https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Physiotherapy CANADA Advancing health through scientific inquiry and knowledge translation Pour l’avancement de la santé par l’enquête scientifique et la transmission du savoir Volume 70 Number 3 Summer 2018 Highlights Thirteenth Issue in a Special Series on GUEST EDITORAL Education in Physiotherapy Standing at a Critical Nexus in the Evolution of Physiotherapy / À la croisée des chemins dans l’évolution de la physiothérapie Sixth Issue in a Special Series on ARTICLES Exercise Prescription for Persons Living with Gait Training after Stroke on a Self-Paced Treadmill with and Complex Health Conditions without Virtual Environment Scenarios: A Proof-of-Principle Study by C.L. Richards, F. Malouin, A. Lamontagne, B.J. McFadyen, F. Dumas, F. Comeau, N.-M. Robitaille, and J. Fung Physiotherapists’ and Physiotherapy Students’ Perspectives on the Use of Mobile or Wearable Technology in Their Practice by J. Blumenthal, A. Wilkinson, and M. Chignel “A Learned Soul to Guide Me”: The Voices of Those Living with Kidney Disease Inform Physical Activity Programming by T.L. Parsons, C. Bohm, and K. Poser Official Journal of the Canadian Physiotherapy Association Revue officielle de l’Association canadienne de physiothérapie
https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 ER AU Wthihsayt’esanr?ew Who should Why CC C attend? attend? MM M •The strength of 3 organizations YY Y working together • Public & private practitioners • Actionable training and CCMMCM • Managers latest scientific updates MMYYMY • More clinical and special • Clinic owners CCYYCY interest practice streams • Academics • Apply what you learn right CCMMCYYMY • PTA’s & PRT’s away – help your patients KK K • More opportunities for social • Students and boost your practice and networking time What to do: Early Bird View the program Travel & Accommodations Deadline Visit Montreal18.ca/program Check out travel discounts and Register before September 30 to view the program as it hotel information on Montreal18.ca for our best rates! develops Book your room now to avoid Montreal18.ca/registration disappointment at Montreal18.ca/housing-conference-hotels Closing Keynote: Emma Stokes President, WCPT
https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82
https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Osteopathic Studies Osteopathy manual practice provides the necessary therapeutic reasoning skills and manual treatment approaches to achieve optimal results by viewing the body as a whole. Educational program for health-care practitioners • Myofascial, visceral, and cranial techniques • Emphasis on development • Specific osteoarticular adjustments • A robust and progressive curriculum of palpation skills • Internationally-renowned instructors and • Proven clinical methodology • Supervised clinical practice highly skilled assistants We warmly invite you to participate in our information evenings: • Montreal Campus: May 10th and July 12th at 7:00 pm • Toronto Campus: April 24th May 29th, June 26th and July 24th at 7:00 pm • Vancouver Campus: April 19th at 7:00 pm Next Semester • Halifax Campus: May 24th at 7:00 pm Fall 2018 For further details regarding the program or the information evening, or to enroll in the program, please contact our registrar by phone: Montreal-Vancouver-Halifax: 1-855-698-9614 OCansatdeiaon pCoalletghe yof Toronto: 1-855-381-6388 www.ceosteo.ca MovingUp_EN_Journal_pr.pdf 1 2017-10-02 2:36 PM 2783-Demi page Physiotherapy Canada-ang.indd 1 2018-04-04 1:26 PM CLIENT CEO ÉPREUVE #1 CONTACT Bernard Philie DATE D’ÉPREUVE April 4, 2018 1:26 PM 70, rue des Jonquilles DATE OUVERTURE 03/26/18 COULEUR Cyan Magenta Yellow Black PMS Saint-Mathieu-de-Beloeil DU DOSSIER Quebec J3G 0G7 450.813.7240 Nº DOSSIER 2783 APPROBATION : NOUS DEMANDONS VOTRE COLLABORATION POUR www.fitzback.com VOUS ASSURER QUE CES DOCUMENTS RÉPONDENT À VOS ATTENTES ET [email protected] QU’AUCUNE ERREUR NE S’Y TROUVE. FITZBACK GRAPHIQUES NE POURRA ÊTRE TENU RESPONSABLE DES ERREURS APRÈS VOTRE APPROBATION. PROJET 2783-Demi page Physiotherapy Canada-ang FORMAT FINI 7.625 x 4.9 pouces — Demi page C M Y CM MY CY CMY K
https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Physiotherapy Advancing health through scientific inquiry and knowledge translation CANADA Pour l’avancement de la sante´ par l’enqueˆ te scientifique et la transmission du savoir VOLUME 70 NUMBER 3 Summer 2018 ISSN-0300-0508 E-ISSN-1708-8313 TABLE OF CONTENTS GUEST EDITORIAL 199 Standing at a Critical Nexus in the Evolution of Physiotherapy ORIGINAL ARTICLES D.M. Walton EDUCATION SERIES 201 A` la croise´e des chemins dans l’e´volution de la physiothe´rapie D.M. Walton 204 Self-Management Strategies for Malignant Lymphedema: A Case Report with 1-Year and 4-Year Follow-Up Data S.M. Shallwani and A. Towers 212 Neuropathic Pain after Shoulder Arthroplasty: Prevalence, Impact on Physical and Mental Function, and Demographic Determinants H. Razmjou, L.J. Woodhouse, and R. Holtby 221 Gait Training after Stroke on a Self-Paced Treadmill with and without Virtual Environment Scenarios: A Proof-of-Principle Study C.L. Richards, F. Malouin, A. Lamontagne, B.J. McFadyen, F. Dumas, F. Comeau, N.-M. Robitaille, and J. Fung 231 Clinician’s Commentary J. Vaughan-Graham 233 Gross Motor Outcomes of Children Born Prematurely in Northern Ontario and Followed by a Neonatal Follow-Up Programme R. Be´langer, C. Mayer-Crittenden, M. Minor-Corriveau, and M. Robillard 240 Let’s Talk about the Talk: Exploring the Experience of Discussing Student Performance at the Mid- and Final Points of the Clinical Internship J. Yeldon, R. Wilson, J. Laferrie`re, G. Arseneau, S. Gu, M. Hall, K.E. Norman, K. Yoshida, and B. Mori 249 Clinician’s Commentary J. Coleman 251 Physiotherapists’ and Physiotherapy Students’ Perspectives on the Use of Mobile or Wearable Technology in Their Practice J. Blumenthal, A. Wilkinson, and M. Chignel 262 Simulation Experiences in Canadian Physiotherapy Programmes: A Description of Current Practices M. Melling, M. Duranai, B. Pellow, B. Lam, Y. Kim, L. Beavers, E. Miller, and S. Switzer-McIntyre
https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 EXERCISE PRESCRIPTION 272 Clinician’s Commentary SERIES C. Le´ger COCHRANE COLLABORATION 274 Variation in the Geographic Distribution of Physiotherapy Student Clinical Placements in Rural Saskatchewan T.I. Shah, S. Milosavljevic, P.L. Proctor, A.M. McQuarrie, C. Cuddington, and B. Bath 280 Facilitators of and Barriers to Providing Access to Community-Based Exercise Programmes for Adults with Post-Stroke Aphasia from the Perspective of Programme Representatives M. Fairbairn, E. Wicks, S. Ait-Ouali, O. Drodge, D. Brooks, M. Huijbregts, and D. Blonski 289 ‘‘A Learned Soul to Guide Me’’: The Voices of Those Living with Kidney Disease Inform Physical Activity Programming T.L. Parsons, C. Bohm, and K. Poser 296 Clinician’s Commentary I.R. Barrett 298 What Does Cochrane Say about . . . Non-Pharmacological Treatment of Neuropathic Pain? INSTRUCTIONS FOR AUTHORS 299
https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Physiotherapy SCIENTIFIC EDITOR CANADA Dina Brooks, PT, PhD INTERNATIONAL ADVISORY BOARD Professor, Canada Research Chair, Department of Physical Therapy, University of Toronto, Toronto, ON Rik Gosselink, PhD, PT Professor, Department of Rehabilitation Sciences, Katholieke ASSOCIATE EDITORS Universiteit Leuven, Leuven University, Belgium Denise Connelly, PhD, BScPT Karen Grimmer-Somers, PhD, MMedSci, BPhty, Associate Professor, School of Physical Therapy, University of CertHealthEc, LMusA Western Ontario, London, ON Professor, School of Health Sciences Director, Centre for Allied Health Evidence, University of South Australia, Australia Isabelle Gagnon, pht, PhD Assistant Professor, School of Physical and Occupational Meg E. Morris, BAppSC(Physio), MAppSc, Grad Dip(Geron), Therapy, McGill University, Montre´al, QC PhD, FACP Professor and Chair, School of Physiotherapy, University of S. Jayne Garland, PhD, PT Melbourne, Australia Professor and Department Head, Department of Physical Therapy, University of British Columbia, Vancouver, BC Kenneth J. Ottenbacher, OT, PhD Russel Shearn Moody Distinguished Chair in Neurological Michael A. Hunt, PhD, PT Rehabilitation, Senior Associate Dean for Graduate Research Associate Professor, Department of Physical Therapy, Education, School of Allied Health Sciences, University of University of British Columbia, Vancouver, BC Texas Medical Branch, USA Marilyn MacKay-Lyons, BSc(PT), MSc(PT), PhD Carol L. Richards, PhD, PT, FCAHS Professor, School of Physiotherapy, Dalhousie University, Professor and Canada Research Chair in Rehabilitation, Halifax, NS Department of Rehabilitation Medicine, Laval University, Quebec City, QC Stephanie Nixon Associate Professor, Department of Physical Therapy, Peter Rosebaum, MD, CM, FRCP(C) University of Toronto, Toronto, ON Professor, Department of Pediatrics, McMaster University Hamilton, ON Christine B. Novak, BSc(Kin), BSc(PT), MSc, PhD Associate Professor, Department of Surgery, University of Julius Sim, BA, MSc(Soc), MSc(Stat), PhD Toronto / Toronto Rehab-UHN and Research Associate, Primary Care Musculoskeletal Research Centre, Keele University Health Network, Toronto, ON University, UK Tom Overend, PhD, BSc(PT) STATISTICAL CONSULTANT Associate Professor, School of Physical Therapy, University of Western Ontario, London, ON Paul Stratford, PT, MSc Professor Emeritus, School of Rehabilitation Science, Marco Pang, BScPT, PhD McMaster University, Hamilton, ON Assistant Professor, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong PUBLISHER Alex Scott, PhD Canadian Physiotherapy Association Associate Professor, Department of Physical Therapy, Centre 955 Green Valley Crescent, Suite 270, Ottawa, ON for Hip Health and Mobility, University of British Columbia, K2C 3V4 Canada Vancouver, BC Tel.: 613-564-5454 or 800-387-8679, Fax: 613-564-1577 E-mail: [email protected] EDITORIAL OFFICE www.physiotherapy.ca University of Toronto Press – Journals Division Competing Interest Statements for Physiotherapy Canada 5201 Dufferin St., North York, ON M3H 5T8 Canada Editorial Board members are available online at Tel.: 416-667-7810, Fax: 416-667-7832 or 1-800-221-9985 http://www.utpjournals.press/journals/ptc/editorial-board E-mail: [email protected], www.utpjournals.press
https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 STATEMENT OF PURPOSE OBJECTIF Physiotherapy Canada is the official, scholarly, refereed journal of Physiotherapy Canada est la publication scientifique officielle re´vise´e the Canadian Physiotherapy Association, giving direction to excellence en profondeur de l’Association canadienne de physiothe´rapie. Son in clinical science and reasoning, knowledge translation, therapeutic objectif est de fournir des orientations a` l’excellence en sciences et skills and patient-centred care. en raisonnement clinique, transmission du savoir, compe´tences the´rapeutiques et soins centre´s sur le patient. Recognized as one of the top five evidence-based journals of physiotherapy worldwide, Physiotherapy Canada publishes the Reconnu comme l’un des cinq grands journaux de physiothe´rapie results of qualitative and quantitative research including systematic reposant sur des faits scientifiques dans le monde, Physiotherapy reviews, meta analyses, meta syntheses, public/health policy research, Canada publie les re´sultats de recherches qualitatives et quantitatives, clinical practice guidelines, and case reports. Key messages, clinical notamment des revues syste´matiques, des me´ta-analyses, des commentaries, case studies, evidence-based practice articles, brief me´tasynthe`ses, des recherches en politiques de la sante´ ou en reports, and book reviews support knowledge translation to clinical politiques publiques, des directives en pratique clinique et des practice. e´tudes de cas. Ses messages cle´s, commentaires cliniques, e´tudes de cas, articles fonde´s sur des faits scientifiques, re´sume´s de discussions Founded in 1923, Physiotherapy Canada meets the diverse needs of et comptes-rendus de livres favorisent la transmission du savoir a` la national and international readers and serves as a key repository of pratique clinique. inquiries, evidence and advances in the practice of physiotherapy. Fonde´e en 1923, Physiotherapy Canada re´pond aux divers besoins de Physiotherapy Canada (ISSN 0300-0508) is published four times per lecteurs canadiens et e´trangers et se positionne comme un ve´ritable year in spring, summer, fall and winter by the University of Toronto recueil sur la recherche, les faits scientifiques et les progre`s dans la Press for the Canadian Physiotherapy Association. pratique de la physiothe´rapie. EDITORIAL SUBMISSIONS PRE´ SENTATIONS D’ARTICLES Physiotherapy Canada welcomes manuscripts reporting results of Physiotherapy Canada accepte les articles qui font e´tat de re´sultats qualitative or quantitative research. Systematic reviews, meta analyses de recherche qualitative ou quantitative. Les examens syste´matiques, (quantitative), meta syntheses (qualitative), public/health policy research, les me´ta-analyses (quantitatives), les me´tasynthe`ses (qualitatives), clinical practice guidelines, case reports (quantitative), case studies les recherches sur les politiques publiques et de sante´, les guides de (qualitative), evidence-based practice articles and brief reports are pratique clinique, les rapports de cas (quantitatifs), les e´tudes de cas also welcomed. Submissions are now being accepted online via (qualitatives), les articles sur la pratique factuelle et les rapports de Physiotherapy Canada’s online peer-review system ScholarOne. me´moire sont aussi les bienvenus. Vous pouvez pre´senter vos articles To log in or see submission guidelines, please go to https://mc04. en ligne graˆce au syste`me e´lectronique d’examen par les pairs manuscriptcentral.com/ptc. For technical support information ScholarOne de Physiotherapy Canada. Pour ouvrir une session ou or questions regarding the editorial process please contact us at pour connaˆıtre les lignes directrices sur la pre´sentation d’un article, [email protected]. consultez la page https://mc04.manuscriptcentral.com/ptc. Pour obtenir un soutien technique ou des re´ponses a` vos questions Physiotherapy Canada is indexed by Allied and Complementary concernant le processus re´dactionnel, veuillez communiquer avec Medicine Database (AMED), CrossRef, Cumulative Index to Nursing nous a` [email protected]. and Allied Health Literature (CINAHL), Google Scholar, National Archives Publishing Co., Online Computer Library Center (OCLC), Physiotherapy Canada est indexe´e par Allied and Complementary PEDro, PubMed Central (PMC), Rehabilitation & Sports Medicine Medicine Database (AMED), CrossRef, l’index cumulatif des publica- Source, ScholarsPortal, Scopus, SIPX, and the Web of Science tions sur les soins infirmiers et les soins parame´dicaux (CINAHL), (Science Citation Index Expanded). Google Scholar, National Archives Publishing Co., Online Computer Library Center (OCLC), PEDro, PubMed Central (PMC), Rehabilitation The statements and opinions in this journal are solely those of the & Sports Medicine Source, ScholarsPortal, Scopus, SIPX et Web of contributors and not those of the publisher or of the Canadian Science (Science Citation Index Expanded). Physiotherapy Association. Les opinions publie´es dans cette revue sont celles des contributeurs COPYRIGHT et ne repre´sentent pas les opinions de l’e´diteur ou de l’Association 6 Canadian Physiotherapy Association, 2018. All rights reserved. No canadienne de physiothe´rapie. part of this material may be reproduced, stored in a retrieval system, or transcribed in any form or by any means, electronic, mechanical, DROIT D’AUTEUR photocopying, recording, or otherwise, without written permission 6 Association canadienne de physiothe´rapie, 2018. 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GUEST EDITORIAL / E´ DITORIALISTE INVITE´ https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Standing at a Critical Nexus in the Evolution of Physiotherapy David M. Walton, PhD, PT Historians define epochs of history in terms of critical still catching up to the Digital Revolution, recognize that periods, sometimes defined by major natural events, you, I, and everyone around you is currently in the political shifts or movements, major wars, shifts in middle of what many historians and futurists believe is artistry and aesthetics, or as revolutions and ages. It can the most important shift in human history—the Infor- be somewhat misleading to do so because progress mation, or Data, Age. never really stops, but revolutions are often defined by sudden leaps forward in cognition, techniques, or tech- THE INFORMATION REVOLUTION nology in a certain area. For example, the Agricultural The amount of data being created, captured, and Revolution (200–400 years ago) was a time in which techniques to farm and harvest the land progressed so stored daily is staggering, almost impossible for most of us rapidly that large gatherings of people could be sustained to fathom. It is estimated that, by 2013, Google alone had by a relatively small number of dedicated farmers. This, in processed more than 20 petabytes (1,000,000,000,000,000 turn, allowed groups of humans to live in close proximity bytes) of data every day, and if Gordon Moore’s law of ex- to one another; hence, populations, communities, and ponential growth1 in digital computing power is correct, towns were born. It meant that not everyone needed to you can expect that that figure has doubled or quadrupled focus on managing their own food supplies, so large by now. Most of those data are stored indefinitely. Whether swaths of these townsfolk needed new jobs. Thus, the it is your online searches, social media posts, the locations Industrial Revolution (150–250 years ago) led to a rapid you visit, number of steps you take, photos you snap, your advancement in manufacturing and early automation, resting heart rate, your Netflix habits, your bank balance, mostly in the textile and manufacturing sectors, but also or even when you go to bed and wake up, data have in farming and education. become a highly valuable commodity coveted by private companies, governments, and many other entities. Some historians recognize a Transportation Revolution marked largely by the invention of the steam engine, The Information Age means a lot of things; it means followed by automobiles and airplanes—making it far that you currently, right now, have immediate access to easier for people to connect with those in other towns the world’s collective knowledge, and the means to this and countries. More recently, many reading this editorial access is likely in your pocket. It means that we are all will have lived through the Digital Revolution, which constantly connected to one another, and, perhaps most started in the 1960s, when semiconductors and micro- important, it means that those with the computational chips enabled computing power to be achieved in a power and know-how are able to make frighteningly small package that lived in people’s living rooms or accurate predictions about everything—from what you offices. will likely enjoy watching next on YouTube to when you are most likely to die.2 Of course, none of these technologies have stopped progressing simply because a revolution and its ensuing Consider that thousands of people every day voluntarily age has passed—anyone who has visited a farm recently send their genetic material to any one of a growing will immediately recognize that agricultural technology number of private genotyping companies to learn what continues to progress. Also notable, when one scans the their DNA says about their ancestry. This task, as re- timeline of human history, is that the interval between cently as 2003, took 13 years and cost millions of dollars, these revolutions appears to be rapidly shrinking. As we yet today, it takes a few weeks to receive the results and stand now and scan the horizon of 2018, while many are costs about $100 (US). Of course, these companies do not dispose of those data after they have been analyzed; From the School of Physical Therapy, Western University, London, Ont. Correspondence to: David M. Walton, School of Physical Therapy, Rm. EC1443, Western University, 1201 Western Rd., London, ON N6G 1H1; [email protected]. Competing Interests: None declared. The Physio Moves Canada project was funded by the following arm’s-length, not-for-profit organizations: Canadian Physiother- apy Association (CPA), Ontario Physiotherapy Association (OPA), Physiotherapy Alberta Association and College, Manitoba Physiotherapy Association, Association que´ be´ coise de la physiothe´ rapie, Nova Scotia Physiotherapy Association, New Brunswick Physiotherapy Association, and Newfoundland/Labrador Physiotherapy Association. The author is a member of the CPA and OPA but earns no personal income from, and has no other financial connection with, any of these entities. 199
