CASE STUDIES

Supporting Clinical Practice Behavior Change Among Neurologic Physical Therapists: A Case Study in Knowledge Translation Susan B. Perry, PT, DPT, NCS, Hallie Zeleznik, PT, DPT, NCS, and Terry Breisinger, PT, MPT, NCS

Background and Purpose: Physical therapists tend to underuse research evidence in clinical practice. Emerging research on knowledge translation activities (KTAs) provides guidance to address this problem. We describe a yearlong effort to promote clinical practice behavior change in neurologic physical therapists. Case Description: Physical therapy stroke and brain injury teams in an inpatient rehabilitation setting implemented a quality improvement project to encourage use of a novel, evidence-supported gait training method (nonsupported gait training [NSGT]) for patients with hemiparesis. Intervention: The project consisted of multidimensional KTAs, including (1) quarterly staff meetings at which NSGT was introduced, reviewed, and discussed; (2) group and individual dialogue regarding successes, challenges, solutions, and clinical decision-making; (3) ongoing monitoring of and aggregate feedback about appropriate NSGT attempts via chart audit; and (4) ongoing reminders, role modeling, and clinical consultation. Specific staff perceptions about the approach, captured by a mid-year survey, further informed targeted problem-solving and clinical case presentations. Outcomes: In the first, second, and fourth quarter, 50%, 60%, and 73% of eligible patients were trained with NSGT, respectively. A mid-year survey showed that 19% of therapists were very/moderately familiar with NSGT before the quality improvement project, versus 78% at the 6-month point. Thirty-three percent stated that they used NSGT almost always/often before the project, versus 66% at the 6-month point. Discussion: Extensive multidimensional KTAs were feasible in inpatient rehabilitation and were accompanied by a moderate increase in documented and self-reported frequency of NSGT attempts. Clin-

Physical Therapy Program, Chatham University, Pittsburgh, Pennsylvania (S.B.P.); and Outpatient Neuro/Vestibular Program (H.Z.) and Stroke Rehabilitation Program, UPMC Centers for Rehab Services, Pittsburgh, Pennsylvania (T.B.). This work was presented as a poster at the American Physical Therapy Association’s Combined Sections Meeting in 2013. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jnpt.org). Correspondence: Susan B. Perry, PT, DPT, NCS, Physical Therapy Program, Chatham University, Pittsburgh, PA 15232 ([email protected]). C 2014 Neurology Section, APTA. Copyright  ISSN: 1557-0576/14/3802-0134 DOI: 10.1097/NPT.0000000000000034

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ical teams may benefit from adopting KTAs that best support clinical practice change. Video Abstract available (see Supplemental Digital Content 1, http:// links.lww.com/JNPT/A69) for more insights from the authors. Key words: behavior change, knowledge translation, neurologic physical therapy (JNPT 2014;38: 134–143)

INTRODUCTION

E

vidence-based practice has been defined as the use of the current best evidence, integrated with professional expertise, to make clinical decisions for an individual patient.1 An underlying premise of evidence-based practice is that new knowledge generated by scientific research leads to a change in behavior and better outcomes for patients. However, health care practitioners tend to underuse research evidence in clinical practice.2 In a survey of 488 physical therapist (PT) members of the American Physical Therapy Association, 84% reported the need to increase their use of evidence in daily practice.3 A more recent survey of PTs providing services to people with stroke in Ontario found that almost 88% used research in their clinical decisions 5 times or less per month.4 Barriers that interfere with the application of evidence into practice include insufficient time to read articles and implement changes, lack of efficacy interpreting research results, lack of awareness of the evidence, disagreement with practice guideline recommendations, the presence of external barriers, and lack of administrative support.5−8 The process of moving research findings into action is known as knowledge translation (KT).9−11 Many methods to facilitate KT have been studied. Attendance at continuing education workshops appears to have a small influence on professional practice.12,13 Alternative strategies include interactive didactic educational sessions, the use of “opinion leaders,” outreach visits, follow-up discussion and feedback, reminders, and individual consultations.12 For example, Brennan et al14 compared clinical outcomes from 34 therapists who attended a 2-day continuing education course on the management of neck pain with outcomes from 11 therapists who additionally participated in an ongoing clinical improvement project after the 2-day course was completed.14 The improvement project consisted of monthly review and discussion of manual therapy techniques, and one 4-hour JNPT r Volume 38, April 2014

