Telephone-Delivered Exercise Advice and Behavior Change Support by Physical Therapists for People with Knee Osteoarthritis: Protocol for the Telecare Randomized Controlled Trial.

BACKGROUND: Exercise and physical activity are a core component of knee osteoarthritis (OA) care, yet access to physical therapists is limited for many people. Telephone service delivery models may increase access. OBJECTIVE: Determine the effectiveness of incorporating exercise advice and behavior change support by physical therapists into an existing Australian nurse-led musculoskeletal telephone service for adults with knee OA. DESIGN: Randomized controlled trial with nested qualitative studies. SETTING: Community, Australia-wide. PARTICIPANTS: One hundred seventy-five people ≥45 years of age with knee symptoms consistent with a clinical diagnosis of knee OA. Eight musculoskeletal physical therapists will provide exercise advice and support. INTERVENTION: Random allocation to receive existing care or exercise advice in addition to existing care. Existing care is a minimum of one phone call from a nurse for advice on OA self-management. Exercise advice involves 5-10 calls over 6 months from a physical therapist trained in behavior change support to prescribe, monitor, and progress a strengthening exercise program and physical activity plan. MEASUREMENTS: Outcomes will be measured at baseline and at 6 and 12 months. Primary outcomes are knee pain and physical function. Secondary outcomes include other measures of knee pain, self-efficacy, physical activity and its mediators, kinesiophobia, health service usage, work productivity, participant-perceived change, and satisfaction. Additional measures include adherence, adverse events, therapeutic alliance, satisfaction with telephone-delivered therapy, and expectation of outcome. Semi-structured interviews with participants with knee OA and therapists will be conducted. LIMITATIONS: Physical therapists cannot be blinded. CONCLUSIONS: This study will determine if incorporating exercise advice and behavior change support by physical therapists into a nurse-led musculoskeletal telephone service improves outcomes for people with knee OA. Findings will inform development and implementation of telerehabilitation services.

Using simulation pedagogy to teach clinical education skills: A randomized trial.

INTRODUCTION: Supervision of students is a key role of senior physiotherapy clinicians in teaching hospitals. The objective of this study was to test the effect of simulated learning environments (SLE) on educators' self-efficacy in student supervision skills. METHODS: A pilot prospective randomized controlled trial with concealed allocation was conducted. Clinical educators were randomized to intervention (SLE) or control groups. SLE participants completed two 3-hour workshops, which included simulated clinical teaching scenarios, and facilitated debrief. Standard Education (StEd) participants completed two online learning modules. Change in educator clinical supervision self-efficacy (SE) and student perceptions of supervisor skill were calculated. Between-group comparisons of SE change scores were analyzed with independent t-tests to account for potential baseline differences in education experience. RESULTS: Eighteen educators (n = 18) were recruited (SLE [n = 10], StEd [n = 8]). Significant improvements in SE change scores were seen in SLE participants compared to control participants in three domains of self-efficacy: (1) talking to students about supervision and learning styles (p = 0.01); (2) adapting teaching styles for students' individual needs (p = 0.02); and (3) identifying strategies for future practice while supervising students (p = 0.02). CONCLUSIONS: This is the first study investigating SLE for teaching skills of clinical education. SLE improved educators' self-efficacy in three domains of clinical education. Sample size limited the interpretation of student ratings of educator supervision skills. Future studies using SLE would benefit from future large multicenter trials evaluating its effect on educators' teaching skills, student learning outcomes, and subsequent effects on patient care and health outcomes.

Physical Therapists, Telephone Coaches, and Patients With Knee Osteoarthritis: Qualitative Study About Working Together to Promote Exercise Adherence.

BACKGROUND: Integrated models of care are recommended for people with knee osteoarthritis (OA). Exercise is integral to management, yet exercise adherence is problematic. Telephone-based health coaching is an attractive adjunct to physical therapist-prescribed exercise that may improve adherence. Little is known about the perceptions and interpretations of physical therapists, telephone coaches, and patients engaged in this model of care. OBJECTIVES: The purpose of this study was to explore how stakeholders (physical therapists, telephone coaches, and patients) experienced, and made sense of, being involved in an integrated program of physical therapist-supervised exercise and telephone coaching for people with knee OA. DESIGN: A cross-sectional qualitative design drawing from symbolic interactionism was used. METHODS: Semistructured interviews with 10 physical therapists, 4 telephone coaches, and 6 patients with painful knee OA. Interviews were audiorecorded, transcribed, and analyzed using thematic analysis informed by grounded theory. RESULTS: Four themes emerged: (1) genuine interest and collaboration, (2) information and accountability, (3) program structure, and (4) roles and communication in teamwork. Patients reported they appreciated personalized, genuine interest from therapists and coaches and were aware of their complementary roles. A collaborative approach, with defined roles and communication strategies, was identified as important for effectiveness. All participants highlighted the importance of sharing information, monitoring, and being accountable to others. Coaches found the lack of face-to-face contact with patients hampered relationship building. Therapists and coaches referred to the importance of teamwork in delivering the intervention. LIMITATIONS: The small number of physical therapists and telephone coaches who delivered the intervention may have been biased toward favorable experiences with the intervention and may not be representative of their respective professions. CONCLUSIONS: Integrated physical therapy and telephone coaching was perceived as beneficial by most stakeholders. Programs should be structured but have some flexibility to give therapists and coaches some freedom to adjust treatment to individual patient needs as required. Opportunities for visual communication between telephone coaches and patients could facilitate relationship building.

Power and promise of narrative for advancing physical therapist education and practice.