200 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 they add them to their growing databanks to optimize ing for someone to decide the idea was too outlandish their own machine learning–based, predictive algorithms or crazy. Although some indeed thought I may be crazy, for the next person. In the process, however, these private almost all said it was necessary and timely. Their support companies are building one of the largest databases of was critical as this was a project that would not have intimately personal health information ever created. Truly, gotten off the ground through traditional tri-council re- the Information Age in which we are currently living is search grant competitions. simultaneously fascinating and terrifying. As often happens, the project grew from encompass- Technology is advancing in multiple fantastic ways, ing a narrowly focused ethnography to include other fantastic in this case being used in its literal sense of questions and methodologies: a phenomenological study being related to fantasy. Whether it be gene editing for of the lived experience of physiotherapy clients receiving diseases or designer offspring, nanobots, or virtual or care for mobility impairments and a series of clinician augmented reality inhabited by bionic or augmented focus sessions for a pseudo-SWOT (strengths, weaknesses, humans, it is hard to keep up with it all. More important, opportunities, and threats) analysis, which was adapted perhaps, is that it will not stop. There is no finish line in slightly to be an analysis of threats, opportunities, re- this race. We are rapidly closing in on the projected date search, and training priorities. of the singularity (loosely predicted to occur 30–100 years from now), the time at which computers are ex- After nearly a full year of planning, with invaluable pected to match, then rapidly surpass, human intelli- support from a dedicated team both locally and at the gence. What happens then? The somewhat frightening Canadian Physiotherapy Association and its branches, answer seems to be that no one really knows.3 Several the project travelled from Norris Point, Newfoundland, groups around the world are actively working on strat- to Whitehorse, Yukon, mostly by car, through summer egies, guidelines, and policies to ensure a thriving future and fall 2017. During that period, I visited 26 unique for humanity, initiatives to which readers in physio- clinical sites; engaged directly with 116 clinicians, 30 therapy may want to pay attention. clients, and numerous other stakeholders (administrators, inter-professional colleagues); collected hours of video This, in a roundabout way, brings me to the main and audio recordings; and took copious notes. Prelimi- thesis of this editorial and provides context for the nary findings have been shared with radio audiences, Physio Moves Canada project. It is a grand idea that was print media,4,5 television stations, and the leaders of intended as a starting point to answer a critical question: national and provincial physiotherapy bodies. The entire Where does physiotherapy fit into this unpredictable experience will not only influence my own research pro- future, and are physiotherapists moving fast enough to gramme but has also changed me as a person. remain relevant? Now the hard work begins. Those hours of recordings HOW ARE CANADIAN PHYSIOTHERAPISTS PREPARING FOR and pages of notes need to be analyzed, and I and THE FUTURE? my local team are doing just that. Over the coming year, we anticipate several publications arising out of In 2016, I dreamed of a project with a narrowly de- this project, focusing (respectively) on threats facing the fined research question: What are clinicians doing today practice of physiotherapy in Canada; opportunities for to prepare for tomorrow? The intention was to explore physiotherapy in Canada; research priorities, as described unique or innovative practices—partly as a physiotherapy by Canadian physiotherapists; training and educational academic interested in how clinicians were preparing for priorities, as described by front-line clinicians; the mean- the future and partly as a former clinician who was be- ing and importance of mobility to Canadians; and a coming increasingly aware that practice had very likely focused ethnography of innovative physiotherapy prac- changed in the nearly 7 years since I had been in routine tices in Canada. The first of these publications is nearing practice. This was also an opportunity to reconnect with completion. the realities of front-line practice and ensure that the research questions being asked were important. Some The hope is that these publications, and related out- personal reflection at the time also revealed that I had no puts through other avenues, are not frightening and good sense of what it was like to provide physiotherapy do not induce pessimism or hopelessness. The world care outside my own little bubble in southwestern around us is rapidly changing, and while some of these Ontario, including care to marginalized populations, changes may threaten traditional models of care, many Indigenous communities, and military personnel; in re- will offer opportunities for professional evolution. I mote and rural settings; and in other unique practice hope the outputs lead to deep introspection and mean- settings and populations. ingful actions to prepare the physiotherapy profession for the coming years. What comes after the Information Thus was born the idea of a cross-Canada–focused Revolution? The term ‘‘Deus Revolution,’’ has been pro- ethnography of unique and innovative physiotherapy posed, which will see humans intervening in the very practice. I pitched this idea to key stakeholders, including processes and meanings of nature and reality in the professional physiotherapy associations in Canada, look- ways that early humans believed only a god could. Is
Walton A` la croise´ e des chemins dans l’e´ volution de la physiothe´ rapie 201 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 physiotherapy living up to its full potential now, in the Biomedicine; 2017 Nov 13–16; Kansas City, MO. https://doi.org/ Information Age, and are physiotherapists adequately 10.1109/BIBM.2017.8217669. prepared to leverage what comes next and use it toward 3. Baer D. Nine crazy things that could happen after the singularity, further professional evolution? In the words of Louis when robots become smarter than humans. Business Insider Pasteur, ‘‘Fortune favours the prepared mind.’’ In addition [newspaper on the Internet]. 2015 Dec 18 [cited 2018 Mar 8]. to the ongoing work of several tremendously passionate Available from: http://www.businessinsider.com/predictions-for- and visionary thinkers in leadership, academics, and clini- after-singularity-2015-11/#everything-is-going-to-change-1. cal practice, I hope that Physio Moves Canada represents 4. Sher J. Physiotherapy strides spurred by adversity. The London Free one additional step toward ensuring that we are, indeed, Press [newspaper on the Internet]. 2018 Feb 8 [cited 2018 Mar 8]. prepared. Available from: http://lfpress.com/2018/02/08/physiotherapy- strides-spurred-by-adversity/wcm/58f3ad8e-a75f-a0b9-0aae- REFERENCES 7d0007f31f9d. 5. Mayne P. Tour answers physio’s questions, raises more. Western 1. Moore GE. Progress in digital integrated electronics. Proc Int News [newspaper on the Internet]. 2018 Feb 8 [cited 2018 Mar 8]. Electron Devices Meeting (IEDM ’75). 1975; 21:11–13. Available from: http://news.westernu.ca/2018/02/nation-wide-tour- answers-physios-questions-raises/. 2. Avati A, Jung K, Harman S, et al. Improving palliative care with deep learning. In: Hu X, Gong Y, Shyu C-R, et al., editors. Proceedings of DOI:10.3138/ptc.70.3.gee the 2017 IEEE International Conference on Bioinformatics and A` la croise´e des chemins dans l’e´volution de la physiothe´rapie David M. Walton, Ph. D., pht. Les historiens de´finissent les diverses e´poques en textile et de la fabrication, mais e´galement dans les fonction de pe´riodes cruciales de l’histoire, caracte´rise´es milieux de l’agriculture et de l’enseignement. par des e´ve´nements naturels majeurs, des bouleverse- ments ou mouvements politiques importants, des grandes Certains historiens attestent d’une Re´volution des guerres, des changements artistiques ou esthe´tiques ou transports, marque´e en grande partie par l’invention des re´volutions et des aˆges. Il peut eˆtre quelque peu trom- de la locomotive a` vapeur, suivie de l’automobile et de peur de fonctionner de cette fac¸on puisque le progre`s ne l’avion, qui facilitent les de´placements entre les villes et s’arreˆte jamais, mais les re´volutions sont souvent de´finies les pays. Si on avance dans le temps, bien des lecteurs par des bonds soudains dans un domaine de la cognition, ont ve´cu la Re´volution nume´rique, qui s’est amorce´e des techniques ou de la technologie. Par exemple, la dans les anne´es 1960 lorsque les semi-conducteurs et Re´volution agricole (il y a 200 a` 400 ans) refle`te une e´po- les micropuces ont permis d’emmagasiner une grande que ou` les techniques agraires ont e´volue´ a` une rapidite´ capacite´ de traitement dans de petites machines ins- telle qu’une vaste population pouvait eˆtre nourrie par un talle´es dans des salons ou des bureaux. nombre relativement modeste d’agriculteurs. Ce phe´no- me`ne a permis de vivre plus pre`s les uns des autres, ce De toute e´vidence, aucune de ces technologies n’a qui a favorise´ la formation de populations, de com- cesse´ d’e´voluer a` la fin d’une re´volution ou d’une e`re munaute´s et de villes. Puisque l’ensemble de la socie´te´ donne´e. Quiconque a visite´ une ferme re´cemment sait n’avait plus a` cultiver ses propres aliments, de larges que la technologie agricole continue de se transformer. pans de la population ont duˆ se trouver de nouveaux Par ailleurs, lorsqu’on examine la ligne de temps de emplois. C’est ainsi que la Re´volution industrielle (il y a l’histoire humaine, on constate que l’intervalle entre les 150 a` 250 ans) te´moigne des avance´es de l’industrialisa- re´volutions semble s’amenuiser. Et maintenant, en 2018, tion et de l’automatisation, surtout dans les secteurs du alors que bien des gens tentent encore de s’adapter a` la Re´volution nume´rique, il faut admettre que vous, moi et tout notre entourage sommes actuellement au cœur de Affiliation : School of Physical Therapy, Western University, London (Ontario) Correspondance a` : David M. Walton, School of Physical Therapy, salle EC1443, Western University, 1201 Western Rd., London (Ontario) N6G 1H1; [email protected] Conflits d’inte´ reˆ ts : L’auteur n’a aucun conflit d’inte´ reˆ ts a` de´ clarer. Le projet Physio Moves Canada a e´ te´ finance´ par les organismes a` but non lucratif inde´ pendants suivants : Association canadienne de physiothe´ rapie (ACP), Ontario Physiotherapy Association (OPA), Physiotherapy Alberta College and Association, Association manitobaine de physiothe´ rapie, Association que´ be´ coise de la physiothe´ rapie, Nova Scotia Physiotherapy Association, New Brunswick Physiotherapy Association et Newfoundland/Labrador Physiotherapy Association. L’auteur est membre de l’ACP et de l’OPA, mais ne tire aucun revenu professionnel de ces entite´ s et n’a aucun autre lien financier avec elles.
202 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 ce que de nombreux historiens et futurologues conside`- Il n’y a pas de ligne d’arrive´e. Nous approchons rapide- rent comme le plus grand bouleversement de l’histoire ment de la date projete´e de la singularite´ (dont l’ave`ne- de l’homme, l’E` re de l’information. ment est pre´vu d’ici 30 a` 100 ans), le moment auquel les ordinateurs devraient e´galer, puis rapidement surpasser, LA RE´ VOLUTION DE L’INFORMATION l’intelligence humaine. Que se passera-t-il alors? La La quantite´ de donne´es cre´e´es, saisies et entrepose´es re´ponse plutoˆt alarmante semble eˆtre que personne ne le sait3. Plusieurs groupes dans le monde s’affairent a` chaque jour est pratiquement impossible a` imaginer. En e´tablir des strate´gies, des directives et des politiques effet, on estime qu’en 2013, Google a` elle seule traitait pour garantir un avenir prospe`re a` l’humanite´; les per- plus de 20 pe´taoctets (1 000 000 000 000 000 d’octets) de sonnes inte´resse´es a` la physiothe´rapie devraient peut-eˆtre donne´es par jour, et si la loi de la croissance exponen- s’y pencher. tielle1 de la puissance informatique e´nonce´e par Gordon Moore se ve´rifie, ce chiffre a double´ ou meˆme quadruple´ D’une manie`re de´tourne´e, ce constat me rame`ne au depuis. La plupart de ces donne´es sont entrepose´es in- sujet principal de cet e´ditorial et met en contexte le projet de´finiment. Vos recherches en ligne, vos messages dans Physio Moves Canada, une belle ide´e conc¸ue comme les me´dias sociaux, les lieux que vous visitez, le nombre point de de´part pour trouver la re´ponse a` une question de pas que vous parcourez, les photos que vous prenez, essentielle : ou` la physiothe´rapie se situe-t-elle dans cet votre fre´quence cardiaque au repos, vos habitudes sur avenir impre´visible, et les physiothe´rapeutes progressent- Netflix, votre solde bancaire ou meˆme l’heure a` laquelle ils assez vite pour demeurer pertinents? vous vous couchez et vous vous re´veillez sont tous des donne´es d’une grande valeur, convoite´es par l’entreprise COMMENT LES PHYSIOTHE´ RAPEUTES CANADIENS SE prive´e, les gouvernements et de nombreuses autres PRE´ PARENT-ILS A` L’AVENIR? entite´s. En 2016, j’ai reˆve´ d’un projet dont la question de L’E` re de l’information veut dire bien des choses. Elle recherche e´tait tre`s de´limite´e : que font les cliniciens signifie qu’en ce moment meˆme, vous avez un acce`s aujourd’hui pour se pre´parer a` demain? L’intention e´tait imme´diat au savoir collectif du monde et que le moyen d’explorer les pratiques uniques ou novatrices, en partie de cet acce`s est probablement dans votre poche. Elle a` titre de chercheur en physiothe´rapie inte´resse´ par la signifie que nous sommes tous connecte´s les uns aux manie`re dont les cliniciens se pre´paraient a` l’avenir autres en tout temps et, surtout, que ceux qui posse`dent et en partie en qualite´ d’ancien clinicien, de plus en la puissance et le savoir informatiques peuvent faire des plus conscient que la pratique quotidienne avait suˆ re- pre´dictions d’une justesse effrayante sur tout, du pro- ment change´ depuis qu’il l’avait quitte´e pre`s de sept ans chain clip que vous aurez envie de regarder sur YouTube plus toˆt. C’e´tait e´galement l’occasion de renouer avec les au moment le plus probable de votre mort2. re´alite´s de la premie`re ligne et de m’assurer de poser des questions de recherche importantes. A` l’e´poque, une Songez que, chaque jour, des milliers de personnes re´flexion personnelle m’a e´galement re´ve´le´ que je n’avais expe´dient volontairement du mate´riel ge´ne´tique a` l’une pas vraiment ide´e de ce qu’e´tait l’expe´rience de la des socie´te´s prive´es de ge´notypage de plus en plus physiothe´rapie hors de ma petite bulle au sud-ouest de foisonnantes pour savoir ce que leur ADN re´ve`le au sujet l’Ontario, y compris les soins aux populations mar- de leur ascendance. Pas plus tard qu’en 2003, il fallait ginalise´es, aux communaute´s autochtones et au personnel pre´voir 13 ans et des millions de dollars pour mener militaire, dans les populations des re´gions rurales et cette taˆche a` bien, mais aujourd’hui, quelques semaines e´loigne´es et dans les autres milieux de pratique et popu- suffisent, en e´change d’une centaine de dollars ame´ricains. lations plus particuliers. Ne croyez pas que ces entreprises prive´es se de´barrassent de vos donne´es apre`s leur analyse. Elles en enrichissent C’est ainsi qu’est ne´e l’ide´e d’une e´tude ethnographi- leurs bases de donne´es pour optimiser leurs algorithmes que transcanadienne des pratiques uniques et novatrices pre´dictifs d’apprentissage automatique en vue du prochain en physiothe´rapie. J’ai propose´ cette ide´e a` des interve- client. Ce faisant, elles cre´ent l’une des plus vastes bases nants cle´s, y compris les associations professionnelles de donne´es intimement personnelles sur la sante´ jamais de physiothe´rapie au Canada, m’attendant a` me faire vue. Vraiment, l’E` re de l’information dans laquelle nous dire que c’e´tait trop fou ou farfelu. Certains ont bel et vivons est a` la fois fascinante et terrifiante. bien trouve´ l’ide´e folle, mais presque tous ont dit que c’e´tait ne´cessaire et opportun. Leur soutien s’est re´ve´le´ La technologie e´volue de multiples fac¸ons fantastiques, capital, parce que le projet n’aurait pas pu de´coller au ou` le terme fantastique est pris dans son sens litte´ral lie´ a` moyen des demandes de subventions habituelles aux l’imaginaire. La manipulation ge´ne´tique pour traiter des trois conseils. maladies ou faire des be´be´s sur mesure, les nanorobots, la re´alite´ virtuelle ou augmente´e peuple´e d’humains bio- Comme c’est souvent le cas, le projet est passe´ d’une niques ou augmente´s. . . c’est difficile de suivre. Surtout, e´tude ethnographique tre`s circonscrite a` un mode`le c¸a ne s’arreˆte pas; c’est une course qui ne finit jamais. incluant d’autres questions et me´thodologies : une e´tude
Walton A` la croise´ e des chemins dans l’e´ volution de la physiothe´ rapie 203 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 phe´nome´nologique des expe´riences ve´cues par des certains de ces changements peuvent menacer les mode`les clients en physiothe´rapie traite´s pour des troubles de la de soins traditionnels, plusieurs offriront des possibilite´s mobilite´ et une se´rie de se´ances axe´es sur les cliniciens d’e´volution professionnelle. J’espe`re que les articles susci- en vue d’une analyse pseudo-FFPM (forces, faiblesses, teront une profonde introspection et des mesures de fond possibilite´s et menaces), le´ge`rement adapte´e pour devenir pour pre´parer la profession de physiothe´rapeute des une analyse des menaces, des possibilite´s, des recherches prochaines anne´es. Qu’est-ce qui suivra l’E` re de l’infor- et des priorite´s de formation. mation? Le terme « Re´volution divine » a e´te´ propose´ : les humains interviendront dans les processus et les Apre`s presque un an de planification, graˆce au soutien fondements meˆmes de la nature et de la re´alite´, par des inestimable d’une e´quipe de´voue´e, tant locale qu’au sein me´thodes que les premiers humains croyaient re´serve´es de l’Association canadienne de physiothe´rapie et de ses aux dieux. Le milieu de la physiothe´rapie re´alise-t-il son sections, le projet s’est promene´ de Norris Point, a` Terre- plein potentiel maintenant, a` l’E` re de l’information, les Neuve, jusqu’a` Whitehorse, au Yukon, pendant l’e´te´ et physiothe´rapeutes sont-ils bien pre´pare´s a` exploiter ce l’automne 2017, surtout en voiture. Pendant cette pe´riode, qui viendra ensuite et a` l’utiliser pour favoriser l’e´volu- j’ai visite´ 26 e´tablissements cliniques diffe´rents, e´change´ tion de la profession? Comme le dit Louis Pasteur : « La directement avec 116 cliniciens, 30 clients et de nom- chance ne sourit qu’aux esprits bien pre´pare´s ». S’ajou- breux autres intervenants (administrateurs, colle`gues tant au travail continu de plusieurs penseurs follement interprofessionnels), recueilli des heures d’enregistre- passionne´s et visionnaires des secteurs du leadership, ments vide´o et audio et pris d’abondantes notes. Les de la recherche et de la pratique clinique, j’espe`re que re´sultats pre´liminaires ont e´te´ transmis a` un auditoire Physio Moves Canada repre´sente une e´tape de plus pour radiophonique et te´le´visuel, dans les me´dias imprime´s4,5 garantir que nous soyons bel et bien pre´pare´s. et a` la direction des organismes de physiothe´rapie na- tional et provinciaux. Toute cette expe´rience influencera RE´ FE´ RENCES non seulement mon propre programme de recherche, mais il m’a e´galement transforme´ personnellement. 1. Moore GE. Progress in digital integrated electronics. Proc Int Electron Devices Meeting (IEDM ’75). 1975; 21:11–3. Le plus dur reste a` faire. Ces heures d’enregistrement et ces pages de notes doivent eˆtre analyse´es, ce que 2. Avati A, Jung K, Harman S et coll. Improving palliative care with mon e´quipe et moi nous affairons a` faire. D’ici un an, deep learning. Sous la direction de Hu X, Gong Y, Shyu C-R et coll., nous anticipons publier plusieurs articles issus de ce directeurs. Proceedings of the 2017 IEEE International Conference projet, qui porteront respectivement sur les menaces on Bioinformatics and Biomedicine; 13 au 16 nov. 2017 Kansas City, qu’affrontera la pratique de la physiothe´rapie au Canada, MO. https://doi.org/10.1109/BIBM.2017.8217669. les possibilite´s qui s’offriront a` la pratique de la physio- the´rapie au Canada, les priorite´s de recherche de´crites 3. Baer D. Nine crazy things that could happen after the singularity, par les physiothe´rapeutes canadiens, les priorite´s en when robots become smarter than humans. Business Insider formation et en enseignement selon les cliniciens de [journal sur Internet]. 18 de´c. 2015 [cite´ le 8 mars 2018]. Disponible a` premie`re ligne, le sens et l’importance de la mobilite´ http://www.businessinsider.com/predictions-for-after-singularity- pour les Canadiens et une e´tude ethnographique cible´e 2015-11/#everything-is-going-to-change-1. des pratiques novatrices en physiothe´rapie au Canada. La premie`re de ces publications est presque termine´e. 4. Sher J. Physiotherapy strides spurred by adversity. The London Free Press [journal sur Internet]. 8 fe´v. 2018 [cite´ le 8 mars 2018]. J’espe`re que ces publications et que les articles con- Disponible a` http://lfpress.com/2018/02/08/physiotherapy-strides- nexes transmis par d’autres voies ne seront pas anxioge`nes spurred-by-adversity/wcm/58f3ad8e-a75f-a0b9-0aae-7d0007f31f9d. et n’inciteront pas le pessimisme ou le de´sespoir. Le monde qui nous entoure e´volue rapidement, et meˆme si 5. Mayne P. Tour answers physio’s questions, raises more. Western News [journal sur Internet]. 8 fe´v. 2018 [cite´ le 8 mars 2018]. Disponible a` http://news.westernu.ca/2018/02/nation-wide-tour- answers-physios-questions-raises/. DOI:10.3138/ptc.70.3.gef