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session of hands-on instruction from the course instructor, 5 months after the continuing education course. Improvement in patient outcomes (ie, Neck Disability Index scores) was not associated with attendance at the 2-day continuing education conference alone. However, therapists who participated in the ongoing project demonstrated improved patient outcomes and significantly lower median physical therapy charges (better cost effectiveness). Additional evidence for the value of knowledge translation activities comes from a randomized controlled trial comparing the effect of a 2-day CE workshop with and without ongoing educational support on improving patient outcomes with neck pain.15 The continued support from the course instructor consisted of two follow-up meetings. These meetings included content review, skill demonstration and practice, and discussion; and a patient cotreatment with discussion and clinical decision-making analysis. Patients treated by therapists in the ongoing education group experienced less disability in fewer visits compared with the CE-only group. Colleagues who are seen as influential and trustworthy appear to improve KT.12 Such local opinion leaders or “knowledge brokers” act as a link between clinicians and the research evidence.16 They are respected by their coworkers, and they play an important role in disseminating and encouraging use of evidence, applying evidence in their own practice and providing clinical mentoring. Russell et al17 evaluated the impact of knowledge brokers on self-reported knowledge and use of 4 pediatric assessment tools by PTs. Knowledge about all 4 assessments and clinical use of 3 of them increased significantly after the knowledge brokers’ intervention. These changes remained at a 1-year follow-up. A recent review described 3 themes of characteristics of effective KT methods: relevance, accessibility, and format.2 Research findings that are most relevant to clinical practice will more likely be used in clinical decisions. Evidence that is clearly summarized and provided in a swift, simple, and timely format is also more likely to be adopted. An educational format that is tailored to the audience allows acknowledgement of individual needs and challenges, while emphasizing local resources that can enable utilization of new information. In summary, the evidence supports KT activities that are interactive, ongoing, customized to individual needs and local contingencies, and readily accessible. Informed by this research, we devised a plan to address the departmental clinical goal of translating evidence into clinical practice. As supervisors of inpatient neurologic rehabilitation units who are also clinical PTs who practice nearly full-time, the authors (H.Z. and T.B.) were invested in optimizing patient care and promoting evidence-based practice. Informal observations of the gait training strategies used by coworkers when treating patients with hemiparesis indicated a tendency to use “conventional” strategies such as significant physical assistance and the use walking aids (eg, hemiwalkers, walkers, and quad canes). High levels of challenging practice that allowed errors were minimized by optimizing safety, and, perhaps, by therapist routine. As an alternative to this approach, we developed and trialed a gait-training approach that used intensive, error-based practice without physical support/equipment/devices. While not previously explicitly

Supporting Clinical Practice Behavior Change

described in the literature, the elements of this strategy are supported by evidence.18−22 After trialing the approach (“nonsupported gait training” [NSGT]) with patients for approximately 1 year, the authors were interested in encouraging their coworkers to do the same. The purpose of this case study was to describe a yearlong quality improvement (QI) initiative that used multiple KT activities to increase therapist use of evidence-supported gait training for patients with hemiparesis.

METHODS Setting and Participants This KT case study was carried out at an urban, tertiary care trauma center (University of Pittsburgh Medical Center Mercy Hospital). A total of 2 PT team leaders (80% clinical, 20% administrative), 10 staff PTs, 1 PT assistant, and 4 to 5 rehab aides were assigned to the inpatient stroke and brain injury units. Expected caseload size was 4 to 5 patients, with 8 visits per day. The entry-level degrees of the 10 staff PTs were evenly divided between PTs with entry-level professional education at the master’s or doctoral degree level. Six therapists were Certified Brain Injury Specialists. As full-time clinicians on inpatient rehabilitation units, all PTs commonly managed patients who required physical assistance. With the complement of staff described above, additional trained help was readily available when needed. While we did not formally document familiarity with the concept of evidence-based practice, as staff at a large teaching hospital, all therapists were frequently exposed to in-house evidence-based presentations, and funds for external continuing education were provided on an annual basis.

