PHYSIOTHERAPY CANADA

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 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 71  Number 2  Spring 2019 Highlights Fifteenth Issue in a Special Series on ARTICLES Education in Physiotherapy Labelling a Patient’s Change Status: It’s a Confidence Game by P.W. Stratford Fifth Issue in a Special Series on Professional Values: Results of a Scoping Review and Preliminary Physiotherapy in Primary Care Canadian Survey by A.M. Boyczuk, J.J. Deloyer, K.F. Ferrigan, K.M. Muncaster, V. Dal Bello-Haas, and P.A. Miller First Issue in a Special Series on Paediatric Enhancing Pelvic Health: Optimizing the Services Provided Physiotherapy by Primary Health Care Teams in Ontario by Integrating Physiotherapists by S. Dufour, A. Hondronicols, and K. Flanigan Official Journal of the Canadian Physiotherapy Association Revue officielle de l’Association canadienne de physiothérapie

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https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 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’enquete scientifique et la transmission du savoir VOLUME 71 NUMBER 2 SPRING 2019 ISSN-0300-0508 E-ISSN-1708-8313 TABLE OF CONTENTS ORIGINAL ARTICLES 103 Estimating the Threshold Value for Change for the Six Dimensions of the EDUCATION SERIES Impairment Inventory of the Chedoke-McMaster Stroke Assessment PRIMARY CARE SERIES R. Beyer, C. Wharin, E. Gillespie, K. Odumeru, P.W. Stratford, and P.A. Miller 111 Clinician’s Commentary S. Gregor 113 Expérimentation d’une formation sur le trouble développemental de la coordination destinée aux enseignants en éducation physique L. Lachapelle-Neveu, C. Carrier, M. Fink-Mercier, M. Larivière, C. Ruest, I. Demers, D.B. Maltais et C. Camden 121 Labelling a Patient’s Change Status: It’s a Confidence Game P.W. Stratford 130 Mechanical Diagnosis and Therapy and Morton’s Neuroma: A Case Report M.D. Post 134 Professional Values: Results of a Scoping Review and Preliminary Canadian Survey A.M. Boyczuk, J.J. Deloyer, K.F. Ferrigan, K.M. Muncaster, V. Dal Bello-Haas, and P.A. Miller 144 Clinician’s Commentary K.E. Norman 146 Essential Elements for Advancing Cultural Humility through a Community-Based Physical Therapy Practicum in a Métis Community S. Oosman, L. Durocher, T.J. Roy, J. Nazarali, J. Potter, L. Schroeder, M. Sehn, K. Stout, and S. Abonyi 158 Clinician’s Commentary K. Gasparelli 160 Promoting Professional Behaviours in Physical Therapy Students Using Standardized Patient Feedback M.A. Riopel, B. Litwin, N. Silberman, and A. Fernandez-Fernandez 168 Enhancing Pelvic Health: Optimizing the Services Provided by Primary Health Care Teams in Ontario by Integrating Physiotherapists S. Dufour, A. Hondronicols, and K. Flanigan

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 176 Enhancing Access to Physical Therapy Services for People Experiencing Poverty and Homelessness: The Lighthouse Pilot Project S. Oosman, G. Weber, M. Ogunson, and B. Bath PAEDIATRIC PHYSIOTHERAPY 187 Developing and Validating a Step Test of Aerobic Fitness among Elementary School SERIES Children R.M. Hayes, D. Maldonado, T. Gossett, T. Shepherd, S.P. Mehta, and S.L. Flesher 195 Clinician’s Commentary D.B. Maltais COCHRANE COLLABORATION 196 What does Cochrane Say about ... the Use of Acupuncture in Rehabilitation?

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Physiotherapy SCIENTIFIC EDITOR CANADA Dina Brooks, PhD, MSc, BSc (PT) INTERNATIONAL ADVISORY BOARD Professor, Vice-Dean & Executive Director School of Rehabilitation Science, McMaster University, Rik Gosselink, PhD, PT Hamilton, ON Professor, Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven University, Belgium ASSOCIATE EDITORS Karen Grimmer-Somers, PhD, MMedSci, BPhty, Denise Connelly, PhD, BScPT CertHealthEc, LMusA Associate Professor, School of Physical Therapy, University of Professor, School of Health Sciences Director, Centre for Allied Western Ontario, London, ON Health Evidence, University of South Australia, Australia Isabelle Gagnon, pht, PhD Meg E. Morris, BAppSC(Physio), MAppSc, Grad Dip(Geron), Assistant Professor, School of Physical and Occupational PhD, FACP Therapy, McGill University, Montreal, QC Professor and Chair, School of Physiotherapy, University of Melbourne, Australia S. Jayne Garland, PhD, PT Professor and Department Head, Department of Physical Kenneth J. Ottenbacher, OT, PhD Therapy, University of British Columbia, Vancouver, BC Russel Shearn Moody Distinguished Chair in Neurological Rehabilitation, Senior Associate Dean for Graduate Research Michael A. Hunt, PhD, PT Education, School of Allied Health Sciences, University of Associate Professor, Department of Physical Therapy, Texas Medical Branch, USA University of British Columbia, Vancouver, BC Carol L. Richards, PhD, PT, FCAHS Marilyn MacKay-Lyons, BSc(PT), MSc(PT), PhD Professor and Canada Research Chair in Rehabilitation, Professor, School of Physiotherapy, Dalhousie University, Department of Rehabilitation Medicine, Laval University, Halifax, NS Quebec City, QC Stephanie Nixon Peter Rosebaum, MD, CM, FRCP(C) Associate Professor, Department of Physical Therapy, Professor, Department of Pediatrics, McMaster University University of Toronto, Toronto, ON Hamilton, ON Kathleen E. Norman, BScPT, PhD Julius Sim, BA, MSc(Soc), MSc(Stat), PhD Associate Professor and Associate Director (Research and Primary Care Musculoskeletal Research Centre, Keele Post-Professional Programs), School of Rehabilitation Therapy, University, UK Queen’s University, Kingston, ON STATISTICAL CONSULTANT Brenda O’Neill, BScPT, Fellow HEA, PhD Centre for Health and Rehabilitation Technologies (CHART), Paul Stratford, PT, MSc Institute Nursing and Health Research, Sch Health Sciences, Professor Emeritus, School of Rehabilitation Science, Ulster University, Northern Ireland McMaster University, Hamilton, ON Tom Overend, PhD, BSc(PT) PUBLISHER Associate Professor, School of Physical Therapy, University of Western Ontario, London, ON Canadian Physiotherapy Association 955 Green Valley Crescent, Suite 270, Ottawa, ON Marco Pang, BScPT, PhD K2C 3V4 Canada Assistant Professor, Department of Rehabilitation Sciences, The Tel.: 613-564-5454 or 800-387-8679, Fax: 613-564-1577 Hong Kong Polytechnic University, Kowloon, Hong Kong E-mail: [email protected] www.physiotherapy.ca Alex Scott, PhD Competing Interest Statements for Physiotherapy Canada Associate Professor, Department of Physical Therapy, Centre Editorial Board members are available online at for Hip Health and Mobility, University of British Columbia, http://www.utpjournals.press/journals/ptc/editorial-board Vancouver, BC Jenny Setchell, BSc(PT), Grad Cert (Appl PT), PhD NHMRC Research Fellow, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia EDITORIAL OFFICE University of Toronto Press - Journals Division 5201 Dufferin St., North York, ON M3H 5T8 Canada Tel.: 416- 667-7810, Fax: 416-667-7832 or 1-800-221-9985 E-mail: [email protected], www.utpjournals.press

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 STATEMENT OF PURPOSE OBJECTIF Physiotherapy Canada is the official, scholarly, refereed journal of the Physiotherapy Canada est la publication scientifique officielle revisée Canadian Physiotherapy Association, giving direction to excellence in en profondeur de l’Association canadienne de physiotherapie. Son clinical science and reasoning, knowledge translation, therapeutic skills objectif est de fournir des orientations a l’excellence en sciences et en and patient-centred care. raisonnement clinique, transmission du savoir, compeétences theérapeutiques et soins centreés sur le patient. Recognized as one of the top five evidence-based journals of physiotherapy worldwide, Physiotherapy Canada publishes the results Reconnu comme l’un des cinq grands journaux de physiotheérapie of qualitative and quantitative research including systematic reviews, reposant sur des faits scientifiques dans le monde, Physiotherapy meta analyses, meta syntheses, public/health policy research, clinical Canada publie les reésultats de recherches qualitatives et quantitatives, practice guidelines, and case reports. Key messages, clinical notamment des revues systeématiques, des meéta-analyses, des commentaries, case studies, evidence-based practice articles, brief métasyntheses, des recherches en politiques de la sante ou en reports, and book reviews support knowledge translation to clinical politiques publiques, des directives en pratique clinique et des eétudes practice. de cas. 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https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 ARTICLE Estimating the Threshold Value for Change for the Six Dimensions of the Impairment Inventory of the Chedoke-McMaster Stroke Assessment Rachel Beyer, BSc, MSc(PT); Caitlin Wharin, BSc, MSc, MSc(PT); Ellen Gillespie, BSc, MSc(PT); Kathleen Odumeru, BSc, MSc(PT); Paul W. Stratford, MSc, PT; Patricia A. Miller, PhD, PT ABSTRACT Purpose: Our purpose was to estimate a threshold value for change for the six dimensions of the Impairment Inventory of the Chedoke-McMaster Stroke Assessment and the confidence in labelling a person as having improved or not. Method: Secondary analysis of two data sets, previously reported by two research teams, consisted of two statistical analyses. The first analysis used a multiple of the standard error of measurement to calculate the threshold value for change for the six dimensions. The second analysis used the diagnostic test method to calculate a threshold improvement value and the confi- dence a clinician had in labelling a person as having improved or not on the leg, foot, and postural control dimensions. Results: The threshold value for change was determined to be 1 impairment point (i.e., stage) for the arm, hand, leg, foot, and postural control dimensions and 2 impairment points for the shoulder pain dimension. The positive predictive values associated with the leg, foot, and postural control dimensions were 74%, 59%, and 65%, respec- tively. Conclusions: Clinicians can use a change of 1 impairment point for the arm, hand, leg, foot, and postural control dimensions and a change of 2 impairment points for the shoulder pain dimension to identify true change in a patient’s motor recovery. Key Words: outcome assessment; recovery of function; stroke. RÉSUMÉ Objectif : parvenir à une valeur seuil de changement aux six dimensions de l’inventaire des déficiences de l’évaluation Chedoke-McMaster de l’AVC ainsi que de la confiance à déclarer que l’état d’une personne s’est amélioré ou non. Méthodologie : l’analyse secondaire de deux ensembles de données, dont deux équipes de recherche avaient déjà rendu compte, s’est déclinée en deux analyses statistiques. La première faisait appel à un multiple de l’écart-type de mesure pour calculer la valeur seuil de changement aux six dimensions. La seconde puisait dans la méthode de test diagnostique pour calculer une valeur d’amélioration du seuil et la confiance du clinicien à déclarer que l’état d’une personne s’est amélioré ou non dans les dimensions du contrôle de la jambe, du pied et de la posture. Résultats : les chercheurs ont établi que la valeur seuil de changement correspondait à 1 point de déficience (phase) pour les dimensions du contrôle du bras, de la main, de la jambe, du pied et de la posture et de 2 points de déficience pour la dimension de la douleur de l’épaule. Les valeurs prédictives positives associées aux dimensions de contrôle de la jambe, du pied et de la posture s’élevaient à 74 %, 59 % et 65 %, respectivement. Conclusions : les cliniciens peuvent utiliser un changement d’1 point de déficience des dimensions de contrôle du bras, de la main, de la jambe, du pied et de la posture, et un changement de 2 points de déficience pour la dimension de la douleur de l’épaule pour déclarer un véritable change- ment dans le rétablissement moteur du patient. The Chedoke-McMaster Stroke Assessment (CMSA) is sions of the CMSA–II to assess motor recovery without an internationally used,1–12 performance-based outcome knowing the threshold value that represents a true measure with two parts: the Impairment Inventory (II) change. By true change, we mean that a patient’s status and the Activity Inventory (AI).13 The CMSA was devel- has truly changed and is not an artifact of a random fluc- oped to assess patients who had experienced a stroke tuation in a truly unchanged patient. This deficiency and were receiving treatment in a rehabilitation set- prompted our current study. ting.1,13,14 Presently, there is no threshold value for change reported for any of the six dimensions of the We performed a search of the literature to identify CMSA–II. Consequently, clinicians are using the dimen- articles reporting on the CMSA. Our search identified evidence of reliability and validity for both the From the Physiotherapy Program, School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, Hamilton, Ont. Correspondence to: Patricia A. Miller, School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Rm. 403, 1400 Main St. West, Hamilton, ON L8S 1C7; [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. The information in this article was presented, in part, as a poster presentation at the 2018 Ontario Physiotherapy Association conference. This research was completed in partial fulfillment of the requirements for the MScPT degree at McMaster University. Physiotherapy Canada 2019; 71(2);103–110; doi:10.3138/ptc.2017-87 103

104 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 CMSA–II1,4,5,9,11,12,15–18 and the CMSA–AI1 in the context Chedoke-McMaster Stroke Assessment of stroke rehabilitation. In addition, we found evidence of The CMSA–II has six dimensions – arm, hand, shoulder validity for the CMSA–AI in the context of rehabilitation after acute brain injury,19 rehabilitation for acute neuro- pain, leg, foot, and postural control – and is scored on a 7- logical conditions,20 and in-patient geriatric care.21 More- point (1–7) scale1,13 that corresponds to the Brunnstrom over, we found that a minimal clinically important stages of motor recovery.13 Higher scores represent a difference existed for the CMSA–AI, reported as 7 when higher stage of motor recovery, with the exception of determined by physiotherapists20 and 8 when deter- shoulder pain, which is scored on the basis of severity.13 mined by stroke patients and their caregivers.22 The CMSA–AI measures functional outcomes and is com- posed of a gross motor function index and a walking Clinicians have consistently reported that an identi- index.13 The gross motor function index consists of 10 fied barrier to the use of standardized measures in clini- items related to the activities of bed mobility, sitting, cal practice is that scores may lack meaning.23,24 Stokes standing, and transfers, and the walking index consists of and O’Neill reported that although clinicians are aware of 5 items that score walking indoors and walking outdoors.13 the purpose of outcome measures, they have low confi- The items from both indices are scored on a 7-point scale dence in interpreting scores in a meaningful way and low that corresponds to the adult FIM, with higher scores re- confidence in their knowledge of measurement proper- presenting higher functional independence.13 ties.23 In addition, Duncan and Murray reported that clinicians have concerns about the clinical relevance of Study 1 outcome measures.24 Moreover, Salbach and colleagues The goal of Study 1 was to estimate a threshold value conducted a cross-sectional survey from which they determined that 78% of physiotherapist respondents for change for the six dimensions of the CMSA–II based agreed that research findings were useful to their prac- on a multiple of the SEM. tice, although 55% agreed that there was a divide between research and practice.25 Participants The original investigators recruited patients admitted Together, these findings suggest that a gap exists between clinicians’ confidence in interpreting scores and to the stroke unit of the Chedoke-McMaster Rehabilita- how these scores are applied in clinical practice. In this tion Centre, a regional, tertiary care institution.1,13 Over study, we aimed to address this barrier by providing a 9 months, the investigators recruited 32 participants clinically relevant threshold value for change. (16 men, 16 women).13 Of these participants, 18 had hemiplegia involving the left side and 14 had hemiplegia The purpose of this study was to estimate values that involving the right side.1 On admission, the mean (range: would serve as the threshold value for true change for the min–max) for the following we reported: participants’ CMSA–II dimensions in persons undergoing rehabilita- age, 70 (54–85) years; time after onset, 9 (1–24) weeks; tion after stroke. The estimate was based on the results of length of hospital stay, 9 (2–21) weeks; CMSA–II score on two different approaches applied to data from two pro- admission, 23 (14–34); and CMSA–AI score on admission, spective cohort studies. The two objectives of our study 52 (14–98).13 Further information about participants’ were to estimate (1) the threshold value for change (both characteristics and data collection can be found in the improvement and deterioration) based on a multiple of CMSA manual.13 the standard error of measurement (SEM; Study 1) and (2) the threshold improvement value and increased con- Data analysis fidence in labelling an individual as improved using diag- We used the CMSA manual to perform the following cal- nostic test methodology (Study 2). In addition, we present a clinical vignette to describe how the results of culations: SEM and minimal detectable change (MDC) at this study could be used by a clinician. 90% CI (MDC90) for the six dimensions of the CMSA using the type 2,1 intraclass correlation coefficient (ICC) values (re- METHODS ported in the manual’s Table 4–5); number of clients at each Our investigation consisted of performing secondary recovery stage on admission for the impairment dimensions, and SD for the CMSA impairment dimensions using the analyses of two data sets using different participant sam- stage of impairment frequency data (Table 4–4).13 Specifi- ples, reported previously by separate research cally, the values from the frequency distribution reported in teams.1,13,26 In this article, we use information from both Table 4–4 were applied to calculate the mean and SD for this data sets to estimate a threshold value for change using sample. The SEM was calculated using the equation two statistical methods. Study 1 used data reported in the CMSA manual,13 and Study 2 used data from Dang and SEM ¼ SD Â pffiffiffi1ffiffiffiÀffiffiffiffiffiIffiCffiffiffiCffiffiffi27; colleagues.26 and the 95% CI was obtained by adapting the method re- ported by Stratford and Goldsmith.28 We obtained an estimate for the MDC90 value by mul- tiplying the SEM by the square root of 2 and the z value

