidence of validity. ABI-CA scores were lower overall than the CB&M, indicating the ABI-CA may have greater capacity to evaluate improvements in advanced motor skills in children with ABI. Multi-centre research is needed to confirm the ABI-CA's test-retest reliability and, assuming acceptability, assess responsiveness to change.

Clinical assessment of reactive postural control among physiotherapists in Ontario, Canada.

Reactive postural control, the ability to recover from an external perturbation to stability, ultimately determines whether an individual will fall following a loss of balance and should be routinely incorporated in balance assessment. The purpose of this study was to identify (1) methods used to assess reactive postural control in clinical practice and (2) factors associated with regular assessment of reactive postural control. A cross-sectional survey was conducted. Three hundred and fifty-seven physiotherapists in Ontario, Canada who treated adults with balance impairments answered questions about the components of balance they assess and how they assess reactive control in their practice. Of the 273 respondents who assessed reactive postural control at least some of the time, 15.4% used a standardized measure, 79.1% used a non-standardized approach, and 5.5% used both. Forty-five methods of assessing reactive control were reported. The most common methods used were non-standardized perturbations (43.5%; 104/239 respondents) and movement observation (18.8%; 45/239). The remaining 43 methods were each used by less than 8% of respondents. Practice area had the strongest association with regular assessment of reactive postural control (>60% of the time), and respondents working with neurological disorders were more likely to regularly evaluate reactive control than those working with people with orthopedic conditions. Despite the availability of valid standardized measures to evaluate reactive postural control, respondents relied primarily on non-standardized approaches and observational assessment. Future work should examine the factors influencing choice of reactive control assessment tools and awareness of standardized measures for reactive postural control.

Assessment of the postural control strategies used to play two Wii Fit™ videogames.

The Nintendo Wii Fit™ may provide an affordable alternative to traditional biofeedback or virtual reality systems for retraining or improving motor function in populations with impaired balance. The purpose of this study was to evaluate postural control strategies healthy individuals use to play Wii Fit™ videogames. Sixteen young adults played 10 trials of Ski Slalom and Soccer Heading respectively. Centre of pressure (COP) excursion and three-dimensional movement data were acquired to determine variability in medial-lateral COP sway and shoulder-pelvic movement. While there was no difference in medial-lateral COP variability between games during trial 1, there was a significant difference after 10 trials. COP sway increased (59-75 mm) for Soccer Heading while it decreased (67-33 mm) for Ski Slalom from trial 1 to trial 10. During Ski Slalom participants demonstrated decreased shoulder and pelvic movement combined with increased pelvic-shoulder coupling. Conversely, participants demonstrated greater initial shoulder tilt when playing Soccer Heading, with no reduction in pelvic rotation and tilt. Participants decreased pelvic and trunk movements when skiing, suggesting a greater contribution of lower extremity control while they primarily used a trunk strategy to play Soccer Heading.

A demonstration project of a multi-component educational intervention to improve integrated post-fracture osteoporosis care in five rural communities in Ontario, Canada.

UNLABELLED: This study evaluated a multi-component intervention (educational materials and outreach visits) to increase knowledge and improve post-fracture care management in five rural communities in Canada. One hundred and twenty-five patients pre- intervention and 149 post-intervention were compared. No significant improvement in post-fracture care was documented suggesting that a more targeted intervention is needed. INTRODUCTION: Currently, the majority of patients with a low trauma fracture are under-investigated and under-treated for osteoporosis. We set out to evaluate an educational intervention on increasing knowledge of post-fracture care among health care professionals (HCPs) and fracture patients and on improving post-fracture management. METHODS: We studied five rural communities in Ontario, Canada, using a multi-component intervention ("Behind the Break"), including educational material for HCPs and patients and educational outreach visits to physicians. The study had a historical control, non-equivalent pre/post design. Telephone surveys were carried out with individuals > or =40 years of age who had a low trauma fracture in 2003 (n = 125) or in 2005 (n = 149). Family physicians and emergency department staff were also surveyed. RESULTS: A total of 4,207 educational packages were distributed. Seventy-three percent of family physicians had an outreach visit. Two-thirds indicated that they received enough information about post-fracture follow-up to incorporate it into their practice. Despite this, no significant improvement in post-fracture care was documented (32% in the "pre" group had a bone mineral density test and 25% in the "post" group). Of those diagnosed with osteoporosis, the majority were prescribed a bone-sparing medication (63% "pre" and 80% "post"). CONCLUSION: A more targeted intervention linking fracture patients to their physician needs to be evaluated in rural communities.