Nonsupported Gait Training The approach to NSGT that we trialed was intended to allow people with acute hemiparesis to perform early walking with limited equipment (ankle ace-wrap) and no physical support. A description of NSGT appears in Appendix 1. Patients are permitted to experience gait deviations and noncatastrophic loss of balance. Safety was assured by close noncontact guarding by 2 PTs, or a PT and a rehab aide. When necessary, assistance was provided to avoid a fall. The approach consisted of extensive and repetitive practice of walking under these conditions. Although NSGT has not been systematically studied, it uses principles supported by evidence related to skill acquisition in a population with stroke. These include highly repetitious, task-specific training; intensity and challenge; and error detection and adaptation.18−22 To help therapists evaluate when it was appropriate to implement this approach, the authors developed key criteria for patient readiness. The 5 criteria were based on the authors’ clinical experience using NSGT with various patients. These criteria were as follows: 1. Medically stable 2. Able to stand for 30 seconds without physical assistance 3. Able to advance the hemiparetic limb without assistance in approximately 75% of attempts 4. Able to stabilize the hemiparetic knee during stance phase 5. Able to understand and attend to the walking task.

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Patients were deemed appropriate for NSGT even if they required moderate assistance for weight-shifting, balance, or trunk control to accomplish ambulation.

Description of the QI Initiative Evidence suggests that the optimal environment for the uptake of new evidence includes administrative buy-in, interactive training, a clinical champion that can encourage the clinical behavior change, and ongoing follow-up and support.5,23−25 With this in mind, we planned a multipronged approach for formally introducing and promoting NSGT. Following institutional guidelines, we proposed this project as a 2011 QI initiative and received approval from the director of therapy services and the hospital QI board. Furthermore, the project was submitted to the institutional QI review committee, which determined that the project as described, including planned eventual dissemination, did not require submission to the University of Pittsburgh internal review board. As a formal departmental QI project, all therapists were expected and encouraged (though not required) to participate. To prepare for the project, we developed guidelines for patient readiness, NSGT implementation and progression, and documentation of NSGT and walking-related outcomes. In November 2010, the authors presented the first 1-hour therapist training session that included the following: r An overview of the QI project, explaining that the quality indicator would be attempts at NSGT use via retrospective chart audit of all patient with hemiparesis. r Research evidence that supports NSGT. r Five key criteria that a patient should meet before a trial of NSGT, and interventions that may help a patient meet these criteria. r Guidelines for implementation and progression of NSGT, with trouble-shooting ideas. r The procedure/location for documenting the key criteria, NSGT attempts, and walking-related outcomes in the electronic medical record. Walking-related outcomes were to be documented every 3 days, beginning when the patient was

first able to complete the test, and included (1) self-selected walking speed based on 1 trial of the 10-Meter Walk Test,26 including episodes of loss of balance requiring therapist assistance; and (2) performance on the Timed Up and Go27 based on 1 trial, including episodes of loss of balance requiring therapist assistance. This training session concluded with a video presentation of a clinical case study illustrating a patient in his initial NSGT trial, and his walking-related outcomes at rehab days 6, 14, and 27. Therapists were encouraged to begin using NSGT when appropriate and to consult with the authors (H.Z. and T.B., who worked on the brain injury and stroke units, respectively) if they had questions about specific patients. Reminders of the key criteria and the NSGT implementation guidelines were posted in the brain injury and stroke gyms. Three follow-up meetings were held with the staff PTs, in February, May, and November 2011 (meeting numbers 2, 3, and 4, respectively; see Table 1). The purposes of these meetings were to “continue the conversation” about NSGT, to provide quarterly aggregate chart audit data about appropriate NSGT use, and to facilitate discussion among therapists and the authors about advantages, drawbacks, successes, and barriers associated with NSGT. Because of an unexpected change in staff resources, we were unable to collect third-quarter data. In addition to the quarterly meetings, the 2 team leaders (H.Z. and T.B.) worked alongside the staff on a daily basis. They were able to function as opinion leaders, encouraging therapists and role-modeling clinical implementation of NSGT. While we did not track the frequency of reminders or consultation, this normal interaction provided many organic opportunities for discussions about individual patients regarding NSGT readiness, barriers, and clinical decision-making. These were sometimes initiated by staff and sometimes by the supervisors.

