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.

Investigating health disparities in vestibular rehabilitation.

BACKGROUND: Health disparities (HD) impact care delivery and health outcomes in individuals with vestibular disorders (IVD). OBJECTIVE: The purpose of this study is to identify whether health disparities (HD) exist in Vestibular Rehabilitation (VR) between individuals identifying as Caucasians or racial or ethnic minorities (REM). METHODS: This study was a retrospective chart review of IVD who attended outpatient VR between 1/2014 and 9/2020. Data recorded included age, gender, race/ethnicity, vestibular diagnosis, VR interventions, and pre-post outcome measures such as Dizziness Handicap Inventory (DHI), and Activities-Specific Balance Confidence Scale (ABC), Gait speed (GS), and Functional Gait Assessment (FGA). Chi-squared tests, one-tailed, and two-tailed t-tests (α= 0.05) were utilized to compare Caucasian and REM groups. RESULTS: Three hundred and forty-three charts (N = 343) met inclusion/exclusion criteria. REM demonstrated higher median DHI scores (46 vs. 38, p = 0.008) and lower ABC scores (53.10% vs. 66.30%, p <  0.001) at VR evaluation compared to Caucasians. There were no statistically significant differences in DHI, ABC, FGA, and GS scores between Caucasians and REM at discharge. CONCLUSIONS: VR was able to equalize HD in DHI and ABC which initially existed between REM and Caucasians. VR therapists should work with public health and policy researchers to improve access to VR.

Chemodenervation Algorithm: Functional and Aesthetic Considerations for Facial Harmony in Patients with Post-Facial Paralysis Synkinesis.

Management of post-facial paralysis synkinesis has evolved for the past decade with diversification of neuromuscular retraining, chemodenervation, and advanced surgical reanimation techniques. Chemodenervation with botulinum toxin-A is a commonly used treatment modality for synkinesis patients. Treatment has shifted from solely weakening the unaffected contralateral facial musculature for rote symmetry to selective reduction of undesired or overactive synkinetic muscles, allowing for a more organized motion of the recovered musculature. Facial neuromuscular retraining should be considered a crucial component of treating patients with synkinesis along with soft tissue mobilization, but specifics of these are beyond the scope of this article. Our goal was to create a descriptive platform for our method of chemodenervation treatment in the evolving field of post-facial paralysis synkinesis. A multi-institutional and multidisciplinary comparison of techniques was performed with photograph and video creation, review, and discussion over an electronic platform with all authors. Anatomic specifics of each region of the face and individual muscles were considered. A muscle by muscle algorithm for synkinesis therapy was created to include chemodenervation with botulinum toxin that should be considered for patients suffering from post-facial paralysis synkinesis.

Consensus Among International Facial Therapy Experts for the Management of Adults with Unilateral Facial Palsy: A Two-Stage Nominal Group and Delphi Study.

Background: Nonsurgical rehabilitation of unilateral peripheral facial palsy (FP) varies globally with controversy regarding best practice. Objective: To develop facial therapist consensus regarding what should be included or excluded in rehabilitation of adults with FP of any etiology. Three clinical presentations: flaccid, paretic and synkinetic, were separately considered. Methodology: A two-stage study was conducted: a nominal group technique (NGT) to develop a questionnaire plus Delphi study. Delphi participants were recruited worldwide, through an experience-based inclusion questionnaire. The final Delphi questionnaire included 166 items for each clinical presentation covering assessment, outcome measures, and interventions, for example, education, eye care, neuromuscular retraining, and electrical modalities. Inclusion/exclusion agreement was set at 80%, indicating participant consensus. Items reaching 70-79% were deemed "near-included/near-excluded." Results: Averaged across all presentations, 24.9% of the 166 items were included, (e.g., Sunnybrook Facial Grading System, patient education and neuromuscular retraining), 26.9% of the 166 items were excluded, (e.g., gross strengthening and electrical stimulation); 48.2% were neither included nor excluded. Conclusion: This study brings together the global community's expertise as a first step toward establishing best practice for specialist facial therapy. It is hoped this will guide clinical decision making, advance research, and optimize patient outcomes in this challenging field.

Estimating the minimal clinically important difference for balance and gait outcome measures in individuals with vestibular disorders.

