Use of the knowledge to action model improved physical therapist adherence to a common clinical practice guideline across multiple settings: a multisite case series.

BACKGROUND: When a new guideline is published there is a need to understand how its recommendations can best be implemented in real-world practice. Yet, guidelines are often published with little to no roadmap for organizations to follow to promote adherence to their recommendations. The purpose of this study was to evaluate the impact of using a common process model to implement a single clinical practice guideline across multiple physical therapy clinical settings. METHODS: Five organizationally distinct sites with physical therapy services for patients with peripheral vestibular hypofunction participated. The Knowledge to Action model served as the foundation for implementation of a newly published guideline. Site leaders conducted preliminary gap surveys and face-to-face meetings to guide physical therapist stakeholders' identification of target-behaviors for improved guideline adherence. A 6-month multimodal implementation intervention included local opinion leaders, audit and feedback, fatigue-resistant reminders, and communities of practice. Therapist adherence to target-behaviors for the 6 months before and after the intervention was the primary outcome for behavior change. RESULTS: Therapist participants at all sites indicated readiness for change and commitment to the project. Four sites with more experienced therapists selected similar target behaviors while the fifth, with more inexperienced therapists, identified different goals. Adherence to target behaviors was mixed. Among four sites with similar target behaviors, three had multiple areas of statistically significantly improved adherence and one site had limited improvement. Success was most common with behaviors related to documentation and offering patients low technology resources to support home exercise. A fifth site showed a trend toward improved therapist self-efficacy and therapist behavior change in one provider location. CONCLUSIONS: The Knowledge to Action model provided a common process model for sites with diverse structures and needs to implement a guideline in practice. Multimodal, active interventions, with a focus on auditing adherence to therapist-selected target behaviors, feedback in collaborative monthly meetings, fatigue-resistant reminders, and developing communities of practice was associated with long-term improvement in adherence. Local rather than external opinion leaders, therapist availability for community building meetings, and rate of provider turnover likely impacted success in this model. TRIAL REGISTRATION: This study does not report the results of a health care intervention on human participants.

Development, Implementation, and Use of a Process to Promote Knowledge Translation in Rehabilitation.

OBJECTIVE: To examine the use and effect of the Battery of Rehabilitation Assessments and Interventions on evidence-based practice (EBP) over 6 years. DESIGN: Successive independent samples study. SETTING: Large rehabilitation system. PARTICIPANTS: Successive samples of allied health clinicians (N=372) in 2009 (n=136), 2012 (n=115), and 2015 (n=121). INTERVENTIONS: The Battery of Rehabilitation Assessments and Interventions includes 2 components: (1) a process to synthesize, adapt, and make recommendations about the application of evidence; and (2) a process to implement the recommended practices in 3 levels of care. MAIN OUTCOME MEASURES: To assess the effect of the project, surveys on EBP perspectives, use, and barriers were conducted before Battery of Rehabilitation Assessments and Interventions implementation and 3 and 6 years after implementation. Questions about effect of the project on clinical practice were included 3 and 6 years postimplementation. RESULTS: Survey data indicate the Battery of Rehabilitation Assessments and Interventions resulted in a significant increase in use of EBPs to make clinical decisions and justify care. As a result of the project, survey participants reported a substantial increase in use of outcome measures in 2012 (74%) and 2015 (91%) and evidence-based interventions in 2012 (62%) and 2015 (82%). In 2012, significant differences (P≤.01) in effect of the Battery of Rehabilitation Assessments and Interventions on practice were identified between therapists who were directly involved in the project and Interventions compared with uninvolved therapists. In 2015, no significant differences existed between involved and uninvolved therapists. CONCLUSIONS: After 6 years of sustained implementation efforts, the Battery of Rehabilitation Assessments and Interventions expedited the adoption of EBPs throughout a large system of care in rehabilitation.

Using Simulation-Based Mastery Learning to Achieve Excellent Learning Outcomes in Physical Therapist Education.