Beyer et al. Estimating the Threshold Value for Change for the Six Dimensions of the CMSA Impairment Inventory 105 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 associated with a 90% CI (z = 1.65). MDC90 represents a highest score on the measure, and the measure could not range of difference values between test and retest owing quantify further improvement. to random fluctuations in truly unchanged participants.27 From the standpoint of a clinician, if a change greater We were not able to apply diagnostic test methodol- than the MDC90 – either improvement or deterioration – ogy to the arm, hand, or shoulder pain dimensions is observed, a patient would be labelled as changed.27 because we could not access any data from a prospective However, the exact certainty of, or confidence in, this cohort study that included both scores for these CMSA– inference is unknown.29 AI dimensions and scores for important improvement; these data would have given us a reference measure of Study 2 upper extremity function. The three goals of Study 2 were to obtain estimates of Using the STATA software, we applied non-parametric (1) a threshold improvement value, (2) a CI for the receiver operating characteristic (ROC) curve analysis to threshold improvement value, and (3) the extent to identify the threshold improvement value. An ROC curve which valid inferences could be drawn when using the plots sensitivity against 1-specificity.30 The area under identified threshold improvement values to differentiate the curve (AUC) can be interpreted as a validity index.22 among patients who had improved and those who had The AUCs range from 0 to 1, with an area of 0.5, indicat- not. ing that a measure does no better than chance at label- ling a patient as improved or not.30 We considered Participants misclassification errors in either direction to be equally We obtained data from a pre-existing database con- important (i.e., labelling a truly improved patient as not improved would carry the same weight as labelling a taining de-identified and anonymized data, previously truly unimproved patient as improved). Accordingly, our reported by Dang and colleagues.26 Ethics approval was approach was to identify the threshold improvement obtained from the Hamilton Integrated Research Ethics value that jointly maximized sensitivity and specificity. Board; permission to use the data set was granted by the We applied the STATA add-on bootstrap program roc- senior investigator of the Dang and colleagues study.26 mic.ado to identify the 95% CI for the threshold improve- ment value.31 To do this, we obtained 500 bootstrap The database contained information obtained by samples, with replacement, for each impairment scale chart review for patients admitted to a stroke rehabilita- estimate. tion unit between July 1996 and July 1998.26 This data set consisted of 74 participants (48 men, 26 women), who RESULTS were assessed using the CMSA at an average of 15.6 (SD 8.6) days post-stroke.26 The sample had a mean age Study 1 of 65.3 (SD 12.4) years.26 A total of 41 participants had Table 1 reports the Type 2,1 ICCs, SEM and 95% CI, had left-sided cerebral vascular accidents, and 33 had had right-sided cerebral vascular accidents.26 The aver- and MDC90 values for the arm, hand, shoulder pain, leg, age length of stay in the stroke rehabilitation unit was foot, and postural control dimensions of the CMSA–II. 44.8 (SD 24.4) days.26 Further information related to the Point estimates of the MDC90 for the arm, hand, shoulder sample’s characteristics and data collection can be found pain, leg, foot, and postural control dimensions of the in the original publication.26 CMSA–II were 1.39, 1.25, 1.80, 1.01, 1.25, and 1.31 impair- ment points (i.e., stages), respectively. Data analysis We analyzed the data using STATA, version 14.2 (Stata- Study 2 Corp LP, College Station, TX). We used diagnostic test Of the 74 participants in the study by Dang and collea- methodology to estimate the threshold improvement gues,26 71 had CMSA–II stage scores of less than 7 and value for the leg, foot, and postural control dimensions of the CMSA.30 Diagnostic test methodology requires a di- Table 1 Reliability and Minimal Detectable Change Estimates: Study 1 chotomized reference standard to classify participants as improved or not improved.30 On the basis of the work of Impairment category ICC(2,1) (95% CI) SEM (95% CI) MDC90 Huijbregts and colleagues,22 we used CMSA–AI scores, dichotomized at an improvement of 8 points, as a refer- Arm 0.84 (0.72, 0.92) 0.60 (0.48, 0.80) 1.39 ence standard: improved (!8 points) or not improved Hand 0.85 (0.72, 0.92) 0.54 (0.43, 0.72) 1.25 (<8 points).22 We used the 8-point reference standard Shoulder pain 0.75 (0.55, 0.87) 0.77 (0.63, 1.05) 1.80 because it represents a conservative improvement in Leg 0.92 (0.85, 0.96) 0.43 (0.34, 0.57) 1.01 lower extremity function from the patient’s perspective.22 Foot 0.85 (0.71, 0.92) 0.54 (0.43, 0.72) 1.25 We excluded participants with scores of 7 on the individ- Postural control 0.80 (0.63, 0.90) 0.56 (0.45, 0.74) 1.31 ual CMSA–II dimensions at admission because 7 is the ICC = intra-class correlation coefficient; SEM = standard error of measurement; MDC = minimal detectable change.

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Sensitivity106 Physiotherapy Canada, Volume 71, Number 2 0.00 0.25 0.50 0.75 1.00 ≥1 ≥2 ≥3 0.00 0.25 0.50 0.75 1.00 1 – Specificity Figure 1 Receiver operating characteristic curve for the leg dimension, with improvement threshold values labelled: Study 2. Sensitivity ≥1 0.00 0.25 0.50 0.75 1.00 ≥3 ≥2 0.00 1.00 0.25 0.50 0.75 1 – Specificity Figure 2 Receiver operating characteristic curve for the foot dimension, with improvement threshold values labelled: Study 2. were eligible for analysis in our study. Another 12 patients sion, and 1.0 (95% CI: 0.70, 1.30) for the postural control had CMSA–AI improvement scores of less than 8 points, dimension. Table 2 provides the sensitivity and specificity and 59 participants had change scores of 8 points or for the improvement score of each impairment dimension. more.26 DISCUSSION The ROC curves are shown in Figures 1–3. The AUCs Two questions to consider when appraising the extent were 0.77 (95% CI: 0.66, 0.89) for the leg dimension, 0.62 (95% CI: 0.44, 0.81) for the foot dimension, and 0.70 (95% to which valid inferences can be drawn from a measured- CI: 0.56, 0.83) for the postural control dimension. For all change score are as follows: (1) What is the threshold impairment dimensions, the threshold improvement change or improvement value and (2) how confident can value that jointly maximized sensitivity and specificity a clinician be if the threshold value is applied to inform a was 1 impairment point: 1.0 (95% CI: 0.85, 1.15) for the decision concerning a patient’s change status? To our leg dimension, 1.0 (95% CI: 0.09, 1.91) for the foot dimen- knowledge, a threshold value for the CMSA–II

Beyer et al. Estimating the Threshold Value for Change for the Six Dimensions of the CMSA Impairment Inventory 107 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 – Figure 3 Receiver operating characteristic curve for postural control, with improvement threshold values labelled: Study 2. Table 2 Sensitivity and Specificity for Improvement Scores (Study 2) the confidence a clinician has in applying this value. The interpretation of MDC90 in our study is that 90% of the Dimension and threshold improvement Sensitivity, Specificity, unchanged patients demonstrated random fluctuations value %% of approximately 1 point between test and retest. Leg 100.00 0.00 Our second validation method applied an anchor- 0 72.88 75.00 based approach that used diagnostic test methodology to 1 27.12 100.00 identify a threshold improvement change value. In addi- 2 6.78 100.00 tion to estimating a threshold improvement value, the 3 0.00 100.00 anchor-based method allows one to calculate the confi- >3 dence in applying the threshold value. Both methods Foot 98.31 16.67 produced a similar threshold value for change or 0 61.02 58.33 improvement for the leg, foot, and postural control di- 1 22.03 83.33 mensions, supporting a threshold value of 1 point. 2 5.08 100.00 3 0.00 100.00 We recognize that the CI for the AUC of the foot >3 dimension presented in Study 2, reported as 0.62 (95% Postural control 100.00 0.00 CI: 0.44, 0.81), contains the null value of 0.5. A value of 0 66.67 63.64 0.5 indicates that the measure does no better than 1 25.00 100.00 chance at correctly labelling a person as improved or 2 5.00 100.00 not.30 We speculate that this finding may be the result of 3 0.00 100.00 an increased variability due to a lack of consistency in >3 how therapists administer and score the foot dimension of the CMSA–II. Therefore, the threshold improvement dimensions has not been reported in the literature. Our value of 1 impairment point for the foot dimension iden- study applied two discrete samples and methods to esti- tified in Study 2 should be interpreted with caution. mate a threshold change value for the CMSA–II dimen- sions. The first method produced a threshold change This study had a few limitations. First, the MDC esti- value (MDC90) of approximately 1 impairment point for mate was based on a secondary analysis of data gathered the arm, hand, leg, foot, and postural control dimensions more than 2 decades ago, and we are uncertain of the and 2 impairment points for the shoulder pain dimen- impact this timeline might have on our results.1,13,26 sion. Although MDC90 provides an estimate for a thresh- However, we speculate that the estimate of MDC would old change value, it does not provide information about be primarily affected by the clinicians’ experience with the measure and the distribution of motor impairment present in the patient sample. To the extent that the clini- cians in the historical study had between 4 months and

108 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 0 10 20 30 40 50 60 70 80 90 100 Post-Measure Chance of Improvement Pre-Measure Chance of Improvement 0 10 20 30 40 50 60 70 80 90 100 Improve 1 Point Improve ≥ 2 Points No Change Figure 4 Information gain curves for leg improvement change values of 1 and 2 impairment points. 5 years experience, we suspect that our results would patients). Specifically, the reassessment interval is sched- generalize to contemporary clinicians with similar levels uled for a point at which the therapist anticipates that of experience. Second, the information used in our analy- approximately 50% of patients with a prognosis similar to sis was limited to the data reported by the original Mr. Smith’s would be expected to improve by at least authors in terms of sample size, patient characteristics, 1 point.32 and recruitment procedures.1,13,26 Using the method described by Stratford and Riddle,29 A third limitation of our study was that the CMSA–AI and to graph the relationship between the pre- and post- cutoff score of 8 was based on a sample size of 7 patients intervention measure chance of improvement, we from the Huijbregts and colleagues’ study.22 This cutoff applied the sensitivity and specificity values reported in score was identified in a study by Barclay-Goddard20 that Table 2 for the leg threshold values of 1 (sensitivity 73, included a sample of 22 participants, 12 of whom had specificity 75) and 2 points (sensitivity 27, specificity 100). experienced a stroke. However, a sensitivity analysis Figure 4 shows the estimated chance of improvement using a cutoff score of 7 yielded the same threshold before interpreting a patient’s leg-change score against improvement value of 1 impairment point for each mea- the estimated chance of improvement afterward by ap- sure. Despite these limitations, we believe that our esti- plying the patient’s measured-change score to the mated change threshold value of approximately 1 point is improvement scores of 1 (thin, arcing line) and 2 points supported by the fact that two estimation methods (thick, angled line). The dashed, diagonal line represents applied to two separate samples obtained from two geo- no increase in confidence in making a decision about a graphical locations converged on the same estimated patient’s improvement status. The thin and thick lines value. represent the chance that a patient has improved given a change of more than 1 or 2 points, respectively. Clinical vignette Mr. Smith is a 70-year-old man admitted to the stroke If, on reassessment, Mr. Smith’s leg score improved by 1 point, the physiotherapist’s confidence that this appar- rehabilitation unit of a regional tertiary care hospital after ent improvement represented a true improvement, experiencing a right anterior cerebral artery stroke rather than a random fluctuation in a truly unchanged 2 weeks ago. On admission, the physiotherapist assessed patient, would increase from 50% to 75%. This is shown him using the CMSA and determined that he had a score by the arrow in Figure 4. If Mr. Smith improved by 2 or of Stage 3 on the leg dimension of the CMSA–II. The ther- more points, the physiotherapist could rule in an apist constructed the following measurable goal: to improvement with absolute certainty (i.e., post–leg score increase Mr. Smith’s leg function by at least one stage in chance of improvement = 100%). 4 weeks. The improvement value of 1 point, or stage, comes from this study’s change estimates; the time frame In this vignette, the physiotherapist scheduled the re- for scheduling the reassessment comes from the phy- assessment when he or she estimated a 50% chance that siotherapist’s experience (e.g., a chart review of similar this patient would achieve at least a 1-point

Beyer et al. Estimating the Threshold Value for Change for the Six Dimensions of the CMSA Impairment Inventory 109 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 improvement. A feature of Figure 4 is that it illustrates the shoulder pain dimension to identify true change in a the potential information gain for a spectrum of pre- patient’s motor recovery. assessment estimates of improvement, ranging from 0 to 100. For example, suppose the patient in this scenario REFERENCES was unable to be reassessed at the time the therapist an- ticipated a 50% change, hypothetically at 4 weeks, and 1. Gowland C, Stratford P, Ward M, et al. Measuring physical that the assessment actually occurred at 8 weeks. This impairment and disability with the Chedoke-McMaster Stroke increase would likely affect the therapist’s pre-measure Assessment. Stroke. 1993;24(1):58–63. https://doi.org/10.1161/01. estimate of this patient’s chance of improvement. Rather STR.24.1.58. Medline:8418551 than assigning a 50% chance of improvement, the thera- pist would likely assign a greater chance of improvement, 2. Kamper DG, Fischer HC, Cruz EG, et al. Weakness is the primary say 75%. Figure 4 shows that an improvement of 1 point, contributor to finger impairment in chronic stroke. Arch Phys Med combined with a pre-measure chance of 75% improve- Rehabil. 2006;87(9):1262–9. https://doi.org/10.1016/j. ment, now yields a post-measure chance of improvement apmr.2006.05.013. Medline:16935065 of approximately 88%. 3. Liao LR, Ng GY, Jones AY, et al. Whole-body vibration intensities in CONCLUSION chronic stroke: a randomized controlled trial. Med Sci Sports Exerc. The CMSA is a widely used, performance-based out- 2016;48(7):1227–38. https://doi.org/10.1249/MSS.0000000000000909. Medline:26918558 come measure that has demonstrated evidence of both reliability and validity.1,4,5,9,11,12,13,15–18 Previously, there 4. Huang M, Pang MYC. Psychometric properties of Brief-Balance was no threshold value for change reported for dimen- Evaluation Systems Test (Brief-BESTest) in evaluating balance sions of the CMSA–II. Our study identified a threshold performance in individuals with chronic stroke. Brain Behav. 2017;7 value-for-change score of 1impairment point for the arm, (3):e00649. https://doi.org/10.1002/brb3.649. Medline:28293482 hand, leg, foot, and postural control dimensions and 2 impairment points for the shoulder pain dimension. Hav- 5. Nas K, Gur A, Cevik R, et al. The relationship between physical ing these values, clinicians can better determine whether impairment and disability during stroke rehabilitation: effect of their patients have experienced a clinically relevant cognitive status. Int J Rehabil Res. 2004;27(3):181–4. https://doi.org/ change. 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Valach L, Signer S, Hartmeier A, et al. Chedoke-McMaster Stroke stroke. However, no threshold value for change has been Assessment and modified Barthel Index self-assessment in patients reported for any of its six dimensions. with vascular brain damage. Int J Rehabil Res. 2003;26(2):93–9. https://doi.org/10.1097/00004356-200306000-00003. What this study adds Medline:12799602 Clinicians can use a change of 1 impairment point 11. Meier Khan C, Oesch P. Validity and responsiveness of the German (i.e., stage) for the arm, hand, leg, foot, and postural con- version of the Motor Activity Log for the assessment of self-perceived trol dimensions and a change of 2 impairment points for arm use in hemiplegia after stroke. NeuroRehabilitation. 2013;33 (3):413–21. Medline:23949073 12. Schuster C, Hahn S, Ettlin T. Objectively-assessed outcome measures: a translation and cross-cultural adaptation procedure applied to the Chedoke McMaster Arm and Hand Activity Inventory (CAHAI). BMC Med Res Methodol. 2010;10(1):106–15. https://doi.org/10.1186/1471- 2288-10-106. Medline:21114807 13. Gowland C, Van Hullenaar S, Torresin W, et al. Chedoke–McMaster Stroke Assessment: development, validation, and administration manual. Hamilton (ON): McMaster University and Hamilton Health Sciences; c1995. 14. Moreland J, Gowland C, Van Hullenaar S, et al. Theoretical basis of the Chedoke-McMaster Stroke Assessment. Physiother Can. 1993;45:231–8. 15. Knorr S, Brouwer B, Garland SJ. Validity of the Community Balance and Mobility Scale in community-dwelling persons after stroke. Arch Phys Med Rehabil. 2010;91(6):890–6. https://doi.org/10.1016/j. apmr.2010.02.010. Medline:20510980

