Clare Delany

Do Activity Levels Increase After Total Hip and Knee Arthroplasty

BackgroundPeople with osteoarthritis (OA) often are physically inactive. Surgical treatment including total hip arthroplasty or total knee arthroplasty can substantially improve pain, physical function, and quality of life. However, their impact on physical activity levels is less clear.Questions/purposesWe used accelerometers to measure levels of physical activity pre- and (6 months) postarthroplasty and to examine the proportion of people meeting the American Physical Activity Guidelines.MethodsSixty-three people with hip or knee OA awaiting arthroplasty were recruited from a major metropolitan hospital. Physical activity was measured using accelerometry before, and 6 months after, surgery. The ActiGraph GT1M (ActiGraph LLC, Fort Walton Beach, FL, USA) was used in this study and is a uniaxial accelerometer contained within a small activity monitor designed to measure human movement through changes in acceleration, which can then be used to estimate physical activity over time. Questionnaires were used to assess patient-reported changes in pain, function, quality of life, and physical activity. Complete data sets (including valid physical activity data) for both time points were obtained for 44 participants (70%). At baseline before arthroplasty, the activity level of patients was, on average, sedentary for 82% of the time over a 24-hour period (based on accelerometry) and self-rated as “sometimes participates in mild activities such as walking, limited shopping, and housework” according to the UCLA activity scale.ResultsThere was no change in objectively measured physical activity after arthroplasty. The majority of participants were sedentary, both before and after arthroplasty, and did not meet the American Physical Activity Guidelines recommended to promote health. This was despite significant improvements in self-reported measures of pain, function, quality of life, and physical activity after arthroplasty.ConclusionsDespite patient-reported improvements in pain, function, and physical activity after arthroplasty, objectively measured improvements in physical activity may not occur. Clinicians should incorporate strategies for improving physical activity into their management of patients after hip and knee arthroplasty to maximize health status. Future research is needed to explore the factors that impact physical activity levels in people after arthroplasty.Level of EvidenceLevel IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A study of critical reflection in health professional education: 'learning where others are coming from'.

A dominant focus of clinical education for health professional students is experiential learning through an apprentice model where students are exposed to a range of clinical scenarios and conditions through observation initially, and then through supervised clinical practice. However experiential learning may not be enough to meet the need for health professionals to be flexible, self-aware and understanding of alternative perspectives or ‘where other people are coming from.’ Critical reflection skills are recognised as a way of thinking and a process for analysing practice, that enables learning from, and redeveloping professional practice in an ongoing way. This paper describes and examines the effect of a three hour per week, six week critical reflection program, grounded in knowledge paradigms of postmodernism, reflexivity and critical theory, on third year undergraduate physiotherapy students’ experience of their first clinical placements. The theoretical basis of the program provides a potential bridge with which to link and broaden the established framework of clinical reasoning theories. Within the program, students’ critical reflection discourse focused on notions of power, hierarchies, connecting with others and relationships. Their feedback about the effects of the program highlighted themes of validation and sharing; a break in clinical performance and a broadening of their spheres of knowledge. These themes resonated with students’ overall experiences of learning in clinical placements and provide some evidence for the inclusion of critical reflection as a valid and worthwhile component of early clinical education.

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.

A study of physiotherapy students' and clinical educators' perceptions of learning and teaching

Background: Clinical education is a key component to learning in the health professions. Aims: This qualitative study investigated how physiotherapy students and clinical educators perceived their respective roles in learning and teaching clinical skills during students’ first clinical placements. Methods: Separate physiotherapy student and educator focus groups were conducted in two major teaching hospitals in Melbourne, Australia during students’ first clinical placements. Results: The key difference between students’ and educators’ perspectives of their role was their description of how to build knowledge within clinical placement settings. Clinical educators’ focused on steps involved in their teaching tasks, rather than ways to facilitate learning. Their conception of teaching was to impart structured knowledge to students in response to knowledge deficits. Students also identified knowledge gaps but they proposed alternative practical ways to build their knowledge. Their conception of learning was to move from an initial static identification of knowledge deficits, to a more dynamic search for methods and people that might build their knowledge and understanding. Conclusions: The findings of this research were used to develop a set of teaching and learning statements and strategies that are grounded in the perspectives and experiences of students and educators in the clinical education setting.

