Prue Morgan

Gait function and decline in adults with cerebral palsy: a systematic review

Abstract Purpose: The aim of this systematic review was to identify, appraise and synthesize the evidence describing gait decline in adults with cerebral palsy (CP). Method: Comprehensive searches were conducted in MEDLINE (1970–), EMBASE (1980–), CINAHL (1982–) and AMED (1985–) databases to June 2012. Two reviewers independently completed data extraction and analysis using a modified version of the Downs and Black quality tool. Results: From the 485 papers identified, 16 met the inclusion criteria. Most studies used samples of convenience. The reported mean ages of the study groups varied from 22 to 42.6 years. Decline in gait function was measured variably with the period of decline undefined or from an unknown reference time during childhood. Results suggest that mobility decline occurs in 25% or more of adults with CP. Those at higher risk of gait decline are those with worse initial gait ability, bilateral rather than unilateral motor impairment, older age and higher levels of pain or fatigue. Conclusion: Many ambulant adults with CP experience mobility decline earlier than their nondisabled peers. More information regarding the natural history of mobility change over the lifespan in adults with CP augmented with self-efficacy qualitative data is needed to direct health advice and appropriate interventions for this group. Implications for Rehabilitation The literature suggests 25% or more of ambulant adults with cerebral palsy experience gait decline. Higher risk of gait decline occurs in those who are older, less independent in gait, have bilateral motor impairment and higher levels of pain or fatigue. Use of standardized gait measurement tools augmented with self-efficacy measures will aid provision of health advice and interventions.

Breakeven, Cost Benefit, Cost Effectiveness, and Willingness to Pay for Web-Based Versus Face-to-Face Education Delivery for Health Professionals

Background The introduction of Web-based education and open universities has seen an increase in access to professional development within the health professional education marketplace. Economic efficiencies of Web-based education and traditional face-to-face educational approaches have not been compared under randomized controlled trial conditions. Objective To compare costs and effects of Web-based and face-to-face short courses in falls prevention education for health professionals. Methods We designed two short courses to improve the clinical performance of health professionals in exercise prescription for falls prevention. One was developed for delivery in face-to-face mode and the other for online learning. Data were collected on learning outcomes including participation, satisfaction, knowledge acquisition, and change in practice, and combined with costs, savings, and benefits, to enable a break-even analysis from the perspective of the provider, cost-effectiveness analysis from the perspective of the health service, and cost-benefit analysis from the perspective of the participant. Results Face-to-face and Web-based delivery modalities produced comparable outcomes for participation, satisfaction, knowledge acquisition, and change in practice. Break-even analysis identified the Web-based educational approach to be robustly superior to face-to-face education, requiring a lower number of enrollments for the program to reach its break-even point. Cost-effectiveness analyses from the perspective of the health service and cost-benefit analysis from the perspective of the participant favored face-to-face education, although the outcomes were contingent on the sensitivity analysis applied (eg, the fee structure used). Conclusions The Web-based educational approach was clearly more efficient from the perspective of the education provider. In the presence of relatively equivocal results for comparisons from other stakeholder perspectives, it is likely that providers would prefer to deliver education via a Web-based medium. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN): 12610000135011; http://www.anzctr.org.au/trial_view.aspx?id=335135 (Archived by WebCite at http://www.webcitation.org/668POww4L)

Effectiveness of Web-Based Versus Face-To-Face Delivery of Education in Prescription of Falls-Prevention Exercise to Health Professionals: Randomized Trial