https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 CASE REPORT Self-Management Strategies for Malignant Lymphedema: A Case Report with 1-Year and 4-Year Follow-Up Data Shirin M. Shallwani, MSc, PT;*†‡ Anna Towers, MD*§ ABSTRACT Purpose: Malignant lymphedema is an accumulation of interstitial fluid caused by tumour infiltration or compression of lymphatic vessels. Our objective is to describe self-management strategies for malignant lymphedema using a case report. Client Description: A 50-year-old woman with advanced breast cancer was referred to our centre with a 3-month history of unexplained left-arm edema, subsequently diagnosed as malignant lymphedema caused by tumour compression of the axillary lymph nodes. Intervention: She undertook a physiotherapist-guided, modified lymphedema treatment programme, with self-management interventions including self-bandaging and exercise. Limb volumes and leisure exercise levels were measured over a 1-year period. Data were collected from her follow-up visit 4 years post-diagnosis of lymphedema. Measures and Outcome: Within the first month, the patient’s excess limb volume reduced from 26.8% to 5.9% and, 1 year later, remained stable at 3%. Over time, her exercise levels increased (1-year follow-up: 33.5 MET-hours per week). At 4 years, her excess limb volume was 9.7%, and exercise levels were at 36 MET-hours per week. Implications: A woman with moderate malignant arm lymphedema caused by advanced breast cancer successfully adhered to a guided self-management programme and benefited from reduced swelling and improved self-reported physical function in the long term. This case provides oncology health professionals with knowledge about self- management options for malignant lymphedema. Key Words: breast neoplasms; exercise; lymphedema; self-care. RE´ SUME´ Objectif : le lymphœde` me malin de´ signe une accumulation de liquide interstitiel cause´ par l’infiltration d’une tumeur ou la compression des vaisseaux lymphatiques. Les auteurs utilisent un rapport de cas pour de´ crire des strate´ gies d’autogestion du lymphœde` me malin. Description de la cliente : une femme de 50 ans atteinte d’un cancer du sein avance´ a e´ te´ dirige´ e vers le centre des auteurs parce qu’elle pre´ sentait un œde` me inexplique´ du bras gauche depuis trois mois. Cet œde` me a ensuite e´ te´ diagnostique´ comme un lymphœde` me cause´ par la compression d’une tumeur sur les ganglions axillaires. Intervention : la patiente a entrepris un traitement modifie´ du lymphœde` me, oriente´ par des physiothe´ rapeutes et comportant des interventions d’autogestion, y compris les changements de bandages et des exercices. Les auteurs ont mesure´ le volume des membres et le taux d’exercices de loisir sur une pe´ riode d’un an. Ils ont recueilli les donne´ es jusqu’au rendez-vous de suivi quatre ans apre` s le diagnostic de lymphœde` me. Mesures et re´ sultats : au cours du premier mois, le volume exce´ dentaire du membre de la patiente est passe´ de 26,8 % a` 5,9 % et e´ tait demeure´ stable un an plus tard, a` 3 %. Au fil du temps le taux d’exercice de la patiente a augmente´ (suivi d’un an : 33,5 e´ quivalents me´ taboliques de l’effort [MET]-heures par semaine). Au bout de quatre ans, le volume exce´ dentaire de son bras e´ tait de 9,7 %, et son taux d’exercice, de 36 MET-heures par semaine. Conse´ quences : une femme pre´ sentant un lymphœde` me malin mode´ re´ du bras cause´ par un cancer du sein avance´ a suivi un programme d’autogestion oriente´ et observe´ une diminution de son œde` me et une ame´ lioration autode´ clare´ e de sa fonction physique a` long terme. Ce cas fournit aux professionnels en oncologie de des connaissances sur les possibilite´ s d’autogestion du lymphœde` me malin. Lymphedema is an abnormal accumulation of protein- dema include surgical resection of the lymph nodes, rich interstitial fluid due to obstruction, trauma, or de- radiation-induced lymph node fibrosis, obesity, and age.2,3 velopmental abnormality of the lymphatic system.1 It is Less well recognized is malignant lymphedema, which is estimated that more than 20% of women develop upper caused by direct tumour infiltration or compression of limb lymphedema after being diagnosed with breast the lymphatic vessels.4 Malignant lymphedema is often cancer.2 Common risk factors for cancer-related lymphe- characterized by the rapid onset and progression of edema From the: *Lymphedema Program; †Physiotherapy Department, McGill University Health Centre; §Department of Oncology, McGill University, Montreal; ‡School of Rehabilitation Sciences, University of Ottawa, Ottawa. Correspondence to: Shirin M. Shallwani, School of Rehabilitation Sciences, University of Ottawa, 451 Smyth Rd., Room 1125, Ottawa, ON K1H 8M5; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: None declared. Acknowledgements: The authors express their deepest gratitude to Mrs. C. for sharing her story and providing feedback on the article. The authors also thank Pamela Hodgson, Roanne Thomas, and Angela Yung for their assistance with data collection and manuscript review. Physiotherapy Canada 2018; 70(3);204–211; doi:10.3138/ptc.2016-94 204
Shallwani and Towers Self-Management Strategies for Malignant Lymphedema: A Case Report with 1-Year and 4-Year Follow-Up Data 205 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 and may be associated with skin changes and general volume, and patients reported satisfaction and feelings weakness.4 This is prevalent in people with advanced or of being in control. metastatic cancer, and studies have reported that as many as 85% of individuals at the end of life may be Little is known about self-management interventions affected by edema of various causes.5,6 for complex types of lymphedema, including malignant lymphedema. In this article, we present a unique case of Important effects of lymphedema include swelling in a motivated woman with malignant lymphedema success- the limbs and other areas because of the accumulation fully adhering to a modified CDT programme with an of fluid and increased susceptibility to infections because emphasis on self-management strategies. This case may of impaired lymphatic function. Lymphedema has been help guide health professionals working with the lym- found to have negative effects on psychological well- phedema patient population. Our objectives are to (1) being, upper extremity function, and quality of life in describe self-management strategies for malignant lym- women with breast cancer.7,8 Chronic edema has also phedema using a case report and (2) raise awareness of been found to be associated with recurrent infections, the diagnosis and treatment of malignant lymphedema hospitalizations, and time off work.9 in the oncology setting. The authors obtained informed consent from the patient to publish this case report. Complete decongestive therapy (CDT), the standard treatment for lymphedema, consists of two phases. The CLIENT DESCRIPTION reductive phase involves 24-hour, multilayer compres- A 50-year-old, right-handed woman, Mrs. C., was sion bandaging, daily manual lymphatic drainage, reme- dial exercises, and skin care under the care of a certified diagnosed in February 2012 with cancer of the left breast, lymphedema therapist. Once maximum edema reduc- which had spread to the ipsilateral axillary lymph nodes. tion is obtained, the maintenance phase includes daily She commenced chemotherapy with paclitaxel and tras- compression (daytime custom-made or standard garment tuzumab, with no planned surgery or radiotherapy. In and nighttime bandaging or garment), self-massage, ex- June 2012, she was referred to our specialized hospital- ercise, and skin care to control the lymphedema. CDT, based lymphedema clinic with a 3-month history of particularly compression therapy, has been found to unexplained left-arm edema, which she reported was be effective in the treatment of lymphedema, including worsening over time. This was subsequently diagnosed cases of malignant lymphedema.10–12 Unfortunately, lym- by a specialized physician as malignant lymphedema phedema is a lifelong, irreversible condition, and manag- caused by tumour compression of the axillary lymphatic ing it can be costly and time consuming.10 Even with structures. daily interventions, frequent therapist appointments, and expensive compression materials, patients may be unable On assessment, the left upper limb had a positive to fully comply with the demands of traditional CDT. Stemmer sign, and the lymphedema was classified as moderate in severity (26.8% excess volume).19 Mrs. C. Barlow and colleagues13 have defined self-management reported avoiding any use of her left upper limb for her as daily activities, such as cooking. the individual’s ability to manage the symptoms, treat- INTERVENTION ment, physical and psychosocial consequences and life style changes inherent in living with a chronic condition. Modified complete decongestive therapy programme Efficacious self-management encompasses ability to moni- We immediately initiated a modified CDT programme, tor one’s condition and to effect the cognitive, behavioural and emotional responses necessary to maintain a satisfac- with an emphasis on self-management interventions, tory quality of life. Thus, a dynamic and continuous process with Mrs. C. at the hospital outpatient physiotherapy of self-regulation is established. (p.178) department. The programme was delivered under the guidance of a physiotherapist certified in lymphedema Educating patients about self-management strategies, such therapy. Self-management strategies are described in as self-massage, skin care, compression garments, and Table 1. exercise, may be valuable in helping them to successfully control their lymphedema.1 Exercise programmes have Initially, we scheduled therapist follow-up visits every been found to be effective for people with lymphe- week to track limb measurements and review self- dema,14,15 but other self-management strategies have management strategies as needed. After 4 months, as a been less explored in the literature.16,17 In their review, result of the improvement in Mrs. C.’s lymphedema McNeely and colleagues11 found moderate evidence sup- management, we reduced the frequency of therapist porting the use of compression garments and bandag- sessions to every 3–4 weeks until 1 year. After she was ing in managing lymphedema. Tidhar and colleagues18 discharged from the physiotherapy department, Mrs. C. studied 30 participants in a self-bandaging programme; had follow-up visits at the lymphedema clinic every 6– they found significant improvements in lymphedema 12 months, as per regular procedure. The outcome measures described next were collected at follow-up visits.
206 Physiotherapy Canada, Volume 70, Number 3 Table 1 Lymphedema Self-Management Interventions Recommended to Mrs. C Intervention Description Frequency Daily https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Compression therapy (self-applied) Multilayer, short-stretch bandages, worn 24 h/d (reductive) or during nighttime (maintenance) Daily Exercise b3–5 d/wk Self-massage Custom-made, flat-knit compression garment Daily (separately or with remedial exercises) Skin care (arm sleeve and glove), worn during daytime (maintenance) Daily Self-measurement Deep breathing or Casley-Smith remedial exercises20 Daily Weekly (reductive) General aerobic and resistance exercises Monthly (maintenance) Simple lymphatic drainage (Casley-Smith method20) Careful hygiene and application of low-pH moisturizer1 Regular inspection for cracks, wounds, or infections Circumferential tape measurement (2–4 predetermined anatomic points on edematous limb) Limb volume self-bandaging every day (sometimes rebandaging to The treating physiotherapist assessed circumferential correct loosening compression). At home or the com- munity centre, she also performed daily deep breathing, tape measurements at specified distances in relation to remedial20 or general aerobic and resistance exercises, anatomical landmarks18 on both upper limbs at each or self-massage.20 Self-bandaging continued over several appointment. This method has shown to have high relia- months to accommodate limb-volume fluctuations (poten- bility and validity.21 Limb volumes were calculated using tially attributed to chemotherapy, steroid medication, the truncated cone method. Percentage of excess volume and weight changes). When Mrs. C.’s medical status (PEV) in the affected (lymphedematous) limb compared stabilized and her treatment changed to trastuzumab only, with the unaffected limb was calculated: PEV ¼ [(affected her limb measurements stabilized, and she obtained a limb volume—unaffected limb volume)/unaffected limb custom-made compression garment for maintenance volume] Â 100. The unaffected limb was also remeasured (December 2012). The garment consisted of an arm sleeve at each visit to capture any fluctuations in volume that and a separate glove, both of compression class 1 (20– could be related to the effects of chemotherapy, weight 30 mmHg). About 1 year after she had begun the CDT changes, or other factors. programme, she was continuing daytime compression (garment and occasional self-bandaging) and daily exercise. Exercise level At clinic follow-up visits every 3–4 months, Mrs. C. Limb volume and percentage of excess volume When Mrs. C. first presented to our clinic (June 2012), reported on the type, frequency, duration, and intensity of deliberate leisure exercise she had performed in the her lymphedema was moderate in severity,19 with 26.8% previous week. Using the 2011 Compendium of Physical excess volume in her left arm compared to her right arm Activities22 as a guide, we calculated levels of leisure (17.1% upper arm, 41.6% lower arm). She had a BMI of exercise in metabolic-equivalent task (MET) hours per 31.2. Four weeks after initiating the modified CDT pro- week. A MET is estimated as the energy cost of a given gramme, Mrs. C.’s left upper-limb volume was reduced activity divided by resting energy expenditure (1 MET ¼ from 2,847 millilitres to 2,323 millilitres, and PEV was 3.5 mL/min/kg oxygen consumption). reduced to 5.9% (5.9% upper arm, 6.0% lower arm). Despite several fluctuations in limb volume, PEV was MEASURES AND OUTCOMES stable overall at 3.0% (–0.9% upper arm, 8.8% lower arm) by June 2013 (see Figure 1). In September 2013, Adherence to modified complete decongestive therapy her BMI was 29.1. programme Exercise level Mrs. C. successfully learned self-bandaging, garment In June 2012, Mrs. C. had been avoiding all functional care, self-massage, and exercises by practising with the physiotherapist during her weekly appointments and by activities requiring the use of her left upper limb as well following written instructions and photographed or video- as any deliberate leisure exercise (0 MET h/wk). In July taped sessions at home. She also enrolled in an exercise 2012, she commenced a community-based exercise pro- programme at a community centre, where a trainer pro- gramme, described in Table 2. Exercise intensity, dura- vided close supervision and communicated regularly with tion, and frequency were increased gradually, with a the treating physiotherapist. maximum of one new exercise introduced per session. Over several months, Mrs. C. augmented her exercise During the reductive phase of the modified CDT pro- gramme (commencing in June 2012), Mrs. C. practised
Shallwani and Towers Self-Management Strategies for Malignant Lymphedema: A Case Report with 1-Year and 4-Year Follow-Up Data 207 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Figure 1 Percentage of excess volume in Mrs. C.’s lymphedematous limb. Table 2 Details of Exercise Programme Carried Out by Mrs. C. Date Frequency Exercise programme July 2012 3–4 Â /wk Casley-Smith remedial or deep-breathing exercises daily Tai chi or qigong, 1-h classes, 1–2 classes/wk Low- to moderate-intensity cardiovascular training on recumbent bike, 10–15 min/session, 2–3 sessions/wk Core and lower body resistance exercises, 2–3 sessions/wk September 2012 4–5 Â /wk Tai chi or qigong, 1-h classes, 2 classes/wk Low- to moderate-intensity cardiovascular training on recumbent bike or walking, 15–30 min/session, 3–4 sessions/wk Core and lower body resistance exercises, 2–3 sessions/wk Upper body* resistance exercises (lateral and forward shoulder raises, long-arm triceps pull-down, short-range row pull), 2–3 sessions/wk February 2013 6–7 Â /wk Tai chi, qigong, or yoga, 2 classes/wk Moderate-intensity interval cardiovascular training on recumbent bike, recumbent cross-trainer, or walking and jogging, 30–60 min/session, 4–5 sessions/wk Resistance exercises for upper body,† core, and lower body, 2–3 sessions/wk *Exercises performed with left upper limb in compression bandage, with left elbow in neutral position and using low resistance (1–3 lb). † Exercises performed with left upper limb in compression garment (arm sleeve and glove). level (see Figure 2) and reported increased use of her left pharmacological treatment with trastuzumab. To control upper limb for daily activities, including cooking, bath- her lymphedema, she wore a compression class 2 (30– ing, and typing on the computer. 40 mmHg) arm sleeve and glove. Her lymphedema remained mild in severity, with an excess limb volume Four-year follow-up of 9.7% (0.4% upper arm, 21.5% lower arm). At this In June 2016, more than 4 years after being diagnosed time, her BMI was 30.8. She continued daily exercise of with lymphedema, Mrs. C. was continuing to receive
208 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Figure 2 Leisure exercise levels in metabolic-equivalent task (MET) hours per week. walking, dragon boat paddling, and weight training, should be made available and accessible to individuals reaching an average of 36 MET hours per week. On eval- with this condition. uation, she reported having improved physical function, noting increased walking tolerance and motivation. Self-management strategies for malignant lymphedema ‘‘Last month, we stayed two weeks in Europe. There, I Few studies have explored self-management interven- was able to walk, on average, fifteen kilometres a day! That motivates me a lot, makes me think that I still can.’’ tions in the population with lymphedema, particularly in cases of malignant lymphedema, in which management She also stressed the value of lymphedema self- may be complex and intensive over a lengthy period. management strategies from a patient’s perspective. Self-management strategies are important because they empower patients with the knowledge and tools to Lymphedema is a chronic disease; educating the patient adequately manage their lymphedema.18 Moreover, given and his caregivers in self-management makes lymphe- the potential health care demands of CDT, such ap- dema treatment accessible to everybody . . . Also, I think proaches can potentially improve patients’ adherence to that the fact of knowing how to control it could improve and success with treatment. In a study of patients with the self-confidence and self-esteem of the patient. breast cancer–related lymphedema, the self-care modal- ities recommended by clinicians were generally consis- IMPLICATIONS tent with current guidelines; however, the prescription rates of these strategies tended to decrease over time.25 Awareness of malignant lymphedema In addition, sub-optimal adherence by patients to these Lymphedema is a debilitating consequence of cancer modalities was reported in this analysis. and its treatment, and it is associated with chronic swell- In this article, we present a unique case report of ing, increased risk of cellulitis, long-term functional Mrs. C., a motivated woman with malignant upper limb issues, and poor quality of life.9,23,24 Malignant lymphe- lymphedema caused by advanced breast cancer who suc- dema, caused by direct tumour invasion or obstruction cessfully adopted and tailored self-management strategies. of the lymphatic vessels, has not been well explored in Over time, she benefited from improved limb volume, the literature. As demonstrated by Mrs. C.’s history, there leisure exercise levels, and self-reported physical func- may be a lack of awareness in the medical community of tion. This is particularly important in cases of malignant the appropriate and timely diagnosis and treatment of lymphedema, in which it may not always be possible malignant lymphedema. With improving survival rates to stabilize fluctuations in volume because of chang- in advanced cancer, more people live with the complex, ing tumour responses and effects of treatment. Self- long-term issues caused by cancer, including lymphe- management strategies may instead offer patients acces- dema. Oncology health professionals need to be in- sible treatment options to manage the symptoms associated formed about the different causes and factors associated with their lymphedema, maximize their physical function, with lymphedema. Likewise, suitable treatment options and improve their feelings of confidence and self-esteem.