Chart Audit Procedure The purpose of the chart audit was to determine frequency of appropriate NSGT attempts. Using a confidential

Table 1. Timeline of Staff Meetings and Chart Audits1 Timeline

Action

November 2010

Meeting 1

November-December 2010 February 2011

Chart audits Meeting 2

February-March 2011 May 2011

Chart audits Meeting 3

August-October 2011 November 2011

Chart audits Meeting 4

Process Initial training QI project overview. Description of key indicators, NSGT, and video demonstration Documentation guidelines, including gait outcomes Audit November and December charts Review of first-quarter data Discussion about use and barriers Presentation of 2 patient cases with gait outcomes extracted from chart audit Clarification of documentation Audit January, February, and March charts Review of second-quarter data Discussion about use and barriers Clarification of documentation Administration of staff survey on use Audit August, September, October and charts Review of fourth-quarter data Discussion of use and barriers Patient case presentation highlighting clinical decision-making

Abbreviations: NSGT, nonsupported gait training; QI, quality improvement. 1 Clinical consultation and role-modeling were on-going for the entire year.

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e-mail network, therapists notified the author completing the chart audit (H.Z.) of the names of patients with hemiparesis due to brain injury or stroke. Reminders were sent to staff via e-mail about this procedure at least monthly, in an attempt to ensure that all possible charts were audited. Charts were retrospectively audited in batches after patient discharge. First, documentation of the physical therapy services provided was reviewed to determine whether the 5 criteria were or were not met. Occasionally, inferences were necessary because of unclear documentation. For example, therapists were instructed to document a patient’s standing balance: level of assist and time in standing. Often, therapists stopped documenting quiet standing balance once the patient moved to more dynamic activities. In these cases, it was inferred that the patient could stand for 30 seconds with supervision. After a determination regarding patient readiness was made, the supervisor sought documentation about whether or not the therapist had attempted NSGT. Documentation of NSGT had a designated location in the electronic medical record (physical therapy notes). It was understood by the staff, and assumed during the chart audit, that if this area was left blank, NSGT did not occur. The intervention was considered to be attempted if it was documented at least 1 time. The supervisor tracked the number of patients who met all the criteria and for whom a trial of NSGT was provided as appropriate. The supervisor also tracked the numbers of patients who met the criteria but were not provided with a trial, who met the criteria but were provided with a trial (inappropriately), or did not meet the criteria and were not provided with a trial.

Therapist Questionnaire At meeting number 3, therapists completed a questionnaire about their familiarity with and use of NSGT in the 6 months before and the 6 months since the initial November 2010 training. They also provided information about perceived barriers to their use of NSGT (see Appendix 2). The questionnaire used a Likert-type scale with responses of very familiar/moderately familiar/somewhat familiar/not familiar with research evidence that supports NSGT, the key criteria that indicated patient readiness, and the implementation procedure. Another question asked how often the therapist used NSGT with patients with hemiparesis who met the readiness criteria. Response options for this question were almost always or always, often, sometimes, or almost never or never. These responses were adapted from a questionnaire used by Brown et al.28 A list of potential barriers to NSGT use was based on relevant barriers to clinical practice change previously published.5,29 Using a Likert scale ranging from strongly agree to strongly disagree, each therapist was asked to rate the extent to which he or she perceived that each barrier interfered with their ability to use NSGT.

