Leslie G. Portney

Using the International Classification of Functioning, Disability and Health as a Framework to Examine the Association Between Falls and Clinical Assessment Tools in People With Stroke

Background: Falls in people with stroke are extremely common and present a significant health risk to this population. Development of fall screening tools is an essential component of a comprehensive fall reduction plan. Objective: The purpose of this study was to examine the accuracy of clinical measures representing various domains of the International Classification of Functioning, Disability and Health (ICF) relative to their ability to identify individuals with a history of multiple falls. Design: A case series study design was used. Setting: The study was conducted in a community setting. Participants: Twenty-seven people with stroke participated in the study. Measurements: Clinical assessment tools included the lower-extremity subscale of the Fugl-Meyer Assessment of Sensorimotor Impairment (FMLE) and Five-Times-Sit-to-Stand Test (STS) representing the body function domain, the Berg Balance Scale (BBS) representing the activity domain, the Activities-specific Balance Confidence (ABC) Scale as a measure of personal factors, and the physical function subscale of the Stroke Impact Scale (SIS-16) as a broad measure of physical function. We used receiver operating characteristic (ROC) curves to generate cutoff scores, sensitivities, specificities, and likelihood ratios (LRs) relative to a history of multiple falls. Results: The FMLE and the STS showed a weak association with fall history. The BBS demonstrated fair accuracy in identifying people with multiple falls, with a cutoff score of 49 and a positive LR of 2.80. The ABC Scale and the SIS-16 were most effective, with cutoff scores of 81.1 and 61.7, respectively, positive LRs of 3.60 and 7.00, respectively, and negative LRs of 0.00 and 0.25, respectively. Limitations: A limitation of the study was the small sample size. Conclusion: The findings suggest that the ICF is a useful framework for selecting clinical measures relative to fall history and support the need for prospective study of tools in more-complex domains of the ICF for their accuracy for fall prediction in people with stroke.

A comparison of three measures of disease progression in ALS.

Effective clinical trials in neuromuscular research require accurate and sensitive methods to quantitate disease progression. The purpose of this study was to concurrently compare manual muscle testing (MMT), maximal voluntary isometric contraction (MVIC), and a functional scale (the ALS Score). Twenty patients with ALS were tested ten times at monthly intervals using each of the three methods. High inter-rater reliability for each of the three methods was demonstrated. All three methods demonstrated a decline over the testing period. However, MMT and the ALS Score were less sensitive to early change. A wide variation of percent of normal MVIC was demonstrated within each MMT grade and extensive overlap between MMT grades was observed. MVIC is the method of choice in studying patients in the early stages of ALS and in studies conducted over a short period of time.

The accuracy of individual Berg Balance Scale items compared with the total Berg score for classifying people with chronic stroke according to fall history.

Background and Purpose: To determine whether individual Berg Balance Scale (BBS) items or a group of items would have greater accuracy than the total BBS in classifying community-dwelling people with stroke with a history of multiple falls. Methods: The subjects were 44 community-dwelling individuals with chronic stroke; 34 had one or no falls in the past six months, and 10 had multiple falls. Each BBS item was dichotomized at three points along the scoring scale of 0-4: between scores of 1 and 2, 2 and 3, and 3 and 4. Sensitivity (Sn), specificity (Sp), and positive (+LR) and negative (−LR) likelihood ratios were calculated for all items for each scoring dichotomy based on their accuracy in classifying subjects with a history of multiple falls. These findings were compared with the total BBS score where the cutoff score was derived from receiver operating characteristic curve analysis. Results: Dichotomized point 3-4 for items B11 (turning 360 degrees), B12 (alternate foot on stool), B13 (tandem stance), and B14 (standing on one leg) all revealed Sn greater than 60%. B14 had the best Sn and Sp (0.90 and 0.50). Combining B11, B12, or B13 with B14 did not improve Sn. Total BBS receiver operating characteristic curve revealed a cutoff score of 52 (Sn = 90% and Sp = 41%). Conclusion: Using selected items from the BBS may be more time efficient and accurate than the total BBS score for classifying people with chronic stroke living in the community with a history of multiple falls. Prospective study is needed to validate these findings relative to fall prediction.

Applying concepts of responsiveness to patient management in neurologic physical therapy.

Determining whether real change has taken place as a result of treatment and whether that change constitutes important change are challenges central to evidence-based physical therapist practice. Recently, the literature reporting these values for clinical measures has expanded considerably. In this article, we discuss some of the indices for identifying real change and important change, and how physical therapists can use these indices to enhance the interpretability of change scores derived from clinical measures. Specifically, we define and discuss the uses of the minimal detectable change and the minimal clinically important difference. We provide suggestions for how these indices can be used to make change scores more meaningful to therapists, patients, their caregivers, and third-party payers. Accurate interpretation and application of these indices are crucial to informed patient management and clinical decision making. We also present some of the limitations confronted as we try to apply these values across various patient diagnostic groups and across the spectrum of initial level of impairment. Finally, recommendations are made for directions for future research in this important area of outcomes research and how clinicians can contribute to these efforts.