Shallwani and Towers Self-Management Strategies for Malignant Lymphedema: A Case Report with 1-Year and 4-Year Follow-Up Data 209 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Considering the pathophysiology of malignant lym- practising the different methods of self-management, phedema caused by tumour compression of the axillary may also enhance the successful long-term control of lymph nodes, it can be argued that chemotherapy may lymphedema. Patients may benefit from frequent oppor- have contributed to the positive changes in Mrs. C.’s out- tunities to connect with lymphedema-trained specialists comes. In fact, the long-term control of lymphedema can for problem solving and feedback, particularly when likely be attributed to effective anti-cancer treatment. treatment is initiated. This is best done through in- However, the findings of immediate short-term improve- person follow-up visits, but alternative options can include ment in Mrs. C.’s edema after a 3-month history of the use of videoconferencing or other communication increasing limb volume despite receiving chemotherapy technology tools. are likely a result of initiating CDT. Also, given the chronic fluid accumulation and fibrosclerotic changes Appropriate patient education may involve giving ver- associated with lymphatic stress and the irreversibility bal instructions and using combined multidimensional, of lymphedema, lifelong management with compression and sometimes creative, approaches, including non- therapy is usually necessary for patients with malignant verbal methods such as diagrams, written instructions, lymphedema. Thus, this case report highlights the poten- photographs, and videos.29 Demonstration and hands- tial value of self-management options for successfully on practice sessions may be particularly useful to ensure controlling this condition. that patients and caregivers are comfortable with the different techniques. Effective performance of certain It is important to note that some patients with lym- self-management techniques, particularly applying com- phedema may not have the capacity to learn and fully pression bandages and donning garments, often require implement these strategies because of physical restric- manual dexterity, strength, and flexibility. Thus, care- tions (e.g., joint stiffness from arthritis), symptoms (e.g., givers can also play an important role in facilitating self- fatigue), psychological issues (e.g., severe anxiety), or management.29 cognitive limitations (e.g., inability to read and follow instructions). In particular, patients with advanced or It is important that oncology health professionals, metastatic cancer with concerns such as muscle weak- lymphedema-trained clinicians, patients, and caregivers ness, pain, and loss of energy may not be able to ade- be informed about the different treatment components quately perform certain self-management techniques. In and options to appropriately manage lymphedema. Clini- such cases, the role of caregivers, family members, and cians, particularly those trained in lymphedema therapy, community health care providers in supporting these would benefit from opportunities to acquire the skills patients becomes increasingly important. and resources to adequately educate patients in self- management practices. Regular, effective communication In our clinical experience, and as this case report among health professional colleagues about lymphedema demonstrates, most patients and their caregivers can assessment, treatment methods and associated precau- benefit from some level of guidance on self-management tions, and coordination of clinical interventions would strategies to control lymphedema. Such education can be helpful to enable a holistic approach to lymphedema be a valuable addition to patient-centred practice. Self- care, particularly in complex cases requiring long-term management techniques should be tailored and adapted management. to a patient’s status, including medical status, symptoms and physical capacity, and access to social support and Finally, financial support and additional resources, financial resources. Further studies exploring treatment such as professional support in exercise training, may be strategies, particularly in complex types of lymphedema, especially beneficial for patients during CDT. Patient are needed. safety and lymphedema-related precautions related to exercise are important to consider. Specialized inter- Effective self-management of lymphedema ventions that are accessible by and cost effective for The successful implementation of self-management the population with lymphedema need to be further explored. strategies for lymphedema depends on several factors. Research has reported that barriers to the optimal self- Long-term lymphedema management management of lymphedema were related to physical Given the chronic, irreversible nature of lymphedema, capacity (difficulty with bandaging, modifying clothing), time, discomfort, financial costs, and motivation.26,27 its long-term management requires careful consideration. Patient knowledge has been identified as an important The CDT strategies necessary to maintain stable limb factor in adherence to self-care strategies for individuals volumes can be particularly challenging for patients with breast cancer–related lymphedema.28 Educating to observe over time. In our report, despite Mrs. C.’s patients soon after diagnosis about the development adherence to compression therapy and exercise, she and progression of lymphedema, available treatments, demonstrated an increase in her lower arm volume from and their role in managing the condition may be benefi- her 1-year visit to her 4-year visit and similar changes in cial. Among affected individuals and their caregivers, her BMI. In general, several factors may influence the motivation and a willingness to learn, as well as actually progression of lymphedema, including disease and treat- ment status, nutritional status and body weight, activity
210 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 levels, compression tolerance, and other potential triggers cancer patients with lymphedema: a systematic review of patient- (trauma, injury, cellulitis infection).19 Also, it is important reported outcome instruments and outcomes. J Cancer Surviv. to note the challenges of assessing lymphedema using 2013;7(1):83–92. http://dx.doi.org/10.1007/s11764-012-0247-5. circumferential measures, such as difficulty with captur- Medline:23212603 ing hand volumes. Nonetheless, the long-term manage- 9. Moffatt CJ, Franks PJ, Doherty DC, et al. Lymphoedema: an ment of lymphedema has been documented as a chal- underestimated health problem. QJM. 2003;96(10):731–8. http:// lenge for this population,30 and it is an area requiring dx.doi.org/10.1093/qjmed/hcg126. Medline:14500859 further investigation. Follow-up therapist visits, nutri- 10. Lasinski BB, McKillip Thrift K, Squire D, et al. A systematic review of tional counselling, and community-based programmes the evidence for complete decongestive therapy in the treatment of such as exercise classes, educational workshops, and lymphedema from 2004 to 2011. PM R. 2012;4(8):580–601. http:// support groups may be useful strategies for helping dx.doi.org/10.1016/j.pmrj.2012.05.003. Medline:22920313 patients manage their lymphedema over time. 11. McNeely ML, Peddle CJ, Yurick JL, et al. Conservative and dietary interventions for cancer-related lymphedema: a systematic review KEY MESSAGES and meta-analysis. Cancer. 2011;117(6):1136–48. http://dx.doi.org/ 10.1002/cncr.25513. Medline:21381006 What is already known on this topic 12. Hwang KH, Jeong HJ, Kim GC, et al. Clinical effectiveness of Although traditional decongestive therapy has been complex decongestive physiotherapy for malignant lymphedema: a pilot study. Ann Rehabil Med. 2013;37(3):396–402. http://dx.doi.org/ found to be effective in the treatment of lymphedema, 10.5535/arm.2013.37.3.396. Medline:23869338 the successful, long-term management of this condition 13. Barlow J, Wright C, Sheasby J, et al. Self-management approaches for may be costly and time consuming for affected indi- people with chronic conditions: a review. Patient Educ Couns. viduals. Little is currently known about self-management 2002;48(2):177–87. http://dx.doi.org/10.1016/S0738-3991(02)00032-0. strategies for lymphedema, particularly malignant lym- Medline:12401421 phedema. 14. Chang CJ, Cormier JN. Lymphedema interventions: exercise, surgery, and compression devices. Semin Oncol Nurs. 2013; What this study adds 29(1):28–40. http://dx.doi.org/10.1016/j.soncn.2012.11.005. 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https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 ARTICLE Neuropathic Pain after Shoulder Arthroplasty: Prevalence, Impact on Physical and Mental Function, and Demographic Determinants Helen Razmjou, PT, PhD;*†‡ Linda J. Woodhouse, PT, PhD;§¶ Richard Holtby, BS, MB, FRCSC**†† ABSTRACT Purpose: The objectives of this survey study were to provide an estimate of the prevalence of neuropathic pain (NP) and to explore the cross-sectional and longitudinal group differences postoperatively. Method: A cohort of consecutive patients who had undergone total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), or humeral head replacement (HHR) were surveyed within an average of 3.8 years after surgery. Questionnaires completed at the time of the survey were the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale, the visual analogue scale (VAS) for pain, the Western Ontario Osteoarthritis of the Shoulder (WOOS) index, the Patient Health Questionnaire–9 (PHQ–9), and a satisfaction questionnaire. Results: Of the 141 candidates who were invited to participate in the study, 115 patients participated (85 TSA, 21 HHR, and 9 RSA), for an 82% response rate. Five patients (4%) met the criteria for NP, of whom one had a loosening of the prosthesis and required further surgery. Having NP was associated with greater pain (VAS; p ¼ 0.001), greater depression (PHQ–9; p ¼ 0.001), more disability (WOOS; p ¼ 0.030), and less satisfaction with the surgery (p ¼ 0.014). There was no relationship between the presence of NP and patients’ age, sex, preoperative pain, range of motion results, or WOOS scores (p > 0.05). Conclusions: Persistent pain of neuropathic origin is not common after shoulder arthroplasty, but it is a significant contributor to poor mental and physical well-being and thus warrants further research. Key Words: neuropathic pain; prevalence; shoulder arthroplasty. RE´ SUME´ Objectif : la pre´ sente e´ tude par sondage visait a` e´ valuer la pre´ valence de la douleur neuropathique (DN) et a` explorer les diffe´ rences transversales et longitudinales des groupes apre` s l’ope´ ration. Me´ thodologie : la pre´ sente e´ tude visait a` sonder une cohorte de patients conse´ cutifs qui avaient subi une arthroplastie totale de l’e´ paule (ATE´ ), une arthroplastie inverse´ e de l’e´ paule (AIE´ ) ou un remplacement de la teˆ te de l’hume´ rus (RTH), en moyenne 3,8 ans apre` s l’intervention. Au moment du sondage, les patients ont rempli les questionnaires sur l’e´ chelle autoadministre´ e de la Leeds Assessment of Neuro- pathic Symptoms and Signs (S-LANSS; e´ valuation des signes et symptoˆ mes de la douleur neuropathique de Leeds), l’e´ chelle visuelle analogique (E´ VA) de la douleur, le score du Western Ontario Osteoarthritis of the Shoulder (arthrose de l’e´ paule de Western Ontario, ou WOOS), le questionnaire sur la sante´ du patient-9 (PHQ-9) et un questionnaire sur la satisfaction. Re´ sultats : des 141 candidats qui ont e´ te´ invite´ s a` participer a` l’e´ tude, 115 ont obtempe´ re´ (85 ATE´ , 21 RTH et 9 AIE´ ), ce qui repre´ sente un taux de re´ ponse de 82 %. Cinq patients (4 %) respectaient les crite` res de DN, dont un pre´ sentait un descellement de la prothe` se qui ne´ cessitait une nouvelle ope´ ration. La DN s’associait a` plus de douleur (E´ VA, p ¼ 0,001), plus de de´ pression (PHQ-9, p ¼ 0,001), plus d’incapacite´ (WOOS, p ¼ 0,030) et moins de satisfaction envers l’ope´ ration (p ¼ 0,014). Il n’y avait pas de relation entre la DN du patient et son aˆ ge, son sexe, sa douleur pre´ ope´ ratoire, son amplitude de mouvements apre` s l’ope´ ration ou les scores WOOS (p > 0,05). Conclusions : la douleur persistante d’origine neuropathique n’est pas courante apre` s une arthroplastie de l’e´ paule, mais elle nuit de manie` re significative au bien-eˆ tre mental et physique, ce qui justifie la poursuite des recherches sur le sujet. Shoulder arthroplasty is an effective means of improv- of patients continues to suffer from persistent postopera- ing pain and disability in patients with advanced osteo- tive pain.8–10 The postoperative pain is either nociceptive arthritis of the glenohumeral joint.1–7 However, a subset or neuropathic in nature. Nociceptive is taken from the From the: *Department of Rehabilitation, Holland Orthopaedic & Arthritic Centre; ‡Sunnybrook Research Institute; **Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre; †Department of Physical Therapy; ††Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto; §Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton; ¶McCaig Institute for Bone and Joint Health, Calgary. Correspondence to: Helen Razmjou, Holland Orthopaedic & Arthritic Centre, 43 Wellesley St. E., Toronto, ON M1Y 1H1; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: Helen Razmjou was partially supported by the Holland Centre Musculoskeletal Clinician Investigator Funding Program and the Suzanne and William Holland Funding, Sunnybrook Health Sciences Centre, during the study period. Physiotherapy Canada 2018; 70(3);212–220; doi:10.3138/ptc.2016-99 212
Razmjou et al. Neuropathic Pain after Shoulder Arthroplasty: Prevalence, Impact on Physical and Mental Function, and Demographic Determinants 213 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Latin word nocere and means ‘‘harm’’ or ‘‘hurt,’’ referring the glenohumeral joint with or without rotator cuff tear to noxious chemical, thermal, and mechanical stimuli requiring a shoulder replacement. The exclusion criteria mediated by the receptors in the skin, bone, connective included the inability to speak or read English, evidence tissue, and muscles. In contrast, neuropathic pain (NP) of infection, underlying metabolic disease, osteonecrosis, is elicited from an injury or disease of the neurons in or capsulorraphy arthropathy. Patients with primary the peripheral or central nervous system.11–13 Whereas osteoarthritis and an intact rotator cuff underwent TSA, nociceptive pain is caused by the stimulation of pain and patients with rotator cuff tear arthropathy or mas- receptors and resolves once the stimulus has been re- sive rotator cuff tear underwent RSA. HHR was performed moved, NP is produced by the release of inflammatory in younger patients with a normal glenoid articular sur- mediators, including neuropeptides and neurotransmitters, face or those with severe glenoid deficiency. Standardized secondary to injury or damage to peripheral nerves or preoperative clinical data, surgical findings, and follow-up the central nervous system,14,15 and it may persist for data that had been collected prospectively were extracted months or years beyond the apparent healing of the from a shoulder research database. All subjects provided damaged tissues. Nociceptive pain tends to be well local- informed consent. Approval for use of human subjects ized, sharp, aching, or throbbing in nature. NP is described was obtained from the Research Ethics Board of the as burning, tingling, or shooting or like electric shock in Sunnybrook Health Sciences Centre. nature, and it is particularly recognized by the presence of chronic allodynia (pain resulting from a light stimulus) and Rehabilitation hyperalgesia (increased sensitivity to normal stimuli).16–19 All patients were given a comprehensive rehabilita- There is a significant literature on NP occurring after tion protocol to follow after surgery. A sling was worn lower extremity joint replacement.20–27 However, there for 2 weeks after TSR or HHR and for 4 weeks after RSA; is minimal information on NP after shoulder arthroplasty. active assisted mobilization started on day 1 after sur- The only study, by Bjørnholdt and colleagues,10 reported gery. Sub-maximal isometric exercises started at 4 weeks the prevalence of presumed NP to be 13% at 1 or 2 years after TSR or HHR and 6 weeks after RSA. Active exercises post–shoulder arthroplasty. In their study, Bjørnholdt started at 6 weeks in a lying position and progressing to and colleagues translated a French questionnaire, the an upright position. Resistive exercises started at 8–10 Douleur Neuropathique (DN4),28 into Danish to measure weeks after TSR or HHR and 12 weeks after RSA. Exer- NP in their sample, whose data they had extracted from cises related to internal rotation followed the other direc- the Danish Shoulder Arthroplasty Register. The DN4 has tions of movement with a 4-week delay to avoid strain not been validated for sensitivity or specificity in patients on the subscapularis tendon. with shoulder arthroplasty, and further assessment of the subject in a different population with a more estab- Baseline and follow-up outcome measures lished measure of NP will add to the body of knowledge Baseline data were collected at 2–3 weeks before sur- in this area. gery, and follow-up data were collected at 6 months and Persistent pain of neuropathic origin is a significant 1 year after surgery. Baseline and follow-up data included contributor to poor physical function, impaired health- the visual analogue scale (VAS) for average pain, the related quality of life, and greater use of health care.29,30 Western Ontario Osteoarthritis Shoulder (WOOS) index Exploring the prevalence of this disabling condition, for self-reported disability,5 and active, pain-free range which results in intractable pain after shoulder arthro- of motion (ROM). The ROM assessment was performed plasty and its potential predisposing factors, warrants with the patient in an upright position and was based further research. The objectives of this study were to on the performance component of the Constant-Murley provide an estimate of the prevalence of NP and to score.31 Flexion, abduction, external rotation, and internal explore the cross-sectional and longitudinal differences rotation (hand behind back) were measured separately between patients with and without postoperative NP. and given a score ranging from 0 to 10 for each direction In addition, the role of patient characteristics in the (maximum 40). presence of postoperative NP was explored. Survey outcome measures METHODS The questionnaires completed at the time of the sur- Patient population vey were (1) the Self-Administered Leeds Assessment of This was a survey of a cohort of consecutive patients Neuropathic Symptoms and Signs (S-LANSS) pain scale,32 which was used to identify the existence of NP after who had undergone total shoulder arthroplasty (TSA), surgery; (2) the WOOS index, to measure self-reported humeral head replacement (HHR), or reverse shoulder disability;5 and (3) the Patient Health Questionnaire–9 arthroplasty (RSA) over a period of 12 years (2002–2014). (PHQ–9), to identify potential depressive or mental dis- The inclusion criteria were individuals aged older than orders.33 In addition, all patients were asked to rate the 18 years and a diagnosis of advanced osteoarthritis of amount of pain on an average day using the VAS and to respond to the following question: ‘‘How satisfied are
214 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Figure 1 Diagram of recruitment process. prevalence of an unknown condition. For the purpose of TSA ¼ total shoulder arthroplasty; HHR ¼ humeral head replacement; this study, with a level of confidence of 1.96 and a better RSA ¼ reverse shoulder arthroplasty. precision of 7%, a minimum of 89 cases with complete data were deemed necessary. you with the results of your surgery?’’ Their satisfaction level was rated on a 6-point Likert scale: very satisfied, Statistical analysis somewhat satisfied, a little bit satisfied, a little bit dis- The estimate of prevalence was calculated as number satisfied, somewhat dissatisfied, and very dissatisfied. of NP cases divided by the total number of subjects. De- S-LANSS scores range from 0 to 24,34,35 and scores scriptive statistics (means, SD) were calculated for varia- of 12 or more suggest NP;35,36 the S-LANSS has shown bles of interest for NP and non-NP groups. validity and reliability for identifying NP after lower extremity joint arthroplasty.26,27,32 The WOOS index has Cross-sectional group differences 19 questions and has been reported to be valid and reli- Baseline and follow-up differences between the NP able in patients with glenohumeral osteoarthritis.5 The PHQ–9 has nine items and has shown validity in patients and non-NP groups in pain, perceived disability, and with musculoskeletal disorders and osteoarthritis.37–41 level of depressive or mental conditions were explored using the VAS, WOOS, and PHQ–9, respectively. Cross- Initially, a letter that described the nature of the study sectional differences were examined using Wilcoxon was mailed to study candidates. A second letter with five two-sample tests for non-normally distributed continuous questionnaires attached was mailed approximately 10 days data. Recovery from pain and disability was examined as later. Patients who did not respond received another the amount of change in VAS and WOOS between base- reminder at approximately 2 months. The 6-week and 3- line data and data collected at the time of the survey. month post-surgical data and the most recent medical Fisher’s exact tests were used for categorical data. records of patients who met the criteria for having NP were reviewed to rule out any prosthetic failure or other Predictors of neuropathic pain medical conditions that might have contributed to chronic The S-LANSS score was the dependent variable. The NP. predictors of NP were age, sex, and baseline, 6-month, Sample size and 1-year VAS, ROM, and WOOS scores. Univariable logistic regressions were used to examine the relation- The sample size calculation for estimating the preva- ship between NP and individual predictors. Statistical lence was based on a formula suggested by Daniel.42 In analyses were performed using the SAS statistical soft- this formula, ware (version 9.1.3; SAS Institute, Cary, NC). Statistical results were reported using two-tailed p-values, with n ¼ Z2Pð1 À PÞ significance set at p < 0.05. d2 RESULTS Z is the Z statistic for level of confidence (1.96 for 95% A total of 141 patients were contacted, of whom 115– CI), P is the expected prevalence of 13%, and d is preci- sion. Use of a precision of 10% or more has been sug- 67 (58%) women and 48 (42%) men, for a response rate of gested for preliminary studies that are investigating the 82%—participated in the study (see Figure 1). Five patients had bilateral surgeries. To avoid bias related to using patients with bilateral problems as independent cases due to violating the assumption of independence,43–46 one joint of the patients who had bilateral surgeries was randomly selected and included in the study. We found no statisti- cally significant differences in age, sex, or preoperative level of disability on the basis of respondents’ and non- respondents’ WOOS (p > 0.05). The final sample included 85 (74%) participants with TSA, 21 (18%) participants with HHR, and 9 (8%) participants with RSA. The mean time frame between surgery and final data collection was 3.8 (SD 2) years, with a range of 2–12 years. Estimated prevalence Five patients with TSA met the criteria for having NP (NP group; prevalence 4%). The means on the S-LANSS were 18.20 (SD 2.4) and 0.52 (SD 1.70) for the NP and non-NP groups, respectively. None of the patients with NP had bilateral shoulder joint arthroplasty. All patients had osteoarthritis of the
Razmjou et al. Neuropathic Pain after Shoulder Arthroplasty: Prevalence, Impact on Physical and Mental Function, and Demographic Determinants 215 Table 1 Baseline Differences in Patients with and without NP No. (%) of patients* Statistics Z-value,*† FET, https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Variable NP group Non-NP group p-value (n ¼ 5) (n ¼ 110) or t-value 0.22 1.22 0.40 Age, y, mean (SD) 65 (10) 69 (9) FET ¼ 0.24 Sex 0.38 2 (40) 66 (60) FET ¼ 0.22 Female 3 (60) 44 (40) 0.72 Male FET ¼ 0.21 Affected side 4 (80) 50 (45.4) Right 1 (20) 60 (54.5) FET ¼ 0.24 0.32 Left Type of arthroplasty 5 (100) 80 (72.7) t ¼ 0.66 0.54 TSA – 21 (19.1) HHR – 9 (8.2) 0.47 0.64 RSA 1.09 0.27 Mechanism of injury 3 (60) 86 (78.2) Insidious 2 (40) 24 (21.8) 0.34 0.73 Traumatic 10.08 (9) 7.42 (7) 0.25 0.80 Symptom duration, mo, mean (SD) Self-report outcome measures, mean (SD) 23.00 (11) 28.50 (17) 0.93 0.35 Baseline 5.00 (3) 6.35 (3) 0.05 0.96 WOOS (0–100) 67.33 (33) 75.15 (22) 0.01 0.99 VAS (0–10) 1.33 (2) 1.78 (2) 0.00 1.00 6 mo 0.33 0.74 WOOS (0–100) 69.20 (26) 79.44 (21) VAS (0–10) 1.80 (2) 1.40 (2) 1y WOOS (0–100) 8.00 (6) 8.24 (6) VAS (0–10) 21.33 (16) 23.38 (9) Range of motion (0–40) 22.80 (15) 26.24 (9) Baseline 6 mo 1y *Unless otherwise indicated. † Z-values are based on the Wilcoxon two-sample non-parametric test. NP ¼ neuropathic pain; FET ¼ Fisher’s exact test; TSA ¼ total shoulder arthroplasty; HHR ¼ humeral head replacement; RSA ¼ reverse shoulder arthroplasty; WOOS ¼ Western Ontario Osteoarthritis of the Shoulder index; VAS ¼ visual analogue scale. glenohumeral joint, with non-specific synovitis intra- results were comparable between the groups at baseline operatively. There was no history of alcoholism or diabetes and at 6 months and 1 year after surgery (see Table 1). among the patients with NP. No patient had a documented However, cross-sectional comparisons at the time of the history of cervical radiculopathy or carpal tunnel syndrome survey revealed statistically significant group differences before or after surgery. One patient had a history of on the VAS, WOOS, and PHQ–9, with the NP group having chronic pain. Review of the 6-week and 3-month post- more pain, disability, and depression (see Table 2). The operative data did not indicate any evidence of intra- lack of group differences at baseline may indicate the operative or perioperative nerve injury. absence of NP before surgery because this condition is associated with higher reports of pain and physical and The mean amount of time between date of surgery mental disability. and the last clinical or imaging assessment was 1.95 (SD 0.5) years. An electronic data search and the most recent Of the non-NP group, 107 (97%) patients reported radiographs and follow-up reports of the patients with being satisfied with the surgery, and only 3 patients re- NP showed a loosening of the prosthesis in only one ported being dissatisfied. Although 2 participants (40%) case at 5 years after surgery. This patient had an asso- in the NP group reported dissatisfaction, having NP did ciated rotator cuff tear for which he had a repair before not affect overall satisfaction in 3 (60%) patients in that undergoing TSA. group (see Table 2). Cross-sectional group differences Recovery No statistically significant group differences were The change over time in VAS and WOOS was assessed found in age, sex distribution, mechanism of injury, or between the baseline and postoperative scores collected at symptom duration. The VAS and WOOS scores and ROM the time of the survey. The NP group did not report any
216 Physiotherapy Canada, Volume 70, Number 3 Table 2 Cross-Sectional Group Differences at Time of Survey in VAS, neurological damage according to 6-week or 3-month WOOS, PHQ–9, and Satisfaction data. One patient experienced a mechanical failure of the prosthesis and underwent a revision surgery 5 years https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Mean (SD) Statistics* after the original TSA and 1 year after completing the survey. Of interest is the fact that none of the patients in NP group Non-NP group Z-value our sample who had RSA or HHR reported NP despite a (n ¼ 5) (n ¼ 110) or FET p-value much higher incidence of neurological deficits reported in non-anatomic arthroplasties.47 Variable (interval) 7 (1) 1 (2) 3.94 0.001 VAS (0–10) 60 (37) 88 (16) À2.19 0.030 There has been an increasing interest in postoperative WOOS (0–100) 7 (4) 2 (4) 0.001 NP in the field of arthroplasty.20–27 In the early stages PHQ–9 (0–27) 3.46 of healing after joint arthroplasty, surgically related in- flammation or damage to tissues is expected to produce Satisfaction, no. (%)† 0.014 0.014 nociceptive pain. However, why a subset of patients con- Very satisfied tinues to have persistent pain long after the local in- Somewhat satisfied 3 (60) 92 (83.6) flammation or hyperthermia has subsided is not clear. A bit satisfied 0 13 (11.8) Failure after shoulder arthroplasty has been attributed A bit unsatisfied 0 2 (1.8) to rotator cuff insufficiency,48 excessive posterior glenoid Somewhat unsatisfied 0 1 (0.9) wear,9,49 periprosthetic fractures, aseptic loosening of the Very dissatisfied 1 (20) 1 (0.9) glenoid component, or pain secondary to perioperative 1 (20) 1 (0.9) neurological complications.8 Common nerve injuries after shoulder arthroplasty involve brachial plexus or *Based on the Wilcoxon two-sample test. axillary nerve damage,50 with occasional radial nerve51 or † Statistics were calculated for two categories: satisfied and unsatisfied. median nerve palsy.52 Factors that contribute to periph- NP ¼ neuropathic pain; FET ¼ Fisher’s exact test; VAS ¼ visual analogue eral nerve injuries involve manipulation of the arm,53 scale; WOOS ¼ Western Ontario Osteoarthritis of the Shoulder index; aberrant retractor placement, excessive traction,54 inter- PHQ-9 ¼ Patient Health Questionnaire–9. scalene blockade,55 and the actual design of the implant, which may increase strain on the lateral and medial improvement in pain (p ¼ 0.33) or disability (p ¼ 0.08) roots of the median nerve.52 Fortunately, arthroplasty- over time, and the non-NP group showed a statistically related neurological injuries are relatively rare, and the significant improvement in both scores (p < 0.0001). majority are reversible within a few months.47,56,57 Predictors of neuropathic pain The NP prevalence of 4% in our study is lower than We found no relationship between age, sex, and base- that reported by Bjørnholdt and colleagues,10 who stated a prevalence of 13% in 538 patients at 1 or 2 years after line VAS, WOOS, or ROM scores on the one hand and de- shoulder arthroplasty. Bjørnholdt and colleagues used a velopment of NP (p > 0.05) on the other (see Table 3). Danish version of the DN4 to measure NP. The DN4 con- Similarly, neither the 6- nor the 12-month VAS, WOOS, sists of 10 items: 7 items are related to the quality of pain or ROM scores predicted NP at an average of 3.8 years and its association with abnormal sensations and are after surgery (p > 0.05). based on an interview with a patient, and 3 items are related to a clinical examination and include the presence DISCUSSION or absence of touch or pinprick hypoesthesia and tactile To reduce selection bias associated with the preva- allodynia. The total score is calculated as the sum of all 10 items, and the cutoff value for the diagnosis of NP is a lence of NP, our study population consisted of patients total score of 4 out of 10. In Bjørnholdt and colleagues’ with advanced osteoarthritis of the glenohumeral joint study, a score of 4 out of 7 was considered to be positive who had undergone three different arthroplasty proce- NP.10 dures. We contacted all patients who met the inclusion criteria and had an acceptable response rate of 82%. The present study showed that five patients (4%) had experienced persistent pain of neuropathic origin at an average of 3.8 years after TSA, and none of them had Table 3 Preoperative Predictors of Neuropathic Pain Development Independent variable Wald w2 p-value OR 95% CI Sex, male/female 0.75 0.39 0.04 0.7, 2.77 Age, y 1.30 0.25 0.95 0.86, 1.04 Preoperative VAS for pain (0–10) 1.28 0.26 0.82 0.59, 1.15 Preoperative WOOS for disability (0–100) 0.51 0.48 0.98 0.92, 1.04 Preoperative pain-free ROM (0–40) 0.01 0.93 0.99 0.86, 1.15 OR ¼ odds ratio (point estimate); VAS ¼ visual analogue scale; WOOS ¼ Western Ontario Osteoarthritis of the Shoulder index; ROM ¼ range of motion.
