Experienced Clinical Decision-Making in Physical Therapist Management of Concussion: A Qualitative Study.

OBJECTIVE: The recent publication of the Physical Therapy Evaluation and Treatment After Concussion Clinical Practice Guideline is intended to assist clinicians in their decision-making specific to evaluation and intervention. Clinical practice guidelines are supported by best available evidence, though it is unknown what other factors drive clinical decision-making in the realm of concussion management. The purpose of this study was to explore factors related to the process of clinical decision-making of experienced physical therapists who treat individuals with concussion. METHODS: This grounded theory approach used semi-structured interviews of physical therapists who have practiced concussion management ≥3 years and have treated ≥15 individuals for postconcussion symptoms in the last year. Following the inductive approach, deductive qualitative methodology was used to explore alignment with recent guidelines. Member checking was used to ensure trustworthiness. RESULTS: Ten therapists' experience in treating concussion ranged from 5 to 20 years. Four overarching themes were identified that contribute to clinical decision-making: expert practice behaviors through use of reflection in action, clinical reasoning, collaboration, and evidenced informed practice; therapeutic alliance building using individualized education, reassurance, and relationship building; adaptability in prioritizing, assessing, and responding to patients' needs; and listening and observing. Clinician decision-making statements showed alignment with clinical practice guideline recommendations. CONCLUSION: Experienced therapists demonstrate a consistent approach that parallels the current clinical practice guideline while building off clinical experience to tailor individualized care focusing on patient centeredness. These factors may assist more novice clinicians to develop and improve their management strategies for optimal outcomes. IMPACT: Identified themes may broaden frameworks and guidelines for the management of individuals postconcussion specific to the field of physical therapy.

Physical therapy students' application of an imaging decision rule for acute knee pain.

BACKGROUND: Evidence supports direct referral for imaging by physical therapists. Accuracy and self-efficacy for imaging decisions have not been investigated in entry-level doctor of physical therapy (DPT) students. OBJECTIVE: The purpose of this study was to understand the relationship between entry-level DPT instruction and accuracy and self-efficacy for imaging referral due to acute knee trauma. A second purpose was to identify relationships between accuracy and self-efficacy. METHODS: An online survey was sent via e-mail to program directors in accredited DPT programs in the United States with an invitation to forward the survey to DPT students. The survey captured demographic information and included five questions that assessed the respondent's ability to apply the Ottawa Knee Rules (OKR). Self-efficacy was assessed using the Physiotherapist Student Self-Efficacy (PSE) questionnaire, a self-rated 5-point Likert scaled tool. RESULTS: Of 240 surveys, DPT students who completed imaging coursework had greater accuracy and higher self-efficacy (68.0% correct (95% CI, 63.6-72.5), PSE = 3.67, P < .001) compared to students who had not (45.8% correct (95% CI, 40.8-50.7), PSE = 2.67, P < .001). Conclusion: Accuracy by DPT students who completed imaging coursework was significantly improved and comparable to values from autonomous providers.

Team Approach to Delayed Pediatric Vestibular Diagnosis: A Case Study.

BACKGROUND AND PURPOSE: This report highlights the challenges of diagnosing pediatric vestibular neuritis following dental treatment and addressing fear avoidance behaviors. CASE DESCRIPTION: An 11-year-old boy came to physical therapy with vestibular dysfunction following dental treatment that was unable to be diagnosed by emergency department staff. The participant received multispecialty treatment for 6 weeks. MEASUREMENTS: Computerized Dynamic Posturography, Limits of Stability, Dizziness Handicap Inventory, Functional Gait Assessment, Dynamic Visual Acuity, and Modified Clinical Test of Sensory Interaction on Balance. OUTCOMES: Most notable improvements were seen in Limits of Stability and Computerized Dynamic Posturography. The participant made a full return to school and sport. CONCLUSIONS: The difficulty of pediatric vestibular neuritis diagnosis led to fear avoidance behaviors that were addressed by a collaborative specialty approach. WHAT THIS ADDS TO EVIDENCE: This is the first documented case of pediatric vestibular neuritis as a complication of a dental procedure with intervention focused on fear avoidance behaviors.

Serial Subtraction Alters Lateral Step-down Tibiofemoral Kinematics in Healthy Adults.

This study evaluated the effects of two types of cognitive dual-tasking on three-dimensional knee kinematics during the lateral step-down. 19 healthy individuals (22.05±1.61 yrs., 173.92±9.21 cm, 67.99±12.65 kg) participated in this study. Participants completed 5 repetitions of a lateral step-down task for each leg and each testing condition (control, Stroop, and serial subtraction by seven). An electromagnetic motion sensor was attached to the femur via compression clamp placed about the medial and lateral epicondyles. Another sensor was attached 2 cm below the ipsilateral tibial tuberosity. A custom MATLAB algorithm located the knee joint axis of rotation from dynamic knee flexion and extension. Discrete kinematics at peak flexion were used in this study. Paired samples t-tests were used to compare average frontal, transverse, and sagittal plane knee position at maximum flexion between conditions for each leg. No significant differences were found for either limb between control and Stroop conditions. Comparisons revealed significant differences in frontal and transverse plane knee angles at peak flexion between the control and serial subtraction by seven conditions. These findings indicate serial subtraction by seven requires different cognitive processing abilities which may cause greater interference with some aspects of motor control.