This perspective article provides a justification for and an overview of the use of narrative as a pedagogical tool for educators to help physical therapist students, residents, and clinicians develop skills of reflection and reflexivity in clinical practice. The use of narratives is a pedagogical approach that provides a reflective and interpretive framework for analyzing and making sense of texts, stories, and other experiences within learning environments. This article describes reflection as a well-established method to support critical analysis of clinical experiences; to assist in uncovering different perspectives of patients, families, and health care professionals involved in patient care; and to broaden the epistemological basis (ie, sources of knowledge) for clinical practice. The article begins by examining how phronetic (ie, practical and contextual) knowledge and ethical knowledge are used in physical therapy to contribute to evidence-based practice. Narrative is explored as a source of phronetic and ethical knowledge that is complementary but irreducible to traditional objective and empirical knowledge-the type of clinical knowledge that forms the basis of scientific training. The central premise is that writing narratives is a cognitive skill that should be learned and practiced to develop critical reflection for expert practice. The article weaves theory with practical application and strategies to foster narrative in education and practice. The final section of the article describes the authors' experiences with examples of integrating the tools of narrative into an educational program, into physical therapist residency programs, and into a clinical practice.

New perspectives on the theory of justice: implications for physical therapy ethics and clinical practice.

Recent revisions of physical therapy codes of ethics have included a new emphasis concerning health inequities and social injustice. This emphasis reflects the growing evidence regarding the importance of social determinants of health, epidemiological trends for health service delivery, and the enhanced participation of physical therapists in shaping health care reform in a number of international contexts. This perspective article suggests that there is a "disconnect" between the societal obligations and aspirations expressed in the revised codes and the individualist ethical frameworks that predominantly underpin them. Primary health care is an approach to health care arising from an understanding of the nexus between health and social disadvantage that considers the health needs of patients as expressive of the health needs of the communities of which they are members. It is proposed that re-thinking ethical frameworks expressed in codes of ethics can both inform and underpin practical strategies for working in primary health care. This perspective article provides a new focus on the ethical principle of justice: the ethical principle that arguably remains the least consensually understood and developed in the ethics literature of physical therapy. A relatively recent theory of justice known as the "capability approach to justice" is discussed, along with its potential to assist physical therapy practitioners to further develop moral agency in order to address situations of health inequity and social injustice in clinical practice.

Moral agency as enacted justice: a clinical and ethical decision-making framework for responding to health inequities and social injustice.

This is the second of 2 companion articles in this issue. The first article explored the clinical and ethical implications of new emphases in physical therapy codes of conduct reflecting the growing evidence regarding the importance of social determinants of health, epidemiological trends for health service delivery, and the enhanced participation of physical therapists in shaping health care reform in a number of international contexts. The first article was theoretically oriented and proposed that a re-thinking of ethical frameworks expressed in codes of ethics could both inform and underpin practical strategies for working in primary health care. A review of the ethical principle of "justice," which, arguably, remains the least consensually understood and developed principle in the ethics literature of physical therapy, was provided, and a more recent perspective-the capability approach to justice-was discussed. The current article proposes a clinical and ethical decision-making framework, the ethical reasoning bridge (ER bridge), which can be used to assist physical therapy practitioners to: (1) understand and implement the capability approach to justice at a clinical level; (2) reflect on and evaluate both the fairness and influence of beliefs, perspectives, and context affecting health and disability through a process of "wide reflective equilibrium" and assist patients to do this as well; and (3) nurture the development of moral agency, in partnership with patients, through a transformative learning process manifest in a mutual "crossing" and "re-crossing" of the ER bridge. It is proposed that the development and exercise of moral agency represent an enacted justice that is the result of a shared reasoning and learning experience on the part of both therapists and patients.

Closing the gap between ethics knowledge and practice through active engagement: an applied model of physical therapy ethics.

Physical therapist practice has a distinct focus that is holistic (ie, patient centered) and at the same time connected to a range of other providers within health care systems. Although there is a growing body of literature in physical therapy ethics knowledge, including clinical obligations and underlying philosophical principles, less is known about the unique ethical issues that physical therapists encounter, and how and why they make ethical decisions. As moral agents, physical therapists are required to make autonomous clinical and ethical decisions based on connections and relationships with their patients, other health care team members, and health institutions and policies. This article identifies specific ethical dimensions of physical therapist practice and highlights the development and focus of ethics knowledge in physical therapy over the last several decades. An applied ethics model, called the "active engagement model," is proposed to integrate clinical and ethical dimensions of practice with the theoretical knowledge and literature about ethics. The active engagement model has 3 practical steps: to listen actively, to think reflexively, and to reason critically. The model focuses on the underlying skills, attitudes, and actions that are required to build a sense of moral agency and purpose within physical therapist practice and to decrease gaps between the ethical dimensions of physical therapist practice and physical therapy ethics knowledge and scholarship. A clinical case study is provided to illustrate how the ethics engagement model might be used to analyze and provide insight into the ethical dimensions of physical therapist practice.

In private practice, informed consent is interpreted as providing explanations rather than offering choices: a qualitative study.

QUESTION: How do physiotherapists working in private practice understand and interpret the meaning and significance of informed consent in everyday clinical practice? DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Seventeen physiotherapists purposefully recruited from metropolitan private practices where treatment was on a one-on-one basis. RESULTS: Therapists defined informed consent as an implicit component of their routine clinical explanations, rather than a process of providing explicit patient choices. Therapists' primary concern was to provide information that led to a (therapist-determined) beneficial therapeutic outcome, rather than to enhance autonomous patient choice. Explicit patient choice and explicit informed consent were defined as important only if patients requested information or therapists recognised risks associated with the treatment. CONCLUSION: Physiotherapists defined informed consent within a context of achieving therapeutic outcomes rather than a context of respect for patient autonomy and autonomous choice. Physiotherapy practice guidelines developed to ensure compliance with ethical and legal obligations may therefore be followed only if they fit with therapists' understanding and interpretation of a desired therapeutic outcome.