Razmjou et al. Neuropathic Pain after Shoulder Arthroplasty: Prevalence, Impact on Physical and Mental Function, and Demographic Determinants 217 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 The DN4 questionnaire was originally developed in is evidence that some patients with advanced osteo- French,28 and although it has established validity in French arthritis undergoing joint replacement have altered pain for low back pain, traumatic nerve injuries, inflammatory perception before surgery.69–71 Production of inflamma- osteoarthritis, and diabetes mellitus,28,58–60 it has not been tory cytokines may promote local chronic inflammation validated in patients with shoulder arthroplasty or in of the joint, leading to NP in a subset of patients with Danish. In a validity study by Walsh and colleagues,61 osteoarthritis.72,73 However, a lack of significant between- there was fair agreement between the S-LANSS and the group differences before surgery and at 6 months and 1 DN4 in patients with low-back-related leg pain. NP was year after surgery may indicate that NP symptoms took identified in 15 subjects (33%) using the S-LANSS and in longer than 1 year to develop. Measuring inflammatory 19 subjects (42%) using the DN4, indicating that the DN4 factors in the synovial fluid of candidates for arthroplasty might have exaggerated the existence of NP. We are in in future studies may improve our understanding of agreement with Walsh and colleagues61 that the cutoff the predictors of NP development after joint arthroplasty point for the classification of NP of the S-LANSS and surgery. DN4 may not be congruent and that the DN4 may over- estimate the presence of NP. In terms of satisfaction, although the NP group was more likely to be dissatisfied with the surgery, three The prevalence of 4% after shoulder arthroplasty was patients in this group reported high satisfaction. Report- lower than that reported for total knee arthroplasty ing being content with surgery despite experiencing (TKA), which ranges from 6%24,25 to 43%.62 Most com- persistent pain may be related to better coping abilities monly, the prevalence rate is reported at 10%–15%, with and the response-shift phenomenon known to occur values reported of 11%,63 13%,23, and 14%.26,64 In a recent after musculoskeletal surgeries.74,75 The relationship be- study that examined the prevalence and predictive value tween NP and satisfaction with surgery has been explored of patient-related factors after TKA, no relationship was in patients after TKA: Phillips and colleagues64 reported found among age, sex, and development of NP.26 How- that more than 80% of the dissatisfied patients had high ever, the NP group reported higher levels of pain, stiff- levels of pain, and 45% had possible NP. ness, and physical dysfunction than the non-NP group as early as 1 year after surgery. One explanation for the Our study has several limitations. First, it used the data lower rate of NP in patients after TSA may be the lower of patients operated on by one surgeon who specialized level of morbidity and mortality in patients undergoing in shoulder arthroplasty reconstruction at an academic shoulder compared with knee arthroplasty.65,66 Fehringer centre, and these data may limit the generalizability of and colleagues66 reported that after adjusting for multiple our results and underestimate the prevalence of NP in risk factors, the number of complications and readmis- non-academic centres. Other limitations of the study sions and length of stay were lower for patients with are those characteristics of survey designs. For example, TSA than for patients with TKA. This may also account the time frame between the arthroplasty and the survey for the delay in the development of NP in shoulder was different for each patient, and the presence of NP patients. On the basis of our findings, the development before surgery could not be verified because the S- of NP occurred at some point between 1 year and an LANSS was not available at baseline. In addition, the average of 3.8 years after the surgery. present study was based on self-report tools; including an objective sensory assessment in future studies will Patients identified as having NP had similar levels improve the accuracy of detecting NP. Finally, the results of pain, disability, and ROM before surgery and at 6 of an analysis of rare conditions in cohort studies should months and 1 year after surgery. However, at an average be viewed with caution. of 3.8 years, the pain (VAS) and physical disability (WOOS) reported by the NP group were higher at a statistically sig- CONCLUSIONS nificant level. In addition, the NP group reported higher The prevalence of NP was 4% after shoulder arthro- levels of depression and lower levels of overall satisfaction with the surgery. The presence of depression, anxiety, and plasty; it was associated with higher levels of disability higher disability is significantly and independently asso- and depression and with lower satisfaction with the sur- ciated with persistent pain after TKA25,27,67,68 and is ex- gery at an average of 3.8 years after TSA. Patient demo- pected to be the case after upper extremity arthroplasty. graphics were not predictors of NP development. Although In the present study, the average PHQ–9 score of 7 indi- persistent pain of neuropathic origin does not appear to cates mild depression, and the VAS score of 7 out of 10 be common after shoulder arthroplasty, when present, it and WOOS score of 60 out of 100 indicate moderate to seems to contribute to poor mental and physical well- severe pain and disability, respectively. being and warrants further research. In our study, age, sex, mechanism of injury, and KEY MESSAGES symptom duration were not predictors of developing NP, and neither preoperative pain nor perceived disability What is already known on this topic played a significant role in the development of NP. There There is a significant body of knowledge on neuro- pathic pain (NP) after lower extremity joint replacement.
218 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 However, information on the prevalence and nature of Res Ther. 2011;13(2):210. http://dx.doi.org/10.1186/ar3305. the factors that may contribute to developing NP after Medline:21542894 shoulder arthroplasty is very limited. 12. Schaible HG. Pathophysiologie des schmerzes [Pathophysiology of pain]. Orthopade. 2007;36(1):8, 10–2, 14–6. Medline:17106742. What this study adds 13. Schaible HG. Peripheral and central mechanisms of pain generation. This study showed that only 4% of patients who had Handb Exp Pharmacol. 2007;(177):3–28. Medline:17087118. 14. Omoigui S. The biochemical origin of pain: the origin of all pain is undergone shoulder arthroplasty featured NP qualities inflammation and the inflammatory response. Part 2 of 3— that could not be explained by preoperative characteristics. inflammatory profile of pain syndromes. Med Hypotheses. Patients who participated in the present study did not 2007;69(6):1169–78. http://dx.doi.org/10.1016/j.mehy.2007.06.033. differ in pain, disability, or range of motion up to 1 year Medline:17728071 after surgery; this finding may indicate a need for a more 15. Omoigui S. The biochemical origin of pain—proposing a new law of comprehensive assessment of neuropathic symptoms at pain: the origin of all pain is inflammation and the inflammatory longer follow-ups. Diagnostic and therapeutic strategies response. Part 1 of 3—a unifying law of pain. Med Hypotheses. implemented early in the course of recovery are expected 2007;69(1):70–82. http://dx.doi.org/10.1016/j.mehy.2006.11.028. to improve satisfaction with surgery, and physical and Medline:17240081 mental well-being, in patients who may develop NP in 16. Bouhassira D, Attal N. 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https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 ARTICLE Gait Training after Stroke on a Self-Paced Treadmill with and without Virtual Environment Scenarios: A Proof-of-Principle Study Carol L. Richards, PhD, PT, OC;*† Francine Malouin, PhD;*† Anouk Lamontagne, PhD, PT;‡§ Bradford J. McFadyen, PhD;*† Francine Dumas, MSc, PT;*† Franc¸ois Comeau, MSc, PEng;*† Nancy-Michelle Robitaille, MD, FRCP (C);† Joyce Fung, PhD, PT‡§ ABSTRACT Purpose: The purpose of this proof-of-principle study was to show that virtual reality (VR) technology could be coupled with a self-paced treadmill to further improve walking competency in individuals with chronic stroke. Method: A 62-year-old man with a chronic right hemispheric stroke participated in a treadmill walking programme involving first a control (CTL) protocol, then VR training. In CTL training, he walked without time constraints while viewing still pictures and reacting to treadmill movements similar to those that he would have experienced later in VR training. In VR training, he experienced treadmill movements programmed to simulate changes encountered in five virtual environments rear-projected onto a large screen. Training difficulty in nine sessions over 3 weeks was increased by varying the time constraints, terrain surface changes, and obstacles to avoid. Effects on walking competency were assessed using clinical measures (5 m walk test, 6 min walk test, Berg Balance Scale, Activities-specific Balance Confidence scale) and ques- tionnaires (Assessment of Life Habits Scale and personal appraisal). Results: CTL and VR training resulted in a similar progression through the training sessions of total time walked on the treadmill. The VR training led to an additional increase in speed as measured by walking 5 metres as fast as possible and distance walked in 6 minutes, as well as improved balance self-efficacy and anticipatory locomotor adjustments. As reported by the participant, these improved outcomes transferred to real-life situations. Conclusions: Despite the limited potential for functional recovery from chronic stroke, an individual can achieve improvements in mobility and self-efficacy after participating in VR-coupled treadmill training, compared with treadmill training with the same intensity and surface perturbations but without VR immersion. A larger scale, randomized controlled trial is warranted to determine the efficacy of VR-coupled treadmill training for mobility intervention post-stroke. Key Words: anticipatory locomotor control; self-efficacy; stroke; virtual reality; walking competency. RE´ SUME´ Objectif : la pre´ sente e´ tude de validation visait a` de´ montrer que la re´ alite´ virtuelle (RV) peut eˆ tre jumele´ e a` un tapis roulant autocontroˆ le´ pour ame´ liorer l’aptitude a` marcher des personnes ayant un accident vasculaire ce´ re´ bral (AVC) chronique. Me´ thodologie : un homme de 62 ans ayant un AVC chronique de l’he´ misphe` re droit a participe´ a` un programme de marche sur tapis roulant, d’abord au moyen d’un protocole de controˆ le (CTL), puis d’un entraıˆnement en RV. Pendant l’entraıˆnement CTL, l’homme a marche´ sans contrainte de temps tout en regardant des images fixes et en re´ agissant aux mouvements du tapis roulant semblables a` ceux repris par la suite en RV. Pendant l’entraıˆnement en RV, il a ressenti les mouvements du tapis roulant programme´ s pour simuler les changements observe´ s dans cinq environnements virtuels re´ troprojete´ s sur grand e´ cran. La difficulte´ de l’entraıˆnement au cours de neuf se´ ances re´ parties sur trois semaines a augmente´ en variant les contraintes de temps, les changements de surface du terrain et les obstacles a` e´ viter. Les chercheurs ont e´ value´ les effets sur l’aptitude a` marcher a` l’aide de mesures cliniques (tests de marche de cinq me` tres et de six minutes, e´ chelle d’e´ valuation de l’e´ quilibre de Berg, e´ chelle de confiance en l’e´ quilibre pendant des activite´ s) et de questionnaires (e´ chelle d’e´ valuation des habitudes de vie et e´ valuation personnelle). Re´ sultats : l’entraıˆnement CTL et celui en RV ont suscite´ une progression similaire de la dure´ e totale de marche sur le tapis roulant pendant les se´ ances d’entraıˆnement. L’entraıˆnement en RV a favorise´ une ame´ lioration supple´ mentaire de la marche rapide sur cinq me` tres et de la distance parcourue en six minutes, de meˆ me qu’une meilleure auto-efficacite´ de l’e´ quilibre et de meilleurs ajustements locomoteurs anticipe´ s. Comme From the: *Department of Rehabilitation; †CIRRIS Research Centre, Universite´ Laval, Quebec City; ‡School of Physical and Occupational Therapy, McGill University, Montreal; §Feil/Oberfeld/CRIR Research Centre, Jewish Rehabilitation Hospital, Laval, Quebec. Correspondence to: Joyce Fung, School of Physical and Occupational Therapy, McGill University, 3654 Prom. Sir-William-Osler, Montreal, QC H3G 1Y5; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: None declared. This work was supported by grants from the Canadian Stroke Network, the Canada Foundation for Innovation, and the Fonds de la recherche du Que´ bec – sante´ (FRQS). Carol L. Richards holds the Universite´ Laval Research Chair in Cerebral Palsy. Joyce Fung is a McGill University William Dawson Scholar, and Anouk Lamontagne holds a Senior Research Scientist Award from the FRQS. Acknowledgements: The authors thank the engineering team and research assistants for their contributions to the technical development of the virtual reality system and their assistance in carrying out the project, and they thank Anne Durand for the clinical evaluations. Physiotherapy Canada 2018; 70(3);221–230; doi:10.3138/ptc.2016-97 221
222 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 l’a indique´ le participant, cette ame´ lioration des re´ sultats se transposait dans la vie quotidienne. Conclusions : malgre´ le potentiel limite´ de re´ cupe´ ration fonctionnelle en cas d’AVC chronique, une personne peut ame´ liorer sa mobilite´ et son auto-efficacite´ apre` s avoir participe´ a` un entraıˆnement sur tapis roulant jumele´ a` la RV, par rapport a` un entraıˆnement sur tapis roulant de la meˆ me intensite´ et selon les meˆ mes perturbations de la surface du sol, mais sans l’immersion de la RV. Un essai ale´ atoire et controˆ le´ a` plus vaste e´ chelle s’impose pour de´ terminer l’efficacite´ de l’entraıˆnement sur tapis roulant jumele´ a` la RV dans le cadre d’une intervention de mobilite´ apre` s un AVC. Rehabilitation interventions using virtual reality (VR) and the cognitive components of gait, such as planning, consist of a range of computer technologies that can be decision making, and self-efficacy, in persons with used to artificially generate sensory information in the chronic stroke.16,17 We undertook this study to show form of a virtual environment (VE) that is interactive that VR could be applied to gait training and to estimate and perceived as being similar to the real world.1–3 any VR-specific changes by comparing the mobility- Because it is not always feasible to physically replicate related outcomes for one individual with chronic stroke realistic community scenarios in a clinic or to safely train who followed the locomotor VR-based training pro- patients in the community, VR technology gives thera- gramme after completing a CTL training programme pists a unique opportunity to expose patients to, and with the same intensity and treadmill perturbations. The train them in, these scenarios in a risk-free and graded results of this study have previously been presented at a manner while providing intensive training and multi- conference.18 sensory feedback1,4 METHODS Jaffe and colleagues5 reported that persons with chronic stroke who had trained by stepping over virtual Subject and design objects projected in a head-mounted display while walk- A 62-year-old man entered the study 32 months after ing on a motorized treadmill showed more improve- ments in fast walking and obstacle clearance than those the onset of a right hemispheric stroke of thrombo- who practised walking over real foam objects on a walk- embolic origin. He walked with an ankle-foot orthosis way. In another study that compared treadmill training on the left leg and used a cane. A retired manager of a alone with treadmill training while engaging in VR large supermarket, he lived with his wife in his own scenes,6 the VR group improved significantly more than home and participated in its upkeep. He understood the control group in walking speed and community directions well and could communicate verbally without walking time after training. difficulty. He first carried out a 3-week CTL protocol of treadmill training (walking while looking at still pictures). A recent scoping review7 has documented that 10 of Twenty-six days after the follow-up evaluation of the 14 studies using gait speed as the main outcome reported CTL protocol—that is, with a washout period of more significantly greater increases after VR-based intervention than 6 weeks—he began the VR training. Such a pro- compared with other interventions. Other studies found tocol, although limited by the sequential CTL training significant improvements in other spatiotemporal gait followed by the VR training, allowed us to estimate the parameters such as cadence,8 step length,8–10 step time,8 effects that were specific to the VR training as a proof of stride length,9 and gait symmetry,10 as well as larger lower concept to precede a larger scale, randomized controlled limb joint excursion and ankle plantarflexion movement trial. The subject gave informed, written consent, and the and power, for VR-based intervention11,12 over other ethics committee of our rehabilitation research centres interventions. A more recent systematic review13 focused approved the protocol. on commonly assessed, clinical mobility outcome mea- sures to examine the effectiveness of VR training in Experimental procedures: the virtual reality–based locomotor the population with subacute stroke. The meta-analyses training system conducted on gait speed, Berg Balance Scale scores, and timed up-and-go measures all favoured VR training VR-based locomotor training is provided by means of when time dose was matched between balance and gait a walking simulator that is coupled with VEs that are training with and without VR. rear-projected onto a large screen. Details of this walking simulator and the first three VEs have been reported To our knowledge, however, other than training the in earlier research.2,3,14,15 The subject, wearing a safety locomotor adjustments that accompany the planning harness and stereo glasses, walked while using a sliding required for stepping over an obstacle,5 no studies have handrail (to simulate the use of a cane) on a self-paced, specifically targeted, simultaneously, the motor and motorized treadmill mounted on a motion platform with cognitive demands of walking in a rich and changing six degrees of freedom and engaged in the VE scenarios. environment in people with chronic stroke, especially A dedicated microcontroller with a proportional–integral– individuals who need to improve their walking com- derivative algorithm, based on the subject’s position petency to meet the demands of community ambulation. and obtained from a potentiometer tethered to his waist, As a result, our group has developed a VR-coupled tread- enabled real-time matching of the subject’s walking mill system2,3,14,15 to enable training both the physical speed with the speed of the moving VE scene. VEs were
Richards et al. Gait Training after Stroke on a Self-Paced Treadmill with and without Virtual Environment Scenarios: A Proof-of-Principle Study 223 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Figure 1 The first three levels of the VE: (a) screenshots of outdoor and indoor VEs used for the first three levels of training and (b) VR training progression in the corridor walking VE; red arrows (level 2) indicate terrain changes, and red circles (level 3) indicate moving obstacles. VE ¼ virtual environment; VR ¼ virtual reality. created using Softimage XSI, version 2015 (Autodesk, San The distance walked in each VE was set to 40 metres; this Rafael, CA) and controlled using the Computer Assisted corresponded to the street-crossing scene, thereby repli- Rehabilitation Environment (CAREN) system (Motek BV, cating a real environment. Thus, in level 1 training, the Amsterdam). subject walked a distance of 40 metres within a set time. In level 2 training, we added surface perturbations to the Thus, the scene progression and the motions of the various combinations of pitch and roll planes, and in platform, which mimicked the terrain changes encoun- level 3 training, we added moving obstacles (Figure 1). tered in the VEs, were synchronized with the instantaneous Two additional VEs (train station and beach walk) that treadmill speed and distance covered. Paradigms available used longer walking distances (90 m and 100 m, respec- in CAREN allowed us to vary the animation conditions tively) were included as an advanced level 4 progression (platform movements, timing, obstacle trajectories, and (not shown) because they integrated all of the previous speeds), create ambient sounds, and detect collisions levels with increasing complexity.16–18 between the subject and obstacles. The results were displayed as short, positive or negative feedback anima- Training procedures tions, and a bar graph showed the subject’s average The subject attended nine training sessions over a walking speed, compared with his natural speed, for each trial. 3-week period for each programme. The set-up and preparation for each session in both programmes were The first three VEs (street crossing, corridor walking, similar and included a 3-minute treadmill habituation and park stroll) incorporated parameters and features period (first with lights on and then with lights off) and that we could manipulate to increase the difficulty of continuous monitoring of heart rate and blood pressure. the walking task (level 1 ¼ time constraint set; level 2 ¼ All training sessions were provided by the same therapist, terrain changes added; level 3 ¼ moving obstacles added). who stood on the moving platform beside the subject.