INTRODUCTION: The 2 aims of this observational study are (a) to describe the implementation and feasibility of a bed mobility skills simulation-based mastery learning (SBML) curricular module for physical therapist students and (b) to measure learning outcomes and student perceptions of this module. REVIEW OF LITERATURE: Simulation-based mastery learning is an outcome-based educational approach that has been successful in other health professions but has not been explored in physical therapy education. SUBJECTS: Eighty-seven students in a single cohort of a Doctor of Physical Therapy program. METHODS: The SBML module in this pretest-posttest study included a pretest, instruction, initial posttest, and additional rounds of instruction and assessment as needed for all learners to achieve the minimum passing standard (MPS) set using the Mastery Angoff and Patient Safety methods. Outcome measures were bed mobility assessment pass rates and scores, additional student and faculty time compared with a traditional approach, and student perceptions of their self-confidence and the module. RESULTS: All students achieved the MPS after 3 rounds of training and assessment beyond the initial posttest. Mean Total Scores improved from 67.6% (12.9%) at pretest to 91.4% (4.8%) at mastery posttest (P < .001, Cohen's d = 1.8, 95% CI [1.4-2.1]); mean Safety Scores improved from 75.2% (16.0%) at pretest to 100.0% (0.0%) at mastery posttest (P < .001, Cohen's d = 1.5, 95% CI [1.2-1.9]). Students who did not achieve the MPS at the initial posttest (n = 30) required a mean of 1.2 hours for additional instruction and assessment. Survey results revealed an increase in student confidence (P < .001) and positive student perceptions of the module. DISCUSSION AND CONCLUSION: Implementation of this SBML module was feasible and resulted in uniformly high levels of bed mobility skill acquisition. Based on rigorous learning outcomes, feasible requirements for implementation, and increased student confidence, SBML offers a promising approach for wider implementation in physical therapy education.

Systematic Development and Validity Evidence for a Checklist to Assess Bed Mobility Skills Among Physical Therapy Students.

INTRODUCTION: Assessments with strong validity evidence are necessary to accurately assess health professions students' performance of clinical skills. The aim of this study was to develop and validate a checklist assessment of physical therapy students' performance of bed mobility skills. METHODS: A checklist was developed using a 4-step process: 1) evidence review and preliminary checklist development, 2) Delphi review to reach consensus on content, 3) pilot testing and checklist editing, 4) final round of Delphi review. Consensus during Delphi review was defined as 100% of participants rating an item "keep as is" and zero comments in Round 1, and >50% of participants rating each item agree/strongly agree in subsequent Delphi rounds. Interrater reliability (IRR) was measured by two raters scoring 32 recorded exam simulations. RESULTS: All 48 items of the checklist reached consensus after three rounds of Delphi review (12 participants in Round 1, 11 participants in Rounds 2-3). IRR was substantial with 88.5% agreement, Cohen's kappa coefficient=0.61, p<0.001, 95% CI [0.56, 0.66]. DISCUSSION: This checklist has potential to be used to assess student readiness to evaluate and train patients in bed mobility tasks for first-time clinical experiences and to serve as a methodological template for future checklist development.

Checklist-Style Rubric Development for Practical Examination of Clinical Skills in Entry-Level Physical Therapist Education.

BACKGROUND: Grading rubrics used in the assessment of physical therapy students' clinical skills should be developed in a method that promotes validity. This study applied a systematic approach to the development of rubrics to assess student performance within a Doctor of Physical Therapy curriculum. PARTICIPANTS: Ten faculty participated. METHODS: Checklist-style rubrics covering four clinical skills were developed using a five-step process: 1) evidence-based rubric item development; 2) multiple Delphi review rounds to achieve consensus on item content; 3) pilot testing and formatting of rubrics; 4) final Delphi review; 5) weighting of rubric sections. Consensus in the Delphi review was defined as: ≥75% of participants rate each item Agree/Strongly Agree in two consecutive rounds, no statistically significant difference between Likert ratings on the final two rounds for each item using the Wilcoxon signed-rank test (p>0.05), and a reduction in participant comments between the first and last rounds. RESULTS: All rubric items achieved consensus with: 100% agreement, no statistically significant difference between the two final sets of ratings (p=0.102 to 1.000), and a decrease in the number of comments from 81 in Round 1 to 21 in Round 5. CONCLUSION: This method of rubric development resulted in rubrics with validity, acceptability, and time efficiencies.

Stride management assist exoskeleton vs functional gait training in stroke: A randomized trial.