Older adults who resistance train improve physical function and adopt long-term exercise habits despite COVID-19 restrictions.

Exercise interventions targeting older adults often focus on acute changes, but lasting improvements require the adoption of long-term, independent exercise habits. This study aimed to assess the influence of eight-weeks of resistance training (SSSH) on clinically relevant fall-risk indicators in older adults and to evaluate if SSSH participation altered independent exercise engagement 12 months later. Sixty adults aged 50 yrs+ were randomised into SSSH, Walk, or Control groups and completed questionnaires and muscle strength and flexibility tests pre/post 8 weeks. SSSH and Walk met 2x/wk for 60 min. Twelve months later 24 participants also completed a follow-up survey amid COVID-19 restrictions. Eight-week group changes were analysed using one-way ANOVA with Bonferroni post hoc analyses, and survey responses were compared using paired t-tests with a Bonferroni correction. SSSH demonstrated greater absolute changes over 8 weeks in sleep quality, activity engagement, 30-second-sit-to-stand and upper-body flexibility than Walk or Controls (p < 0.05). Twelve months later, SSSH participants reported significantly increasing independent resistance (+68), aerobic (+125) and flexibility (+26) training minutes per week (all p < 0.01). In conclusion, SSSH reduced fall risk in 8 weeks and sparked older adults to begin and sustain positive exercise habits 12 months later, despite COVID-19 restrictions.

Comparison of Azure Kinect overground gait spatiotemporal parameters to marker based optical motion capture.

BACKGROUND: Instrumented measurement of spatiotemporal parameters during walking can provide valuable information on an individual's overall function and health. Efficient, inexpensive, and accurate measurement of overground walking spatiotemporal parameters would be a critical component of providing point-of-care assessments of gait function, concussion recovery, fall-risk, and cognitive decline. Depth cameras combined with skeleton pose tracking algorithms, such as the Microsoft Kinect with body tracking software, have been used to measure walking spatiotemporal parameters. However, the ability of the latest generation Microsoft Kinect sensor, the Azure Kinect, to accurately measure overground walking spatiotemporal parameters has not been evaluated in the literature. RESEARCH QUESTION: The purpose of this work was to compare overground walking spatiotemporal parameters measurements from a 12 camera Vicon optical motion capture system to measurements of a single Azure Kinect with body tracking SDK (software development kit). METHODS: Spatiotemporal parameters of overground walking were simultaneously collected on twenty young healthy participants. Stride length, stride time, step length and step width were derived from ankle joint center locations and measurements from the two instruments were compared using descriptive statistics, scatter plots, Pearson correlation analyses, and Bland-Altman analyses. RESULTS: Pearson correlation coefficients were greater than 0.87 for all spatiotemporal parameters with most parameters demonstrating very strong (> 0.9) agreement. The mean of the differences for stride length between measurements was 35.6 mm for the left limb and 39.1 mm for the right limb, both of which are less than 3% of average stride length. Mean of the differences for step width and stride time were less than 2% and 1% of their averages respectively. SIGNIFICANCE: A single Microsoft Azure Kinect with body tracking SDK can provide clinically relevant measurement of walking spatiotemporal parameters, providing accessible and objective measurements that can improve clinical decision making across a variety of patient populations.

Comparison of Azure Kinect and optical retroreflective motion capture for kinematic and spatiotemporal evaluation of the sit-to-stand test.

BACKGROUND: The sit-to-stand test (STS) is commonly used to evaluate functional capabilities within a variety of clinical populations. Traditionally STS is a timed test, limiting the depth of information which can be gained from its evaluation. The Azure Kinect has the potential to add in-depth analysis to STS. Despite these potential benefits, the recently released (2019) Azure Kinect has yet to be evaluated for its ability to accurately assess STS. RESEARCH QUESTIONS: Purposes of this work were to compare data captured during STS using both a 12 camera Vicon motion capture system and the Azure Kinect; and to calculate kinematic and spatiotemporal variables related to the four phases of the STS cycle. METHODS: Spatiotemporal and kinematic measures for STS were simultaneously collected by both devices for 15 participants. Cycle waveforms were compared for right and left hip and knee flexion/extension angular displacement, right and left hip and knee flexion/extension angular velocity, and knee-to-ankle separation ratio. Evaluated discrete outcome variables included: phase time points, maximum knee extension velocity from phases 3 to 4, medial-lateral pelvic sway range, and total time to completion. Waveform summary data were compared using R, R2, and RMSE. Discrete variables were analyzed using Spearman's Rank correlation coefficient. RESULTS: R and R2 values between the two systems indicated high levels of correlation (all R values > 0.711, all R2 values > 0.660). Although there was an overall high level of agreement between waveform shapes, high RMSE values indicated some minor tracking errors for Kinect within the STS cycle. Spearman's Rank correlation coefficient indicated high levels of correlation between the systems for discrete variables (all R values > 0.89), with the exception of medial-lateral pelvic sway range. SIGNIFICANCE: The Azure Kinect provides valuable insight into STS movement strategies allowing for improved precision in clinical decision making across multiple clinical populations.