RESULTS The QI initiative spanned 12 months (Table 1). In the first quarter, 16 of 41 patients with hemiparesis met the 5 readiness criteria, and 50% of them attempted NSGT. In the second quarter, 20 of 38 patients met the criteria, and 60% of

Supporting Clinical Practice Behavior Change

them attempted NSGT. In the fourth quarter, 11 of 26 patients met the criteria, and 73% attempted NSGT. At meeting number 2, staff brought up the following as positives about NSGT and the QI project: attempts at NSGT were generally positive, patients seemed to enjoy walking without devices, and documentation requirements were not burdensome although it was difficult to remember to document the outcomes every 3 days. Barriers that were identified in the discussion are listed in Table 2. The authors subsequently clarified documentation of readiness criteria (eg, gait characteristics and balance) and outcome measures, and provided encouragement and problem-solving strategies that they believed would increase use of the approach. Just before meeting number 3, therapists were notified via e-mail of the decision that outcome measures should be documented only at 3 time points: as soon as the patient met the criteria to participate in NSGT, the day NSGT was attempted, and on or near the day of discharge at the Institute. The decision to document outcome measures at only 3 time points was based on our observation that documentation of outcomes was inconsistent, and that there was limited value in obtaining measurements at a frequency of every third day. Discussion similar to that described earlier ensued at meeting number 3. The new documentation requirement was reviewed. On the basis of chart audit, it appeared that while therapists were attempting NSGT, they did not always continue it as part of the patient’s daily physical therapy session. Staffs were reminded that NSGT should be used frequently and intensely to best promote recovery of walking function. Also, on the basis of the review of physical therapy notes, it appeared that NSGT was sometimes attempted when the patient no longer required physical assistance, that is, they were able to walk at the supervision level. Such a patient is already walking “without support”; NSGT should have been attempted sooner. We reiterated the patient readiness criteria for NSGT as outlined previously. During meeting number 3, in addition to review of the documentation requirements, 9 of the 10 therapists completed the questionnaire. On the basis of the data from the questionnaire, the median duration of clinical experience among the PTs was determined to be 3 (mean = 7.6, range = 1-20) years. The questionnaire revealed that in the 6 months before the project, 19% of therapists had been very familiar or moderately familiar with NSGT, and in comparison, 6 months Table 2. Barriers to NSGT Use Cited by Therapists 3 Months After Initial Training Ambiguity about documentation Uncertainty about the level of patient cognition needed for NSGT and to perform the outcome measures Indecision about when to attempt NSGT—for example, attempting when the patient could not stand unsupported proved to be unsuccessful The large amount of space required by the wide walking path deviation that patients tend to demonstrate Environmental distractions that interfere, since attention to walking and balance appears to be quite important Patient fatigue that limits NSGT duration at times Inability to attempt NSGT on the weekends because of limited staff Abbreviation: NSGT, nonsupported gait training.

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after the initial training, 78% indicated this level of familiarity. Furthermore, 33% stated that they used NSGT almost always or often before the training, and conversely, 66% at the time the questionnaire was administered. The most commonly cited barriers to the use of NSGT were “inadequate human resources (not enough help)” and “difficult to know when the patient is ready or appropriate for NSGT” (Table 3). No therapists felt that the following were barriers: “feel the benefit to the patient/myself will be minimal” and “lack of research evidence to support NSGT.” On the basis of the information from the questionnaire, it was decided that the clinical decision-making process regarding patient readiness for NSGT was an important barrier to providing this approach. For this reason, the authors included 2 clinical cases in meeting number 4. The goal was to provide additional information and opportunities for discussion, to allow PTs to better understand the criteria for readiness and thereby overcome this barrier. Survey results were shared with the staff PTs in this meeting, and discussion focused on ways to solve human resource and environmental barriers to the use of NSGT.

DISCUSSION During a yearlong, multidimensional effort to encourage an alternative approach to conventional gait training for patients with hemiparesis, the frequency of appropriate NSGT attempts increased progressively. This project consisted of quarterly interactive didactic sessions, including patient video/case presentations, group discussions on successes and challenges, and feedback on behavior change (chart audit summaries). The project also incorporated ongoing reminders and clinical consultation with therapists acting as opinion leaders. The inclusion of these multiple elements was intended to influence behavior change, in a way that was relevant, simple, and efficient,2 among staff PTs who were involved in the treatment of patients with hemiparesis. Daily and quarterly discussions focused on challenges and solutions that considered local barriers and resources. Implementation was convenient in that all meetings, reminders, and consultation took place on-site during the course of the normal workday. The departmental

