Physiotherapists' moral distress: Mixed-method study reveals new insights.

BACKGROUND: Moral distress is a well-recognized term for emotional, cognitive, and physical reactions of  professionals, when facing conflicts between perceived obligations and institutional constraints. Though studied across medical roles, limited research exists among physiotherapists. RESEARCH QUESTION: What factors contribute to Moral distress among physiotherapists and how do they cope? OBJECTIVES: To develop and test a multifaceted model of Moral distress and gain an in-depth understanding of the phenomena. RESEARCH DESIGN: A 2017-2022 mixed-methods study: (1) Survey of 407 physiotherapists quantitatively testing a literature-based model analyzing relationships between Moral distress, Moral sensitivity, Locus of control, Self-efficacy, Ethical climate perceptions and demographics, analyzed by descriptive and inferential statistics, multiple comparisons and structural equation modelling (SPSS26, SAS, AMOS); (2) Semi-structured interviews with 21 physiotherapists examining Moral distress experiences using meticulous phenomenological analysis. PARTICIPANTS AND CONTEXT: Israeli physiotherapists from various occupational settings recruited via professional networks. ETHICAL CONSIDERATIONS: The Haifa University Ethics Committee authorized the study. Informed consent was obtained for the anonymous survey and before interviews regarding recording, and quote use. FINDINGS: Quantitative results showed moderately high average Moral distress, significantly higher among women and paediatric physiotherapists, positively correlating with Moral sensitivity. Qualitative findings revealed intense emotions around Moral distress experiences, inner conflicts between care ideals and constraints, and coping strategies like reflective skills. Senior therapists, despite higher self-efficacy and moral sensitivity, still reported persistent high distress. DISCUSSION: Moral distress has complex links with moral sensitivity, self-efficacy, perceived professional autonomy and organizational support. A renewed framework emerged explaining relations between moral distress and personal, professional and organizational factors. CONCLUSIONS: Multidimensional insights help identify Moral distress causes and coping strategies among physiotherapists, advancing theory. Conclusions can shape ethics training programs and competencies.

Quantification of Daily-Living Gait Quantity and Quality Using a Wrist-Worn Accelerometer in Huntington's Disease.

Background: Huntington's disease (HD) leads to altered gait patterns and reduced daily-living physical activity. Accurate measurement of daily-living walking that takes into account involuntary movements (e.g. chorea) is needed. Objective: To evaluate daily-living gait quantity and quality in HD, taking into account irregular movements. Methods: Forty-two individuals with HD and fourteen age-matched non-HD peers completed clinic-based assessments and a standardized laboratory-based circuit of functional activities, wearing inertial measurement units on the wrists, legs, and trunk. These activities were used to train and test an algorithm for the automated detection of walking. Subsequently, 29 HD participants and 22 age-matched non-HD peers wore a tri-axial accelerometer on their non-dominant wrist for 7 days. Measures included gait quantity (e.g., steps per day), gait quality (e.g., regularity) metrics, and percentage of walking bouts with irregular movements. Results: Measures of daily-living gait quantity including step counts, walking time and bouts per day were similar in HD participants and non-HD peers (p > 0.05). HD participants with higher clinician-rated upper body chorea had a greater percentage of walking bouts with irregular movements compared to those with lower chorea (p = 0.060) and non-HD peers (p < 0.001). Even after accounting for irregular movements, within-bout walking consistency was lower in HD participants compared to non-HD peers (p < 0.001), while across-bout variability of these measures was higher (p < 0.001). Many of the daily-living measures were associated with disease-specific measures of motor function. Conclusions: Results suggest that a wrist-worn accelerometer can be used to evaluate the quantity and quality of daily-living gait in people with HD, while accounting for the influence of irregular (choreic-like) movements, and that gait features related to within- and across-bout consistency markedly differ in individuals with HD and non-HD peers.

Multidisciplinary intensive outpatient rehabilitation program for patients with moderate-to-advanced Parkinson's disease.

BACKGROUND: Intensive, multi-disciplinary, rehabilitation programs for patients with Parkinson's disease (PWPs) have shown to be effective. However, most programs are based on in-patient service, which is expensive. OBJECTIVE: To demonstrate the feasibility of a multidisciplinary, intensive, outpatient rehabilitation program (MIOR) for moderate to advanced Parkinson's Disease (H&Y≥2). METHOD: The MIOR program takes place at a community rehabilitation center ('Ezra Le'Marpe'), 3 times a week, 5 hours, 8 weeks, and includes 20 PWPs in each cycle. The multi-disciplinary team includes physical, occupational, speech and hydro therapists. Additional activities include, social work groups, boxing, dancing and bridge. RESULTS: Data was collected retroactively for the first two years. Data analysis includes 158 patient files who completed the program (mean disease duration 10.1±6 and mean H&Y stage 2.8±0.67). Assessments were performed at the beginning and end of the intervention. Positive results were collected: improvement in number of falls (p < 0.0001), Functional Independence Measure (p < 0.0001), quality of life (p < 0.01), balance (p < 0.0001), upper limb function (p < 0.0001) and paragraph reading vocal intensity (p < 0.01). CONCLUSIONS: MIOR is a feasible program, showing positive results in moderate to advanced PWP's, improving quality of life, daily function, and motor performance. The current outcomes demonstrate feasibility of MIOR in addition to medical treatment.