OBJECTIVE: To test the hypothesis that gait training with a hip-assistive robotic exoskeleton improves clinical outcomes and strengthens the descending corticospinal drive to the lower limb muscles in persons with chronic stroke. METHODS: Fifty participants completed the randomized, single-blind, parallel study. Participants received over-ground gait training with the Honda Stride Management Assist (SMA) exoskeleton or intensity-matched functional gait training, delivered in 18 sessions over 6-8 weeks. Performance-based and self-reported clinical outcomes were measured at baseline, midpoint, and completion, and at a 3-month follow-up. Corticomotor excitability (CME) of 3 bilateral leg muscles was measured using transcranial magnetic stimulation. RESULTS: The primary outcome, walking speed, improved for the SMA group by completion of the program (0.24 ± 0.14 m/s difference, p < 0.001). Compared to the functional group, SMA users had greater improvement in walking endurance (46.0% ± 27.4% vs 35.7% ± 20.8%, p = 0.033), took more steps during therapy days (4,366 ± 2,426 vs 3,028 ± 1,510; p = 0.013), and demonstrated larger changes in CME of the paretic rectus femoris (178% ± 75% vs 33% ± 32%, p = 0.010). Participants with hemorrhagic stroke demonstrated greater improvement in balance when using the SMA (24.7% ± 20% vs 6.8% ± 6.7%, p = 0.029). CONCLUSIONS: Gait training with the SMA improved walking speed in persons with chronic stroke, and may promote greater walking endurance, balance, and CME than functional gait training. CLINICALTRIALSGOV IDENTIFIER: NCT01994395. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that gait training with a hip-assistive exoskeleton increases clinical outcomes and CME in persons with chronic stroke, but does not significantly improve walking speeds compared to intensity-matched functional gait training.

Enhanced gait-related improvements after therapist- versus robotic-assisted locomotor training in subjects with chronic stroke: a randomized controlled study.

BACKGROUND AND PURPOSE: Locomotor training (LT) using a treadmill can improve walking ability over conventional rehabilitation in individuals with hemiparesis, although the personnel requirements often necessary to provide LT may limit its application. Robotic devices that provide consistent symmetrical assistance have been developed to facilitate LT, although their effectiveness in improving locomotor ability has not been well established. METHODS: Forty-eight ambulatory chronic stroke survivors stratified by severity of locomotor deficits completed a randomized controlled study on the effects of robotic- versus therapist-assisted LT. Both groups received 12 LT sessions for 30 minutes at similar speeds, with guided symmetrical locomotor assistance using a robotic orthosis versus manual facilitation from a single therapist using an assist-as-needed paradigm. Outcome measures included gait speed and symmetry, and clinical measures of activity and participation. RESULTS: Greater improvements in speed and single limb stance time on the impaired leg were observed in subjects who received therapist-assisted LT, with larger speed improvements in those with less severe gait deficits. Perceived rating of the effects of physical limitations on quality of life improved only in subjects with severe gait deficits who received therapist-assisted LT. CONCLUSIONS: Therapist-assisted LT facilitates greater improvements in walking ability in ambulatory stroke survivors as compared to a similar dosage of robotic-assisted LT.

Allowing intralimb kinematic variability during locomotor training poststroke improves kinematic consistency: a subgroup analysis from a randomized clinical trial.

BACKGROUND: Locomotor training (LT) to improve walking ability in people poststroke can be accomplished with therapist assistance as needed to promote continuous stepping. Various robotic devices also have been developed that can guide the lower limbs through a kinematically consistent gait pattern. It is unclear whether LT with either therapist or robotic assistance could improve kinematic coordination patterns during walking. OBJECTIVE: The purpose of this study was to determine whether LT with physical assistance as needed was superior to guided, symmetrical, robotic-assisted LT for improving kinematic coordination during walking poststroke. DESIGN: This study was a randomized clinical trial. METHODS: Nineteen people with chronic stroke (>6 months' duration) participating in a larger randomized control trial comparing therapist- versus robotic-assisted LT were recruited. Prior to and following 4 weeks of LT, gait analysis was performed at each participant's self-selected speed during overground walking. Kinematic coordination was defined as the consistency of intralimb hip and knee angular trajectories over repeated gait cycles and was compared before and after treatment for each group. RESULTS: Locomotor training with therapist assistance resulted in significant improvements in the consistency of intralimb movements of the impaired limb. Providing consistent kinematic assistance during robotic-assisted LT did not result in improvements in intralimb consistency. Only minimal changes in discrete kinematics were observed in either group. LIMITATIONS: The limitations included a relatively small sample size and a lack of quantification regarding the extent of movement consistency during training sessions for both groups. CONCLUSIONS: Coordination of intralimb kinematics appears to improve in response to LT with therapist assistance as needed. Fixed assistance, as provided by this form of robotic guidance during LT, however, did not alter intralimb coordination.