224 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Figure 2 Pictorial representation of the subject’s progression through the training using characteristics of the virtual environment scenarios. S ¼ session. Control training protocol as forward-backward inclines, medio-lateral tilts, vertical The subject walked at his preferred walking speed displacements in the walking surface, or a combination of these movements. To help refine the progression of while looking at still pictures of scenes (not related to difficulty, the amplitude of the surface changes could be walking), persons, or animals projected onto the screen modulated from 25% to 100% of the amplitudes negotiated for 8 seconds each. As he walked, he experienced random comfortably by healthy, well-habituated persons. surface perturbations in the pitch and roll planes similar to those that he would later experience in VR training. In level 3, the subject was required to make appropriate He learned to react to these unexpected perturbations anticipatory locomotor adjustments to avoid collisions and to continue walking. while also adapting to changes in terrain and facing the time constraint. Train station and beach walk were level Virtual reality training protocol 4 integrator scenarios, in which the subject walked 90 The subject trained his walking skills with five VEs metres and 100 metres, respectively, and encountered a combination of time constraints, terrain changes, and (Figure 2) that allowed for four levels of complexity. The moving obstacles. choice of VE, the levels of difficulty, and the progression in the VEs were determined by a member of the team Assessment procedures (FM) on the basis of clinical objectives for improving the subject’s walking competency. For example, in Clinical measures session 1, he walked while engaging in three VEs at level For each training protocol, evaluations were made 1. In session 4, he trained with the same three VEs, but with terrain changes (level 2) and moving obstacles (level before training (pre-training), after 3 weeks of training 3). He began a level 4 scenario in session 5. (post-training), and at 3-week follow-up (follow-up) by a research physiotherapist trained in applying these tests. Three levels of difficulty were adjusted for the street The following measures were used to assess mobility crossing, corridor walking, and park stroll scenarios, in and balance: the 5-metre walk test at comfortable and which the subject walked 40 metres. In level 1, he was fast speeds,19 the 6-minute walk test,20–24 the Berg Balance given a set time to complete the trial without encounter- Scale,25–28 and the Canadian French version (ABC-CF)29 ing changes in terrain or obstacles. The time given to of the Activities-specific Balance Confidence scale.30–33 complete the trial was initially based on approximately 75% of the subject’s over-ground walking speed and was Questionnaires adjusted with his progression. The Assessment of Life Habits Scale (Life-H), an instru- In level 2, terrain changes were added along with the ment based on the Disability Creation Process model34,35 time constraint. The subject experienced these changes and validated to evaluate many aspects of the social
Richards et al. Gait Training after Stroke on a Self-Paced Treadmill with and without Virtual Environment Scenarios: A Proof-of-Principle Study 225 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Figure 3 Graphical representation of walking time and speed during training: (a) time dedicated to habituation (CTL-H, VR-H) and gait training (CTL-W, VR-W) in each session and (b) minimum (CTLmin, VRmin) and maximum (CTLmax, VRmax) walking speeds during each session. CTL ¼ control; VR ¼ virtual reality. participation of people with disabilities, was used to RESULTS determine the impact of training on community integra- tion. The analysis targeted 20 mobility-related life habits Walking duration and speed during the training sessions relevant to walking competency from the three dimen- As illustrated in Figure 3a, for both the CTL and the sions of the test: Housing, Mobility, and Community Living. The Life-H questionnaire was administered by a VR training programmes, the time walked in the warm- specialist in this measure. up habituation period (white symbols) and during train- ing in each session (dark symbols) was similar. In both At the end of the study, the subject was interviewed training programmes, walking duration increased with by one of the investigators (FM) using a personal appraisal successive sessions, and total training time for the CTL questionnaire. He responded to three questions designed training and VR training amounted to 125.8 and 127.2 to obtain his opinion on the CTL and VR training pro- minutes, respectively. Figure 3b shows that, during CTL grammes and the effect of the training on his daily life. training (white and dark squares), when the subject
226 Physiotherapy Canada, Volume 70, Number 3 Table 1 Clinical Outcome Measures at Different Time Points CTL training VR training https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Measure Pre Post Follow-up Pre Post Follow-up 5 m speed, m/s Comfortable 0.74 0.81 0.90 0.84 0.85 0.84 Fast 0.94 1.04 1.04 1.04 1.11 0.95 6MWT, m 304 325 307 326 362 334 Berg Balance Scale, max. 56 48 49 50 50 50 50 ABC-CF scale, max. 100 97 88 89 89 99 98 Life-H Housing* 1. Sweeping and vacuuming inside your home 24 2 22 4 2. Making a bed 66 8 86 8 3. Emptying waste baskets and taking out the garbage 66 6 66 8 4. Entering and exiting your home 68 8 88 8 5. Moving from one room to another in your home 68 8 88 8 6. Moving around in your bathroom 68 8 88 8 7. Moving from one floor to another in your home 68 8 88 8 8. Getting from the street to the entrance of your home 66 6 66 8 9. Moving around the grounds of your home during the summer 68 6 68 8 Life-H Mobility* 10. Getting around on the sidewalk 66 6 66 8 11. Getting around on the street 66 6 66 8 12. Crossing an intersection with a traffic light 66 6 66 8 13. Crossing an intersection without a traffic light 68 6 66 8 14. Getting around on uneven surfaces (grass, etc.) 66 6 66 8 15. Walking as a means of transportation 68 6 66 8 Life-H Community Life* 16. Going to, entering, and moving around service establishments in your neighbourhood 6 8 8 86 8 17. Going to, entering, and moving around in local businesses 28 8 86 8 Note: Scores that improved by 2 points from pre-training to follow-up are italicized for CTL training and bolded for VR training. *2 ¼ accomplished with difficulty and required an assistive device (or adaptations) and human assistance; 4 ¼ performed without difficulty but with an assistive device (or adaptation) and human assistance; 6 ¼ performed with difficulty and required an assistive device (or adaptation); 8 ¼ performed without difficulty with an assistive device (or adaptation). CTL ¼ control; VR ¼ virtual reality; pre ¼ pre-training; post ¼ after 3 wk training; follow-up ¼ at 3 wk follow-up; 6MWT ¼ 6-minute walk test; ABC-CF ¼ Activities-Specific Balance Confidence scale, Canadian French version; Life-H ¼ Assessment of Life Habits Scale. walked at his preferred speed, the minimum and maxi- However, his confidence was regained with VR training mum speeds he attained changed very little. In contrast, (99/100) and at follow-up (98/100). during VR training (white and dark diamonds), the sub- ject increased his maximum gait speeds from session to Initial scores for the 17 Life-H items (Housing, Mobility, session, likely attesting to his continued interest and the and Community Life) that were 8 or more are presented challenges offered by the VEs. in Table 1. Although a change in score of 0.5 points has been shown to be clinically significant in persons with After CTL training, comfortable and fast walking stroke,36 we took a conservative approach and con- speeds increased by 0.7 metre/second (12%) and 1.0 sidered changes of 2 or more at follow-up to be signifi- metre/second (11%), respectively (Table 1). A 21-metre cant. The significant changes that occurred after the increase in the distance walked in 6 minutes (6.9%) was CTL training were related mostly to mobility in the also observed. After VR training, additional increases in home (items 1–7, 16, and 17, in italic), and those that speed during fast walking (0.7 m/s, or 6.7%) and in the occurred after the VR training were related to mobility distance walked in 6 minutes (36 m, or 11%) were noted, outside the home and activities such as crossing a street and the comfortable walking speed remained unchanged. (items 8–15, in bold). No positive effect on dynamic balance could be detected given the initial near-perfect score (therefore, showing a The subject’s responses to the questions about his ceiling effect). However, the subject’s perception of and appraisal of the two types of training are translated from confidence in his balance, as measured by the ABC-CF French and presented in the Appendix. His responses scale, changed over time. The very high initial score (97/ underscore his improved confidence in his walking 100) decreased by 9 points in the post-CTL evaluation capacity, especially outdoors; his improved planning and (88/100) and remained stable up to the start of VR training. decision-making ability; and his expression of newfound self-efficacy.
Richards et al. Gait Training after Stroke on a Self-Paced Treadmill with and without Virtual Environment Scenarios: A Proof-of-Principle Study 227 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 DISCUSSION CTL training (see Figure 3). Finally, the increase in walk- In this proof-of-principle study, we examined the ing distance that the subject achieved after the VR train- ing could be related to the training that occurred during effects of a VR-based locomotor training programme the nine additional sessions of VR training and, likely, to that challenged both the physical and the cognitive an increase in walking activities outside the training dimensions of gait on different outcomes characterizing sessions, given the subject’s augmented confidence in mobility, balance, and community integration. Our his walking ability (see Appendix). findings indicated that VR training not only led to improvements in some physical aspects of walking but The near maximal ABC-CF score before CTL training also specifically improved balance self-efficacy and pro- (97/100) indicates that the subject was confident in moted the development of confidence in walking capacity, most balance activities, but it decreased by 9 points after locomotor planning abilities, and anticipatory locomotor CTL training and remained stable in the follow-up evalua- adjustments.37 Evidence of motor planning and anticipa- tion. Such a decrease can be interpreted as a response tory adjustments stemmed from biomechanical gait mea- shift,39 which is not uncommon for self-reported mea- sures (not reported here) and from the subject’s appraisal sures, when subjects realize that a task is more difficult of the VR training. to perform during daily activities than initially perceived. The stability of the scores in the three tests after the first The subject reported that the perturbations he experi- pre-training score suggests that the subject learned to enced while walking on the treadmill corresponded to more correctly grade his confidence. VR training led to what he saw in the VEs. For example, when an avatar a 10-point improvement over this new baseline, twice was about to cross in front of him in the train station the 5-point change needed to be minimally clinically scenario, he learned to modify his speed to avoid it. significant in persons after stroke.33 He also saw upcoming terrain changes, such as in the corridor walking scenario, and maintained upright Changes in accomplishment scores for the life habits balance to counter the pitch-and-roll motions of the that required a combination of mobility and use of the treadmill, which mimicked those terrain changes (see hands and executive functioning related to locomotion Figure 1b). Moreover, a transfer to real-life situations revealed that the VR training led to improvements be- occurred, as the subject reported in the personal ap- yond those attained after the CTL training. For example, praisal questionnaire (see the Appendix). Indeed, an the subject further improved his score for making a bed important component of gait training, one that can or carrying out the garbage as well as for habits related be uniquely and safely applied using VR, is training a to mobility in the community, such as crossing a street. subject to make anticipatory locomotor adjustments, These findings suggest that the VR training produced such as adapting posture and instantaneous speed in added benefits for life habits requiring motor planning, anticipation of surface perturbations and upcoming the combination of motor tasks and decision making. obstacles. Although postural reactions can be elicited with a self-paced treadmill capable of random surface The subject’s responses to the questions that were put perturbations, as achieved with CTL training, anticipa- to him converge with our findings from the ABC-CF tory adjustments can be trained only when upcoming scale and the Life-H by indicating that he had trans- perturbations are visually detected, as in the VEs we ferred the skills he had practised during the VR training used. Thus, VR gait training can target both avoiding to real-life situations. He emphasized the importance of obstacles37 and adapting to changing terrain, both of the self-confidence that he had gained from the VR train- which are considered essential to independent com- ing and the sense of self-efficacy and empowerment that munity ambulation.38 he felt when faced with novel situations. Although the 3-week CTL walking programme did not CONCLUSIONS AND CLINICAL IMPLICATIONS focus on increasing walking speed or endurance as such, This subject with chronic stroke found that the VR the training had some effects on physical conditioning. In addition, the VR training yielded further improvement training was motivating and resulted in improvements in fast walking speed; this could be related to the walking in both the physical and the cognitive aspects of his ‘‘sprints’’ required in the VEs when, for instance, the walking ability in real life. Not only was he able to walk subject increased his speed to avoid obstacles, catch a faster and farther, but he was also able to adapt his walk- train, or cross a street. Speed modulation is especially ing speed and function better in community-related relevant to community ambulation. It is also noteworthy mobility and locomotion-related life habits. He also re- that the added complexity of the VR did not delay the ported that he had learned to better plan his locomotor progression of the training or require more habituation strategies and make better decisions. Overall, he had because of increased cognitive processing because the more self-confidence and a sense of improved self- subject achieved the same amount of walking practice efficacy and empowerment. Collectively, these results through all nine sessions of the VR training as in the show that gait training using VR has the potential to improve functional mobility after stroke. Although the
228 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 improvements can be attributed to both VR and tread- stroke, who did not require more time throughout the mill gait training, it seems that VR leads to additional training duration, compared with treadmill walking alone, functional gains in speed and endurance as well as in to adjust to the demands and complexity of different VEs. self-efficacy. Thus, VR training can be used as a tool to enhance community ambulation in persons with chronic REFERENCES stroke. Nevertheless, a larger scale, randomized controlled trial is warranted to determine the efficacy of VR-coupled 1. Deutsch JE, Mirelman A. Virtual reality-based approaches to enable treadmill training for mobility intervention after stroke. walking for people poststroke. 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https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 230 Physiotherapy Canada, Volume 70, Number 3 APPENDIX Personal Appraisal Questionnaire Question 1: Have you noticed changes in your walking ability? e Claims that he has better balance, that he steps with more assurance and walks more naturally. He knows that he can because he could do so in VR training in different situations. e His brother-in-law, with whom he worked in his yard, found that he walked better on uneven ground and on slopes. e He could rake and pick up leaves without problem and moved about his yard with more ease without his cane. He noted that he depends less on his cane when he walks outdoors. e When he goes for walks, he varies his rhythm and can walk faster. He no longer fears walking on uneven surfaces or where there are stones. e He proceeds without worrying like he used to; he has gained a lot of confidence. He is no longer afraid to walk on carpets and claims that he is more solid when walking on all kinds of surfaces. e When he had to climb a flight of stairs without a handrail, he did not panic; he was confident and knew how to manage. He examined the situation as he had learned to do in VR training . . . to plan what he had to do. . . . He could find a strategy to climb the stairs without a problem. e Same thing for crossing a street . . . he could choose a strategy, not panic and adapt accordingly. First, he told himself that he would follow the woman who was crossing the street beside him; when he saw that she walked faster than him, he did not panic, but continued, and when the light signal began to flash, he could walk faster and cross the street in time. Question 2: What was the added value of the VR training? e At night, he thought about what he had practised, what he was told, and how he would manage the next time he faced similar situations. ‘‘I review the situations and plan my strategies.’’ e He reviewed his strategies and thought about how he could use them in his daily life. Question 3: Could you have achieved the same results by practicing in real life? e ‘‘No. VR training shows us that we can do things that are more difficult and that we fear without danger because we wear a harness; thus, we dare to do more because we know that it’s not dangerous.’’ ‘‘When we manage to do more without failing and without problems, we develop self- confidence.’’ e ‘‘Because of that, we dare to do more in real life, but, especially, we have learned to evaluate dangers and risks. We know what to pay attention to. It develops our capacity to make decisions.’’‘‘It helped me prepare for my driving exam.’’ VR ¼ virtual reality.