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.

Making a difference: incorporating theories of autonomy into models of informed consent

Background: Obtaining patients’ informed consent is an ethical and legal obligation in healthcare practice. Whilst the law provides prescriptive rules and guidelines, ethical theories of autonomy provide moral foundations. Models of practice of consent, have been developed in the bioethical literature to assist in understanding and integrating the ethical theory of autonomy and legal obligations into the clinical process of obtaining a patient’s informed consent to treatment. Aims: To review four models of consent and analyse the way each model incorporates the ethical meaning of autonomy and how, as a consequence, they might change the actual communicative process of obtaining informed consent within clinical contexts. Methods: An iceberg framework of consent is used to conceptualise how ethical theories of autonomy are positioned and underpin the above surface, and visible clinical communication, including associated legal guidelines and ethical rules. Each model of consent is critically reviewed from the perspective of how it might shape the process of informed consent. Results and discussion: All four models would alter the process of obtaining consent. Two models provide structure and guidelines for the content and timing of obtaining patients’ consent. The two other models rely on an attitudinal shift in clinicians. They provide ideas for consent by focusing on underlying values, attitudes and meaning associated with the ethical meaning of autonomy. Conclusions: The paper concludes that models of practice that explicitly incorporate the underlying ethical meaning of autonomy as their basis, provide less prescriptive, but more theoretically rich guidance for healthcare communicative practices.

Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators

BackgroundClinical reasoning is fundamental to all forms of professional health practice, however it is also difficult to teach and learn because it is complex, tacit, and effectively invisible for students. In this paper we present an approach for teaching clinical reasoning based on making expert thinking visible and accessible to students.MethodsTwenty-one experienced allied health clinical educators from three tertiary Australian hospitals attended up to seven action research discussion sessions, where they developed a tentative heuristic of their own clinical reasoning, trialled it with students, evaluated if it helped their students to reason clinically, and then refined it so the heuristic was targeted to developing each student’s reasoning skills. Data included participants’ written descriptions of the thinking routines they developed and trialed with their students and the transcribed action research discussion sessions. Content analysis was used to summarise this data and categorise themes about teaching and learning clinical reasoning.ResultsTwo overriding themes emerged from participants’ reports about using the ‘making thinking visible approach’. The first was a specific focus by participating educators on students’ understanding of the reasoning process and the second was heightened awareness of personal teaching styles and approaches to teaching clinical reasoning.ConclusionsWe suggest that the making thinking visible approach has potential to assist educators to become more reflective about their clinical reasoning teaching and acts as a scaffold to assist them to articulate their own expert reasoning and for students to access and use.

Effect of home mechanical in‐exsufflation on hospitalisation and life‐style in neuromuscular disease: A pilot study

Mechanical in‐exsufflation (MI‐E) augments the weakened cough of patients with neuromuscular disease (NMD), clearing secretions and overcoming atelectasis. Little has been published on the impact of MI‐E alone on rates of hospitalisation and quality of life (QOL). The aim of this study was to assess the impact of home MI‐E on hospital admissions and life‐style in children with NMD.

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.

Physical activity perceptions and beliefs following total hip and knee arthroplasty: a qualitative study.

Abstract Background: Despite improvements in pain and physical capacity experienced by patients following total hip arthroplasty (THA) and total knee arthroplasty (TKA), recent studies suggest that levels of physical activity may not change. This study aimed to qualitatively explore people’s beliefs and perspectives about physical activity at 6 months following THA or TKA for the treatment of osteoarthritis (OA). Methods: Semi-structured interviews were conducted with 10 participants (age range 51–78 years) at 6 months post-arthroplasty surgery. Participants were recruited from a concurrent larger quantitative study examining quantitative physical activity levels via accelerometers. Interviews were transcribed, coded and analysed using a thematic approach. Results: Participants described greater capacity to be physically active post-surgery despite no increase in objective measures. Three themes emerged from the interviews relating to the participants perspective of physical activity after surgery: (1) physical activity is for enjoying living; (2) new limitations on physical activity: age and comorbidities; and (3) personal beliefs about physical activity: it is enough to know you can. Conclusion: Individual beliefs and perceptions are important in understanding factors influencing physical activity following THA and TKA. Health practitioners should examine this when developing management plans aimed at optimizing physical activity.