emphasis on NSGT was made apparent by the formalized QI project and the ongoing nature of the meetings/clinical discussion, rather than sharing such information at a typical 1-time in-service. Changes in behavior following similar multidimensional interventions have previously been published. For example, Brown et al28 found an increase in the self-reported use of fallprevention strategies by therapists when they were exposed to outreach visits, and had online training manuals, provider checklists, and patient handouts. Additional elements shown to be of value were dedicated work groups, opinion leaders who encouraged adoption of practice change, and newsletter reminders.28 Bekkering et al30 studied the effect of education, discussion, role-playing, feedback, and reminders on implementation of clinical practice guidelines for low back pain management. Although they did not find differences in patient outcomes between the 2 groups, therapists who had received the “active” approach demonstrated better adherence to the guidelines than therapists who only received the guidelines by mail.31 Participants in many studies of KT self-select to undergo or be randomized into groups with multidimensional educational activities.14,15,17 However, the departmental QI initiative described in this case study exposed all therapists in our clinic to the KT activities. As such, the chart audits and survey results likely reflected a range of therapists’ willingness to try this new approach as an alternative to their own standard practice. Neither formally documented nor self-reported usage of NSGT approached 100%. Beyond the barriers cited in the questionnaire, practice style traits may have influenced whether or not the therapists attempted NSGT. Four traits, proposed by Green et al,32 describe how a clinician responds to new information, how they value various information sources, and the likelihood that information will influence their practice behavior. These authors identify these 4 traits as follows: seekers, who primarily use published data; receptives, who are evidence-oriented but more likely to rely on respected authorities; traditionalists, who are guided by clinical experience and respected authorities; and finally pragmatists, who change practice on the basis of work

Table 3. Summary of Therapist-Perceived Barriers to NSGT Use From Mid-Year Questionnaire (Number of Therapist Responses; n = 9) Strongly Agree Hesitant to try new ideas Feel the benefit to the patient will be minimal Feel the benefit to myself will be minimal Inadequate physical environment (space, etc) Inadequate human resources (not enough help) Lack of organizational support (1 no response) Lack of time Documentation of NSGT and patient outcomes is burdensome Lack of research evidence to support NSGT Lack of confidence I can effectively implement NSGT I forget to implement NSGT Difficult to know when the patient is ready or appropriate for NSGT I rarely see patients who meet all the clinical indicators Others? Hesitant to have patient fall

1 1

Agree

2 4 2 3 2 2 5 1

Neutral

Disagree

Strongly Disagree

1

5 7 7 2 2 1 2 4 8 6 1 2 4 1

3 2 2 2

2 2 3 3 2 5 1 3

4 2 1 1 1 1 1

Abbreviation: NSGT, nonsupported gait training.

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demands, patient flow, and patient satisfaction rather than on scientific validity.32 Korner-Bitensky et al33 reported on the prevalence of these 4 traits in a group of almost 250 physical and occupational therapists from Canada, and found all traits represented in their sample. Over half of these clinicians were classified as pragmatists. While we did not classify the practice style traits of our therapists, it is possible such traits contributed to our results and that some of the therapists may be more influenced by practical aspects of work rather than research evidence. As clinic team leaders, two of the authors (H.Z. and T.B.) took on the role of local opinion leaders. They worked alongside the target PTs and, therefore, had a realistic understanding of departmental resources as well as constraints. On-site change agents may be especially important, since characteristics of the practice environment seem to be an important influence on evidence uptake.25,34 We attempted to identify and overcome constraints to using NSGT in several ways. At the quarterly meetings, discussion on successes and barriers was invited, and the group worked together to attempt to solve cited problems. For example, related to a lack of clinic space, a discussion ensued about alternative locations to perform NSGT. A common barrier cited in the questionnaire was uncertainty about when to initiate NSGT. To address this clinical decision-making gap, we presented 2 patient cases at the fourth quarterly meeting that specifically addressed the issue of patient readiness to participate in NSGT. Such ongoing support appears to be an important element of strategies that enhance KT. For the most part, the clinical challenges associated with implementing this project were those faced by many clinicians treating complex patients in inpatient settings: time availability, the drive to persist over a long interval, and the resistance on the part of some to change their approach to practice. This case study has limitations, and it is not possible to assert that there is a relationship between our intervention and changes in practice. Although QI can contribute to evidencebased practice,35 we did not have a control group of therapists nor were therapists randomized into a group that participated in the intervention. As we relied on therapists to forward us names of patients with hemiparesis, it is possible that some data were missed. Occasionally, unclear documentation necessitated an inference about patient readiness. Furthermore, as this initiative took place concurrent with clinical practice, we did not document each day-to-day instance of encouragement, reminders, and clinical consultation that took place over the year. Quarterly chart audits provided summative feedback about behavior change but not acute/persistent changes that may have occurred in response to group discussion or individual consultation. Other potential influences on therapist behavior change (eg, practice style traits, previous training, beliefs about evidence-based practice, and the fact that this QI effort was supported by departmental administration) were not explicitly studied nor correlated with the results. Since the purpose of this QI project was to influence therapist behavior, not measure NSGT effectiveness, details about treatment intensity and walking-related outcomes were not captured. Finally, while ongoing plans to monitor and sustain behavior changes are an important component of QI,36 we do not have