110 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 16. 1Barreca SR, Stratford PW, Lambert CL, et al. Test-retest reliability, 25. Salbach NM, Jaglal SB, Korner-Bitensky N, et al. Practitioner and validity, and sensitivity of the Chedoke Arm and Hand Activity organizational barriers to evidence-based practice of physical Inventory: a new measure of upper-limb function for survivors of therapists for people with stroke. Phys Ther. 2007;87(10):1284–303. stroke. Arch Phys Med Rehabil. 2005;86(8):1616–22. https://doi.org/ https://doi.org/10.2522/ptj.20070040. Medline:17684088 10.1016/j.apmr.2005.03.017. Medline:16084816 26. Dang M, Ramsaran KD, Street ME, et al. Estimating the accuracy of 18. Levin M, Liebermann D, Parmet Y, Berman S. Compensatory versus the Chedoke-McMaster Stroke Assessment predictive equations for noncompensatory shoulder movements used for reaching in stroke. stroke rehabilitation. Physiother Can. 2011;63(3):334–41. https://doi. Neurorehabil Neural Repair. 2015;30(7):635–46. https://doi.org/ org/10.3138/ptc.2010-17. Medline:22654239 10.1177/1545968315613863. 27. Stratford PW. Getting more from the literature: estimating the 19. 2Crowe JM, Harmer D, Sharp J. Reliability of the Chedoke-McMaster standard error of measurement from reliability studies. Physiother Disability Inventory in acquired brain injury. Canadian Can. 2004;56(1):27–30. https://doi.org/10.2310/6640.2004.15377. Physiotherapy Association Congress; 1996 May 31–June 3; Victoria, BC, Canada. 28. Stratford PW, Goldsmith CH. Use of the standard error as a reliability index of interest: an applied example using elbow flexor strength 20. Barclay-Goddard R. Physical function outcome measurement in data. Phys Ther. 1997;77(7):745–50. https://doi.org/10.1093/ptj/ acute neurology. Physiother Can. 2000;52:138–45. 77.7.745. Medline:9225846 21. Sacks L, Yee K, Huijbregts M, et al. Validation of the Activity 29. Stratford PW, Riddle DL. When minimal detectable change exceeds a Inventory of the Chedoke-McMaster Stroke Assessment and the diagnostic test-based threshold change value for an outcome Clinical Outcome Variables Scale to evaluate mobility in geriatric measure: resolving the conflict. Phys Ther. 2012;92(10):1338–47. clients. J Rehabil Med. 2010;42(1):90–2. https://doi.org/10.2340/ https://doi.org/10.2522/ptj.20120002. Medline:22767887 16501977-0477. Medline:20111850 30. Stratford PW, Riddle DL. A Roland-Morris Questionnaire target value 22. Huijbregts M, Gowland C, Gruber R. Measuring clinically-important to distinguish between functional and dysfunctional states in people change with the Activity Inventory of the Chedoke McMaster Stroke with low back pain. Physiother Can. 2016;68(1):29–35. https://doi. Assessment. Physiother Can. 2000;52:295–304. org/10.3138/ptc.2014-85. Medline:27504045 23. Stokes EK, O’Neill D. Use of outcome measures in physiotherapy 31. 3Froud R, Abel G. Using ROC curves to choose minimally important practice in Ireland from 1998 to 2003 and comparison to Canadian change thresholds when sensitivity and specificity are valued equally: trends. Physiother Can. 2008;60(2):109–16. https://doi.org/10.3138/ the forgotten lesson of Pythagoras. Theoretical considerations and an physio.60.2.109. Medline:20145774 example application of change in health status. PLoS ONE. 2014;9 (12):e114468. https://doi.org/10.1371/journal.pone.0114468. 24. Duncan EA, Murray J. The barriers and facilitators to routine outcome measurement by allied health professionals in practice: a 32. Stratford PW. Diagnosing patient change: impact of reassessment systematic review. BMC Health Serv Res. 2012;12(96):96. https://doi. interval. Physiother Can. 2000;52(3):225–8. org/10.1186/1472-6963-12-96. Medline:22506982

Clinician’s Commentary on Beyer et al.1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 With demands on the Canadian health care system increas- stroke rehabilitation). However, clinicians can educate the ing,2 clinicians need to optimize their treatment protocols to patient that this score represents a true change in status, which help patients return to the community as quickly and safely as may consequently motivate the patient to continue to partici- possible. Canadian stroke best-practice guidelines encourage pate in therapy knowing that her or his efforts are producing evidence-based approaches to reduce the variability in care meaningful results.4 between patients, and they report the benefit of using validated assessment tools to standardize care and guide clinical reasoning Likewise, if there is a 1-point drop in a CMSA–II domain, in rehabilitation settings.3 These tools help clinicians systemati- therapists can more confidently advocate to the health care team cally identify impairments during the initial assessment and for further investigation and treatment, knowing that this change monitor progress over the duration of treatment protocols. Stan- reflects genuine clinical deterioration. Having an improved under- dardized assessment tools also provide a common language for standing of the threshold for change may also enable clinicians to inter-professional team members to use when discussing their use the CMSA–II more easily to set measurable goals. Clinicians patients’ progress, thereby guiding future health care decisions. can use their previous experience to estimate the expected amount of time that patients with a similar presentation will Despite the literature supporting the use of standardized out- improve 1 point on the CMSA–II and then use this information to come measures in physiotherapy, there are many barriers to their determine whether their current patient is progressing at the ex- use. Studies have shown that clinicians do not have enough knowl- pected rate.7 This comparison can guide clinicians to re-evaluate edge of, or confidence in, implementing and interpreting assess- which aspects of the current treatment plan are most effective or ment tools, which explains why many therapists do not use such how to adjust their treatment approach to improve results. measures.4,5 Without an appropriate understanding of how to interpret an initial score or a change in score, it becomes challen- The report by Beyer and colleagues1 helps improve the inter- ging for clinicians to determine whether treatment protocols pretation of change in a CMSA–II score; thus, it would be inter- should be continued as is or modified to maximize recovery. Beyer esting for future research to determine whether the time it takes and colleagues’ recent article in Physiotherapy Canada addresses for an individual to demonstrate a meaningful change provides some of the uncertainties inherent in interpreting a change in any new clinical insights. For example, predictive models using score on the Chedoke-McMaster Stroke Assessment Impairment the CMSA have many errors, thus limiting their clinical use.8 Inventory (CMSA–II),1 a commonly used tool to determine the Current models use initial presentation as their primary input; stage of motor recovery among individuals with stroke.6 inserting the amount of time it takes for a patient to show true change in their CMSA–II score may improve those models that To improve interpretation of the CMSA–II, Beyer and collea- predict recovery. Having better insight into the projected recov- gues used two statistical approaches to determine the magnitude ery for individuals with stroke may improve the organization of of the change in score needed to reflect a true change in patient resources and services for discharge, thereby facilitating im- status.1 First, by computing minimal detectable change (MDC), proved community re-integration. they determined that 1 point in the arm, hand, leg, foot, and pos- tural control domains and 2 points in the shoulder pain domain Future research should also determine threshold improve- represent the threshold value for change (i.e., the expected score ment values for the upper extremity (hand, arm, and shoulder fluctuation in patients who are truly unchanged between tests).1 pain) domains of the CMSA–II to provide insight into change Second, using diagnostic testing methodology (DTM), a thresh- scores beyond MDC values alone. old improvement value (i.e., how much change is needed for clinicians to have confidence that there is a true change) was Sarah Gregor, PT, PhD (student) determined to be 1 point for the leg, foot, and postural control Doctoral Student, Rehabilitation Sciences Institute, domains.1 Upper extremity threshold improvement values were not determined because of limitations in the availability of data. University of Toronto, and Physiotherapist, St. John’s Rehab, Sunnybrook Health Sciences Centre, Stratford and colleagues compared MDC and DTM analyses and found that DTM analysis was more effective in guiding clini- Toronto; [email protected]. cal reasoning for physiotherapists.7 MDC is determined by ana- lyzing individuals who have not changed to quantify test–retest REFERENCES variability.7 In contrast, DTM analysis includes all individuals, and it determines a change score that maximizes sensitivity and 1. Beyer R, Wharin C, Gillespie E, et al. Estimating the threshold value specificity for the measurement tool.7 Therefore, clinicians can for change for the six dimensions of the Impairment Inventory of the have confidence that a change score of 1 point in the foot, leg, Chedoke-McMaster Stroke Assessment. Physiother Canada. 2018;71 and postural control domains represents a clinically important (2):xxx–xx. https://doi.org/10.3138/ptc.2017-87. change. This information can be used to guide clinical decisions. 2. Krueger H, Koot J, Hall RE, et al. Prevalence of individuals Having confidence in interpreting the CMSA–II can help experiencing the effects of stroke in Canada: trends and projections. therapists improve communication with their patients, their pa- Stroke. 2015;46(8):2226–31. https://doi.org/10.1161/ tients’ families, and the health care team. For example, a change strokeaha.115.009616. Medline:26205371 of 1 point may sound minimal to a patient who has spent many hours a week participating in therapy (a scenario common in 3. Hebert D, Lindsay MP, McIntyre A, et al. Canadian stroke best practice recommendations: stroke rehabilitation practice guidelines, update 2015. Int J Stroke. 2016;11(4):459–84. https://doi.org/10.1177/ 1747493016660102. Medline:27443991 111

112 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 4. Jette DU, Halbert J, Iverson C, et al. Use of standardized outcome 7. Stratford PW, Riddle DL. When minimal detectable change exceeds a measures in physical therapist practice: perceptions and diagnostic test-based threshold change value for an outcome applications. Phys Ther. 2009;89(2):125–35. https://doi.org/10.2522/ measure: resolving the conflict. Phys Ther. 2012;92(10):1338–47. ptj.20080234. Medline:19074618 https://doi.org/10.2522/ptj.20120002. Medline:22767887 5. Duncan EA, Murray J. The barriers and facilitators to routine 8. Dang M, Ramsaran KD, Street ME, et al. Estimating the accuracy of outcome measurement by allied health professionals in practice: a the Chedoke-McMaster Stroke Assessment predictive equations for systematic review. BMC Health Serv Res. 2012;12(1):96. https://doi. stroke rehabilitation. Physiother Can. 2011;63(3):334–41. https://doi. org/10.1186/1472-6963-12-96. Medline:22506982 org/10.3138/ptc.2010-17. Medline:22654239 6. Gowland C, Stratford P, Ward M, et al. Measuring physical DOI:10.3138/ptc.2017-87-cc impairment and disability with the Chedoke-McMaster Stroke Assessment. Stroke. 1993;24(1):58–63. https://doi.org/10.1161/01. str.24.1.58. Medline:8418551

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 ARTICLE Expérimentation d’une formation sur le trouble développemental de la coordination destinée aux enseignants en éducation physique Laurence Lachapelle-Neveu, pht.;* Camille Carrier, pht.;* Marianne Fink-Mercier, pht.;* Maxime Larivière, pht.;* Catherine Ruest, pht.;* Isabelle Demers, pht.;{ Désirée B. Maltais, Ph. D., pht.;{‡ Chantal Camden, Ph. D., pht.* RÉSUMÉ Objectif : les meilleures pratiques sur le trouble développemental de la coordination (TDC) incluent le développement de la capacité des enseignants à fa- voriser la participation des enfants aux activités physiques. L’objectif de l’étude est d’évaluer l’impact d’une formation d’une journée, incluant des exposés et des ateliers sur le TDC, sur les perceptions des connaissances, des compétences et des pratiques pédagogiques d’enseignants en éducation physique (EÉP). Méthodologie : étude de cohorte avec devis mixte pré-post-suivi incluant des questionnaires avant, immédiatement après et trois mois après la for- mation. Des analyses descriptives, des tests de Wilcoxon et une analyse thématique ont été réalisés. Résultats : trente-huit, trente-cinq et vingt-deux EÉP ont rempli respectivement les questionnaires au trois temps de mesure. Les perceptions des connaissances, compétences et pratiques pédagogiques des EÉP étaient plus élevées après la formation comparativement aux perceptions initiales (p < 0,006). Initialement, les EÉP rapportaient utiliser certaines stra- tégies pédagogiques générales (p. ex., modifications de la tâche). À la suite de la formation, les EÉP ont fourni des exemples plus concrets et ont rapporté utiliser de nouvelles stratégies (p. ex., offrir de la rétroaction à la suite de la tâche) qui semblent avoir diminué les problèmes comportementaux. Conclu- sion : une formation peut favorablement modifier les perceptions d’EÉP sur leurs connaissances, compétences et pratiques. Plus de recherches sont né- cessaires afin d’évaluer les retombées sur la participation des enfants ayant un TDC. ABSTRACT Purpose: Best DCD practices include developing the ability of teachers to promote the participation of children in physical activities. The purpose of this study is to assess the impact of a one-day training session, including short lectures and workshops on developmental coordination disorder (DCD), on the perceptions that physical education teachers (PET) have of the knowledge, skills, and pedagogical practices. Methods: cohort study with a mixed pre-post- follow-up design that included a questionnaire before, immediately after, and three months after the training. Descriptive analyses, Wilcoxon tests, and a thematic analysis were performed. Results: 38, 35, and 22 PET respectively filled out the questionnaires at the three time-point. The perceptions of the knowledge, skills, and pedagogical practices of the PET were higher after the training compared to the initial perceptions (p < 0.006). At first, the PETs re- ported using certain general pedagogical strategies (e.g., modifying the task). After the training, the PETs gave more concrete examples and reported using new strategies (e.g., offering feedback after the task), which seems to have decreased behavioural problems. Conclusions: training can favourably modify the PETs’ perceptions on their knowledge, skills, and practices. More research is necessary to assess the impact of the participation of children with a DCD. Key Words: best practices; children; continuing education; DCD; physical activity. Le trouble développemental de la coordination (TDC) l’exécution de tâches motrices. Ceci affecte de façon signi- touche 5 à 6 % des enfants d’âge scolaire1. Les enfants at- ficative leur fonctionnement dans leurs activités quoti- teints éprouvent des difficultés dans l’apprentissage et diennes, tant à l’école (p. ex., écriture, jeux dans la cour de Affiliations : *Centre de recherche du Centre hospitalier universitaire de l’Université de Sherbrooke, Université de Sherbrooke; {Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Institut de réadaptation en déficience physique de Québec; ‡Département de réadaptation, Université Laval, Québec. Correspondance à : Chantal Camden, École de réadaptation, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke (Québec) J1H 5N4; [email protected]. Collaborateurs : Tous les auteurs ont conçu l’étude ou ont recueilli, analysé ou interprété les données et ont rédigé ou procédé à l’examen critique de l’article et en ont approuvé la version définitive. Conflits d’intérêts : Les auteurs n’ont aucun conflit d’intérêts à déclarer. Les bailleurs de fonds n’étaient pas impliqués dans la conception de l’étude, la collecte de données, l’analyse des données, la préparation des manuscrits ou les décisions de publication. Remerciements : Les auteurs remercient leurs partenaires, soit les commissions scolaires participantes ainsi que leur conseillère pédagogique respective, l’Institut de réadaptation en déficience physique de Québec, l’Université Laval, le Centre de réadaptation Estrie, l’Université de Sherbrooke et les EÉP ayant participé à leur étude. Physiotherapy Canada 2019; 71(2);113–120; doi:10.3138/ptc.2017-93.f 113

114 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 récréation et gymnastique) qu’à la maison (p. ex. s’habil- était plus marquée chez ceux ayant un TDC23. Les interven- ler)2,3,4. Les enfants ayant un TDC évitent fréquemment tions offertes incluaient des activités de promotion de la les activités sportives afin d’esquiver une possible situation santé recommandées par l’Organisation mondiale de la d’échec5. Éventuellement, cette tendance à l’évitement Santé (OMS) ainsi qu’une présentation visant l’identifica- peut les plonger dans l’isolement et nuire à leur dévelop- tion du TDC. Cela nous laisse croire qu’une formation plus pement physique, social et académique6,7,8. Ceci peut en- spécifique sur le TDC pour les EÉP pourrait être bénéfique trainer une diminution de leur qualité de vie9. Un soutien et favoriser davantage la participation aux activités physi- adéquat est donc primordial2,3,7 pour éviter d’autres con- ques de ces enfants. séquences à long terme10,11. Le rôle des physiothérapeutes auprès des enfants avec un TDC est présenté dans un Les preuves suggèrent qu’un changement est nécessaire module accessible gratuitement en ligne et implique des afin de passer d’un modèle de services thérapeutiques indi- interventions individuelles ou de groupe, de la formation/ vidualisés offerts par les professionnels de la santé vers un soutien aux parents et au milieu scolaire et des adapta- modèle de collaboration entre professionnels, enseignants tions aux besoins de l’enfant12. L’efficacité des approches et autres adultes entourant l’enfant avec le TDC24. Le déve- utilisées par les physiothérapeutes – approches centrées loppement des connaissances sur le TDC de ceux-ci pour- sur la tâche, d’apprentissage moteur et cognitives – est rait avoir des retombées positives sur la participation des bien démontrée13. enfants dans leur environnement. Les formations sur la santé offertes aux enseignants seraient également bénéfi- Le transfert des connaissances et le développement ques, car ceux-ci démontreraient un engagement plus des capacités des adultes dans l’entourage des enfants important dans des projets d’intervention et auraient une font également partie des meilleures pratiques sur le meilleure approche d’éducation à la santé24. TDC14,15. Les enseignants ont une position privilégiée leur permettant de comprendre et de connaître avec pré- L’objectif de cette étude était d’évaluer l’impact d’une cision les capacités physiques ainsi que les différents journée de formation concernant le TDC sur les percep- comportements des élèves en situation d’activités spor- tions des connaissances, du sentiment de compétence et tives16,17. Cette position pourrait favoriser le dépistage des pratiques pédagogiques des EÉP. L’hypothèse de re- précoce par les enseignants. Celui-ci est primordial afin cherche était que la formation sur le TDC aurait un effet d’appliquer rapidement des mesures qui permettront de positif sur les trois variables étudiées immédiatement sui- contrer les difficultés motrices et de prévenir les consé- vant la formation et à court terme. Nous avons aussi quences à long terme. Les EÉP pourraient également exploré la perception des retombées sur le fonctionne- mettre en œuvre des interventions simples et adaptées ment des enfants à court terme. Les facteurs pouvant au milieu scolaire pour ces enfants18. Le site de CanChild avoir un impact sur les changements de connaissances, mentionne notamment la modification de la tâche, du compétences et pratiques pédagogiques ont également matériel utilisé et des attentes comme stratégies d’adap- été explorés. tation gagnantes (http://elearning.canchild.ca/dcd_ workshop/fr/strategies/resource/brochure-enseignants- MÉTHODOLOGIE education-physique.pdf)19, ce qui pourrait contribuer à Le projet a été approuvé par le comité éthique en re- l’augmentation de l’intérêt de l’enfant pour l’activité phy- sique. Actuellement, les enfants présentant un TDC aur- cherche sur l’humain du centre de recherche du Centre aient moins de plaisir dans leurs cours d’éducation hospitalier universitaire de Sherbrooke (CHUS). physique20. Ce constat pourrait être dû au fait que, fré- quemment, aucune adaptation n’est apportée par les en- Dispositif de recherche seignants afin d’ajuster les tâches en fonction de leur Une étude de cohorte utilisant un devis mixte pré- niveau de compétence motrice21. Lorsque les cours en éducation physique sont adaptés aux capacités de l’en- post-suivi a été utilisée. Un questionnaire a été distribué fant, ils peuvent pourtant faciliter l’acquisition des habi- aux participants avant et immédiatement après la forma- letés motrices, augmenter les niveaux d’activité physique tion, ainsi que trois mois plus tard, afin d’évaluer la per- et favoriser une attitude positive envers l’activité phy- ception des connaissances, des compétences et des sique et la santé22. pratiques pédagogiques des EÉP. Cependant, à ce jour, peu d’études démontrent l’impact Participants, procédures d’échantillonnage et de recrutement de stratégies de partage de connaissances aux EÉP sur leur Un échantillon non probabiliste composé des EÉP tra- pratique. Une étude réalisée dans un milieu défavorisé en Afrique du Sud a permis d’identifier que des interventions, vaillant auprès des enfants de la maternelle jusqu’à la implantées par des étudiants en physiothérapie durant sixième année dans deux différentes régions du Québec neuf semaines, ont amélioré les habiletés motrices et la (Canada) a été utilisé. Un niveau de connaissance pré- condition physique de tous les enfants; et l’amélioration alable sur le TDC ne faisait pas partie des critères d’inclu- sion de l’étude. À l’automne 2015, les EÉP ont reçu une invitation de la conseillère pédagogique de leur région pour les inviter à participer à une formation sur le TDC. Un courriel a ensuite été envoyé aux EÉP inscrits à la