Clinician’s Commentary on Richards et al.1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Over the next two decades, the number of people living with the technology.14 Thus, consideration needs to be given to inter- stroke in Canada is expected to rise significantly—from 405,000 vention eligibility (for whom will this intervention be relevant, in 2013 to an estimated 726,000 in 2038—as a result of aging, and in what clinical setting might it be available?) to ensure reduced stroke mortality, and population growth.2 Although that newly developed interventions are relevant and accessible stroke mortality is decreasing, stroke survivors are living with to a large proportion of the stroke population during neuro- disabilities;2, 3 40% of them will have moderate to severe impair- rehabilitation. ments,4 and as much as 40% of them will have limited to no walking ability.5 Thus, the recovery of functional walking capacity Although Richards and colleagues1 used a follow-up and is a primary goal of post-stroke survivors as well as neuro- washout period, the study participant did not return to baseline rehabilitation therapists.6 clinical measures (except for the Activities-Specific Balance Confidence scale, Canadian French version) after the control The past 3 decades have seen several technological advance- intervention. Therefore, the improvements that occurred after ments in the rehabilitation of locomotion with the introduction the experimental VR intervention may have been, in part, of body weight–supported treadmill training,7 robotic devices because of the combined intervention effects. This is not un- such as the Lokomat,6 and human augmentation through exo- usual in clinical practice and is, in fact, the essence of clinical skeleton devices.8 Simultaneously, virtual reality (VR)—the practice, where interventions are not provided in isolation but ability to simulate real-world objects and events—and virtual rather as a coordinated, progressive combination of inter- environments—providing interactive, context-specific environ- ventions that simultaneously address the multiple aspects of ments simulating everyday events—have been developed as re- the clinical presentation.15 Herein lies the dichotomy between habilitation tools,9 enabling the manipulation of sensory-motor neuro-rehabilitation from a clinical practice perspective and experiences in a safe and progressive environment. neuro-rehabilitation research: No one intervention will solve the complex movement, cognitive, and perceptual problems Richards and colleagues1 have developed a novel rehabilita- sustained as the result of a stroke, but to date, interventions are tion tool consisting of a VR-coupled treadmill system that pro- generally researched in isolation, and, as a result, the evidence vides the person post-stroke with a training environment that base does not reflect the persons or the complex movement simulates both the visual and the physical demands of a real-life problems encountered every day by neurorehabilitation therapists. complex environment, simultaneously challenging the sensory- motor and cognitive components of locomotion. The decision The tools developed over the past three decades, including to investigate this novel intervention with a person 32 months the one by Richards and colleagues,1 primarily address one post-stroke is a welcome addition to the evidence base, which aspect of locomotion rehabilitation—that is, determining the is limited for the population with chronic stroke,10 and it most effective way to improve walking for stroke survivors who demonstrates clinical improvements that identify that ongoing are already walking. However, determining the most effective recovery is possible in this population. Unfortunately, access to way to potentiate walking for stroke survivors who are not able neuro-rehabilitation is scarce for community-dwelling chronic to walk and who may have a combination of physical, cognitive, stroke survivors. and perceptual deficits, remains a fundamental and pressing question for clinicians and stroke survivors alike. This proof-of-principle study highlights the many challenges inherent in neuro-rehabilitation research—in particular, the Julie Vaughan-Graham, PhD, PT interface with clinical practice. The research design was creative Physiotherapist, Physio-Logic Rehabilitation Services; and thorough, using a factorial case study design. The partici- Scientific Associate, Toronto Rehab Research Institute; pant was a community-dwelling independent ambulator with no and Adjunct Lecturer, Department of Physical Therapy, significant cognitive, perceptual, or communication difficulties or other comorbidities that affected his mobility. This clinical University of Toronto, Toronto; presentation will likely be difficult to replicate with larger num- [email protected]. bers of post-stroke participants because approximately 50%– 70% of stroke survivors present with cognitive deficits.11 In addi- REFERENCES tion, the expanding aging population in Canada brings clinical complexity because of the increased likelihood of the co- 1. Richards CL, Malouin F, Lamontagne AJ, et al. Gait training after existence of two or more chronic conditions.12 stroke on a self-paced treadmill with and without virtual environ- ment scenarios: A proof-of-principle study. Physiother Can. A major challenge for all health care providers is managing 2018;70(3):221–30. https://doi.org/10.3138/ptc.2016-97. multi-morbidity in their scope of practice.12 Likewise, access to and use of expensive, complex technologies requires careful 2. Krueger H, Koot J, Hall RE, et al. Prevalence of individuals consideration of access to capital and training investments. experiencing the effects of stroke in Canada: trends and projections. Understanding the facilitators of, and barriers to, the use of Stroke. 2015;46(8):2226–31. https://doi.org/10.1161/STROKEAHA. complex technology in clinical practice is essential.13 Time is 115.009616. Medline:26205371 critical in clinical practice, and, therefore, the challenge for the clinician is weighing the training time required to use the tech- 3. Edwards JD, Koehoorn M, Boyd LA, et al. Is health-related quality of nology effectively and safely, and the time required for appro- life improving after stroke? A comparison of health utilities indices priate set-up, along with the potential benefits and risks of using 231
232 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 among Canadians with stroke between 1996 and 2005. Stroke. 10. Vaughan-Graham J, Cott C, Wright FV. The Bobath (NDT) concept in 2010;41(5):996–1000. https://doi.org/10.1161/STROKEAHA. adult neurological rehabilitation: what is the state of the knowledge? 109.576678. Medline:20360545 A scoping review. Part II: intervention studies perspectives. Disabil 4. Teasell R, Meyer MJ, Foley N, et al. Stroke rehabilitation in Canada: Rehabil. 2015b;37(21):1909–28. https://doi.org/10.3109/ a work in progress. Top Stroke Rehabil. 2009;16(1):11–9. https:// 09638288.2014.987880. Medline:25427891 doi.org/10.1310/tsr1601-11. Medline:19443343 5. Kollen B, Kwakkel G, Lindeman E. Longitudinal robustness of 11. Mahon S, Parmar P, Barker-Collo S, et al. Determinants, prevalence, variables predicting independent gait following severe middle and trajectory of long-term post-stroke cognitive impairment: cerebral artery stroke: a prospective cohort study. Clin Rehabil. results from a 4-year follow-up of the ARCOS-IV study. Neuroepi- 2006;20(3):262–8. https://doi.org/10.1191/0269215506cr910oa. demiology. 2017;49(3-4):129–34. https://doi.org/10.1159/000484606. Medline:16634346 Medline:29145207 6. Calabro` RS, Cacciola A, Berte` F, et al. Robotic gait rehabilitation and substitution devices in neurological disorders: where are we now? 12. Upshur RE, Tracy S. Chronicity and complexity: is what’s good for Neurol Sci. 2016;37(4):503–14. https://doi.org/10.1007/s10072-016- the diseases always good for the patients? Can Fam Physician. 2474-4. Medline:26781943 2008;54(12):1655–8. Medline:19074692 7. Mehrholz J, Pohl M, Elsner B. Treadmill training and body weight support for walking after stroke. Cochrane Database Syst Rev. 13. Schmid L, Gla¨ssel A, Schuster-Amft C. Therapists’ perspective on 2014;(1):CD002840. https://doi.org/10.1002/ virtual reality training in patients after stroke: a qualitative study 14651858.CD002840.pub3. Medline:24458944 reporting focus group results from three hospitals. Stroke Res Treat. 8. Louie DR, Eng JJ. Powered robotic exoskeletons in post-stroke 2016;2016:6210508. https://doi.org/10.1155/2016/6210508. rehabilitation of gait: a scoping review. J Neuroeng Rehabil. Medline:28058130 2016;13(1):53. https://doi.org/10.1186/s12984-016-0162-5. Medline:27278136 14. Glegg SM, Holsti L, Velikonja D, et al. Factors influencing therapists’ 9. Sangani S, Lamontagne A, Fung J. Cortical mechanisms underlying adoption of virtual reality for brain injury rehabilitation. Cyber- sensorimotor enhancement promoted by walking with haptic inputs psychol Behav Soc Netw. 2013;16(5):385–401. https://doi.org/ in a virtual environment. In: Dancause N, Nadeau S, Rossignol S, 10.1089/cyber.2013.1506. Medline:23713844 editors. Progress in brain research. Vol. 218. New York: Elsevier; 2015. p. 313–30. https://doi.org/10.1016/bs.pbr.2014.12.003. 15. Cott CA, Graham JV, Brunton K. When will the evidence catch up with clinical practice? Physiother Can. 2011;63(3):387–90. https:// doi.org/10.3138/physio.63.3.387. Medline:22654245 DOI:10.3138/ptc.2016-97-cc
https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 ARTICLE Gross Motor Outcomes of Children Born Prematurely in Northern Ontario and Followed by a Neonatal Follow-Up Programme Roxanne Be´langer, PhD, SLP;*† Chantal Mayer-Crittenden, PhD, SLP;*† Miche`le Minor-Corriveau, PhD, SLP;*† Manon Robillard, PhD, SLP* ABSTRACT Purpose: The developing brain of a premature infant is vulnerable to injury. As a result, the long-term consequences of a premature birth include motor deficits, cognitive and behavioural problems. It is crucial to identify motor dysfunction during the preschool period because it interferes with a child’s ability to explore the world. The goals of this study were to (1) provide preliminary data on the gross motor outcomes of children born prematurely and (2) determine the proportion and characteristics of the children who had maintained delays over the course of follow-up. Method: A retrospective chart review was conducted on all infants monitored by a neonatal follow-up programme. Each child was assessed by a single physiotherapist from birth until age 2 years. Of the 107 cases identified, 97 individuals were retained for analysis; they had a mean gestational age of 31.1 (SD 2.9) weeks and a mean birth weight of 1.66 (SD 0.53) kilograms. Results: The majority of children assessed were found to have gross motor outcomes in the average range. Children with scores below the average range were most often born very preterm (VPT) or moderately preterm (MPT), with very low or low birth weight, respectively. A total of 17 participants were referred to physiotherapy to address the gross motor delays identified in the follow-up programme; 14 of these 17 had previously been identified as delayed and were being monitored. Late preterm (LPT) children (n ¼ 6) were most often referred, followed by those born extremely preterm (EPT) and VPT (n ¼ 4). In total, 56 children were identified as delayed at one assessment point but were found to be within normal limits by the end of the follow-up period. Conclusion: It is important to periodically monitor premature children. A longitudinal, population-based study is also needed to provide more data on the predictors and long-term motor outcomes of MPT and LPT children. Key Words: gross motor development; neonatal follow-up; prematurity. RE´ SUME´ Objectif : le cerveau du nourrisson pre´ mature´ est vulne´ rable aux le´ sions. Conse´ quemment, des difficulte´ s motrices, ainsi que des troubles cognitifs et comportementaux peuvent eˆ tre observe´ s. Il est essentiel de diagnostiquer les dysfonctions motrices pendant la pe´ riode pre´ scolaire, comme elles com- promettent la capacite´ de l’enfant a` explorer le monde. La pre´ sente e´ tude cherchait a` 1) fournir des donne´ es pre´ liminaires sur la motricite´ grossie` re des enfants ne´ s pre´ mature´ ment et 2) de´ terminer la proportion et les caracte´ ristiques des enfants qui ont maintenu des retards au fil du temps. Me´ thodologie : les chercheurs ont effectue´ une analyse re´ trospective des dossiers de tous les nourrissons ayant fait l’objet d’un programme de suivi ne´ onatal. Une seule physiothe´ rapeute a e´ value´ chaque enfant entre la naissance et l’aˆ ge de deux ans. Des 107 cas, 97 ont e´ te´ conserve´ s en vue de l’analyse. A` la naissance, l’aˆ ge gestationnel moyen e´ tait de 31,1 semaines (E´ T 2,9) et le poids moyen e´ tait de 1,66 kg (E´ T 0,53). Re´ sultats : les re´ sultats ont montre´ que chez la majorite´ des enfants, la motricite´ grossie` re se situait dans une plage moyenne. Les enfants dont les scores se situaient sous la moyenne e´ taient souvent tre` s pre´ mature´ s ou mode´ re´ ment pre´ mature´ s et avaient un poids tre` s faible ou faible a` la naissance, respectivement. Au total, 17 participants ont e´ te´ oriente´ s en physiothe´ rapie afin de cibler les retards constate´ s durant le programme de suivi. De ceux-ci, 14 avaient de´ ja` e´ te´ identifie´ s comme ayant un retard. Les enfants peu pre´ mature´ s (n ¼ 6) e´ taient les plus souvent oriente´ s en physiothe´ rapie, suivis des enfants extreˆ mement pre´ mature´ s et tre` s pre´ mature´ s (n ¼ 4). Au total, 56 enfants identifie´ s comme ayant un retard se sont rattrape´ s et se situaient dans les limites de la norme a` la fin de la pe´ riode de suivi. Conclusion : l’e´ valuation pe´ riodique des enfants pre´ mature´ s est ne´ cessaire. Une e´ tude longitudinale a` plus grande e´ chelle est ne´ cessaire afin de mieux comprendre le portrait clinique a` long terme des enfants mode´ re´ ment pre´ mature´ s et peu pre´ mature´ s. In premature infants, motor skill impairment is a com- A review of preterm children born with a broad gesta- monly reported negative outcome, with cerebral palsy tional age (GA; a37 weeks’ gestation) and without CP (CP) being the most severe form.1 Many preterm children revealed an increased likelihood of childhood motor skill do not go on to develop CP but still present with impaired impairment.2 Prevalences of 19 of 100 and 40.5 of 100 motor skills.2 has been reported for preterm children with moderate From the: *School of Speech-Language Pathology; †ECHO Research Centre, Faculty of Health, Laurentian University, Sudbury, Ont. Correspondence to: Roxanne Be´ langer, Laurentian University, 935 Ramsey Lake Rd., Sudbury, ON P3E 2C6; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: None declared. Physiotherapy Canada 2018; 70(3);233–239; doi:10.3138/ptc.2017-13 233
234 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 and mild to moderate impairment, respectively; in con- MOTOR IMPAIRMENT IN MODERATELY AND LATE trast, the prevalence of CP is estimated to be 6–8 of 100 PRETERM CHILDREN in the general pediatric population.2,3 MPT and LPT infants have historically been perceived It is crucial to identify and remediate motor dysfunc- to have similar risks of developmental problems as neo- tion in children because it interferes with their ability to nates born at term;18 consequently, long-term surveillance explore the world, be involved in social activities, and of these children has not been a priority.19 More recently, acquire future gross and fine motor skills.4,5 A better it has been shown that MPT children are more likely to understanding of the motor trajectory of all preterm have developmental delays at preschool age.19,20 This in- children is important given that the effects of motor skill formation is important given that these infants account impairment can extend beyond the motor domain and for the majority of preterm births.20,21 These studies have into educational, social, and behavioural domains.3,6–10 demonstrated that although they appear more mature, More research is needed to ensure greater clinical with more appropriate weights at birth, LPT infants are recognition of these impairments and to determine the at increased risk of medical complications compared underlying mechanisms associated with general motor with their full-term peers.22 impairment.6 These results from the literature demonstrate that fur- The traditional adverse outcomes of the preterm in- ther studies investigating the long-term follow-up of pre- fant have been widely published: CP and visual, auditory, mature infants of all GAs are required to develop a better and cognitive impairment. However, little is known about understanding of their neurodevelopmental trajectory. the presence of minor morbidities in premature children, Also, ongoing education and collaboration with families even though a higher prevalence has been reported in the and health care specialists are essential to support these literature, including in infants born moderately preterm children into their adult years. (MPT; 32–33 weeks’ gestation) and late preterm (LPT; 34–36 weeks’ gestation).3,11 These minor morbidities METHOD often present later and, although they are not disabling This study reviewed the neurodevelopmental outcomes in the traditional sense, they can create significant chal- lenges in school and social settings.10 of preterm infants who had been born or cared for at a hospital in Northern Ontario. This included children born MOTOR IMPAIRMENT IN EXTREMELY AND VERY in a Level III hospital and later transferred for regional PRETERM CHILDREN care. Following this hospital’s protocol, all infants born at less than 35 weeks’ gestation are assigned to the Large epidemiological studies have been performed hospital’s neonatal follow-up programme (NFUP) when around the world on infants born extremely preterm they are discharged, and they are evaluated over time, (EPT; a28 weeks’ gestation); examples include the EPI- by the same health professionals, using a battery of tests Cure and EPICure 2 studies in the United Kingdom, the that measure gross motor, fine motor, expressive language, Epipage study in France, the EPIBEL study in Belgium, and receptive language development. In this article, only and the EXPRESS study in Sweden.12–15 Overall, the re- the gross motor results are presented. This study received sults have demonstrated that, over time, the pattern of ethics approval from two research ethic boards. major neonatal morbidity and the proportion of prema- ture infants affected were unchanged.12–15 The preva- The sample consisted of all children born between lence was shown to be significantly associated with GA, 2009 and 2014 (N ¼ 107). Exclusion criteria were infants and the mean developmental quotients were lower than with a specific disorder or condition (e.g., a genetic syn- those of the general population.16 drome or CP; n ¼ 10); no deaths occurred. Because long- term outcome correlation is more relevant to GA than Among children born very preterm (VPT; 29–31 weeks’ BW, participants were grouped into the following GA gestation), significantly higher rates of morbidity and categories: EPT, VPT, MPT, and LPT. However, because mortality, as well as adverse long-term outcomes, have developmental outcomes have historically been reported also been reported.4 For example, de Kieviet and collea- according to BW, participants were also categorized gues17 investigated the relationship between GA and birth according to the following BW categories: low BW (LBW; weight (BW) on motor development by completing a 1,501–2,500 g), VLBW (1,001–1,500 g), and extremely low meta-analysis of infants born VPT and with very low birth BW (a1,000 g).11 weight (VLBW; 1,001–1,500 g). Their results demonstrated that compared with their peers born at term, VPT and The final sample consisted of 97 children, with an VLBW children were behind, on average, –0.57 to –0.88 almost equal distribution of boys (n ¼ 46) and girls SD, as measured by three psychometrically sound and (n ¼ 51). The largest proportion of the sample was born widely used motor tests. Difficulties were noted in balance VPT (35.1%), followed closely by those born MPT (25.8%) skills, ball skills, manual dexterity, and fine and gross and those born LPT (23.7%). The mean GA was 31.1 (SD motor development. Furthermore, these delays persisted 2.9) weeks, and the mean BW was 1.66 (SD 0.53) kilo- into elementary school and early adolescence. grams. The highest proportion of children were born with LBW (53.6%), followed by VLBW (32.0%).