Recognition of emotion from subtle and non-stereotypical dynamic facial expressions in Huntington's disease.

Emotion recognition deficits in Huntington's disease (HD) are well-established. However, most previous studies have measured emotion recognition using stereotypical and intense facial expressions, which are easily recognized and artificial in their appearance. By contrast, everyday expressions are often more challenging to recognize, as they are subtle and non-stereotypical. Therefore, previous studies may have inflated the performance of HD patients and it is difficult to generalize their results to facial expressions encountered in everyday social interactions. In the present study, we tested 21 symptomatic HD patients and 28 healthy controls with a traditional facial expression set, as well as a novel stimulus set which exhibits subtle and non-stereotypical facial expressions. While HD patients demonstrated poor emotion recognition in both sets, when tested with the novel, ecologically looking facial expressions, patients' performance declined to chance level. Intriguingly, patients' emotion recognition deficit was predicted only by the severity of their motor symptoms, not by their cognitive status. This suggests a possible mechanism for emotion recognition impairments in HD, in line with embodiment theories. From this point of view, poor motor control may affect patients' ability to subtly produce and simulate a perceived facial expression, which in turn may contribute to their impaired recognition.

Dysphagia characteristics in Huntington's disease patients: insights from the Fiberoptic Endoscopic Evaluation of Swallowing and the Swallowing Disturbances Questionnaire.

BACKGROUND: Huntington's disease (HD) is a neurodegenerative disease characterized by increasing dysphagia as the disease progresses. Specific characteristics of the HD dysphagia are not well defined. OBJECTIVE: To characterize the swallowing disturbances of HD patients, to evaluate the feasibility of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in assessing dysphagia in HD patients, and to discern the relation between FEES findings and patients' self-report on dysphagia symptoms and swallowing related quality of life (SWAL-QOL). METHOD: A retrospective case series in a tertiary referral center. All recruited HD patients underwent Bed Side Swallowing Evaluation (BSE), FEES, the Unified Huntington's Disease Rating Scale (UHDRS), and the Montreal Cognitive Assessment (MoCA). All completed the Swallowing Disturbances Questionnaire (SDQ) and the SWAL-QOL questionnaire. RESULTS: Fourteen HD patients were recruited. All were able to complete the FEES study. The FEES demonstrated delayed swallowing reflex, solid food residues, and pre/post swallowing spillage in most patients (50%, 53.5%, 83.3%, and 87.5%, respectively). The mean SDQ score was 13.2. Significant correlations were found between the SWAL-QOL fear of eating score; the SDQ oral, pharyngeal, and total scores; and the FEES parameters of pureed and solid food bolus flow time. Significant correlations were also found between the total UHDRS score, the volitional cough score, and the SWAL-QOL disease burden score. CONCLUSION: HD patients exhibit prominent unique oropharyngeal dysphagia features that may serve as a marker of disease progression. The FEES and the SDQ are valuable tools for detecting these features in HD patients with swallowing disturbance.

Two Ethnic Clusters with Huntington Disease in Israel: The Case of Mountain Jews and Karaites.

BACKGROUND: Worldwide prevalence estimates of Huntington disease (HD) vary widely, with no reliable information regarding the Jewish population in Israel. METHODS: This specialized tertiary single-center cross-sectional study assessed clinical, cognitive, and demographic characteristics of 84 HD patients who were treated at the Movement Disorder Unit of the Tel Aviv Medical Center, Israel. RESULTS: Our cohort was composed of one-third Ashkenazi Jews, 27% Mountain Jews (Caucasus Jews), 18% Sephardi Jews, and 21% Karaites, with both Mountain Jews and Karaites over-represented compared to their relevant proportion in the population of the state of Israel, which is less than 1%. No between-group differences were detected regarding the number of CAG (cytosine-adenine-guanine) repeats, age at onset, disease duration, years from symptom onset to diagnosis, gender, years of education, Unified Huntington Disease Rating Scale scores, or the Montreal Cognitive Assessment scores. CONCLUSION: We detected clustering of HD among the population treated at our Medical Center, which has the only specialized HD clinic in the country, with a high percentage of HD among 2 relatively small subpopulations of Jews: Mountain Jews and Karaites.

Macro- and micro-level predictors of age categorization: results from the European Social Survey.

This study evaluated macro- and micro-level variables associated with individuals' perception of the ending of youth, the beginning of old age, and the length of the middle age period. The European Social Survey is a biennial multi-country, cross-sectional survey. Our analysis is based on the fourth wave, which included a rotating module on ageism. The source sample consisted of 28 countries and a total of 54,988 respondents. Whereas macro-level variability accounted for 14 % of the variance associated with the perception of the ending of youth, only 5.7 % of the variance associated with the perception of the beginning of old age was accounted for by macro-level variability. Almost 10 % of the variance associated with the perception of the middle age period was associated with macro-level variability. Different patterns of macro- and micro-level correlates emerged for the ending of youth, beginning of old age, and the period of middle age. Overall, results demonstrate that individual differences in the perception of the ending of youth, the beginning of old age, and the length of the middle age period are more pronounced than contextual differences. Results also suggest that individuals' mental maps regarding the timing of these events are not necessarily concordant.