Lachapelle-Neveu et coll. Expérimentation d’une formation sur le trouble développemental de la coordination destinée aux enseignants 115 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 formation afin de leur faire parvenir le formulaire de rapport aux enfants ayant un TDC. Les questionnaires consentement et leur expliquer en quoi consistait le pro- ont été inspirés de questionnaires sur le TDC déjà exis- jet de recherche associé à la formation. Le jour de la for- tants, utilisés dans des études antérieures auprès de phy- mation, des membres de l’équipe de recherche ont siothérapeutes et d’ergothérapeutes12,25. Ceux-ci ont été expliqué le projet et ils étaient disponibles pour répondre révisés par les collaborateurs des milieux scolaires impli- à leurs questions. Les EÉP désirant participer ont été in- qués dans le projet pour s’assurer de la pertinence de vités à signer le formulaire de consentement. chaque question pour les EÉP. Afin d’analyser quantitati- vement les changements dans le temps au niveau des Intervention connaissances, des compétences et des pratiques péda- Une formation d’une journée a été offerte aux EÉP au gogiques, quatre questions portant sur les connaissances, trois sur les compétences et une sur les pratiques péda- début de l’année 2016. La formation a été offerte à deux gogiques se répétaient dans les trois questionnaires (voir reprises (une formation par région). Ces formations ont été le questionnaire de suivi, disponible en appendice 2 en données par la même physiothérapeute, soit une clinicien- ligne, pour connaître les items exacts évalués). Les sept ne ayant développé une expertise sur le TDC. Le contenu questions portant sur les connaissances et les compé- de la formation, intitulée « Activités sportives : aider les tences utilisaient une échelle d’auto-évaluation à 7 points jeunes avec un TDC » incluait la définition et les manifesta- (allant de 1 = fortement en désaccord à 7 = fortement en tions du TDC, ainsi qu’un survol des différentes conditions accord). La question sur les pratiques pédagogiques utili- associées. Les impacts du TDC en éducation physique é- sait une échelle d’auto-évaluation à 10 points (allant de taient également présentés. Une partie importante de la 1 = pas du tout confiant à 10 = entièrement confiant). formation était ensuite consacrée aux adaptations pouvant Une question ouverte demandant aux participants de être faites dans le cadre des activités pédagogiques, incluant donner des exemples sur la façon dont ils ajustaient leurs un résumé de stratégies gagnantes expérimentées dans le pratiques pédagogiques dans leur enseignement a égale- cadre de la pratique clinique de la formatrice. Les EÉP de- ment été incluse dans les trois questionnaires. vaient, en groupe, expérimenter et discuter de la manière dont les différentes adaptations pourraient être mises en Au total, le questionnaire pré-formation comprenait place dans leurs classes. Le rôle et les limites des EÉPS avec 17 questions (14 questions fermées et 3 questions ou- ces enfants étaient finalement exposés ainsi que le proces- vertes), incluant les renseignements personnels (commis- sus de référence lorsque nécessaire. L’impact que l’EÉP sion scolaire, âge, sexe, courriel, années d’expérience, peut avoir dans la prise en charge optimale des enfants pré- niveaux enseignés, nombre d’enfants ayant un diagnostic sentant un TDC était au cœur de la formation (pour davan- de TDC dans leurs classes). Le questionnaire post- tage de précision, voir le guide d’animation de la formation, formation comprenait 15 questions (11 questions fermées disponible en appendice 1 en ligne). Les formations dans et 4 questions ouvertes), incluant la satisfaction en lien les deux régions étaient similaires, mais la formation a été avec l’activité de formation. Le questionnaire trois mois de 4 h 30 au lieu de 5 h 30 dans la deuxième région. Tous post-formation comprenait 17 questions (10 questions les participants ont reçu une version papier du support fermées et 7 questions ouvertes) et incluait des questions visuel (présentation PowerPointMD) de la formation, le sur le nombre d’enfants qu’ils ont identifiés comme formulaire de consentement et le questionnaire pré- ayant possiblement un TDC suivant la formation, le nom- formation. Des documents additionnels différents entre les bre de suivis entrepris ainsi que les démarches réalisées régions ont cependant été remis aux participants en fonc- pour ces enfants, l’impact des changements de pratiques tion des préférences des partenaires. Dans la région 1, un pédagogiques pour les élèves et les facteurs qui ont eu guide sur les déficiences motrices a été remis aux partici- une influence positive/négative sur la capacité des EÉP à pants. Dans la région 2, un cahier du participant regrou- mettre en place des changements de pratiques. pant plusieurs ressources pouvant aider les EÉP dans leur pratique quotidienne auprès des enfants TDC, incluant Les questionnaires pré et post-formation ont été rem- celles distribuées à la première région, a été remis. De plus, plis de façon manuscrite par les participants avant et quelques semaines plus tard, des vidéos présentant diverses après la formation. Le questionnaire trois mois post- stratégies pédagogiques adaptées aux enfants ayant un formation a été rempli de façon électronique, à la suite TDC, réalisées avec des EÉP de la région 2, ont été rendues de l’envoi d’un lien Internet aux participants par l’entre- disponibles aux EÉP de cette région. mise de REDCap. Procédures de collecte des données Analyse des données Les questionnaires pré-formation, post-formation et Les analyses ont identifié que le groupe d’appartenance trois mois post-formation comprenaient des questions (c.-à-d. formation de plus longue durée, ou de plus courte fermées et ouvertes. Ils ont permis de documenter l’auto- durée, mais avec davantage de ressources) n’influençait pas perception des EÉP sur leurs connaissances, leur senti- les changements de perception des connaissances, des ment de compétence et leurs pratiques pédagogiques par compétences et des pratiques pédagogiques, ce qui peut

116 Physiotherapy Canada, Volume 71, Number 2 refléter le fait que les « ingrédients clés » de la formation Tableau 1 Caractéristiques démographiques des participants ayant étaient identiques d’une région à l’autre. Les analyses ont répondu aux questions donc été effectuées de façon combinée pour tous les parti- cipants. Pour les questions fermées, une analyse descriptive Caractéristiques des participants ayant répondu aux questionnaires des données sociodémographiques (âge, genre, nombre https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 d’années d’expérience comme EÉP, niveaux enseignés, Participants pré Participants nombre d’enfants avec un diagnostic médical confirmé de TDC dans leurs classes) a été effectuée. Des scores globaux Caractéristiques No. (%) suivi No. (%) ont tout d’abord été calculés pour les connaissances et les compétences (moyenne des quatre et des trois questions démographiques n = 38 n = 22 incluses dans le questionnaire, respectivement). Pour éva- luer les changements de connaissances, de compétences et Âge de pratiques, un test pour séries appariées de Wilcoxon a été effectué sur les médianes. Le niveau d’alpha a été ajusté 20-30 ans 5 (13,2 %) 5 (22,7 %) pour les comparaisons multiples (p = 0,05/9 = 0,006). La taille d’effet de chaque comparaison a été déterminée avec 30-40 ans 18 (47,4 %) 9 (40,9 %) la statistique Delta de Glass (D) et son importance a été quantifiée selon les critères de Cohen, où > 0,8 = grande 40-50 ans 9 (23,7 %) 5 (22,7 %) taille d’effet et < 0,2 = petite taille d’effet. Afin d’explorer l’influence de certaines variables indépendantes (p. ex., 50 ans et plus 6 (15,8 %) 3 (13,6 %) nombre d’enfants ayant un TDC par classe et nombre d’an- nées d’expérience de l’EÉP) sur les changements quantita- Genre tifs observés, le logiciel SPSS et une analyse de variance univariée (MANOVA) a été utilisée. Pour les questions à ré- Femme 20 (52,6 %) 11 (50 %) ponses ouvertes, une analyse thématique a permis de faire ressortir les idées principales qui se sont dégagées des ré- Homme 18 (47,4 %) 11 (50 %) ponses en texte libre des participants26. Une stratégie de codification mixte a été utilisée, où la liste de « stratégies Nombre d’années d’expérience comme EÉP gagnantes » présentées lors de la formation a été utilisée pour catégoriser les thèmes nommés par les enseignants 0-5 ans 8 (21,1 %) 7 (31,8 %) dans les questionnaires. Afin de documenter les change- ments concernant le type de pratiques pédagogiques dans 6-15 ans 15 (39,5 %) 7 (31,8 %) le temps, une analyse de fréquence a été effectuée sur les différents thèmes émergents. 15 ans et plus 15 (39,5 %) 8 (36,4 %) RÉSULTATS Niveaux enseignés (réponses multiples autorisées) Sur les 51 participants à la formation, 43 ont accepté Maternelle à 6e année 29 (76,3 %) 18 (81,8 %) de participer à l’étude. Cinq EÉP ont été exclus puisqu’ils enseignaient exclusivement au secondaire. Parmi les Préscolaire 10 (26,3 %) 4 (18,2 %) trente-huit (38) EÉP admissibles à l’étude qui ont signé le formulaire de consentement et le questionnaire initial, Classe à effectifs réduits 8 (21,1 %) 3 (13,6 %) trente-cinq (35) ont rempli le questionnaire post-formation et vingt-deux (22) ont rempli tous les questionnaires (taux 1re année 5 (13,2 %) 2 (9,1 %) d’abandon = 42 %). Aucune différence statistique n’a été trouvée entre les caractéristiques sociodémographiques 2e année 6 (15,8 %) 3 (13,6 %) des EÉP ayant seulement complété les questionnaires 1 et 2 (n = 16) et ceux ayant rempli tous les questionnaires 3e année 5 (13,2 %) 1 (4,5 %) (n = 22) (voir le tableau 1). 4e année 3 (7,9 %) 0 (0 %) Impact de la formation sur la perception des connaissances, des compétences et des pratiques pédagogiques de l’EÉP 5e année 2 (5,3 %) 0 (0 %) La perception que les EÉP avaient de leurs connais- 6e année 3 (7,9 %) 1 (4,5 %) sances, compétences et pratiques pédagogiques était plus élevée, et ce, de façon significative, aux question- Nombre d’enfants dans leurs classes ayant un diagnostic médicalement confirmé de TDC Aucun 3 (7,9 %) 2 (9,1 %) 1à4 13 (34,2 %) 7 (31,8 %) 5 et plus 11 (28,9 %) 8 (36,4 %) Ne sait pas 11 (28,9 %) 5 (22,7 %) naires post et suivi en comparaison au questionnaire ini- tial. De plus, il n’y avait pas de différences entre les scores post et de suivi (voir le tableau 2). Les tailles d’effet des différences étaient grandes pour les résultats compa- rant les scores post-formation et initiaux sur le plan des connaissances (D = 1,472), des compétences (D = 1,879) et des pratiques pédagogiques (D = 1,394). Il en était de même pour la différence des résultats pour les scores au suivi à trois mois comparés aux scores initiaux (connais- sances : D = 1,376; compétences : D = 1,608; et pratiques pédagogiques : D = 0,955). Dans le questionnaire trois mois suivant la formation, 91 % des EÉP ont rapporté avoir identifié entre un et cinq enfants avec TDC et fait un suivi au sein de leur école afin d’obtenir du soutien. Facteurs sociodémographiques influençant les résultats Le nombre d’enfants ayant un TDC dans la classe de l’enseignant et le nombre d’années d’expérience n’ont

Lachapelle-Neveu et coll. Expérimentation d’une formation sur le trouble développemental de la coordination destinée aux enseignants 117 Tableau 2 Effets de la formation sur les connaissances, la perception de compétences et les pratiques pédagogiques des EÉP Post-initial Suivi-initial Suivi-post https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Variable Initial Post-formation Suivi Différence Delta de Différence Delta de Différence Delta de Connaissances (n = 38) (n = 35) (n = 22) +2,065* Glass +1,931{ Glass –0,134 Glass +2,514* 1,472 +2,152{ 1,376 –0,363 –0,249 Compétences 4,092* 6,157 6,023 +3,096* +2,119{ –0,977 (1,403) (0,539) (0,545) 1,879 1,608 –0,620 Pratiques 3,000 5,514 5,152 pédagogiques (1,338) (0,585) (0,859) 1,394 0,955 –1,174 4,790 7,886 6,909 (2,220) (0,832) (1,601) * Les chiffres présentés sont les moyennes. nues des EÉP avant la formation. Initialement, les deux { Changement significatif p < 0,006. thèmes identifiés le plus fréquemment étaient la modifi- cation de la tâche et du matériel. Par contre, la majorité pas eu d’influence significative sur les changements de des réponses étaient peu concrètes et détaillées. Dans le connaissances, de compétences et de pratiques pédago- questionnaire post-formation, des stratégies n’ayant pas giques. L’influence du nombre d’enfants reconnus avec été nommées en pré-formation sont ressorties, dont un TDC à la suite de la formation n’a pu être déterminée, notamment de questionner l’enfant. À noter que la quan- puisque la variabilité des résultats était trop faible (c.-à-d. tité de thèmes mentionnés par participant dans le ques- 20 des 22 participants ayant rempli le questionnaire de tionnaire post-formation était plus élevée qu’au départ suivi ont rapporté entre un et cinq jeunes identifiés). (3,5 thèmes par participant comparé à 2,0 en pré- formation). Une plus grande variété de thèmes a égale- Impacts de la formation rapportés par les EÉP sur leurs ment été observée dans les questionnaires post- pratiques pédagogiques formation et de suivi (9 stratégies en pré, 12 stratégies en post et 11 stratégies en suivi). À trois trois mois suivant la Les pratiques pédagogiques connues et utilisées des formation, le nombre de stratégies pédagogiques identifié EÉP ont également évolué positivement lors des trois par participant était moindre qu’en post-formation questionnaires (voir tableau 3). Certaines stratégies utili- (1,8 thème/participant comparé à 3,5), mais les exemples sées pour intervenir auprès des élèves étaient déjà con- illustrant les thèmes étaient beaucoup plus concrets puis- qu’ils représentaient des stratégies véritablement appli- Tableau 3 Effet de la formation sur les pratiques pédagogiques des EÉP quées dans leur classe plutôt que des concepts plus théoriques comme au T2. Les EÉP ont rapporté avoir réa- Stratégies d’adaptation – thèmes identifiés par Nombre d’EÉP ayant lisé plusieurs démarches pour soutenir leurs élèves, les EÉP mentionné ce thème comme discuter avec la direction et le titulaire de l’en- fant, impliquer les parents pour obtenir du soutien, se (n = 22) procurer du matériel leur permettant de modifier la tâche et l’environnement, modifier leur façon d’enseigner Pré Post Suivi et de travailler avec les professionnels de la santé impli- qués auprès de l’enfant. 1. S’assurer de la compréhension de l’enfant 0 31 Selon les EÉP les changements de pratiques ont eu 2. Augmenter la pratique 2 31 divers impacts sur les enfants ayant des difficultés, comme une meilleure estime d’eux-mêmes et un sentiment de 3. Décortiquer l’activité en étapes simples et 3 10 7 fierté face à la réussite d’un plus grand nombre de tâches. Les EÉP ont également rapporté une diminution des pro- s’assurer qu’il réussit une étape avant blèmes comportementaux ainsi qu’une compréhension plus rapide chez les enfants durant les classes. d’en ajouter une autre Les EÉP ont soulevé des défis face à la mise en place 4. Guider physiquement 1 31 de changements des pratiques pédagogiques, soit le manque de temps et de ressources matérielles, ainsi que 5. Donner des repères visuels 4 98 le nombre élevé d’élèves dans les groupes en gymnase. 6. Nommer verbalement la séquence 1 20 7. Modifier le matériel 12 6 3 8. Modifier la tâche 11 12 7 9. Modifier nos attentes 8 77 10. Diminuer les distractions 1 02 11. Questionner l’enfant pour qu’il puisse 0 14 2 apprendre à apprendre 12. Rétroaction avec support visuel (film) 0 40 13. Préparation de l’enseignant + collaboration 0 41 avec titulaire