Background Exercise is an effective intervention for the prevention of falls; however, some forms of exercises have been shown to be more effective than others. There is a need to identify effective and efficient methods for training health professionals in exercise prescription for falls prevention. Objective The objective of our study was to compare two approaches for training clinicians in prescribing exercise to prevent falls. Methods This study was a head-to-head randomized trial design. Participants were physiotherapists, occupational therapists, nurses, and exercise physiologists working in Victoria, Australia. Participants randomly assigned to one group received face-to-face traditional education using a 1-day seminar format with additional video and written support material. The other participants received Web-based delivery of the equivalent educational material over a 4-week period with remote tutor facilitation. Outcomes were measured across levels 1 to 3 of Kirkpatrick’s hierarchy of educational outcomes, including attendance, adherence, satisfaction, knowledge, and self-reported change in practice. Results Of the 166 participants initially recruited, there was gradual attrition from randomization to participation in the trial (n = 67 Web-based, n = 68 face-to-face), to completion of the educational content (n = 44 Web-based, n = 50 face-to-face), to completion of the posteducation examinations (n = 43 Web-based, n = 49 face-to-face). Participant satisfaction was not significantly different between the intervention groups: mean (SD) satisfaction with content and relevance of course material was 25.73 (5.14) in the Web-based and 26.11 (5.41) in the face-to-face group; linear regression P = .75; and mean (SD) satisfaction with course facilitation and support was 11.61 (2.00) in the Web-based and 12.08 (1.54) in the face-to-face group; linear regression P = .25. Knowledge test results were comparable between the Web-based and face-to-face groups: median (interquartile range [IQR]) for the Web-based group was 90.00 (70.89–90.67) and for the face-to-face group was 80.56 (70.67–90.00); rank sum P = .07. The median (IQR) scores for the exercise assignment were also comparable: Web-based, 78.6 (68.5–85.1), and face-to-face, 78.6 (70.8–86.9); rank sum P = .61. No significant difference was identified in Kirkpatrick’s hierarchy domain change in practice: mean (SD) Web-based, 21.75 (4.40), and face-to-face, 21.88 (3.24); linear regression P = .89. Conclusion Web-based and face-to-face approaches to the delivery of education to clinicians on the subject of exercise prescription for falls prevention produced equivalent results in all of the outcome domains. Practical considerations should arguably drive choice of delivery method, which may favor Web-based provision for its ability to overcome access issues for health professionals in regional and remote settings. Trial Registration Australian New Zealand Clinical Trials Registry number: ACTRN12610000135011; http://www.anzctr.org.au/ACTRN12610000135011.aspx (Archived by WebCite at http://www.webcitation.org/63MicDjPV)

Clinical Decision Making in Exercise Prescription for Fall Prevention

Background Physical therapists often prescribe exercises for fall prevention. Understanding the factors influencing the clinical decision-making processes used by expert physical therapists working in specialist fall and balance clinics may assist other therapists in prescribing exercises for fall prevention with greater efficacy. Objectives The objective of this study was to describe the factors influencing the clinical decision-making processes used by expert physical therapists to prescribe exercises for fall prevention. Design This investigation was a qualitative study from a phenomenological perspective. Methods Semistructured telephone interviews were conducted with 24 expert physical therapists recruited primarily from the Victorian Falls Clinic Coalition. Interviews focused on 3 exercise prescription contexts: face-to-face individual therapy, group exercise programs, and home exercise programs. Interviews elicited information about therapist practices and the therapist, patient, and environmental factors influencing the clinical decision-making processes for the selection of exercise setting, type, dosage (intensity, quantity, rest periods, duration, and frequency), and progression. Strategies for promoting adherence and safety were also discussed. Data were analyzed with a framework approach by 3 investigators. Results Participants described highly individualized exercise prescription approaches tailored to address key findings from physical assessments. Dissonance between prescribing a program that was theoretically correct on the basis of physiological considerations and prescribing one that a client would adhere to was evident. Safety considerations also were highly influential on the exercise type and setting prescribed. Terminology for describing the intensity of balance exercises was vague relative to terminology for describing the intensity of strength exercises. Conclusions Physical therapists with expertise in fall prevention adopted an individualized approach to exercise prescription that was based on physical assessment findings rather than “off-the-shelf” exercise programs commonly used in fall prevention research. Training programs for people who prescribe exercises for older adults at risk of falling should encompass these findings.

