A Continuous Quality Improvement Framework for Sustainable Action and Advancement of Diversity, Equity, Inclusion, and Belonging in Physical Therapy.

BACKGROUND AND PURPOSE: To address racial and ethnic disparities, physical therapy organizations, educational institutions, and clinical practices seek to advance diversity, equity, inclusion (DEI), and social justice in health care. Although our professional organizations have crafted proclamations, resource lists, developed new accreditation standards, and strategic plans, we lack a unifying framework and action tools for substantial and sustained progress. In addition, the DEI acronym is missing the essential element of belonging (B), that is, sharing a sense of purpose and feeling safe to contribute opinions as a valued member of an organization. Therefore, the purpose of this position paper is to propose the utilization of a continuous quality-improvement (CQI) framework using Plan-Do-Study-Act (PDSA) cycles to advance DEI-B in physical therapy education and practice. POSITION AND RATIONALE: The CQI framework and PDSA cycles are data-driven, iterative approaches for identifying areas for improvement, implementing interventions, collecting data, analyzing outcomes, and taking evidence-based next action steps. Application of this framework can enhance sustainability of DEI-B goals and foster progress toward the proposed accreditation criteria of the Commission on Accreditation in Physical Therapy Education in this critical area. Tenants for PDSA team success are presented, and PDSA cycles are described. DISCUSSION AND CONCLUSION: Addressing racism and advancing DEI-B efforts in the physical therapy profession requires bold, sustained, and intentional action that incorporates standards, strategies, and methods for measuring change. Examples of PDSA DEI-B initiatives, interventions, and outcomes are provided to illustrate how this approach can be implemented within a physical therapy education program. Using this CQI framework provides our profession with a DEI-B roadmap for advancing incremental and sustained progress.

Facilitators and barriers to enrolling in falls prevention programming among community dwelling older adults.

The purpose of this cross-sectional survey study was to identify factors that increase the likelihood of enrolling in falls prevention programming among community dwelling older adults. A convenience sample of 369 participants completed a written, selfadministered questionnaire on history and beliefs related to falls, and facilitators and barriers associated with enrollment. History of falling, fear of falling, self-efficacy, and recognition of program benefits were all associated with a greatly likelihood to enroll in falls prevention programming. Additionally, seven facilitators were associated with greater likelihood to enroll, including offered close to home (OR = 6.75(3.829-11.898); p = 0.000), free vision screen (OR = 4.816 (1.442-16.084); p = 0.005), friendly leader (OR = 3.930 (2.049-7.538); p = 0.000), coffee hour to socialize (OR = 3.789 (1.309-10.971); p = 0.009), no cost (OR = 3.653 (2.125-6.253); p = 0.000), group exercise (OR = 2.584 (1.341-4.980); p = 0.004), and safe place (OR = 2.378 (1.181-4.789); p = 0.013). Physician advice to attend a program, however, was not associated with likelihood to register (p = 0.99), supporting the need for a paradigm shift from physicians serving as the key change-agent in falls prevention to multiple partnerships. In addition, although 72% of participants were likely to register for a falls prevention program, only 28% knew if a program was being offered in their community. These findings highlight a critical need to disseminate information about falls prevention programming through social marketing in locations where older adults go in their everyday lives.

Support Needs and Coping Strategies as Predictors of Stress Level among Mothers of Children with Autism Spectrum Disorder.

This study examined maternal stress, coping strategies, and support needs among mothers of children with Autism Spectrum Disorder (ASD). A convenience sample of 70 mothers completed the Parent Stress Index Short Form (PSI-SF), Coping Health Inventory for Parents (CHIP), and Modified Family Needs Questionnaire (FNQ). PSI-SF scores reflected clinically significant levels of stress for 77% of mothers, and mothers identified 62.4% of important needs as unmet. The five most frequently reported important unmet needs were (1) financial support; (2) break from responsibilities; (3) understanding of other after-school program children; (4) rest/sleep; (5) help remaining hopeful about the future. Most coping strategies (81%) were identified as helpful. Additionally, both coping strategies and support needs served as predictors for maternal stress. Maternal stress scores decreased by .402 points for each percent increase in helpful coping strategy, and stress scores increased by .529 points with each percent increase in unmet needs. Given large variation in questionnaire responses across participants and studies, utilization of user-friendly questionnaires, such as the PSI-SF, CHIP, and FNQ, is advocated to determine the evolving important needs unique to each family over the child's lifetime as well as guide prioritization of care, compilation of resources, and referrals for additional services.