118 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 La formation a été très appréciée par les participants physiques associées au TDC34. Il est intéressant de noter en raison de son côté pratique et des exemples concrets que trois mois suivant la formation, la majorité des EÉP permettant de comprendre et d’aider les élèves qui ont avaient identifié des jeunes susceptibles d’avoir un TDC un TDC. non diagnostiqué, et qu’ils avaient fait différents suivis pour aider les enfants. Plusieurs études précédentes a- DISCUSSION vaient démontré la capacité des EÉP à reconnaître des Cette étude indique qu’une formation sur le TDC of- manifestations du TDC16,17, mais peu avaient documenté les suivis faits par les EÉP à la suite de l’identification de ferte aux EÉP du primaire a eu des retombées positives à jeunes ayant potentiellement un TDC. Cette donnée re- court terme sur leurs connaissances, compétences et pra- cueillie dans notre étude nous indique que les connais- tiques pédagogiques. Les résultats quantitatifs démon- sances acquises et les compétences développées à la trent une différence significative pour les résultats suite de la formation semblent les avoir rendus plus ha- immédiatement après et trois mois suivant la formation biles en ce qui concerne le suivi de certains enfants avec par rapport aux résultats initiaux, et ce, pour les trois un possible TDC et plus sensibilisés à l’importance de ce variables dépendantes à l’étude. Les tailles d’effet de suivi. La collaboration entre les milieux scolaires et de Cohen (D) étant toutes supérieures à 0,8 suggèrent une santé doit faire partie des bonnes pratiques sur le TDC14. haute signification pratique. Aucune différence n’a été En effet, dans le but d’offrir à l’enfant des interventions notée entre les résultats post-formation et ceux au suivi, précoces l’EÉP est dans une position privilégiée puisqu’il ce qui suggère que les EÉP ont maintenu leurs acquis a un contact quotidien avec l’enfant. après trois mois. Nos résultats sont similaires à une autre étude ayant offert une formation plus générale; cepen- L’utilisation du travail collaboratif pour favoriser la dant, cette étude n’avait pas évalué les pratiques pédago- participation active des enfants en milieu scolaire pour- giques23. Dans les trois mois suivant la formation, les EÉP rait permettre une meilleure continuité des services35. ont mis en place, dans leurs classes, une grande variété Les physiothérapeutes sont encouragés à travailler de de stratégies d’adaptation apprises lors de la formation. concert avec les EÉP afin d’assurer une prise en charge Le fait que les EÉP aient dit avoir mis en place moins de efficiente en première ligne pour les des enfants ayant un stratégies pédagogiques à trois mois, comparativement à TDC. Une équipe multidisciplinaire comprenant les pro- ce qu’ils souhaitent faire immédiatement après la forma- fessionnels de la santé (ergothérapeute, physiothéra- tion, est cohérent avec les différences entre la volonté de peute, psychologue) et l’entourage de l’enfant (parents, changement de comportements et le changement vérita- enseignants) est essentielle pour le dépistage et la mise ble de ceux-ci27. Cela peut également être expliqué par en place d’interventions précoces auprès de l’enfant pré- les défis auxquels les EÉP doivent faire face lors de la sentant un TDC. Les résultats de notre étude misent sur mise en place de changements identifiés dans le ques- l’importance d’un partage de connaissances entre les in- tionnaire de suivi. Le sentiment de confiance des ensei- tervenants en contact avec l’enfant, tel que l’avait dé- gnants peut aussi être un facteur ayant influencé montré le modèle « partnering for change » misant sur un l’application et le maintien des acquis au cours des trois partenariat entre ergothérapeutes et enseignants25. En mois suivant la formation. revanche, ce modèle impliquait une intensité et une fré- quence d’intervention beaucoup plus élevées. Nos résul- Les stratégies pédagogiques rapportées par les EÉP tats qualitatifs démontrent l’intérêt que portent les EÉP sont en lien avec les meilleures pratiques recommandées en ce qui concerne ce partage de connaissances avec les dans les publications scientifiques, soit l’utilisation d’une physiothérapeutes. Ce travail collaboratif permettrait à approche centrée sur la tâche (p. ex., décortiquer la ces enfants d’obtenir le suivi dont ils ont besoin. tâche) ou de l’approche cognitive (p. ex., questionner l’enfant)13,28. Selon les écrits, ces stratégies améliorent le IMPLICATIONS fonctionnement de l’enfant, mais nos résultats indiquent Une intervention telle que celle administrée dans que cela pourrait également conduire à une diminution des problèmes comportementaux, une meilleure com- notre étude permet de maximiser les ressources dispo- préhension des consignes chez les élèves et une augmen- nibles en santé, dans un contexte de contrôle et limita- tation de leur estime de soi. Les enfants ayant un TDC tion des coûts de la santé où les services individualisés ne sont plus enclins à avoir des problèmes de santé mentale peuvent répondre à l’ensemble des besoins24. Ce type en lien avec l’isolement les conduisant vers l’anxiété et la d’intervention devrait donc être encouragé par les ges- dépression29,30,31. Ainsi, il est important de les dépister de tionnaires dans l’organisation des services offerts pour façon précoce et de mettre en place des stratégies dès les enfants présentant un TDC. En amorçant le travail que possible afin de promouvoir la participation active, collaboratif entre les EÉP et les physiothérapeutes, la laquelle pourrait être un médiateur important entre les coopération entre les secteurs de la santé et de l’éduca- difficultés motrices, l’isolement et le bien-être20,32,33 et tion serait optimisée, et la continuité des services serait prévenir les conséquences sociales, psychologiques et

Lachapelle-Neveu et coll. Expérimentation d’une formation sur le trouble développemental de la coordination destinée aux enseignants 119 facilitée afin d’assurer une meilleure prise en charge pour dination et d’implanter des stratégies pour favoriser leur cette clientèle. participation aux activités physiques. https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 LIMITATIONS RÉFÉRENCES L’échantillon non probabiliste limite la possibilité de 1. American Psychiatric Association. Desk reference to the diagnostic généraliser les résultats à d’autres populations ou d’au- criteria from DSM-5. Washington : American Psychiatric Assocation tres contextes. De plus, les participants étaient des parti- Publishing; 2014. cipants volontaires donc possiblement plus enclins à effectuer des changements de pratique comparativement 2. Rivilis I, Hay J, Cairney J et coll. 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https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 ARTICLE Labelling a Patient’s Change Status: It’s a Confidence Game Paul W. Stratford, MSc, PT ABSTRACT Purpose: The past several decades have seen considerable interest in identifying and applying threshold change values with outcome measures commonly used by physiotherapists. The crucial question of interest to clinicians is, To what extent can valid inferences be drawn from an outcome measure’s change or improvement score? To date, typical reporting by researchers includes the presentation of a validity coefficient, often in the form of the area under a receiver operating characteristic curve, and a threshold change or improvement value. A limitation of existing work is that it does not convey the confidence that a clinician can have in a decision based on applying the proposed threshold change value. Methods: This knowledge translation article presents three questions, or building blocks, to consider when making a judgment about a patient’s change status: (1) to what extent does a measure assess change in the context of interest, (2) what is the threshold change value, and (3) how confident can a clinician be in making the correct decision about a patient’s change status when applying the threshold change value? Results: This article provides a process for combining clinical expertise with the results from threshold value studies to enhance confidence in clinical decisions about individual patients’ change status. Conclusions: The article shows how a graph can be used to efficiently translate the results from threshold value studies to convey the chance of making the correct decision about a patient’s change status. Key Words: diagnostic test; outcome assessment; outcome measures; reproducibilty of results. RÉSUMÉ Objectif : depuis quelques décennies, on s’intéresse beaucoup à déterminer et à appliquer les valeurs seuils de changement pour mesurer les résultats cliniques qu’utilisent couramment les physiothérapeutes. Une question intéresse particulièrement les cliniciens : dans quelle mesure des inférences valides peuvent-elles être tirées d’un score de changement ou d’amélioration d’une mesure? Jusqu’à présent, les chercheurs ont surtout présenté des coefficients de validité, souvent sous forme de surface sous la courbe de la fonction d’efficacité du récepteur, et une valeur de changement ou d’amélioration du seuil. Les travaux existants comportent une limite, celle de ne pas transmettre la confiance qu’un clinicien peut porter à une décision d’après l’application de la valeur seuil de changement proposée. Méthodologie : le présent article d’application du savoir s’attarde sur trois questions (ou éléments fondamentaux) à examiner au moment d’évaluer un statut de changement du patient : 1) dans quelle mesure une mesure évalue-t-elle un changement dans le contexte d’intérêt?; 2) quelle est la valeur seuil de changement?; 3) à quel point un clinicien peut-il avoir confiance de prendre la bonne décision sur le statut de changement d’un patient lorsqu’il applique la valeur seuil de changement? Résultats : le présent rapport présente un processus pour combiner les compé- tences cliniques aux résultats des études des valeurs seuils pour accroître la confiance envers les décisions cliniques sur le statut de changement d’un patient donné. Conclusion : l’article démontre comment utiliser un graphique pour transmettre avec efficacité les résultats d’études de valeurs seuils pour établir la chance de prendre la bonne décision à l’égard du statut de changement du patient. Forming measurable goals and assessing whether they cal experience alone and have been to some extent arbi- have been met are fundamental aspects of clinical prac- trary (i.e., not substantiated with evidence). The term tice. Goals can be written in the form of a change score threshold change value is used to represent the minimum (e.g., to increase knee flexion by 9 degrees in 2 wk) or in amount of change on a measure beyond which a patient terms of a terminal target value (e.g., to increase knee is deemed to have changed. Over the past several dec- flexion to 142 degrees in 4 wk). This article focuses on the ades, numerous studies have been devoted to providing former goal; it provides suggestions for how researchers threshold change or improvement values for many out- can better translate the results of their studies and how come measures relevant to physiotherapy practice.1-7 clinicians can apply these results to have greater confi- The intent of providing this information has been to dence when interpreting a patient’s change score. complement clinical expertise with evidence. Historically, the threshold goal value and the expected Although the goal of providing this information has interval for meeting this value have been based on clini- been to assist clinical decision making about a patient’s From the School of Rehabilitation Science, McMaster University, Hamilton, Ont. Correspondence to: Paul Stratford, School of Rehabilitation Science, Institute of Rehabilitation Science, McMaster University, 1400 Main St. West, Hamilton, ON L8S 1C7; [email protected]. Competing Interests: None declared. Physiotherapy Canada 2019; 71(2);121–129; doi:10.3138/ptc.2018-18 121

122 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 change status, investigators have not formally reported the characteristic of interest beyond measurement error. how applying an evidence-based threshold change value Before proceeding, it is important to establish that validity translates into level of confidence in interpreting a is neither an all-or-none property nor a property of a test change value and reporting it in the medical record. Ex- or measure. Validity exists to a degree, and it exists in a isting studies have typically only examined the validity of specific context.9 For example, the 6-minute walk test may a measure in a declared context and reported a single display moderate correlations with other lower extremity threshold change or improvement value. However, these functional status measures in persons with osteoarthritis of two requisite pieces of information fall short of offering the hip or knee, but lower correlations when applied to complete and clinically relevant answers to the question, varsity athletes. This distinction matters because investiga- To what extent can valid inferences be drawn from an tors have often made pronouncements such as “Measure X outcome measure’s change or improvement score? This is valid” that ignore the fact that validity is context specific article introduces three sub-questions that serve as build- and not an all-or-none property. ing blocks to assist in answering that question. Validation designs METHODS Having acknowledged this point, the next step is to The three questions, each of which builds on the pre- review frequently reported validation study designs. vious one, are as follows: For many outcomes relevant to patients seen by phy- 1. To what extent does a measure assess change in the siotherapists (e.g., pain, functional status, health-related context of interest? quality of life), no gold or error-free standard exists. Accordingly, three construct validation designs are fre- 2. What is the threshold change value? quently applied: 3. How confident can a clinician be in making the cor- Convergent construct validation: The first design is rect decision about a patient’s change status when based on the premise that measures believed to be as- applying the threshold change value? sessing the same characteristic should display moder- ate to high correlations.10 The answers to these questions would be provided by Known-groups validation: The second design exam- researchers and presented in a format that is easily inter- ines a measure’s ability to detect significantly different preted by clinicians, typically a graph. Clinicians would amounts of change (typically improvement) in groups then use this information to make a decision about a that, on the basis of theory or existing evidence, measure’s ability to assess change (Question 1), deter- should change by different amounts.10 Test statistics mine whether a patient met the threshold change value for this design include the t-test for independent sam- (Question 2), and assess the chance of making the correct ple means, F statistic, and area under the receiver op- decision about a patient’s change status given that they erating characteristic (ROC) curve. Of these analytics, had applied the threshold value (Question 3). ROC curve analysis is perhaps used most often because, in addition to providing a validity coefficient This article answers each question in turn, accompa- (the area under the ROC curve), it can be applied to nied by one or more examples using Roland-Morris Ques- estimate a threshold improvement value.11 tionnaire (RMQ) data from patients with low back pain. Discriminant validation: The third design is based on a contrast analysis. Specifically, the outcome mea- Background scenario applied to subsequent examples sure’s change scores are correlated with change scores The RMQ is a 24-item pain-related disability measure. from (1) a measure believed to be assessing a similar characteristic and (2) a measure believed to be asses- Each item is scored 0 if left blank or 1 if endorsed.8 Total sing a characteristic different from the characteristic RMQ scores can vary from 0 to 24 points, with higher scores of interest.10 Support for the outcome measure under representing greater levels of pain-related disability. The sce- investigation exists if a substantially higher correlation nario’s sample consisted of 200 patients with low back pain is obtained with the comparison measure assessing whose initial RMQ scores ranged from 3 to 23. The sample’s the same characteristic compared with the compari- mean initial and follow-up scores were 12.8 (SD 5.1) and 7.1 son measure assessing a different characteristic. (SD 6.1), respectively. According to an external reference standard, 64 patients remained unchanged and 136 patients Example: To what extent does a measure assess change in improved. Analyses for these data were performed using the context of interest? STATA, version 15.1 (StataCorp, College Station, TX). To provide continuity with subsequent examples, this RESULTS one uses a known-groups validation design. Specifically, a researcher applied an ROC curve analysis to the scenario’s Question 1: To what extent does a measure assess change in data set and generated a validity coefficient in the form of the context of interest? This question focuses on the validity of a measured change score: the measure’s ability to assess true change in

Stratford Labelling a Patient’s Change Status: It’s a Confidence Game 123 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Figure 1 ROC curve with selected RMQ improvement values (area under ROC curve = 0.9053). ROC = receiver operating characteristic; RMQ = Roland-Morris Questionnaire. the area under the ROC curve (see Figure 1).11 The re- has changed. This limitation is addressed in the Question searcher produced the ROC curve by plotting sensitivity 3 commentary. against 1 – specificity for all possible change scores, as ca- tegorized by an external reference standard. The area Two study designs and analytic methods have been under the curve is interpreted as follows: The area can applied to estimate a threshold change value at the level vary from 0 to 1, with an area of 0.5 – represented by the of an individual patient. One method applies a test–retest area below the diagonal line – indicating that a measure reliability design (distribution-based method) and the does no better than chance alone at distinguishing other uses a known-groups validation design (anchor- between unimproved and improved patients. The area based method).5 under this ROC curve is 0.90 (95% CI: 0.86, 0.94). Given the proximity of 0.90 to an area of 1 and the narrow CI, the Applying a test–retest reliability design interpretation is that, in the context of these study pa- In brief, the reliability design assembles a group of pa- tients, the measure displays a high level of validity in dis- tinguishing between unimproved and improved patients. tients with the condition of interest and applies the out- come measure under investigation at two points in time. Question 2: What is the threshold change value? A crucial assumption is that a patient’s true value for the Paralleling investigations that provide information characteristic has not changed over the reassessment interval. Stated another way, any difference in a patient’s about the validity of outcome measures have been stu- results between test and retest is a result of measurement dies targeting the identification of the measures’ thresh- error, where measurement error includes errors owing to old change values. The threshold change value is what inherent variation in the patient, rater, or equipment and would be applied when writing a patient’s measurable interactions among the patient, rater, and environ- goal. Although reporting a single threshold change value ment.12 is necessary when doing this, it is restrictive when inter- preting the measured change obtained from a patient. Calculating the standard error of measurement When a single threshold change value is applied, it sug- A second critical assumption, the verification of which gests – albeit implicitly – that all change scores, either greater than or less than the threshold value, are inter- is almost always absent from these studies, is that the dis- preted with the same level of confidence. Presumably, tribution of errors has a normal distribution, with a mean the greater the change beyond the identified threshold of zero. This latter assumption is essential because the value, the more confident a clinician can be that a patient reliability-obtained threshold change value is based on a normal distribution. Specifically, the analysis calculates the standard error of measurement (SEM), which pro- vides an estimate of measurement error in the same units as the original measurement.13