Golf as a Physical Activity to Potentially Reduce the Risk of Falls in Older Adults with Parkinson's Disease.

Advanced age is associated with an increased risk for falls in aging adults. Older adults are also more likely to be diagnosed with Parkinson's disease (PD), with advanced age as the most significant risk factor. PD is a neurodegenerative disorder with four Cardinal motor symptoms: rigidity, bradykinesia, postural instability, and tremor. Thus, people (person)-with-Parkinson's disease (PwP) have an even greater risk of falling than non-disorder age-matched peers. Exercise is an activity requiring physical effort, typically carried out to sustain or improve overall health and fitness, and it lowers the risk of falls in the general population. The sport of golf provides a low-impact all-around workout promoting a range of motion, activation of muscles in the upper and lower body, flexibility, and balance. Swinging a golf club offers a unique combination of high amplitude axial rotation, strengthening postural musculature, coordination, and stabilization, demonstrating the potential to impact PD symptoms positively. Golf may be a novel exercise treatment regimen for PD to use in conjunction with traditional medical therapy. We completed a literature review to determine the relationship between the game of golf, PD, and the risk of falls. We concluded that regularly playing golf can lower the risk for falls in community ambulating older adults with PD and demonstrates the potential to improve quality of life for PwP.

KNOWLEDGE OF VESTIBULAR OCULAR DYSFUNCTION AND UTILIZATION OF VESTIBULAR OCULAR MOTOR SCREENING (VOMS) TOOL COMPONENTS AMONG PROFESSIONAL SPORTS LEAGUE ATHLETIC TRAINERS.

BACKGROUND: The Vestibular Ocular Motor Screen (VOMS) is a relatively new measurement tool intended for the non-vestibular practitioner to identify vestibular ocular dysfunction (VOD) following sport related concussion (SRC). Specific knowledge of VOD and usage of the VOMS among athletic trainers in professional sports leagues is currently unknown. HYPOTHESIS/PURPOSE: The purpose of this study was to examine knowledge of VOD following SRC and utilization of the VOMS tool and other vestibular ocular tests and measures among athletic trainers in professional sports. STUDY DESIGN: Cross Sectional Study. METHODS: A total of 117 athletic trainers from Major League Baseball, the National Basketball Association, the National Football League and Major League Soccer, with a mean of 17 ± 9 years in the athletic training profession were surveyed via Qualtrics™ with a response rate of 33%. The survey contained three primary sub-sections; demographics, knowledge of vestibular ocular deficits following SRC, and VOMS component utilization at baseline, acute and return-to-play phases of management. Total knowledge scores as well as percentage of utilization based on concussion management stages were calculated. RESULTS: The average percentage correct on the knowledge items was 56% (range of 30% to 65%). There was no difference in knowledge score among athletic trainers with formal post-professional concussion training (p = 0.29) compared to those with no formal training. There was no relationship found between total years practicing and total knowledge score, r = -.128, (p = 0.17). Smooth pursuit testing was the most commonly utilized (70%) in clinical practice and Visual Motion Sensitivity (VMS) was the least utilized (17%). Balance assessment measures to examine vestibular functioning remained the highest utilized examination technique at all-time points in management of SRC. CONCLUSION: The range of correct responses from 30% to 65% indicates that at the time of survey the participants had decreased knowledge of VOD following SRC. There was low overall utilization of all VOMS components despite recent evidence showing good sensitivity and low false positive rates in SRC. The results of this study identify an opportunity for future training specific to vestibular-ocular impairments and assessment following concussion injury. LEVEL OF EVIDENCE: 2c.

Health professions students' attitudes and perceptions of interprofessional biases.

OBJECTIVE: The purpose of this study was to examine attitudes toward interprofessional, team-based care in first-year health professions students. METHODS: A cross-sectional questionnaire was administered to all first-year health professions students in their first semester at one university using the Interprofessional Attitudes Scale (IPAS). Kruskal-Wallis tests were used to analyze the data. KEY FINDINGS: Results indicated only two significant differences among students in IPAS subdomains: teamwork (χ2  = 13.11, df = 3, P = 0.004) and patient-centredness (χ2  = 40.75, df = 3, P < 0.0001). CONCLUSIONS: Not all health professions students come into their formal education with the same level of attitudes toward team-based care. Educators should consider this when designing IPE activities.