Be´ langer et al. Gross Motor Outcomes of Children Born Prematurely in Northern Ontario and Followed by a Neonatal Follow-Up Programme 235 Table 1 Participants’ Characteristics Group; no. of participants (n ¼ 97) https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Characteristic EPT VPT MPT LPT (n ¼ 15) (n ¼ 34) (n ¼ 25) (n ¼ 23) Girls Boys 10 18 16 7 GA, wk, mean (SD) 5 16 9 16 BW, kg, mean (SD) 26.30 (1.30) 30.10 (0.85) 32.30 (0.46) 34.70 (0.93) BW category 0.95 (0.22) 1.47 (0.38) 1.83 (0.32) 2.16 (0.43) ELBW VLBW 7 >5 0 0 LBW 6 17 5 >5 Normal BW >5 13 20 17 Missing data 0 0 0 >5 SGA 0 1 0 4/5 assessments, % >5 >5 >5 0 94.7 91.2 96.0 5 91.3 EPT ¼ extremely preterm (a28 weeks’ gestation); VPT ¼ very preterm (29–31 weeks’ gestation); MPT ¼ moderately preterm (32–33 weeks’ gestation); LPT ¼ late preterm (34–36 weeks’ gestation); GA ¼ gestational age; BW ¼ birth weight; ELBW ¼ extremely low birth weight; VLBW ¼ very low birth weight; LBW ¼ low birth weight; SGA ¼ small for gestational age; 4/5 assessments ¼ proportion of infants who had completed 4 of 5 assessment points. It is important to note that, in some cases, the charac- been strongly correlated with other motor scales, such teristics of the participants in each subgroup did not as the Peabody Developmental Motor Scale–2,26 and de- represent the prevalence rates described in national and spite its lack of normative data, it is widely used in early international population-based studies. For example, a intervention settings, including NFUPs.27 higher prevalence rate of infants born small for gesta- tional age (SGA) was noted in the LPT group. The partic- To determine the average scores obtained on the gross ipants’ characteristics are presented in Table 1. motor assessments, the score given at each appointment and for each participant was retained for statistical anal- The same children were assessed over time by a ysis. For the AIMS, a score below the 5th percentile was multidisciplinary team consisting of a developmental considered below average; for the EIDP, a delay of 3 pediatrician, a physiotherapist, an occupational therapist, months or more was considered below average. It is fairly and a speech-language pathologist. Consequently, the common practice for therapy services to be offered to results give a picture of the developmental motor trajec- children when their gross motor age, as determined by tory among these participants. At the time the study took the EIDP, is 3 months or more below age-related norms.26 place, these assessments had been conducted by the same therapists when the babies were aged 2, 6, 9, 12, RESULTS 18, and 24 months, using the same assessment tools Information about each assessment point can be found and after correcting for prematurity. in Table 2, including the mean GA, BW, and corrected The physiotherapist used the Alberta Infant Motor age (CA) of each participant. The GA and BW categories, Scales (AIMS)23 with non-ambulatory children and, once as well as the SGA status, for those infants who did not the children became ambulatory, the gross motor com- achieve developmental expectations for their CA are ponent of the Early Intervention Developmental Profile also provided. In some cases, there was variability in the (EIDP).24 The participants in this study all became am- age ranges of the participants. The NFUP expects to bulatory; thus, all children were administered the AIMS complete an assessment of each child at ages 2, 6, 9, 12, first, then the EIDP. Developmental gross motor and 18, and 24 months; however, because of clinic schedul- fine motor scales are often used in early intervention ing, travel, and illness, it is not always possible to follow settings as part of the evaluation process to make inter- this schedule exactly. It is important to note, however, vention decisions.25 that the participants were always evaluated according to their CA and according to the developmental milestones The AIMS is a standardized tool that evaluates the expected for that CA. Because individual scores for every motor development of non-ambulatory children aged 0– participant were analyzed over time, the mean age at 18 months and aims to identify children with delayed each assessment did not influence the results. motor development and children with atypical motor development.23 The EIDP consists of six scales and can In total, 56 children (57.7%) were identified as falling be used with children aged 0–6 years.24 The scales were behind at some point during the NFUP. Of these, 17 not established by testing the items with a representative were referred to physiotherapy services for motor im- population; instead, items were assigned to specific ages pairment, 14 of which (82.4%) had been previously iden- on the basis of a review of the literature. The EIDP has tified as delayed. In the group referred for physiotherapy,
236 Physiotherapy Canada, Volume 70, Number 3 Table 2 Assessment Results Assessment, no. (%) of participants* https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Results 1st 2nd 3rd 4th 5th 6th Total Rx (n ¼ 88) (n ¼ 91) (n ¼ 94) (n ¼ 88) (n ¼ 76) (n ¼ 54) (n ¼ 491) (n ¼ 31) GA, wk, mean (SD) BW, kg, mean (SD) 30.0 (3.4) 31.3 (2.9) 31.6 (2.6) 30.9 (2.4) 29.3 (3.2) 31.5 (3.3) n/a 31.4 (3.8) CA, mo, mean (SD) 1.37 (0.45) 1.57 (0.52) 1.62 (0.43) 1.56 (0.39) 1.54 (0.59) 1.64 (0.58) n/a 1.62 (0.56) Assessment result 3.4 (1.3) 13.2 (4.4) 17.0 (7.4) 20.3 (4.5) 23.0 (7.8) n/a 7 (3.3) n/a Within normal limits 74 (84.1) 78 (83.0) 73 (83.0) 60 (78.9) 32 (59.3) n/a Below average 14 (15.9) 81 (89.0) 16 (17.0) 15 (17.0) 16 (21.0) 22 (40.7) 93 n/a Previously delayed 10 (11.0) 8 (50.0) 7 (46.7) 7 (43.8) 13 (59.1) 37 17 (17.5) Below average n/a 2 (20.0) 14 (82.4) EPT 2 (12.5) 1 (6.7) 7 (43.8) 3 (13.6) 19 (20.4) VPT 4 (28.6) 2 (20.0) 6 (37.5) 8 (53.3) 4 (25.0) 9 (40.9) 35 (37.6) 4 (23.5) MPT 6 (42.9) 2 (20.0) 3 (18.8) 4 (26.7) 4 (25.0) 4 (18.2) 20 (21.5) 4 (23.5) LPT 2 (14.3) 3 (30.0) 5 (31.3) 2 (13.3) 1 (6.3) 6 (27.3) 19 (20.4) 3 (17.6) ELBW 2 (14.3) 3 (30.0) 1 (6.3) 2 (13.3) 3 (18.8) 3 (13.6) 13 (14.0) 6 (35.3) VLBW 3 (21.4) 1 (10.0) 6 (37.5) 6 (40.0) 3 (18.8) 7 (31.8) 33 (35.5) 3 (17.6) LBW 6 (42.9) 5 (50.0) 9 (56.3) 7 (46.7) 9 (56.3) 10 (45.5) 44 (47.3) 4 (23.5) SGA 5 (35.7) 4 (40.0) 2 (12.5) 1 (6.7) 2 (12.5) 2 (9.1) 10 (10.8) 9 (52.9) 2 (14.3) 1 (10.0) 3 (17.6) *Except where otherwise indicated. Rx ¼ participants referred to physiotherapy; GA ¼ gestational age; BW ¼ birth weight; CA ¼ chronological age; n/a ¼ not applicable; below average ¼ assessment result below the average range; previously delayed ¼ number of participants identified as delayed in a previous assessment; EPT ¼ extremely preterm (a28 weeks’ gestation); VPT ¼ very preterm (29–31 weeks’ gestation); MPT ¼ moderately preterm (32–33 weeks’ gestation); LPT ¼ late preterm (34–36 weeks’ gestation); ELBW ¼ extremely low birth weight; VLBW ¼ very low birth weight; LBW ¼ low birth weight; SGA ¼ small for gestational age. Table 3 Characteristics of Children Referred to Physiotherapy and within Normal Limits EPT VPT MPT LPT Category WNL Rx WNL Rx WNL Rx WNL Rx (n ¼ 11) (n ¼ <5) (n ¼ 30) (n ¼ <5) (n ¼ 22) (n ¼ <5) (n ¼ 17) (n ¼ 6) Gestation, wk, mean (SD) 26.4 (1.3) 26.0 (1.41) 30.0 (0.83) 30.5 (1.0) 32.3 (0.48) 32 (0.0) 34.5 (0.72) 35.3 (1.21) BW, kg, mean (SD) 0.96 (0.24) 0.92 (0.21) 1.46 (0.38) 1.53 (0.42) 1.85 (0.33) 1.71 (0.04) 2.19 (0.43) 2.1 (0.45) Male, no. Female, no. <5 <5 14 <5 7 <5 13 <5 Mother’s age, mean (SD) 7 <5 16 <5 15 <5 <5 <5 Drug/alcohol use, no. (%) 28.3 (6.0) 27.0 (5.6) 26.6 (4.8) 32.0 (1.4) 27.6 (5.4) 29.5 (12.0) 34.0 (4.86) 32.7 (3.8) CAS, no. (%) 0 0 <5 0 <5 0 <5 <5 SGA, no. (%) 0 0 <5 0 <5 <5 <5 <5 BW category, no. (%) 2 (18.2) 0 <5 0 <5 0 <5 <5 LBW <5 0 11 (36.7) <5 17 (77.3) <5 13 (76.5) <5 VLBW <5 <5 16 (53.3) <5 5 (22.7) 0 <5 <5 ELBW 5 (45.5) <5 <5 0 0 0 RDS <5 <5 <5 <5 0 <5 <5 <5 BPD <5 <5 15 (50.0) 0 <5 <5 0 0 6 (20.0) 0 Note: Percentages are not reported for values < 5. EPT ¼ extremely preterm (a28 weeks’ gestation); VPT ¼ very preterm (29–31 weeks’ gestation); MPT ¼ moderately preterm (32–33 weeks’ gestation); LPT ¼ late preterm (34–36 weeks’ gestation); WNL ¼ within normal limits; Rx ¼ participants referred to physiotherapy; BW ¼ birth weight; CAS ¼ involvement of CAS during follow-up; SGA ¼ small for gestational age; LBW ¼ low birth weight; VLBW ¼ very low birth weight; ELBW ¼ extremely low birth weight; RDS ¼ respiratory distress syndrome; BPD ¼ bronchopulmonary dysplasia. most were born LPT (n ¼ 6; 35.3%), followed by those pregnancy, involvement of the Children’s Aid Society born EPT (n ¼ 4; 23.5%) and VPT (n ¼ 4; 23.5%). during follow-up, SGA status, BW category, diagnosis of respiratory distress syndrome, and diagnosis of broncho- For each GA category, participants referred to physio- pulmonary dysplasia. This information is presented in therapy services for motor impairment and those within Table 3. Because MPT and LPT infants have been his- normal limits were then compared on the basis of the torically perceived to have low risks of developmental risk factors that were reliably available in their medical problems, a statistical comparison was then completed charts: sex, maternal age, drug or alcohol use during
Be´ langer et al. Gross Motor Outcomes of Children Born Prematurely in Northern Ontario and Followed by a Neonatal Follow-Up Programme 237 Table 4 Comparison of MPT and LPT Participants with and without Motor Delay MPT infants, mean (SD) t-test results LPT infants, mean (SD) t-test results https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 Motor Within Motor Within Category delayed normal limits t df p-value delayed normal limits t df p-value Mother’s age, y 29.5 (12.0) 27.6 (5.4) 0.44 18 0.05* 32.7 (3.8) 32.6 (4.9) 0.17 14 >0.05 Birth weight, kg 1.7 (0.04) 1.85 (0.33) –0.73 23 >0.05 2.1 (0.45) 2.2 (0.40) –0.45 21 >0.05 Mann–Whitney results Mann–Whitney Mann–Whitney U-test Z p-value U-test Z p-value Sex 21.5 –1.16 >0.05 37.5 –1.19 >0.05 Drug/alcohol use 27.0 –0.79 >0.05 50.5 –0.04 >0.05 during pregnancy CAS 25.0 –1.19 >0.05 37.0 1.68 >0.05 SGA 31.5 –0.38 >0.05 31.5 –1.91 0.05* BW category 25.5 –0.91 >0.05 51.0 0.00 >0.05 RDS 24.5 –0.83 >0.05 50.5 –0.50 >0.05 BPD 22.0 –2.71 0.01* 51.0 0.00 >0.05 *p < 0.05. MPT ¼ moderately preterm (32–33 weeks’ gestation); LPT ¼ late preterm (34–36 weeks’ gestation); CAS ¼ implications of CAS during follow-up; SGA ¼ small for gestational age; BW ¼ birth weight; RDS ¼ Respiratory Distress Syndrome; BPD ¼ bronchopulmonary dysplasia. to determine if the presence of certain risk factors was development because individual participants, as well as significantly correlated with a referral to physiotherapy the proportion of total individuals identified as delayed services. This information can be found in Table 4. varied from one assessment to another. DISCUSSION The concept of a behavioural phenotype has been The main goal of this study was to provide preliminary used to describe the cluster of behavioural, cognitive, motor, and social difficulties seen in individuals with a data on the gross motor development of preschool chil- common biological disorder, and this concept provides dren born prematurely and without major neurodeve- a framework of understanding for professionals working lopmental disability. We also sought to determine the with this population.4,9–11 The preterm infant has been prevalence and characteristics of the children who had described as having a unique neurodevelopmental and maintained delays over the course of the follow-up. behavioural phenotype, including delays in the develop- ment of motor skills, cognition, executive functioning, The assessment results (see Table 2) revealed delays attention, vision, hearing, and behaviour.11 In this cohort, across the continuum of GA and BW. However, it is im- gross motor delays were noted in approximately 20.0% of portant to note that a decrease in the follow-up rate the sample at 2 years CA. occurred for the last assessment, which may have intro- duced attrition bias, particularly in the LPT group. Most These results are especially important given that all often, children with scores below the average range at children were assessed by the same registered health one assessment point were born VPT (n ¼ 35; 36.1%), professional, using either a standardized or a criterion- with LBW (n ¼ 44; 45.4%), or both, followed by those referenced tool evaluating gross motor outcomes over born MPT (n ¼ 20; 20.6%), with VLBW (n ¼ 33; 34.0%), time. Given the children’s young age at the end of the or both. The proportion of children identified as delayed follow-up, it is unknown whether they experienced at each assessment point varied from 11.0% to 40.7%. spontaneous recovery or whether there was a progres- The proportion of those who had received a subnormal sion to limitation in motor function. It is also unknown score at a previous assessment point also varied and whether delays developed later in children who had ranged from 20.0% to 59.1%. Cases were then analyzed otherwise been identified as being within normal limits. individually to determine whether the same participants It is possible that the difficulties observed in this study (n ¼ 56) had been identified as delayed over time. This are precursors to the long-term complications or minor was not the case, thereby demonstrating fluctuating gross morbidities reported in the current literature. motor development in this cohort. Because of the retrospective nature of this project, Some authors have described childhood development antenatal, postnatal, and parental demographic data were as a fluctuating trajectory, with bursts of skill acquisition, found to be inconsistent; however, the information that followed by periods of stability.4 These results support was reliably available was included for analysis. Parti- this description from the point of view of gross motor cipants referred to physiotherapy services for motor
238 Physiotherapy Canada, Volume 70, Number 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 impairment and those within normal limits were com- This study has several limitations; these include a pared on the basis of these risk factors (see Table 3). small sample size and the retrospective aspect of the re- search design. However, even though the overall sample As MPT and LPT were most often referred for therapy, was small, all preterm infants born in the area were in- statistical analyses were conducted to determine which cluded in the study. The biggest limitation is the attrition risk factors were significantly associated with a physio- bias for the last assessment in the follow-up schedule, therapy referral (see Table 4). For children born MPT, particularly in the LPT group. The high loss of assess- maternal age (p > 0.05) and diagnosis of bronchopulmo- ments in this group may be attributed to the referrals nary dysplasia (BPD; U ¼ 22.0, Z ¼ –2.71, p > 0.05) were for physiotherapy treatment. However, it should be noted significant and suggested that advanced maternal age that, for each group of preterm children (EPT, VPT, MPT, or the presence of BPD are risk factors for gross motor LPT), 91%–96% of the participants received at least three delay. In LPT children, SGA status (U ¼ 31.5, Z ¼ –1.91, assessments between 6 and 24 months CA, demonstrating p > 0.05) was significant; SGA participants were there- consistent follow-up regardless of attrition. fore more often referred to physiotherapy. Small-n research designs play an important role in Even though MPT and LPT infants have historically data collection and knowledge translation because they been perceived to have a low risk of developmental provide information that is directly relevant to the indi- problems, our results support the need for more investi- vidual participants being studied.32 The data obtained gation into the gross motor outcomes of children with a by this study could be used by other NFUPs or early inter- broader range of GA.2,4,11 Kerstjens and colleagues20 vention programmes to better understand the develop- demonstrated that MPT infants had more frequent prob- mental domains that can be at risk in premature infants lems than their peers with fine motor, communication, and monitor them accordingly. Finally, this information and personal–social functioning, but not with gross could also be used to plan larger confirmatory studies. motor functioning or problem solving. Conversely, in the study by Kalia and colleagues,28 28% of LPT infants CONCLUSION qualified for physical therapy. After controlling for co- The results obtained in this study have several im- morbidities associated with prematurity, these authors found that LPT infants had the same risk as VPT infants plications. First, the follow-up of premature children is of requiring interventional therapies. essential. Second, studies investigating neurodevelop- mental outcomes of children born prematurely should In our study, the highest proportion of children re- be longitudinal and multidisciplinary, and occur from ferred to physiotherapy services were also those born birth into the school years. This research design would LPT. However, a large number of LPT participants were allow clinicians to identify the prenatal and postnatal born with LBW, SGA, or both, proportionally higher than risk factors that affect social and academic success. the prevalence rates derived from national and interna- Although our results are preliminary and need to be tional population-based studies. Although these findings interpreted with caution, they suggest the presence of are important, a large-scale, multi-site study would be mild motor delays in children who, until recently, were required to confirm these results.14,15 generally considered to be at decreased risk. While preliminary in nature, our results highlight the In many follow-up programmes, these children fall important role of NFUPs in health care. It has been outside the inclusion criterion for monitoring. Although reported that neonatal follow-up has evolved from eval- evidence for motor outcomes in MPT and LPT children uating the impact of care on infants in the neonatal is emerging, more information is needed to make recom- intensive care unit (NICU) to providing monitoring and mendations about their place in neonatal follow-up. early intervention to high-risk infants and their families.29 Large-scale longitudinal and population-based studies Because motor skills allow a child to explore his or her are required to provide more data on the predictors, risk world, be involved in social activities, and acquire future factors, and long-term outcomes of MPT and LPT chil- skills, the early identification of dysfunction is crucial.5,6,30,31 dren. The conclusions drawn from these studies would To examine all possible avenues of adverse neuro- help determine whether these children are at increased developmental prognosis programmes, it is necessary to risk of delays and should be included in NFUPs. examine the neonatal complications, the social and en- vironmental factors, and the type of long-term conse- KEY MESSAGES quences exhibited by post-NICU children in all regions of Canada. In this clinic, developmentally appropriate What is already known on this topic information is given to parents by the physiotherapist, Physiotherapists play a role in monitoring motor de- as are suggestions for promoting motor development at home. It is possible that this information, given in a velopment and identifying the presence of delays, as timely manner, promoted better outcomes in the children well as educating parents regarding the known difficulties who had been identified as delayed at some point during that can be observed in this population. Although motor follow-up. skill impairment in premature infants is a commonly re- ported negative outcome, little is known regarding the presence of minor morbidities in MPT and LPT children.
Be´ langer et al. Gross Motor Outcomes of Children Born Prematurely in Northern Ontario and Followed by a Neonatal Follow-Up Programme 239 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 What this study adds discharge from hospital for extremely preterm infants in Belgium. This study found that the participants born MPT and Pediatr. 2004;114(3):663–75. https://doi.org/10.1542/peds.2003- 0903-L. LPT were also at risk of impairments in the development 15. Fellman V, Hellstro¨m-Westas L, Norman M, et al.; EXPRESS Group. of their gross motor skills. These results highlight the im- One-year survival of extremely preterm infants after active perinatal portance of neonatal follow-up clinics in the surveillance care in Sweden. JAMA. 2009;301(21):2225–33. https://doi.org/ of all children born prematurely. The need for a longitu- 10.1001/jama.2009.771. Medline:19491184 dinal, population-based study is also emphasized to pro- 16. Moore T, Hennessy EM, Myles J, et al. Neurological and vide more data on the predictors and long-term motor developmental outcome in extremely preterm children born in outcomes of MPT and LPT children. England in 1995 and 2006: the EPICure studies. BMJ. 2012;345:e7961. https://doi.org/10.1136/bmj.e7961. Medline:23212880 REFERENCES 17. de Kieviet JF, Piek JP, Aarnoudse-Moens CS, et al. Motor development in very preterm and very low-birth-weight children 1. Bracewell M, Marlow N. Patterns of motor disability in very preterm from birth to adolescence: a meta-analysis. JAMA. children. Ment Retard Dev Disabil Res Rev. 2002;8(4):241–8. https:// 2009;302(20):2235–42. https://doi.org/10.1001/jama.2009.1708. doi.org/10.1002/mrdd.10049. Medline:12454900 Medline:19934425 18. Loftin RW, Habli M, Snyder CC, et al. Late preterm birth. Rev Obstet 2. Williams J, Lee KJ, Anderson PJ. 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https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 10:16:14 PM - IP Address:43.246.243.82 EDUCATION Let’s Talk about the Talk: Exploring the Experience of Discussing Student Performance at the Mid- and Final Points of the Clinical Internship Jacqueline Yeldon, BA, BKIN, MScPT;* Rose Wilson, BASc, MScPT;* Jacqueline Laferrie`re, BEPS, MScPT;* Gillian Arseneau, BSc, MScPT;* ShanShan Gu, BSc, MScPT;* Mark Hall, BScPT, MScPT, PhD;† Kathleen E. Norman, BScPT, PhD;‡ Karen Yoshida, BScPT, MSc, PhD;* Brenda Mori, BScPT, MSc, PhD* ABSTRACT Purpose: The purpose of this study was to explore the experiences of physiotherapy students and clinical instructors (CIs) when discussing student clinical performance at the mid- and final points of clinical internships. The objectives were to identify why performance assessment discussions are valuable, explore the role of each participant throughout the discussion, identify the challenges associated with these discussions, and explore the effect of the standardized assessment tool on the discussion. Methods: This study used a qualitative descriptive design, consisting of student and CI focus groups in the Greater Toronto Area from January to June 2016. Results: All participants (N ¼ 29) recognized the importance of having face-to-face performance assessment discussions in a quiet and private space. Students and CIs agreed that the Canadian Physiotherapy Assessment of Clinical Performance helped to structure and focus the discussions. Valuable discussions occurred when students were open minded and self-reflected on their performance and when CIs were honest and used their expertise to guide learning. Other key features included mutual preparedness, two-way feedback that was constructive and tangible, and a goal-setting process. Students described the emotional component of these discussions as being challenging, and CIs found it difficult when a student took a more passive role in the discussion. Conclusions: Our findings indicate that valuable discussions can provide meaningful feedback, strengthen the student–CI relationship, and engage the learner in an ongoing and cumulative learning process that contributes to professional development. Key Words: educational measurement; feedback; internship and residency; learning; students. RE´ SUME´ Objectif : la pre´ sente e´ tude visait a` explorer les expe´ riences d’e´ tudiants en physiothe´ rapie et de moniteurs cliniques (MC) lors des discussions sur le rendement clinique des e´ tudiants au milieu et a` la fin de leur stage clinique. Les objectifs consistaient a` de´ terminer l’inte´ reˆ t des discussions sur l’e´ valua- tion de rendement, a` explorer le roˆ le de chaque participant a` la discussion, a` cerner les de´ fis associe´ s a` ces discussions et a` explorer l’effet de l’outil d’e´ valuation normalise´ sur la discussion. Me´ thodologie : la pre´ sente e´ tude faisait appel a` une me´ thodologie descriptive qualitative, compose´ e de groupes de travail d’e´ tudiants et de MC du Grand Toronto entre janvier et juin 2016. Re´ sultats : tous les participants (n ¼ 29) ont convenu de l’importance des discussions d’e´ valuation du rendement en teˆ te a` teˆ te, dans un lieu calme et prive´ . Les e´ tudiants et les MC conviennent e´ galement que l’e´ valuation de rendement clinique de l’Association canadienne de physiothe´ rapie contribuait a` structurer et a` orienter les discussions. Des discussions inte´ ressantes avaient lieu lorsque les e´ tudiants e´ taient ouverts et preˆ ts a` tenir une autore´ flexion sur leur rendement et lorsque les MC e´ taient honneˆ tes et utilisaient leurs compe´ tences pour orienter l’apprentissage. Parmi les autres caracte´ ristiques cle´ s, soulignons une pre´ paration mutuelle, des commentaires bidirectionnels constructifs et tangibles et un processus d’e´ tablissement d’objectifs. Les e´ tudiants trouvaient les aspects e´ motifs de ces discussions exigeants, alors que les MC e´ prouvaient de la difficulte´ lorsqu’un e´ tudiant adoptait un roˆ le plus passif dans la discussion. Conclusions : selon nos observations, des discussions inte´ ressantes peuvent favoriser des commentaires significatifs, renforcer la relation entre l’e´ tudiant et le MC et faire participer l’e´ tudiant a` un processus d’apprentissage continu et cumulatif qui contribue a` son perfectionnement professionnel. From the: *Department of Physical Therapy, University of Toronto, Toronto; ‡School of Rehabilitation Therapy, Queen’s University, Kingston, Ont.; †Department of Physical Therapy, University of Alberta, Edmonton, Alta. Correspondence to: Brenda Mori, Associate Professor, Teaching Stream, Department of Physical Therapy, University of Toronto, 160–500 University Ave., Toronto, ON M5G 1V7; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing interests: None declared. Acknowledgements: This project was completed in partial fulfilment of the requirements for an MSc PT degree at the University of Toronto. Physiotherapy Canada 2018; 70(3);240–248; doi:10.3138/ptc.2016-96 240
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