A task-orientated intervention enhances walking distance and speed in the first year post stroke: a randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of a task-orientated intervention in enhancing competence in walking in people with stroke. DESIGN: Two-centre observer-blinded stratified block-randomized controlled trial. SETTING: General community. SUBJECTS: Between May 2000 and February 2003, 91 individuals with a residual walking deficit within one year of a first or recurrent stroke consented to participate. INTERVENTIONS: The experimental intervention comprised 10 functional tasks designed to strengthen the lower extremities and enhance walking balance, speed and distance. The control intervention involved the practice of upper extremity activities. Subjects in both groups attended sessions three times a week for six weeks. MAIN MEASURES: Six-minute walk test (SMWT), 5-m walk (comfortable and maximum pace), Berg Balance Scale, timed 'up and go'. RESULTS: At baseline, subjects in the experimental (n = 44) and control (n = 47) groups walked an average distance of 209 m (SD = 126) and 204 m (SD =131), respectively, on the SMWT. Mean improvements of 40 m (SD =72), and 5 m (SD =66) were observed following the experimental and control interventions, respectively. The between-group difference was 35 m (95% confidence interval (CI) 7, 64). Significant between-group effects of 0.21 m/s (95% CI 0.12, 0.30) and of 0.11 m/s (95% CI 0.03, 0.19) in maximum and comfortable walking speed, respectively, were observed. People with a mild, moderate or severe walking deficit at baseline improved an average of 36 (SD =96), 55 (SD = 56) and 18 m (SD = 23), respectively, in SMWT performance following the experimental intervention. CONCLUSIONS: Study findings support the efficacy of a task-orientated intervention in enhancing walking distance and speed in the first year post stroke, particularly in people with moderate walking deficits.

Responsiveness and predictability of gait speed and other disability measures in acute stroke.

OBJECTIVES: To identify the most responsive method of measuring gait speed, to estimate the responsiveness of other outcome measures, and to determine whether gait speed predicts discharge destination in acute stroke. DESIGN: A prospective cohort study. SETTING: Five acute-care hospitals. PATIENTS: Fifty subjects with residual gait deficits after a first-time stroke. INTERVENTIONS: Five- (5mWT) and 10-meter walk tests (10mWT) at comfortable and maximum speeds, with 2 evaluations conducted an average +/- standard deviation (SD) of 8 +/- 3 and 38 +/- 5 days poststroke. MAIN OUTCOME MEASURE: Standardized response mean (SRM = mean change/SD of change) was used to estimate responsiveness for each walk test, the Berg Balance Scale, the Barthel Index, the Stroke Rehabilitation Assessment of Movement (STREAM), and the Timed Up and Go (TUG). RESULTS: The SRMs were 1.22 and 1.00 for the 5mWT, and.92 and.83 for the 10mWT performed at a comfortable and maximum pace, respectively. The SRMs for the Berg Balance Scale, the Barthel Index, the STREAM, and the TUG were 1.04,.99,.89, and.73, respectively. The probability of discharge to a rehabilitation center for persons walking at < or = 0.3m/s or > 0.6m/s at the first evaluation was.95 and.22, respectively. CONCLUSIONS: The 5mWT at a comfortable pace is recommended as the measure of choice for clinicians and researchers who need to detect longitudinal change in walking disability in the first 5 weeks poststroke.