124 Physiotherapy Canada, Volume 71, Number 2 A convenient way of thinking about the SEM is to Table 1 Two-by-Two Table for a Threshold Improvement Value of imagine the distribution of difference scores between test 4 RMQ Points and retest.14 The SEM is calculated as the standard devia- https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 tion of the distribution of difference scores divided by the RMQ result Reference standard No square root of 2. Typically, a multiple of the SEM is used Improved change to calculate a quantity known as the minimum detectable change (MDC).15 To acknowledge that there is error asso- Improved 4 109 10 ciated with both the test and the retest values (initial and Unimproved <4 27 54 follow-up assessment measurements in the clinical set- Total 136 64 ting), the SEM is multiplied by the square root of 2. Sub- sequently, this product is multiplied by a z-value Note: Sensitivity: 109 ÷ 136 = 0.8015; specificity: 54 ÷ 64 = 0.8438; (standard normal deviate) associated with the confidence likelihood ratio: 0.8015 ÷ (1 – 0.8438) = 5.13. level of interest, and for this reason the distribution of RMQ = Roland-Morris Questionnaire. difference scores between test and retest must be consis- tent with a normal distribution. For 90% and 95% confi- and specificity values for an improvement value of 4 RMQ dence levels, the z-values are 1.65 and 1.96, respectively. points – the threshold value that maximizes sensitivity and specificity. The interpretation of MDC90, for example, is that 90% of truly unchanged patients would display random fluc- Creating an ROC curve tuations (measurement errors) within the limits defined An ROC curve was then created by plotting sensitivity by MDC90. An important caveat is that the MDC does not provide the chance to label a patient as changed or un- against 1 – specificity for each observed change or changed. To make this determination, one needs to know improvement value. Investigators have commonly consid- the location and distribution of truly changed (either im- ered misclassification errors in either direction to be proved or worsened) patients with respect to the distri- equally important (i.e., declaring a truly unimproved bution of truly unchanged patients. An elaboration of patient as improved and vice versa), and when this qualifi- this concept is provided elsewhere; however, the salient cation is applied, the improvement value associated with point is that these distributions will overlap.16 the ROC curve point closest to the top left corner of the plot is used to identify the threshold change value.11 An Applying diagnostic test methodology advantage of the ROC curve threshold value estimation The deficiency associated with MDC of not being able method over the MDC approach is that it allows one to estimate the chance of making the correct decision when to estimate the chance of making the correct decision the threshold change value is applied.16 This advantage is about a patient’s change status is overcome using a expanded on in the commentary on Question 3. known-groups design that applies diagnostic test meth- odology.16 This design uses a reference standard to clas- Example: What is the threshold change value using sify the change status of patients into two groups. the MDC method? Published reference standards have included global rat- ings of change by patients and clinicians as well as infor- The distribution of difference scores between test and mation from competing measures.5-7 retest for the 64 unchanged patients was consistent with a normal distribution (Shapiro–Wilk Z = 0.79, p = 0.78). Let us return to our sample of 200 patients, a group The standard deviation of the difference between test composed of 64 unchanged patients and 136 changed and retest was 2.5 RMQ points. The SEM was calculated (typically improved) patients. For each change or to be 1.8 RMQ points, and the MDC90 threshold value improvement value on the measure under investigation, was estimated to be 4.2 RMQ change points. For interest, the researcher created a two-by-two table that compared the test–retest intraclass correlation coefficient (Shrout the reference standard’s labelled improvement status – and Fleiss type 2, 1) was 0.82 (95% CI: 0.71, 0.90).17 taken to be the truth – with the improvement status had the measure’s observed change value been used to clas- Example: What is the threshold change value using sify the patients.16 Sensitivity and specificity values were the ROC curve method? calculated for each two-by-two table. Sensitivity represents the proportion of patients correctly identified by the mea- Recall that the reference standard classified 64 pa- sure as improved, divided by all those who truly improved, tients as unchanged and 136 patients as improved. The according to the reference standard. Specificity equals the ROC curve analysis produced the result shown in Figure 1. proportion of patients correctly identified by the measure Inspecting the information in this figure reveals that an as not improved, divided by all those who truly did not improvement of 4 RMQ points provided the optimal improve, according to the reference standard. Table 1 threshold value, given the qualification that misclassifica- shows the two-by-two table and accompanying sensitivity tion errors in either direction are deemed to be of equal importance. For reference, Table 1 shows that 4 RMQ points is the threshold value that maximizes both sensi- tivity and specificity.

Stratford Labelling a Patient’s Change Status: It’s a Confidence Game 125 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Typically, studies applying diagnostic test methodol- studies in the form of growth curves, when available.18 In ogy have reported a single threshold value. A conse- the absence of prognostic studies, it is likely that the quence of this practice is that it assigns equal weight to implicit process involves forming an impression of the all change values meeting or exceeding the threshold expected rate of improvement for a specific patient on value: patients are declared as having improved with the the basis of recollections of the rate of improvement typi- same level of confidence. The opposite is also true: pa- cally seen in similar patients. If one literally equates the tients not meeting the threshold value are labelled unim- typical patient with the average patient, this would repre- proved with the same level of confidence. It is possible sent the 50th percentile, or a 50% chance of meeting the that this unspoken limitation has occurred because in- goal value in the specified interval.19 Information pro- vestigators have not connected threshold values to the vided by growth curves also represents the expected confidence that a clinician can have in applying these va- change for the average patient with the prognostic char- lues. We address this drawback in the discussion of Ques- acteristics of interest. Once again, this would equate with tion 3. a 50% chance of meeting the goal value in the specified interval. Question 3: How confident can a clinician be in making the correct decision about a patient’s change status when applying The second opportunity to implement the pre- the threshold change value? measurement chance of improvement occurs during ongoing patient visits and is shaped by applying informa- There are two considerations when answering this tion gained from sources other than the outcome mea- question. The first one acknowledges a two-step process, sure of interest (e.g., a patient’s comments, clinical which combines information from clinical research with observations, and other measurements). For example, a clinical expertise. The second consideration recognizes patient may state that she has noticed improvement, her that the amount of measured improvement should influ- pain has decreased by 2 points (on a numeric rating scale ence a clinician’s confidence in labelling a patient as im- ranging from 0 to 10 points), and her Modified Schöber proved or not: greater improvement should translate into flexion range has increased. Armed with this information, greater confidence. Because an MDC threshold change the clinician may decide to readminister the RMQ and value does not provide information about the confidence assign a pre-measurement chance of improvement of, for in making a correct decision about a patient’s change sta- example, 75%. tus, in this section we focus on information obtained from studies that apply diagnostic test methodology. Integrating the sensitivity and specificity values: The next step is to use the sensitivity and specificity values Calculating the pre-measurement chance of improvement obtained for the threshold change value to calculate a Quantifying the chance of making the correct decision likelihood ratio: sensitivity ÷ (1 – specificity).20 This like- lihood ratio is combined with the pre-measurement about a patient’s improvement status involves two steps. chance of improvement to estimate the chance of cor- The first step applies clinical expertise, which may include rectly labelling a patient as improved or not. A step-by- information from prognostic studies; the second step step example of this process is shown in the Appendix. builds on the first by integrating sensitivity and specificity values specific to the threshold improvement value. Clini- Using information gain to improve confidence level cal expertise, and information from prognostic studies However, once this concept is understood, a more when it exists, is then applied to assign the pre-measure- ment chance of improvement. practical way of thinking about pre- and post-measure- ment chances of improvement would be to conceptually Applying clinical expertise: The pre-measurement partition the percentage chance continuum into a hierar- chance of improvement represents the chance of chy of about five categories – for example, extremely improvement that a clinician assigns to a patient unlikely (15%), unlikely (16%–40%), a toss-up (41%– before administering and interpreting the result from 60%), likely (61%–85%), and extremely likely (>85%). The the specific outcome measure of interest. It can be im- term information gain is used to describe the extent to plemented at two points in time. The first opportunity which the post-measurement chance of improvement exists when writing a measurable goal. For example, at moves the clinician’s confidence level closer to extremely the time of a patient’s initial assessment, a clinician likely or extremely unlikely compared with the assigned might write, “To decrease the patient’s RMQ score by pre-measurement chance of improvement. 4 points in 2 weeks.” We will assume that 4 points is the threshold value, identified from an ROC curve Another important concept is that the amount of mea- analysis, that maximizes sensitivity and specificity, but sured improvement should influence the confidence in where does the 2-week time frame come from? declaring a patient improved or not. Intuitively, one would expect greater confidence in declaring a patient Often the time frame for meeting a goal value is based whose measured value had increased by a large amount on clinical experience and the results from prognostic to be more likely to have improved than a patient whose

126 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Figure 2 Information gain curves for an RMQ improvement value of 4. RMQ = Roland-Morris Questionnaire. measured value had increased by a small amount. To to the curve below the diagonal. For a pre-measurement date, threshold value studies have not addressed this chance of improvement of 50%, the post-measurement issue. However, this could be efficiently communicated chance of improvement is approximately 19%, suggesting by having researchers present a figure that would display that there is strong evidence that this patient has not im- the confidence or information gain associated with multi- proved. Patient B’s measured improvement of 3 RMQ ple change values. points is also less than 4 points. Accordingly, the post- measurement chance of improvement for this patient To demonstrate the benefit of researchers presenting would also be 19%. information for multiple change values, we can use the two examples presented next to compare the interpretations The measured improvement for both Patients C and D obtained from single and multiple change value reporting was more than 4 RMQ points; however, their pre-mea- for four patients (A, B, C, D). Patient A has a measured surement chance of improvement differed. For Patient C, improvement of 2 RMQ points, Patient B an improvement whose pre-measurement chance of improvement was of 3 RMQ points, Patient C an improvement of 6 RMQ 50%, the post-measurement chance of improvement is points, and Patient D an improvement of 7 RMQ points. 84%, a substantial information gain. However, for Patient For Patients A, B, and C, we assume that the clinician as- D, whose pre-measurement chance of improvement was signed a pre-measurement chance of improvement of 50%. 20%, the post-measurement chance of improvement is For Patient D, we assume that the clinician assigned a pre- 56%, resulting in near-maximum uncertainty as to measurement chance of improvement of 20%. whether there has been any improvement. Maximum uncertainty exists when there is an equal chance of Example: reporting a single threshold RMQ improvement improvement or not (i.e., 50%). The patients’ chances of value of 4 points improvement are shown in Figure 2. Given that the ROC curve analysis identified an Example: reporting multiple RMQ change values improvement of 4 RMQ points as maximizing both sensi- Referring to the values shown in Figure 3, we see that tivity and specificity (i.e., the improvement score that generated the data point closest to the upper left-hand Patient A has a less than 14% post-measurement chance corner of Figure 1), we now examine the interpretations of having improved; Patient B has a 71% chance of having for each of the four patients. Referring to Figure 2 and the improved; and Patient C has a 94% chance of having im- method described in the Appendix, we arrive at the fol- proved; for Patient D, the clinician can identify an lowing results. improvement (100%). Patient A’s measured improvement was 2 RMQ points. The benefit of researchers providing information Given that this improvement is less than 4 points, we refer curves for threshold values other than the threshold

Stratford Labelling a Patient’s Change Status: It’s a Confidence Game 127 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Figure 3 Information gain curves for multiple RMQ improvement values. RMQ = Roland-Morris Questionnaire. value that maximizes sensitivity and specificity is high- on clinicians combining this information with clinical lighted when we take a closer look at Patients B and D. experience and results from prognostic studies. To date, Had the researcher provided information curves for an investigators have dutifully provided validity coefficients improvement value of only 4 RMQ points, Patient B’s and threshold values; however, they have not conveyed measured improvement of 3 RMQ would have been in- the potential benefit of increased confidence in decisions terpreted as no change (i.e., only a 19% chance of when applying these values. In this article, we have de- improvement). However, we see that an improvement of monstrated the benefit of researchers not only presenting 3 RMQ points, combined with a pre-measurement the threshold value, which maximizes sensitivity and spe- chance of improvement of 50%, results in a 71% chance cificity, but also providing information for multiple of improvement, an information gain of 21% in favour of change values in a figure that can be interpreted by clini- declaring the patient improved. cians without calculations. Armed with this information, clinicians are less likely to make errors in labelling a pa- Had the single improvement value of 4 RMQ points tient’s change status (e.g., Patients B and D) and have been applied to Patient D, who had a pre-measurement greater confidence in their decisions. chance of improvement of 20%, the post-measurement chance of improvement would have been about 56% KEY MESSAGES (see, in Figure 2, the bold line above the diagonal): con- siderable uncertainty. However, by including an informa- What is already known on this topic tion curve for an improvement of 7 RMQ points, we see There has been considerable research over the past that the clinician can identify an improvement (see, in Fig- ure 3, the top long- and short-dashed line). Thus, present- several decades into identifying threshold change or ing information curves for multiple threshold values gives improvement values for outcome measures of interest to a clinician greater flexibility in interpreting a change score physiotherapists. These studies typically report a validity and correctly labelling a patient’s change status. coefficient associated with change scores, often the area under a receiver operating characteristic curve, and a sin- CONCLUSION gle threshold change – usually improvement – value, This article introduced three questions for both re- which minimizes misclassification errors. However, they have two important limitations: (1) a failure to report searchers and clinicians to consider. The answers to how confidence in clinical decisions can be altered by ap- these questions depend on researchers communicating plying the advocated threshold value and (2) reporting a comprehensive information in a meaningful manner and single threshold value.

128 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 What this study adds (11):1186–96. https://doi.org/10.1093/ptj/78.11.1186. In this article, we show how confidence in a patient’s Medline:9806623 8. Roland M, Morris R. A study of the natural history of back pain. Part I: change status is informed by the combination of clinical development of a reliable and sensitive measure of disability in low- expertise and research findings in the form of the sensi- back pain. Spine. 1983;8(2):141–4. https://doi.org/10.1097/00007632- tivity and specificity associated with the threshold change 198303000-00004. Medline:6222486 value. Second, we demonstrate that confidence is related 9. Messick S. Validity. In: Linn RL, editor. Educational measurement. to the amount of change. Confidence in decisions about 3rd ed. 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Stratford Labelling a Patient’s Change Status: It’s a Confidence Game 129 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 APPENDIX: SAMPLE CALCULATION FOR DETERMINING THE = 0.8015 ÷ (1 – 0.8438) CHANCE OF MAKING THE CORRECT DECISION FOR A = 5.13. PATIENT WHOSE REASSESSMENT INTERVAL WAS CONSISTENT WITH A 50% CHANCE OF IMPROVING AND Step 3. Calculate the posttest odds: WHO, ON REASSESSMENT, IMPROVED BY 4 ROLAND- MORRIS QUESTIONNAIRE POINTS = pretest odds × likelihood ratio = 1 × 5.13 The general approach is to multiply the pre-measurement = 5.13. chance of improvement, expressed as an odds, with the likelihood ratio. This product, known as the posttest odds, Step 4. Convert the posttest odds to the chance of is then converted to the chance of making a correct deci- making the correct decision: sion. = 100 × [posttest odds ÷ (posttest odds + 1)] Step 1. Convert the 50% pre-measurement chance of = 100 × (5.13 ÷ 6.13) improvement to a pretest odds: = 83.7%. = chance of improving ÷ chance of not improving Step 5. Consider the information gain: = 50 ÷ 50 = 1:1. = post-measurement chance of improvement – pre- measurement chance of improvement Step 2. Calculate the likelihood ratio: = 83.7% – 50% = sensitivity ÷ (1 – specificity) = 33.7 percentage points.