A description of professional pediatric physical therapy education.

PURPOSE: The purpose of this work was to reexamine the status of professional pediatric physical therapy education in the United States. METHODS: A task force designed a 16-item survey and contacted representatives from all professional physical therapy programs. RESULTS: Surveys were gathered from 151 programs for a return rate of 75%. Much variability exists across programs in total number of hours devoted to pediatrics (range, 35-210 hours). In addition, almost 60% of respondents indicated that the individual responsible for delivering the pediatric content will be retiring within the next 15 years. CONCLUSION: These results describe current pediatric professional education and provide numerous opportunities and challenges for the development of optimal professional pediatric education.

Development of physical therapy student cultural competency through international community service.

Many healthcare professions students are unaware of their own ethnocentrism, and movement along the continuum of cultural competence may not be possible until the students encounter individuals whose cultural beliefs, values, and needs differ significantly from their own. This project was an example of an international community service immersion experience in Nicaragua that led to increased cultural competency of five physical therapy students. Through immersion, the students progressed from cultural blindness to cultural precompetence. To further foster student cultural competence, the conceptual framework needs to reflect the multiple facets of an individual's identity and influences on behavior change.

Evaluation of a community-based group fitness program for children with disabilities.

PURPOSE: This study examined the feasibility, safety, and effectiveness of a community-based group fitness program for children with disabilities. METHODS: Twenty-eight children with neuromuscular and developmental disabilities, 6 to 14 years of age, participated. The 16-week community-based program, held twice weekly, consisted of strengthening, aerobic conditioning, and flexibility exercises. A pretest-posttest design was used, and the following outcomes were measured: isometric muscle strength of the knee extensors, hip abductors, and ankle plantarflexors, walking energy expenditure, functional mobility, and fitness. Falls and injury data also were collected. RESULTS: Mean program attendance was 75.3%, and no injuries were reported. Improvements in all clinical outcomes were observed. The most clinically meaningful improvement was in functional mobility with a large effect size (0.87). CONCLUSIONS: Physical therapists partnering with community centers may feasibly and safely shift group fitness programs for school-aged children with disabilities from the medical setting to the community.

Wellness promotion beliefs and practices of pediatric physical therapists.

PURPOSE: The purpose of this study was to elucidate wellness promotion beliefs and practices of pediatric physical therapists. METHODS: From a random sample of 500 American Physical Therapy Association Pediatric Section active members, 257 physical therapists (51%) returned usable questionnaires designed to gather information on professional and personal wellness beliefs and practices. RESULTS: Descriptive statistics and chi-square analyses were performed to describe current wellness promotion practices. Most participants considered wellness multidimensional, valued wellness, and incorporated wellness practices into their personal life. Only 54.5% of respondents, however, reported incorporating wellness into pediatric physical therapy practice. A third of the respondents identified themselves as either thinking or preparing to incorporate wellness promotion into practice. Factors associated with wellness promotion were older age group, knowledge, belief that wellness promotion was a physical therapy responsibility, and participation in personal wellness lifestyle activities. The most frequent barriers cited were external factors related to resources, time, and the child/family. CONCLUSIONS: Current pediatric physical therapy practice reflects a more traditional model of care rather than a wellness promotion approach. With a paradigm shift in healthcare toward wellness promotion, pediatric physical therapists need to align practice with current societal needs and national healthcare campaigns. Continuing education programs that are participatory and well matched to the characteristics and needs of the attendees combined with collegial support may prove fruitful in providing pediatric physical therapists with the knowledge, motivation, and strategies needed to accomplish this goal.

Effectiveness of a school-based backpack health promotion program: Backpack Intelligence.