BACKGROUND: Vestibular Rehabilitation Therapists (VRT) utilize outcome measures to quantify gait and balance abilities in individuals with vestibular disorders (IVD). The minimal clinically important difference (MCID) in gait and balance outcome measures for IVD is unknown. OBJECTIVE: The purpose of this study is to estimate the MCID of the Activities-specific Balance Confidence Scale (ABC), Functional Gait Assessment (FGA), and Gait Speed (GS) using distribution and anchor-based methods relative to the Dizziness Handicap Inventory (DHI) in IVD. METHODS: Data were collected using a retrospective chart review from two outpatient Vestibular Rehabilitation (VR) clinics. Data included demographic characteristics, diagnosis, VR course, and pre and post outcome measures including DHI, ABC, FGA, and GS. The DHI was used to classify subjects as "responders" or "non-responders" in order to calculate MCID values. RESULTS: The total number of subjects analyzed for each outcome measure was 222 for the ABC, 220 for FGA, and 237 for GS. Subjects made statistically significant improvements in ABC, DHI, FGA, and GS (p < 0.001) from pre to post VR. The MCID calculated for ABC, FGA, and GS using the anchor-based approach was 18.1%, 4 points, and 0.09 m/s respectively. The MCIDs calculated using distribution-based approach for the ABC ranged between 7.5-23.5%, FGA ranged between 1.31-4.15 points, and GS ranged between 0.07 m/s-0.22 m/s. CONCLUSIONS: The anchor-based calculations of the MCID of 18.1%, 4 points, and 0.09 m/s for ABC, FGA, and GS respectively for IVD should be used over distribution-based calculations. This is due to strength of DHI as the anchor and statistical analysis. VRT and researches can use these values to indicate meaningful changes in gait and balance function in IVD.

Anatomic Considerations of Perinasal Musculature for Improved Dental Show During Smile in Facial Synkinesis.

Introduction: There is an anatomic explanation for upper lip and midfacial tethering resulting in lack of motion in facial synkinesis. Objective: To measure the effect of perinasal chemodenervation on dental show in the synkinetic population and clarify the anatomic relationship of perinasal musculature. Methods: Literature search was performed on anatomy of the perinasal modiolus, and anatomic evaluation was performed through human anatomic specimen dissection. Photographic outcomes were observed in synkinetic patients receiving chemodenervation to smile antagonists with and without perinasal muscle injections and assessed through naive observer survey. Retrospective outcomes for all patients receiving perinasal chemodenervation was collected utilizing Facial Clinimetric Evaluation Scale, Sunnybrook Facial Grading System (FGS), Facial Disability Index (FDI), and the Synkinesis Assessment Questionnaire. Results: Anatomic dissections demonstrated muscular confluence spanning the nasal sidewall and upper lip tethering the soft tissue to bone. Thirty-four of 53 chemodenervation patients received perinasal Botox experiencing improvement in synkinetic symptoms of the upper lip, nose, and improved dental show as noted on paired t-test for FGS (p = 0.00096), and FDI social p = 0.015) also supported by naive observer surveys (p = 0.03). Conclusions: Human anatomic specimen dissections support a perinasal confluence of musculature with bony attachments that can be successfully treated with chemodenervation in facial synkinesis patients.

Validation of the StepWatch activity monitor in individuals with vestibular disorders.

Purpose: The purpose of this study is to investigate the accuracy of the StepWatch Activity Monitor (SAM in measuring step count for individuals with vestibular disorders.Materials and Methods: Subjects were individuals with a vestibular disorder. The StepWatch Activity Monitor (SAM) was programed, placed on the patient's right ankle, and calibrated. Subjects completed a 2 Minute Walk Test (2 MWT) wearing the SAM. All steps were counted live and by video using a tally counter (TC).Results: Twenty-Six (N = 26) subjects, 9 males and 17 females, with an average age of 61.5 ± 12.4 years (36-80) completed the study. The average number of steps counted by the TC during the 2 MWT was 219.1 ± 25.9 (168-251) compared to 217.4 ± 27.3 (153-252) counted by SAM, an average difference of 1.6 ± 4.6 steps. Regression analysis demonstrated that the mean difference in step count was not significantly different from 0 (t = -1.588, sig. = 0.125). A Bland-Altman plot was created using the 95% upper and lower confidence interval (-0.29-3.44).Conclusion: The results indicate that the SAM accurately measures step count in individuals with vestibular disorders. Researchers and vestibular therapists can use the SAM to collect step count data in individuals with vestibular disorders.

Can Dizziness Handicap Inventory and Activities-Specific Balance Confidence Scores Assess Vestibular Loss After Vestibular Schwannoma Excision?