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 CASE REPORT Mechanical Diagnosis and Therapy and Morton’s Neuroma: A Case Report Michael D. Post, PT, DPT, Dip.MDT ABSTRACT Purpose: Morton’s neuroma (MN) is a neuralgia involving the common plantar digital nerves of the metatarsal region. Evidence-based treatment options for this condition are sparse, and physiotherapy’s usefulness is limited. Client Description: A woman aged 44 years was referred to physiotherapy for left fore­ foot pain lasting 3 months. The podiatrist diagnosed MN using ultrasonography. Examination found positive squeeze test, painful interphalangeals and metatarsal heads, and painful metatarsophalangeal joint (MPJ) extension. Intervention: Repeated flexion of MPJ digit II relieved the patient’s pain. She was treated six times over 3 months to progress treatment, achieve longer lasting pain relief, and recover function to full pain-free status, including running. Measures and Outcome: The patient’s pain reduced after treatment from a variable 2–7 out of 10 on the Numeric Pain Rating Scale to 0 out of 10. After two sessions, the patient’s Lower Extremity Functional Scale score improved, from 56 out of 80 to 70 out of 80, and by discharge, it was 73 out of 80. At 6-month follow-up, the patient was still running pain-free. Implications: This article describes the rapid and lasting improvement in chronic forefoot pain associated with MN after mechanical diagnosis and therapy assessment and treatment. Finding new, effective, conservative interventions is important for this condition because so few evidence-supported treatments exist. The findings from this case report demonstrate the benefit derived from exercise-based treatment and may indicate a role for physiotherapy in managing MN. Key Words: exercise therapy; lower extremity; metatarsalgia; Morton’s neuroma. RÉSUMÉ Objectif : le névrome de Morton (NM) est une névralgie qui touche les principaux nerfs de la région métatarsienne des orteils. Il existe peu de possibilités de traitements fondés sur des données probantes, et l’utilité de la physiothérapie est limitée. Description des clients : une femme de 44 ans a été orientée en physiothérapie parce qu’elle ressentait une douleur à l’avant-pied gauche depuis trois mois. À l’échographie, le podiatre avait diagnostiqué un NV. L’exa­ men a révélé un test de Thompson positif, des douleurs à la tête des interphalangiens et des métatarsiens et une extension douloureuse des articulations métatarsophalangiennes (AMP). Intervention : la flexion répétée de l’AMP II a fait disparaître la douleur de la patiente. Elle a reçu six traitements progres­ sifs répartis sur trois mois pour favoriser une disparition plus prolongée de la douleur et récupérer une fonction entièrement indolore, y compris pendant la course. Mesures et résultats : la douleur de la patiente a diminué après le traitement, passant d’une variable de 2 à 7 sur 10 à 0 sur l’échelle numérique d’évaluation de la douleur. Après deux séances, les résultats à l’échelle fonctionnelle des membres inférieurs (ÉFMI) se sont améliorés, passant de 56 sur 80 à 70 sur 80, et au congé, à 73 sur 80. Au suivi au bout de six mois, la patiente courait encore sans ressentir de douleur. Conséquences : le présent rapport décrit l’amélioration rapide et durable d’une douleur chronique de l’avant-pied causée par un NV après une évaluation par le diagnostic et la théra­ pie mécanique. Il est important de trouver de nouvelles interventions efficaces classiques à cette affection puisqu’il existe si peu de traitements fondés sur des données probantes. Les résultats de ce cas démontrent les avantages d’un traitement reposant sur l’exercice et peut être indicateur d’un rôle pour la physiothérapie dans la prise en charge du NM. Symptomatic Morton’s neuroma (MN) is a common Mechanical diagnosis and therapy (MDT) is a method and painful condition of the foot.1,2 It is the most common of evaluation and treatment that uses end-range, neuropathy after carpal tunnel syndrome.3 A recent sys- repeated movements to evaluate the nature of pain and tematic review concluded that support for non-operative mechanical presentation.5.6 A clinician then makes a pro- and operative management consisted of low-quality visional classification (derangement, dysfunction, pos­ research and sample sizes or of poorly controlled case ture, or other) that guides the treatment approach.5,6 series.1 The current podiatrist clinical practice guidelines Using this method, patient-generated force exercises are do not include manual therapy or physiotherapy as a treat- an integral part of treatment, and they promote patient ment option before surgical intervention to manage MN.4 independence. There is no published application of an From the NYU Langone Health, Langone Orthopedic Center, New York. Correspondence to: Michael D. Post, 2615 Centennial Blvd., Suite 101, Tallahassee, FL 32308, USA; [email protected]. Competing Interests: None declared. Acknowledgements: The author thanks those who contributed to the editing and mentoring process: James Koo, Jeffrey Sam, Jenny Fay, Mark Vorensky, Michael D’Agati, Richard Kassler, Samantha Mindlin. Physiotherapy Canada 2019; 71(2);130–133; doi:10.3138/ptc.2018-42 130

Post Mechanical Diagnosis and Therapy and Morton’s Neuroma: A Case Report 131 active self-treatment approach for MN. The patient con­ sented to this case study being submitted to a medical journal with de-identified details. https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 CLIENT DESCRIPTION Figure 1 Unloaded flexion with self-overpressure. History A woman aged 44 years presented with a 3-month history of non-traumatic, left plantar forefoot pain. Ultra­ sonography identified that she had neuromas measuring 8 × 7 mm and 4 × 4 mm in the first and second web spaces, respectively. Walking and climbing stairs wor­ sened her symptoms, and rest, not putting her weight on her foot, and applying ice improved them. Previous non- operative interventions – soft tissue massage, metatarsal and talocrural mobilizations, intrinsic and extrinsic foot and ankle strengthening, and metatarsal pad orthosis – had failed. Her functional limitation was an inability to run and limited tolerance for walking; previously, she had been a recreational runner. She had no pertinent surgical or medical history except for asthma. Traditional physical examination results and outcomes General observation found a slight metatarsophalan­ geal joint (MPJ) extension resting posture, and tenderness to palpation was most significant at MPJ II. Clinical tests – squeeze test and digital nerve stretch test – were positive.1 Her baseline Lower Extremity Functional Scale (LEFS) score was 56 out of 80, and average resting pain was 2–4 out of 10 on the Numeric Pain Rating Scale (NPRS) but could increase to 7 out of 10 at worst. The LEFS is a valid and reliable, subjective outcome measure, with a minimal clinically important difference (MCID) of 9 points.7 The NPRS is a standard instrument for assessing level of pain, with an MCID of 2 points.8 The global rating of change (GROC) is a reliable and valid, 15-point Likert scale used to measure degree of perceived improvement during an episode of care; meaningful improvement is measured by a 5-point or higher change.9 MDT examination and assessment Movement testing found painful extension of MPJ II and III at end range, with no movement loss, and painful flexion of MPJ II and III, with moderate movement loss. Single-leg heel raise and walking barefoot were painful. Three sets of 20 repetitions, unloaded MPJ flexion with clinician overpressure of MPJ II and III relieved the patient’s pain with walking, and she was able to complete five pain-free repetitions of single-leg heel raises. A provi­ sional classification of derangement was made. INTERVENTION Figure 2 Partial-loaded flexion with self-overpressure. The patient was instructed to perform one set of 20 re­ petitions every 3 hours of unloaded MPJ flexion with self- overpressure (see Figure 1), with additional repetitions as needed when symptomatic.

132 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Second visit digital nerve stretch test was negative, and the patient re­ After 5 days, the patient reported a 75% perceived ported a LEFS score of 73 out of 80, a GROC score of +5 (quite a bit better), and an NPRS score of 0 out of 10. She improvement relative to her overall condition and had had discontinued her use of metatarsal pad orthotics. returned to a walk–jog routine at the gym; NPRS was 2 out of 10 at worst. Because of persistent pain with toe Six-month follow-up walking, the exercise was progressed to partial-loaded At 6-month phone follow-up, the patient reported MPJ flexion with self-overpressure (see Figure 2). The fre­ quency recommendations remained the same, and the continuing her running activities with limitations second­ previous exercise was discontinued. ary to asthma. She reported that she was able to self- manage without seeking further health care. MEASURES AND OUTCOME IMPLICATIONS Third through sixth visit (discharge) In this case, successful treatment was based on classi­ Three days later, the patient rated her pain as 0 out of fying the patient’s syndrome (symptomatic and mechani­ 10 at worst on the NPRS and reported that she had in­ cal response consistent with derangement) instead of creased her running to 3 miles. LEFS score was reassessed targeted at the patho-anatomical or medical diagnosis at 70 out of 80. The patient was instructed to continue of MN. Physiotherapy is not currently considered in the with her current home exercise. The patient returned podiatric clinical practice guidelines for patients with 48 days later after extended travel. Her baseline NPRS suspected symptomatic MN,4 although Cashley and Co­ was 0 out of 10 at the start of each visit. She was able to chrane supported exploration of manual therapy inter­ perform 20 single-leg heel raises and toe walk without vention in the presence of this diagnosis.2 Instead, pain. Visits 4–6 were over a period of 36 days and were diagnosis and management are currently driven by ima­ designed to return the patient to gym activities and to ging and clinical testing without including symptomatic improve her cardiovascular endurance. By discharge, the response to mechanical and repetitive movement testing. History of neuralgic pain in web space Normal radiograph Two or more provocation tests? Yes No Initiate treatment Physiotherapy* Ultrasonography or magnetic resonance imaging Ultrasonography guided steroid injection (up to 3) Decompression with neurolysis and translocation Recurrence: Open neurectomy with transposition Figure 3. Proposed theoretical framework for managing Morton’s neuroma, modified from the current podiatrist clinical practice guidelines. *Denotes new addition to current podiatrist clinical practice guidelines.4

Post Mechanical Diagnosis and Therapy and Morton’s Neuroma: A Case Report 133 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Manual therapy and manipulations have been shown What this study adds to improve symptoms in the treatment of MN in podia­ This is the first published report on a patient with medi­ tric or chiropractic medicine when using clinical tests such as the digital nerve stretch test for diagnosis.2,10,11 cally diagnosed MN who was treated with exercise-based, Waldecker found success with implementing mobiliza­ self-treatment therapy using principles of mechanical diag­ tion and manipulation in treating non-specific metatar­ nosis and therapy. It is also the first case in physiotherapy salgia, but there was no suggestion of potential self- that reports long-term outcomes for this diagnosis. treatment options.12 Govender and colleagues contended that a component of unresolved pain in MN was explained REFERENCES by untreated, mechanically induced metatarsalgia, which may be more amenable to exercise intervention.11 A pro­ 1. Jain S, Mannan K. The diagnosis and management of Morton’s posed theoretical framework (shown in Figure 3), modified neuroma. Foot Ankle Spec. 2013;6(4):307–17. https://doi.org/10.1177/ from the current podiatrist clinical practice guidelines,4 1938640013493464. Medline:23811947 demonstrates the potential usefulness of physiotherapy in the examination, treatment, and triage process for those 2. Cashley DG, Cochrane L. Manipulation in the treatment of plantar with MN. digital neuralgia: a retrospective study of 38 cases. J Chiropr Med. 2015;14(2):90–8. https://doi.org/10.1016/j.jcm.2015.04.003. CONCLUSION Medline:26257593 A thorough mechanical assessment using repeated 3. Latinovic R, Gulliford MC, Hughes RAC. Incidence of common movements should be considered in the presence of an compressive neuropathies in primary care. J Neurol Neurosurg MN diagnosis. The current case shows that the patient re­ Psychiatry. 2006;77(2):263–5. https://doi.org/10.1136/ sponded favourably and her functional symptoms were jnnp.2005.066696. Medline:16421136 resolved after MDT principles were applied with a treat­ ment classification of derangement to guide her active 4. Thomas JL, Blitch EL 4th, Chaney DM, et al.; Clinical Practice self-management. Clinically, a derangement typically re­ Guideline Forefoot Disorders Panel. Diagnosis and treatment of sponds rapidly to intervention, given the appropriate forefoot disorders. Section 3. Morton’s intermetatarsal neuroma. loading strategies.5,6 Repeated movement testing can be J Foot Ankle Surg. 2009;48(2):251–6. https://doi.org/10.1053/ used in early patient management, and in the differential j.jfas.2008.12.005. Medline:19232980 diagnosis process, to facilitate patient care. Additional research is warranted to investigate the treatment effects 5. McKenzie R, May S. The lumbar spine. Waikanae, New Zealand: of using MDT to examine and treat symptomatic patients Spinal Publications; 2003. with identified MN present. 6. McKenzie R, May S. The human extremities. Wellington, New KEY MESSAGES Zealand: Spinal Publications; 2009. What is already known on this topic 7. Binkley JM, Stratford PW, Lott SA, et al. The Lower Extremity Morton’s neuroma (MN) is a neuralgia involving the Functional Scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther. 1999;79(4):371–83. common plantar digital nerves of the metatarsal region. http://doi.org/10.1093/ptj/79.4.371. Medline:10201543 Evidence-based treatment options for this condition are sparse, and the usefulness of physiotherapy is limited. 8. Farrar JT, Young JP, LaMoreaux L, et al. Clinical importance of There is no published application of an active self- changes in chronic pain intensity measured on an 11-point treatment approach for MN. numerical pain rating scale. Pain. 2001;94(2):149–58. Medline:11690728 9. Kamper SJ, Maher CG, Mackay G. Global rating of change scales: a review of strengths and weaknesses and considerations for design. J Man Manip Ther. 2009;17(3):163–70. https://doi.org/10.1179/ jmt.2009.17.3.163. Medline:20046623 10. Sault JD, Morris MV, Jayaseelan DJ, et al. Manual therapy in the management of a patient with a symptomatic Morton’s neuroma: a case report. Man Ther. 2016;21:307–10. https://doi.org/10.1016/ j.math.2015.03.010. Medline:25920337 11. Govender N, Kretzmann H, Price JL, et al. A single-blinded randomized placebo-controlled clinical trial of manipulation and mobilization in the treatment of Morton’s neuroma. J Am Chiropr Assoc. 2007;44(3):8–18. 12. Waldecker U. Limited range of motion of the lesser MTP joints: a cause of metatarsalgia. Foot Ankle Surg. 2004;10(3):149–54. https:// doi.org/10.1016/j.fas.2004.07.001.

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 EDUCATION Professional Values: Results of a Scoping Review and Preliminary Canadian Survey Alana M. Boyczuk, BSc, MScPT, PT;*x Jamie J. Deloyer, BA, MScPT, PT;*{ Kyle F. Ferrigan, BA, MScPT, PT;*{ Kevin M. Muncaster, BSc;* Vanina Dal Bello-Haas, PhD, PT;* Patricia A. Miller, PhD, PT* ABSTRACT Purpose: Physiotherapists in Canada do not have an agreed-on list of core professional values. The purpose of this study was to identify physiotherapy values using a scoping review and to preliminarily identify the core professional values important to Canadian physiotherapists. Method: We undertook (1) a comprehensive scoping review of the primary and grey literature and (2) a cross-sectional survey of Canadian physiotherapists attending the 2016 Canadian Physiotherapy Association Congress. We conducted Ovid MEDLINE, Ovid EMBASE, and CINAHL database and Internet searches to identify peer- reviewed and grey literature. Survey participants were asked to list two professional values that guided their practice. Thematic and content analyses were used to analyze the results of both activities. We combined the results of the scoping review and the survey. Results: A total of 23 Web sites and 11 pri- mary articles were retained from the search; 88 physiotherapists participated in the survey. A final list of 10 professional values (accountability, advocacy, altruism, compassion and caring, equity, excellence, integrity, patient and client centred, respect, and social responsibility) was drawn up after analyzing the scoping review and survey. Conclusions: This study describes the first steps in the process of identifying a set of core professional values for Canadian physiotherapists. Although many of values identified in this survey aligned with values published in the literature, some were unique, and further investiga- tion is required. Key Words: altruism; empathy; professional practice; social responsibility; survey. RÉSUMÉ Objectif : les physiothérapeutes du Canada ne disposent pas d’une liste commune de valeurs professionnelles fondamentales. La présente étude visait à circonscrire les valeurs en physiothérapie au moyen d’une analyse exploratoire et à procéder à une sélection préliminaire des valeurs professionnelles fon- damentales importantes pour les physiothérapeutes canadiens. Méthodologie : les chercheurs ont procédé à 1) une analyse exploratoire complète des publications primaires et non officielles et 2) une analyse transversale des physiothérapeutes canadiens qui ont assisté au congrès 2016 de l’Association canadienne de physiothérapie. Ils ont fait des recherches dans les bases de données Ovid MEDLINE, Ovid EMBASE et CINAHL, ainsi que dans Internet pour extraire les publications parallèles. Ils ont invité les participants au sondage à fournir deux valeurs professionnelles qui orientaient leur pratique. Ils ont recouru à des analyses thématiques et de contenu pour examiner les résultats des deux activités, qu’ils ont combinés. Résultats : au total, les chercheurs ont extrait 23 sites Web et 11 articles primaires de leur recherche, et 88 physiothérapeutes ont participé au sondage. Ils ont retenu une liste finale de dix valeurs professionnelles (redevabilité, prise de position, altruisme, compassion, équité, excellence, intégrité, axe sur les patients et les clients, respect et responsabilité sociale) après avoir examiné l’analyse exploratoire et le sondage. Conclusion : la présente étude décrit les premières étapes du processus pour circonscrire les valeurs professionnelles fondamentales des physiothérapeutes canadiens. De nombreuses valeurs du sondage correspondaient à celles contenues dans les publications scientifiques, mais certaines étaient uniques. Des recherches plus approfondies s’imposent. Core values are at the centre of professionalism and these core values are accepted as the most essential and are the determinants of professional behaviour.1 The va- primary elements on which a profession is built.4 lues of a profession are ideally upheld by all of its mem- Historically, the term value has had many definitions, bers2 and essentially guide everyday practice.3 Thus, which has unavoidably led to ambiguity and From the: *School of Rehabilitation Sciences, McMaster University, Hamilton; {Sports Medicine and Rehabilitation Centre, Barrie, Ont.; {MSK Centre: Rehabilitation and Sports Medicine, Waterloo, Ont.; xVancouver General Hospital, Vancouver Coastal Health, Vancouver. Corresponding author: Patricia A. Miller, School of Rehabilitation Sciences, Faculty of Health Sciences, Institute of Applied Health Sciences, McMaster University, Rm. 403, 1400 Main St. W, Hamilton, ON L8S 1C7; [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 research was supported in part by the Canadian Institutes of Health Research Health Professional Student Research Award given to Alana M. Boyczuk and Jamie J. Deloyer. This research was completed in partial fulfillment of the requirements for the MScPT degree at McMaster University. Acknowledgements: The researchers thank the participants who completed the survey at the 2016 Canadian Physiotherapy Association Congress. Some of this material was presented as a poster at the Ontario Physiotherapy Association InterACTION conference in April 2017 and at the World Confederation for Physical Therapy Congress in July 2017. Physiotherapy Canada 2019; 71(2);134–143; doi:10.3138/ptc.2017-70.e 134