Clinical Performance of Physical Therapy Students in Traditional and Problem-based Curricula

ABSTRACT: This retrospective study examined the effect of problem‐based learning (PBL) on the clinical performance of entry‐level physical therapy students at Simmons College. Students had participated in either a lecture‐based curriculum or a combination of traditional and PBL approaches. Ratings for 50 items representing critical thinking, self‐directed learning, and collaboration on final performance evaluations for three full‐time clinical experiences were examined. Chi‐square analyses were used to determine curricular effects on evaluation scores. These analyses revealed eight instances of curricular effects. Three of the four effects in favor of the PBL approach were in the area of self‐directed learning during the first experience. The four effects in favor of the traditional approach crossed all categories during the first and second experiences. The limitations of the curricular design and performance evaluations included the number of PBL courses in the curriculum; problems with clarity, sensitivity, and application of the performance evaluation tool; and variability in the characteristics of the clinical experiences.

Integrating Objectives for Clinical Education, Research, and Service Learning into Community Health Promotion Projects

Background and Purpose. Health promotion has become an important focus of professional physical therapist education. The combination of service learning, clinical education, and research presents a unique opportunity for students to develop the full professional role of the physical therapist. The purpose of this paper is to describe a community‐based health promotion program that meets this full range of objectives. Students develop, implement, and evaluate a program that meets the health needs of an identified population within the community, using education, screening, and various intervention strategies. The project is carried out across 1 full academic year. Faculty and clinical instructors serve as advisors. Method/Model Description and Evaluation. A fall course covers the full scope of the project, including conducting a needs assessment and developing a proposal to cover the programs theoretical foundation, goals and objectives, educational and therapeutic interventions, an evaluation plan, budgeting, and marketing. Students carry out the programs over an 8‐week period in the spring semester and evaluate it in a follow‐up session in the summer. Students complete a final written report that is presented to the community partner with recommendations for new initiatives or improved procedures. Students deliver oral presentations in a public forum. Outcomes. Several stakeholders, including students, faculty, and community partners, all benefit from these programs. Students gain confidence in leadership and design of health promotion programs as a facet of clinical education and professional practice; projects can contribute to faculty scholarship and community networks; community partners take advantage of needed pro bono services. Discussion and Conclusion. Health promotion programs can be an important component of clinical education, providing opportunities for practice in community settings. The projects address objectives related to research, evidence‐based practice, education, administration, marketing, and consultation.

Preparing Future Health Professionals for Interprofessional Collaborative Practice Part 1: The Context for Learning

The importance of interprofessional education and practice has been well documented for all health care disciplines. Our health care delivery system is challenged by the need to prepare health professions graduates with skills that get them ready to function as collaborative members of the health care team. Educators have long struggled to create interprofessional learning environments that would inculcate the needed values and competencies. The purpose of this article is to share one institutions path in developing an integrated context for learning across several disciplines to assure that graduates can fulfill their full professional roles in clinical care, education, advocacy, leadership, and quality improvement. Through a program called IMPACT Practice, the MGH Institute of Health Professions has developed an array of opportunities for students from different programs to interact with each other, emphasizing the collaborative skills that will benefit patients and clients as well as contribute to positive change within the health care system. These opportunities are based on core competencies developed by the Interprofessional Education Collaborative (IPEC) as well as institutional core competencies that go beyond IPEC to address the full professional role. In the second part of this article, the IMPACT experience will be described through the journey of one student in the Communication Sciences and Disorders program.

Competent in any context: An integrated model of interprofessional education

ABSTRACT While most graduate health professions programs in the United States have accepted the Interprofessional Education Collaborative’s core competencies for collaborative practice, there is no consistent way to integrate the competencies into courses of study already crowded with uniprofessional competencies. A potential negative effect of treating interprofessional education as an add-on is that learners will not engage deeply with the competencies required to work effectively in health care teams. To design an integrated model, one institution adopted a theory from the management literature that frames professional competence as a way of being, not simply a body of knowledge to master. Viewing competence as a way of being ensures that learners can act collaboratively in any context. The model, called IMPACT Practice, provides multiple settings where learners can practice the competencies and make connections to their uniprofessional studies. By embedding the interprofessional competencies into all programs of study, learners come to see collaboration as a core element of what it means to be an effective health professional.

ROUND: Table Discussion: Physical Therapy and Outcome Measures

&NA; The use of outcome measures in the daily practice of physical therapy is becoming as popular a topic as evidence‐based practice. As an introduction to this topic, several highly respected physical therapists with varied backgrounds were asked to provide their reactions and opinions to 8 questions. The invited panel members included:

Implementation of a 1-Year Paid Clinical Internship in Physical Therapy

&NA; The challenge of clinical education in todays health care environment demands that we explore alternative models that respond to productivity standards, reimbursement regulations, and the need for a highly competent physical therapist at entry level. This article describes the implementation of a 1‐year paid clinical internship that provides a cost‐effective method for new graduates to ground their first year of practice in a dedicated educational experience. The internship follows completion of all academic course work. Interns graduate after 4 months, with entry‐level competence documented on the Clinical Performance Instrument. They can then sit for licensure and complete the internship as a licensed physical therapist, although they continue to receive constant mentorship throughout the year. Interns are paid a salary from the start of the internship, typically 50% to 67% of an entry‐level salary. They are matched to clinical sites following submission of résumés and an interview process. Surveys of employers show that interns are costeffective over the year, provide opportunities for staff development for clinical instructors, and provide a ready pool for recruitment. Interns benefit from the comprehensive educational experience and the early salary. Challenges have been addressed from the perspectives of the academic program and clinic. This model and possible variations should be explored further as physical therapy educators struggle to prepare therapists for the level of practice necessary for todays health care setting.