Supporting Clinical Practice Behavior Change

follow-up chart audit data to describe whether attempts at NSGT continued to improve after the conclusion of the QI project. Future studies with scientific rigor are needed to elucidate the optimal mix of interventions that are effective in promoting KT, and the time period over which such interventions should extend to be effective. An objective measure (eg, chart audits) of clinical practice before the interventions would allow better interpretation of the intervention effectiveness. Research that links practice style traits to clinical behavior change would assist planners of departmental intervention looking to customize KT activities to their staff. Similarly helpful would be a determination of the usefulness of initiatives that help sustain a change in practice, such as ongoing meetings, education, peer review, documentation requirements, etc. Finally, a logical outcome for KT studies goes beyond practitioner behavior, extending into improved clinical results for patients

CONCLUSION This case study demonstrates that a yearlong effort to influence evidence-based behaviors was followed by a moderate increase in the documented frequency and self-reported frequency of therapist use of NSGT as part of their plan of PT intervention. The results support the importance of multidimensional KT activities, such as ongoing discussion, interactive education, and clinical consultation, which has been demonstrated in several studies of therapists providing outpatient services. These extensive efforts proved feasible in inpatient neurologic rehabilitation units and serve as a contrast to typical departmental 1-time in-services. Similar clinical units may find such an in-depth, planned approach to staff development useful as well as practical.

APPENDIX 1 Nonsupported Gait Training Background High amounts of task-specific practice have resulted in neuroplastic changes in animals and humans19,37 and are commonly associated with improved skill. Intensity, also important, is often defined as the time in or amount of physical therapy.38−43 Overall, studies demonstrate improvements in motor function, including walking ability, with increased time in therapy.20 Intensity can relate also to the level of challenge. The Challenge Point Framework suggests that a certain level of challenge will result in an optimal potential for learning, and has been preliminarily studied in healthy subjects and subjects with Parkinson disease.21,44,45 “Challenge” (determined largely by task difficulty and the learner’s skill level) is a useful idea in rehabilitation, as PTs frequently alter the challenge of walking tasks. While optimal challenge appears to be critical, knowing the exact challenge “point” for a given patient under certain task conditions is an ongoing, complex, and interesting problem for therapists to solve. Movement errors also appear to be an important driving force in motor learning. Evidence has shown that individuals post-stroke can utilize information gained from errors to improve skills in walking46 and reaching tasks.47 While errors may be necessary for learning, profound physical impairment

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can result in devastating errors, such as an inability to generate a movement or complete a task unassisted. Many people who receive inpatient rehabilitation require significant amounts of physical assistance when walking. Robotic-assisted locomotor training is considered to be useful, since it can provide assistance for leg movements and trunk stability and allow high-repetition training.48 However, the physical constraints of robotic assist that limit variability in walking movements and reduce error signals to the nervous system may not be as beneficial as gait training that allows for errors.49,50 Similarly, there may be instances during overground training during which too much therapist assistance, for example, in the interest of safety, might interfere with error-driven learning. There may be an optimal challenge point for each patient, at which he is safe but also challenged and permitted to commit errors.