A prominent school health issue in the United States is the use of backpacks, however, there is a paucity of literature on the effectiveness of backpack safety programs. The purpose of this paper is to describe a school-based backpack health promotion program: Backpack Intelligence, report on its effectiveness, and suggest avenues for future research. Three-hundred-seventy-two 6th and 7th grade students participated in the program which was integrated into their physical education curriculum. Of those students, 242 completed post-education surveys to assess its effectiveness. Pre-education, 44% reported that their backpack was uncomfortable to carry, and 61% reported two or more warning signs that their backpack was too heavy. Only 57% wore their backpack properly and less than half organized the contents in their backpack correctly. Post-education, 63% reported the program worthwhile. Forty-two percent changed the way they used their backpack, and 93% felt knowledgeable about backpack safety, a 24% increase. Both grade and gender differences were found. Areas identified in the literature as fruitful for future research were suggested. Until we have definitive research on the link between backpack use and injury, interventions may be imperfect, but as a society we are compelled to safeguard the health of our children.

Effects of lower extremity passive stretching: pilot study of children and youth with severe limitations in self-mobility.

PURPOSE: The purpose of this pilot study was to investigate changes in passive range of motion (PROM) of children with severe limitations in self-mobility during periods of physical therapy intervention and naturally occurring periods of no intervention (school vacations). METHODS: A multiple-case time-series design was used to monitor hip and knee PROM over a seven-month period for seven students aged four to 18 years receiving physical therapy in a school setting. PROM measurements were graphed and the Wilcoxon signed rank test was used to evaluate the PROM changes during intervention and nonintervention phases for each individual student and for the students as a group. RESULTS: When PROM changes were pooled for all subjects and all joint motions, the Wilcoxon signed rank test revealed a significant decrease in PROM only after the first nonintervention phase. Significant decreases in PROM were observed in only two of the students after the first nonintervention phase. CONCLUSION: Children and youth with severe limitations in self-mobility may lose PROM during nonintervention periods lasting more than five weeks.

Effects of backpack load and task demand on trunk forward lean: Pilot findings on two boys.

Trunk forward lean (TFL) has been identified as a postural adaptation to increases in backpack load, and spinal forces have been presumed based on TFL. This pilot project examined the combined effects of increasing backpack load and task demand on TFL. Two boys with typical development, aged 11 and 9, were participants. Peak5 Motion Analysis Videography was used to gather 2D kinematic data under three levels of backpack load (0%, 8.5% and 17% body weight) and three levels of task demand (stand, walk and run). Passive reflective markers were placed on anatomical landmarks, and TFL was calculated by the angle formed by a line joining the right acromion and right greater trochanter and a vertical reference line. Descriptive statistics were performed to compare TFL under the nine experimental conditions. Although TFL most often increased with increases in backpack load and task demand, TFL was not dose dependent. Postural patterns varied between participants, and the findings supported a ceiling effect. In conclusion, to compensate for changes in inertia and center of gravity when wearing a backpack, TFL represents a dynamic emergent strategy that varies based on task demand and characteristics of the individual. Further research on TFL is warranted, and clinicians should be cautious when recommending safe carrying loads for children based on posture.

Backpack use in children.

PURPOSE: This article describes backpack use and incidence of back pain in children. METHODS: A convenience sample of 345 children, grades five through eight, served as subjects. A written questionnaire was developed to gather information on demographics, leisure activity level, bag type, locker use, students' perceptions of bag weight and comfort, and students' reports of history of back pain. Scales were provided for students to weigh themselves with and without backpacks. RESULTS: Younger children carried proportionally greater backpack loads. Percentage of body weight by grade was as follows: fifth grade = 19%, sixth grade = 21%, seventh grade = 14%, and eighth grade = 15% body weight. Fifty-five percent of all subjects carried a load greater than 15% of their body weight, and one third of students reported a history of back pain. Percentage of body weight carried, however, was not significantly related to history of back pain. CONCLUSION: Concerns raised by parents and professionals that children are carrying heavy loads are justified; however, the relationship between heavy carrying load and back pain needs further elucidation. Recommendations for physical therapy, backpack safety, and injury prevention are provided.