OBJECTIVE: Evaluate and compare the Dizziness Handicap Inventory with Activities-specific Balance Confidence scores shortly after vestibular schwannoma excision. STUDY DESIGN: Retrospective database review. SETTING: Tertiary care center. PATIENTS: Adults undergoing vestibular schwannoma excision between January 2015 and December 2019. INTERVENTION: Diagnostic, therapeutic, and rehabilitative. MAIN OUTCOME MEASURES: Postoperative change in Dizziness Handicap Inventory scores and Activities-specific Balance Confidence scores 2 to 3 weeks after surgical intervention in relation to preoperative vestibular testing. RESULTS: A total of 49 patients met inclusion criteria. The average change in the Dizziness Handicap Inventory was 6 (p = 0.07, 95% CI 0-13). This was weakly correlated to preoperative caloric testing values (r = -0.31, p = 0.03), but not cervical vestibular evoked myogenic potentials (cVEMP) values (r = -0.17, p = 0.23). The average change in Activities-specific Balance Confidence was -10% (p = 0.007, 95% CI -3 to -17%). This change was moderately correlated with preoperative caloric values (r = 0.42, p = 0.006), but it was not correlated with cVEMP (r = 0.07, p = 0.66). CONCLUSIONS: In vestibular schwannoma patients, factors other than preoperative vestibular function likely affect postoperative Dizziness Handicap Inventory and Activities-specific Balance Confidence scores. The change in Activities-specific Balance Confidence was slightly more consistent with expected physiological vestibular loss, and it represents another tool in a multidisciplinary vestibular evaluation of the postoperative patient.

Facial Nerve Translocation for Low Tension Neurorrhaphy to Masseteric Nerve.

INTRODUCTION: The techniques of facial reanimation are continually evolving in search of the ideal method for rehabilitating the paralyzed face. In the past, alternative cranial nerve motor nuclei have been used to power facial musculature. The trigeminal nerve is gaining popularity as a promising nerve to drive facial motion, particularly in the lower face. OBJECTIVES: This article describes a low-tension technique of using the transposed facial nerve to the trigeminal nerve (masseteric branch) for facial reanimation. METHODS: Six patients over 2.5 years were treated with facial nerve translocation with division at the geniculate and direct neurorrhaphy to the motor branch of the masseter. Patients were evaluated by physical examination, measurement of oral commissure excursion using MEEI FACE-gram software, video assessment, Sunnybrook Facial Grading System, Facial Disability Index, and Facial Clinimetric Evaluation Scale (FaCE). RESULTS: Patients demonstrated early motion within 4 months postoperatively and were placed into facial physical therapy. All demonstrated improvements in oral competence, strong oral commissure excursion with good symmetry, speech improvements, and variable results in facial tone. Synkinesis to the smile antagonists in the lower face was noted and treated with chemodenervation in three of six. No upper division synkinesis was noted. CONCLUSION: The motor branch of the trigeminal nerve is an effective option for facial reanimation via facial nerve translocation and end-to-end neurorrhaphy. Variable results in facial tone were noted with excellent oral commissure excursion. This procedure is safe in the reoperated mastoid.

The impact of symptoms of anxiety and depression on subjective and objective outcome measures in individuals with vestibular disorders.

BACKGROUND: Anxiety and depression are common in individuals with vestibular disorders and anecdotally symptoms of these disorders have been associated with poorer scores on subjective outcome measures of dizziness and balance. It is unknown if symptoms of psychological distress impact individual outcomes with vestibular rehabilitation therapy (VRT). OBJECTIVE: To compare subjective and objective outcome measures in subjects with vestibular disorders who have symptoms of anxiety and/or depression to those who do not exhibit those symptoms. METHODS: A retrospective chart review was performed at two outpatient vestibular rehabilitation clinics. Data recorded included demographics, scores on the Positive and Negative Affective Scale (PANAS), and subjective and objective outcome measures of balance and gait. RESULTS: The PANAS scale was utilized to group subjects (N = 118) into two groups: Subjects with abnormal affect (SAA) (18.6%; N = 22) and subjects with normal affect (SNA) (81.4%; N = 96). Both groups demonstrated a statistically significant improvement in all outcome measures (p < 0.001) from evaluation to discharge. SAA subjects took longer than SNA subjects to achieve goals (p < 0.05). SAA subjects tended to have poorer outcome measure scores at both initial and final assessment, but this was not statistically significant (p > 0.05). CONCLUSIONS: Results from this study indicate that VRT is effective in treating vestibular disorders in individuals with symptoms of psychological distress such as anxiety and depression. However, individuals with these symptoms may not achieve as high of outcomes as those that do not report symptoms of psychological distress.