The Acceptability Among Health Researchers and Clinicians of Social Media to Translate Research Evidence to Clinical Practice: Mixed-Methods Survey and Interview Study

Background Establishing and promoting connections between health researchers and health professional clinicians may help translate research evidence to clinical practice. Social media may have the capacity to enhance these connections. Objective The aim of this study was to explore health researchers’ and clinicians’ current use of social media and their beliefs and attitudes towards the use of social media for communicating research evidence. Methods This study used a mixed-methods approach to obtain qualitative and quantitative data. Participation was open to health researchers and clinicians. Data regarding demographic details, current use of social media, and beliefs and attitudes towards the use of social media for professional purposes were obtained through an anonymous Web-based survey. The survey was distributed via email to research centers, educational and clinical institutions, and health professional associations in Australia, India, and Malaysia. Consenting participants were stratified by country and role and selected at random for semistructured telephone interviews to explore themes arising from the survey. Results A total of 856 participants completed the questionnaire with 125 participants declining to participate, resulting in a response rate of 87.3%. 69 interviews were conducted with participants from Australia, India, and Malaysia. Social media was used for recreation by 89.2% (749/840) of participants and for professional purposes by 80.0% (682/852) of participants. Significant associations were found between frequency of professional social media use and age, gender, country of residence, and graduate status. Over a quarter (26.9%, 229/852) of participants used social media for obtaining research evidence, and 15.0% (128/852) of participants used social media for disseminating research evidence. Most participants (95.9%, 810/845) felt there was a role for social media in disseminating or obtaining research evidence. Over half of the participants (449/842, 53.3%) felt they had a need for training in the use of social media for professional development. A key barrier to the professional use of social media was concerns regarding trustworthiness of information. Conclusions A large majority of health researchers and clinicians use social media in recreational and professional contexts. Social media is less frequently used for communication of research evidence. Training in the use of social media for professional development and methods to improve the trustworthiness of information obtained via social media may enhance the utility of social media for communicating research evidence. Future studies should investigate the efficacy of social media in translating research evidence to clinical practice.

Performance of adults with cerebral palsy related to falls, balance and function: A preliminary report

Aim: To describe performance on standardised measures of functional mobility and identify relationships between gait decline, falls history and risk scores, and Gross Motor Function Classification System (GMFCS) level. Method: Adults with cerebral palsy (CP) aged 30–65 years, GMFCS Levels I–III underwent a single assessment to complete performance and questionnaire measures of balance, mobility and falls. Results: Twenty-five ambulant community dwelling adults with CP participated (mean 41 years) in this study. Fifteen participants (60%) reported gait decline (>age 18). The most frequent self-reported cause of decline was reduced balance (n = 12). Seventeen participants (68%) reported prior falls. Group differences were found between GMFCS levels and falls risk (falls risk for older people-community, p = 0.025), balance (Berg Balance Scale, p = 0.005) and mobility (6 min walk test p = 0.004; timed up and go, p = 0.011). Conclusion: Adults with CP experience mobility decline in early to middle adulthood, with reduced balance performance and elevated falls risk evident. There is urgent need for further research into falls risk factors using prospective falls data.

Enhancing positive attitudes towards disability: evaluation of an integrated physiotherapy program.

Purpose: This study explored whether attitudes towards disability in second year undergraduate physiotherapy students could be enhanced by an on-campus integrated curriculum program. Methods: A pre-post design was used. Year 2 (pre-clinical) students participated in a 12-week program focused on optimising attitudes towards people with acquired or developmental neurological disability. The Discomfort subscale of the Interaction with Disabled Persons scale, rated on a six-point Likert scale, was applied prior to and at completion of the 12-week program, and compared to year 4 students, just prior to graduation. Qualitative data from year 2 reflective narratives was also gathered. Results: Forty-seven second year and 45 fourth year physiotherapy students participated. The difference in Discomfort subscale scores between weeks 1 and 12 of year 2 was statistically significant (p = 0.0016). The difference in Discomfort subscale scores between year 2 week 1 and year 4 students was also statistically significant (p = 0.040). There was no significant difference in attitudes between students at the end of year 2 and the end of year 4 (p = 0.703). Qualitative data supported the development of more positive attitudes towards neurological disability across the 12 week year 2 pre-clinical program. Conclusion: Student attitudes towards people with acquired and/or developmental neurological disabilities can be enhanced through an on campus integrated curriculum program. Implications for Rehabilitation Student attitudes towards disability can be enhanced through an on campus integrated curriculum program. Pre-clinical student attitudes towards disability can achieve levels comparable to that found in senior students following field work experience.