Description Nonsupported gait training uses error-driven learning, high challenge, and high-repetition task practice to train walking skills without the use of equipment. This approach requires patients to walk at the very edge of their ability, in a way that is so difficult that errors will likely occur. Errors that result in catastrophe, that is, a fall, however, are prevented. On the basis of their clinical experience, the authors recommend that patients who are ready to attempt NSGT meet all of the following criteria: stand for 30 seconds without physical assistance, advance the hemiparetic limb for swing phase without assistance approximately 75% of the time, stabilize the hemiparetic knee during stance phase (the knee does not buckle or require physical blocking), understand and attend to the walking task, and be medically stable. The ability to walk without physical assistance is not a prerequisite.

Implementation Nonsupported gait training is begun by first having the patient take 1 or 2 steps without external support of orthotics or assistive devices (an ace-wrap on a profoundly weak ankle is permitted). Extremely close supervision is provided by 2 therapists (or therapist and aide), but the patient is not physically supported (Figure 1). Balance loss is permitted and therapists intervene only if the patient is unable to self-recover. The patient is instructed to take only a few steps at a time until he can step and recover any losses of balance without assis-

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Figure 1. This individual is closely guarded but without physical contact during a bout of non-supported gait training (NSGT).

tance. At that point, he is encouraged to increase the number of steps, continually focusing on maintaining stability, stopping to regain balance if necessary to prevent a fall. Verbal instruction/feedback during walking is limited. Nonsupported gait training moves the therapist away from hands-on-assist to hands-off training that allows errors to occur in a safe environment. These errors provide a high level of challenge. Dosage of NSGT has not been formally studied. Intensity is determined by the level of challenge: walking should be difficult but doable. If the patient is committing multiple errors such that he is unable to take steps forward, unsupported walking is likely too difficult. Frequency and duration of NSGT were not prescribed per se, but it is recommended to have the patient walk as frequently as possible during the physical therapy session and for as far as the patient’s attention, frustration level, and endurance (muscular and cardiopulmonary) permits.

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Supporting Clinical Practice Behavior Change

APPENDIX 2 Therapist Questionnaire Please check √ : Physical therapist

Years of experience:

Student In the 6 months prior to the NSGT Introduction/Inservice (Nov. 2010), how familiar were you with: Very familiar

Moderately familiar

Somewhat familiar

Not familiar

Almost always or always

Often

Sometimes

Almost never or never

Research evidence that supports NSGT Clinical indicators for NSGT Procedure for implementing NSGT

In patients with hemiparesis who meet the clinical indicators, how often did you utilize NSGT?

In the 6 months since the NSGT Introduction/Inservice (Nov. 2010), how familiar have you become with: Very familiar

Moderately familiar

Somewhat familiar

Not familiar

Almost always or always

Often

Sometimes

Almost never or never

Research evidence that supports NSGT Clinical indicatorsfor NSGT Procedure for implementing NSGT

In patients with hemiparesis who meet the clinical indicators, how often do you utilize NSGT? Please rate the extent to which you perceive that each of the following is a barrier to your use of NSGT: Strongly agree

Agree

Neutral

Disagree Strongly Disagree

Hesitant to try new ideas Feel the benefit to the patient will be minimal Feel the benefit to myself will be minimal Inadequate physical environment (space, etc.) Inadequate human resources (not enough help) Lack of organizational support Lack of time Documentation of NSGT and patient outcomes is burdensome Lack of research evidence to support NSGT Lack of confidence I can effectively implement NSGT I forget to implement NSGT Difficult to know when the patient is ready or appropriate for NSGT I rarely see patients who meet all the clinical indicators Others? Other comments or recommendations to encourage use of NSGT

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Supporting Clinical Practice Behavior Change

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Supporting clinical practice behavior change among neurologic physical therapists: a case study in knowledge translation.

Physical therapists tend to underuse research evidence in clinical practice. Emerging research on knowledge translation activities (KTAs) provides gui...
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