Translating Evidence Into Practice via Social Media: A Mixed-Methods Study.

Background Approximately 80% of research evidence relevant to clinical practice never reaches the clinicians delivering patient care. A key barrier for the translation of evidence into practice is the limited time and skills clinicians have to find and appraise emerging evidence. Social media may provide a bridge between health researchers and health service providers. Objective The aim of this study was to determine the efficacy of social media as an educational medium to effectively translate emerging research evidence into clinical practice. Methods The study used a mixed-methods approach. Evidence-based practice points were delivered via social media platforms. The primary outcomes of attitude, knowledge, and behavior change were assessed using a preintervention/postintervention evaluation, with qualitative data gathered to contextualize the findings. Results Data were obtained from 317 clinicians from multiple health disciplines, predominantly from the United Kingdom, Australia, the United States, India, and Malaysia. The participants reported an overall improvement in attitudes toward social media for professional development (P<.001). The knowledge evaluation demonstrated a significant increase in knowledge after the training (P<.001). The majority of respondents (136/194, 70.1%) indicated that the education they had received via social media had changed the way they practice, or intended to practice. Similarly, a large proportion of respondents (135/193, 69.9%) indicated that the education they had received via social media had increased their use of research evidence within their clinical practice. Conclusions Social media may be an effective educational medium for improving knowledge of health professionals, fostering their use of research evidence, and changing their clinical behaviors by translating new research evidence into clinical practice.

DVD-based stories of people with developmental disabilities as resources for inter-professional education.

Purpose. The use of DVD stories about people with developmental disabilities within inter-professional education (IPE) across healthcare disciplines was evaluated. Methods. First year healthcare students (n == 241) from an IPE unit responded to an attitude scale before and after viewing and discussing a DVD portraying the life and healthcare needs of an adult with cerebral palsy; a third round of data collection occurred later. Qualitative data were obtained from four first year and six second year tutors who discussed student reactions to the DVD. Six first year and four second year students participated in focus groups following viewing of a second DVD, about a young girl with developmental disabilities and complex health needs. Results. ANOVA of the attitude scores did not show significant differences from pre- to post-viewing and discussion of the DVD, nor at a third round of data collection. Qualitative analysis revealed that the DVDs did cause students to shift assumptions, perceptions and understanding of the disabilities depicted, and to learn about their own and other professions. Conclusions. DVD scenarios of real people with developmental disabilities in real settings offer a means of providing IPE opportunities. The data also point to the need and directions for the development of a new attitudinal measure.

Translating evidence to practice in the health professions: a randomized trial of Twitter vs Facebook.

Objective: Our objective was to compare the change in research informed knowledge of health professionals and their intended practice following exposure to research information delivered by either Twitter or Facebook. Methods: This open label comparative design study randomized health professional clinicians to receive “practice points” on tendinopathy management via Twitter or Facebook. Evaluated outcomes included knowledge change and self-reported changes to clinical practice. Results: Four hundred and ninety-four participants were randomized to 1 of 2 groups and 317 responders analyzed. Both groups demonstrated improvements in knowledge and reported changes to clinical practice. There was no statistical difference between groups for the outcomes of knowledge change (P = .728), changes to clinical practice (P = .11) or the increased use of research information (P = .89). Practice points were shared more by the Twitter group (P < .001); attrition was lower in the Facebook group (P < .001). Conclusion: Research information delivered by either Twitter or Facebook can improve clinician knowledge and promote behavior change. No differences in these outcomes were observed between the Twitter and Facebook groups. Brief social media posts are as effective as longer posts for improving knowledge and promoting behavior change. Twitter may be more useful in publicizing information and Facebook for encouraging course completion.