Boyczuk et al. Professional Values: Results of a Scoping Review and Preliminary Canadian Survey 135 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 misinterpretation about what a value is and what the Professional organizations in other countries have re- word means. Davis gives a general definition of a value as cognized the importance of identifying a unified set of “an operational belief that one accepts as one’s own and values and behaviour for the PT profession. As part of its that determines behaviour.”1(p.30) Because values are the pursuit to transition to a doctoring profession, for exam- precedents and determinants of behaviour, it is abso- ple, the American Physical Therapy Association (APTA) lutely essential to understand and elucidate the core undertook to explicitly conceptualize its professionalism values of a profession. and professional values.11 After a review of the relevant literature on medical professionalism, 18 physical thera- Although debate continues about whether values can pists participated in a consensus conference to identify a change over time, it is generally believed that certain core final list of seven core values – accountability, altruism, values remain unaltered.5 These unchanging core values compassion and caring, excellence, integrity, professional often include those related to the hallmark characteristics duty, and social responsibility – that encompassed and of a profession and its associated and expected high stan- represented the PT profession in the United States.11 The dard of ethics, such as non-maleficence and beneficence.5 physical therapists decided on the ideal nomenclature for Whereas changes in knowledge, social attitudes, and per- these values, which they believed had sufficient breadth sonal experience may appear to alter values, a thorough and depth to capture professionalism in PT practice.11 In examination of these changes suggests that those values 2003, this document, which defined each value and pro- prone to change are actually secondary or derived values, vided sample indicators, was adopted as an official docu- not core values.5 Thus, the core values of a profession can ment of the APTA.11 be seen as unchanging, or at least as changing very slowly, and can be used to unite its members.5 These core values In a recent study, McGinnis and colleagues explored can offer coherence to a profession5 and can assist in de- the development and integration of these seven core va- fining it because they represent what is important to its lues into the practice of 20 physical therapists.6 The members.6 Furthermore, core values can be considered therapists described how personal values were the foun- the building blocks that underpin the ethical principles of dation for the development of professional values, and individual professional conduct, and they can dictate they reported that not all seven core values were consis- one’s behaviour and influence one’s actions.7 tently integrated into their practice. For example, 90% of the therapists indicated that the core value of integrity Although members of the physiotherapy (PT) profes- was a perceived area of strength, whereas 75% reported sion in Canada have a long-standing history of having a that the core value of caring and compassion was an area code of ethics, there is not an agreed-on set of profes- of strength. However, the vast majority of participants sional core values. With the profession’s relatively recent (95%) indicated that an area of improvement was related transition to autonomous and self-regulated practice8 to behaviour associated with the core value of social come its responsibilities and duty to not only operate in responsibility.6 the public interest but also ensure that the public per- ceives this to be the case.9 This duty underscores the Recognizing that the PT profession of each country re- importance of having a set of common, explicit core va- quires a unique set of values that align with the organiza- lues to guide daily practice and promote the provision of tional culture and health care system in which it the highest quality of patient care. operates, Australian physiotherapists took on a similar initiative to identify their own list of values.12 A qualita- It was once assumed that student health care profes- tive study of 14 experienced Australian physiotherapists sionals automatically adopted the values and associated aimed to identify common values to begin to identify a behaviour of their new profession; however, this is now specifically Australian set of values and behaviour.12 Re- understood to not be the case.1 Rather, the process of de- searchers conducted semi-structured interviews with veloping a professional identity and adopting profes- participants, asking them a set of questions designed to sional values is a conscious process that begins as one stimulate reflection on professional values. After the in- enters a profession.10 Role models, mentors, and individ- terviews, three overarching themes of values emerged ual professional experiences influence the process of pro- from the data: those relevant to the patient and the fessional socialization, in which one’s personal identity patient–therapist partnership; those pertaining to PT integrates with a professional one.10 Professional social- knowledge, skills, and practice; and those that repre- ization is important for individuals to develop their own sented altruistic values.12 personal values in the context of their new professional culture,10 and, thus, it can best occur when the core va- Until now, no initiative has been undertaken to iden- lues of a profession, such as PT, are explicit instead of im- tify the core values of Canadian physiotherapists; thus, plied. If values are explicitly documented, they can be the profession has no set of defined core values that are more readily integrated into the curriculum, and they specific and unique to PT practice in Canada. However, can provide a consistent framework to be followed by all one group of researchers from the University of Western physiotherapists across a nation. Ontario took a step in this direction when, in 2001, it

136 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 published a list of key PT professional behaviours: Data extraction accountability, communication, adherence to legal and The same two researchers who had searched the elec- ethical codes of practice, respect, sensitive practice, cli- ent-centred practice, critical thinking, and professional tronic databases (AMB, KFF) reviewed each article inde- image.13 These behaviours were identified by students pendently for relevance using title and abstract screening. (n = 4), clinical instructors (n = 3), and faculty members Articles were included if they met the inclusion criteria (n = 2) through a consensus process.12 The resulting list given earlier. Any disagreements about inclusion were re- became the foundation of a Comprehensive Professional solved through discussion between the two researchers. Behaviours Development Log,14 which is now used in the After they had removed the excluded articles, they put the assessment of Canadian PT students’ competence in clin- remaining articles through a full-text review to extract ical placement, recognizing the importance of profes- explicit values. The researchers compiled a list of these va- sionalism in addition to clinical knowledge and skills.14 lues and synthesized them into a single list. The list was then discussed with a third researcher (PAM), and when We believe that it is important to explicitly define the the three agreed that a value was appropriate, it was kept core values of practitioners in the current Canadian PT for further discussion with the rest of the research team, in context. As the PT profession in Canada evolves – with an preparation for the development of an amalgamated list of expanding scope of practice, the emergence of new roles, values identified through both the primary literature and an increasing emphasis on the contextual factors that search and the grey literature search. influence the patient–therapist relationship – a list of core professional values can, in fact, provide direction. There- Grey literature review fore, the purpose of this study was to take the first steps in Two other reviewers (JJD, KMM) performed a separate identifying a comprehensive set of core values relevant to Canadian physiotherapists. The results of this study will grey literature search, using the search engine Google inform the development of a more comprehensive survey, (Alphabet Inc., Mountain View, CA) to identify informa- which will undergo a Delphi consensus process to identify tion about the values that had been published by PT reg- an agreed-on, national list of core professional values. ulatory bodies and associations. Sources included the Web sites of national and regional (province or state) PT METHODS organizations and associations in industrialized and pri- We used two approaches: (1) a comprehensive scoping marily English-speaking countries with entry-level PT degree requirements similar to Canada’s (e.g., United review15 of the primary and grey literature and (2) a pre- States, United Kingdom, Australia, and New Zealand). liminary survey of Canadian physiotherapists. To maintain Regulatory board Web sites were identified using Google consistency when determining whether to include a value, by combining the country or region of interest with the we used Davis’s definition of a value as described earlier.1 words physiotherapy or physical therapy and board or col- lege or governing. Professional association Web sites were Primary literature review identified using Google by combining the country of Search strategy interest with the words physiotherapy or physical therapy with association. Two researchers (AMB, KFF) independently searched three electronic databases, Ovid MEDLINE, Ovid EMBASE, An identified Web site was then searched systemati- and CINAHL, using a search strategy developed in collabo- cally using its search function, when available, with the ration with a research health librarian. A variation of the following key words: value, values, core value, profes- following search terms was used for each database: physio- sional, professional value, beliefs, ideals, ethics, or princi- therapy or physical therapy in combination with profes- ples. If the Web site did not have its own search function, sional adjacent to value, belief, moral, standard, or ideal. the Google search engine was used to combine the regu- The initial strategy was developed for Ovid EMBASE and latory area and these key words. These searches were modified accordingly for the remaining searches. All data- conducted in February 2016. bases were searched for terms used from 1980 up to and including February 29, 2016. The results of the searches Inclusion and exclusion criteria were compiled by two researchers using the Web-based We included grey literature if it had been published in citation management software RefWorks (ProQuest LLC, Ann Arbor, MI), available to students and faculty in the English and addressed the professional values specific to Faculty of Health Sciences at our university. PT (e.g., as a mission statement, list of values, code of ethics). If a U.S. state regulatory board or association Inclusion criteria Web site linked to the APTA core values,11 we did not Peer-reviewed articles were included if they had been identify them as new values. published in English and addressed the professional va- Data extraction lues that were specific to PT. Relevant Web pages and documents were saved for further review. Selections were made to emphasize

Boyczuk et al. Professional Values: Results of a Scoping Review and Preliminary Canadian Survey 137 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 inclusiveness so that we would not miss any relevant lected because it is the largest professional conference in source. As in the primary literature review, two research- Canada, and it would give us access to a large number of ers (JJD, KMM) identified values and synthesized them physiotherapists, students, and other PT stakeholders into a single list. This list was then discussed with a third from across the nation. researcher (VD), and when they agreed that a value was appropriate, they kept it for further discussion with the Data analysis rest of the research team. To avoid ambiguity, values that The research team used both thematic16 and content were considered associated, aligned, or related (e.g., access and equity) were combined to form a single value. analysis17 to analyze the survey results. Thematic analysis is a qualitative approach that looks to identify, analyze, Data summary and synthesis and record themes or patterns in the data collected; we Each team of three researchers reviewed the list of va- used it to identify themes in the responses using the par- ticipants’ voices. Content analysis focuses on coding and lues they had identified in the primary and grey literature categorizing the data in a way that reveals trends and pat- searches. Values that the researchers thought were syn- terns in the words used, including frequency of use;18 we onymous were amalgamated into a single value, repre- used this approach to categorize the data and determine sented by the term that was most commonly used for the frequency of responses. Beforehand, we had estab- that word. Definitions of terms were also identified to lished clear and explicit decision-making rules to guide guide the process. When a team disagreed about a value, the thematic analysis and maintain consistency when de- they held a discussion to reach consensus. If consensus termining which values to include (see Figure S1 and was not achieved during this first round, the value was Table S1 in online Appendix 2), a process guided by the brought to the entire team for discussion. values we had identified from the literature and the defini- tion we had used. To achieve consensus about whether to This process yielded two lists of values, one from the include a value, agreement was required by a minimum of primary literature and one from the grey literature, which four of the six research team members (67%). we synthesized into one list. When there were discrepan- cies about ambiguous value terms, all six group members Amalgamation of results discussed them until a consensus was reached. This pro- Once these two processes were completed, the team cess yielded a single, final list of values identified from the two literature searches. of six researchers met and reviewed the results of both the literature review (both peer-reviewed and grey) and Survey of Canadian physiotherapists the survey to identify all similar values that made up the A cross-sectional survey was designed to solicit the final list. thoughts and opinions of attendees at a national profes- RESULTS sional conference about what values and associated be- haviour influenced their practice. We determined that Primary and grey literature reviews the survey should be straightforward and not take much After removing duplicates, we identified 234 articles time to complete because it was to be distributed at the conference. Respondents were asked to (1) provide from the three electronic databases (see Figure 1). After demographic information (including years of profes- removing excluded articles on the basis of title and sional practice and province of employment) and (2) abstract screening, we undertook a full-text review of 43. answer the following two questions: “What are two core Of these articles, 10 included explicit values.12,19–27 From professional values that guide your everyday practice? these articles, 66 value-related terms were extracted and What associated professional behaviour(s) would you compiled into a list. After discussion among the three re- link with each value?” Respondents were given Davis’s searchers, 12 values remained. definition of a value.1 Survey responses remained anony- mous. For the purposes of this article, we report only the Of the 152 Web sites searched (see Appendix 1), 23 results related to the identification of values. The data (15%) explicitly included a list or set of values or value regarding behaviour will be incorporated into the subse- statements. From all 152 Web sites, 15 values were identi- quent Delphi process. Approval to conduct the survey fied, 9 of which (integrity, altruism, professional duty or was secured from the Hamilton Integrated Research professional practice, excellence, accountability, social Ethics Board. responsibility, respect, compassion, caring) were also found in the primary literature. Table 1 lists the values Survey distribution extracted from the literature search. The survey was made available on paper and electron- Survey ically. Survey data were collected at the annual Canadian Participants Physiotherapy Association (CPA) Congress in Victoria, British Columbia, on May 26–28, 2016. This venue was se- A total of 88 respondents (60 women, 27 men, 1 uni- dentified) completed the survey in hard copy (n = 78) or online (n = 10). The majority of respondents were

138 Physiotherapy Canada, Volume 71, Number 2 Records identified through electronic searches https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Grey literature Primary literature Total websites Identified through searched database searching (n = 152) (n = 260) No appropriate records Appropriate records found found After duplicates (n = 49) removed (n = 234) (n = 103) Excluded – value Included – value Excluded following title Included following title statement not present statement present and abstract screening and abstract screening (n = 26) (n = 23) (n = 190) (n = 44) Excluded following full Included following full Unable to be retrieved text review text review (n = 3) (n = 30) (n = 11) Figure 1 Results of primary and grey literature searches. Note: A minimum of 4–6 research team members needed to reach agreement at each stage. Table 1 Values Extracted from the Literature Search Unique to the Common to both grey literature Unique to the primary literature Accountability Collaboration Credibility Altruism Going the extra mile Cultural competency Caring Patient centredness Equity Compassion Honesty Excellence Justice Integrity Truthfulness Professional duty or professional practice Respect Social responsibility practising physiotherapists (59%), with a range of experi- and one did not identify years of practice (1%). Details of ence. The remaining respondents were students (34%), participant characteristics can be found in Table 2. PT stakeholders (5%) or retired (2%). Most respondents resided in Ontario (40%) and British Columbia (32%), Value responses while other provinces of origin included Quebec (6%); All but one participant who completed the survey Alberta, Manitoba, and Nova Scotia (3% each); and New Brunswick, Newfoundland, and Saskatchewan (1% each). identified two values; that respondent noted one value. Among those respondents who were currently working, Therefore, 175 individual value responses were received. 57% (n = 29) had been working 10 years or less. Eight re- Ten responses were excluded on the basis of the decision spondents (9%) did not identify a province of practice, rule criteria outlined in Figure S1 in online Appendix 2, which excluded items deemed not to be values. The final

Boyczuk et al. Professional Values: Results of a Scoping Review and Preliminary Canadian Survey 139 Table 2 Participant Characteristics (N = 88) Table 3 Results of Content Analysis of Survey Responses (N = 88) https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Characteristic No. (%) Value No. of verbatim No. of responses Total responses of coded as Gender 60 (68.2) participants Male 27 (30.7) corresponding Female 1 (1.1) value Unknown Status 52 (59.1) Integrity 16 2 18 Practising 30 (34.1) Empathy 16 1 17 Student 4 (4.5) Caring 9 6 15 Stakeholder 2 (2.3) Patient-centred 4 11 15 Retired Years of practice 14 (15.9) care 9 4 13 New graduate (< 2) 15 (17.0) Honesty 1 12 13 2–10 13 (14.8) Evidence-based 11–30 9 (10.2) 3 8 11 > 30 36 (40.9) practice 8 3 11 Not practising 1 (1.1) Excellence 2 9 11 Unknown Compassion 8 2 10 Province 35 (39.8) Lifelong learning 4 6 10 Ontario 28 (31.8) Respect 4 37 British Columbia 5 (5.7) Ethical practice 4 37 Quebec 3 (3.4) Advocacy 1 56 Alberta 3 (3.4) Collaborative practice 1 34 Manitoba 3 (3.4) Altruism 2 24 Nova Scotia 1 (1.1) Accountability 4 04 New Brunswick 1 (1.1) Stewardship 1 23 Newfoundland 1 (1.1) Quality care 3 03 Saskatchewan 8 (9.1) Equity Unknown Hard work or 1 01 1 01 work ethic Innovation Social responsibility Note: Percentages may not total 100 because of rounding. list compiled from the survey results consisted of 21 values of a review of the primary and grey literatures to develop (see Table 3). Integrity (n = 18) and empathy (n = 17) were a comprehensive list of values relevant to the PT profes- the most commonly identified values, followed by caring sion around the world, and we solicited the opinions of (n = 15) and patient-centred care (n = 15). Canadian physiotherapists. This study is the first to iden- tify core professional values specific to Canadian phy- Combined results siotherapists, and the results will provide the foundation The synthesized results from the primary and grey lit- for a subsequent national Delphi consensus exercise, which is under development. erature and the survey were then combined to identify recurring values. Thirteen values were common to both From our review of the literature, it is evident that sets of results; an additional 6 were found exclusively in there is a dearth of evidence and published work specific the literature and 7 exclusively in the survey; this resulted and relevant to the professional values of physiothera- in 26 distinct values (see Table 4). We then further refined pists. The review identified only 11 articles from which this list by amalgamating some values when they were values relevant to the PT profession could be extracted. closely aligned and identifying others as the behaviour Moreover, the number of explicit value statements or sets associated with those values. We obtained a final list of of values published by PT associations and regulatory 10 values (see Table 5). boards across select countries was also limited, appearing on only 23 of 152 Web sites searched (15%). The limited DISCUSSION attention paid to professional values in the PT literature The purpose of this preliminary study was to begin to underscores the need for an increased awareness of the importance of values in PT practice and the necessity of identify the values and associated behaviour deemed future research in this area. These results highlight the important to Canadian physiotherapists. The research importance of seeking national consensus on the used a two-pronged approach: we synthesized the results

140 Physiotherapy Canada, Volume 71, Number 2 Table 4 Values Identified through the Literature Review and Survey professional core values underpinning the actions of both the members of the profession and the profession Source Values itself. https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Literature review Credibility The results of the survey suggest a lack of understanding Survey respondents Cultural competency among the respondents attending the CPA Congress of Both literature review and survey Going the extra mile what constitutes a value. Participants were asked to list two Justice values that guided their everyday practice, and some of the Professional duty most commonly identified values were integrity, empathy, Truthfulness caring, patient-centred care, compassion, evidence-based Advocacy practice, excellence, lifelong learning, and respect. How- Empathy ever, several participants documented what they valued, Ethical practice rather than documenting a value. For instance, “prompt Evidence-based practice appointments,” which one participant provided, is not a Lifelong learning professional value; rather, it represents what (e.g., beha- Quality care viour) the respondent values. Stewardship Accountability Although each response was compared with the re- Altruism searchers’ agreed-on definition of a value,1 the purpose Caring of the survey was to discover the perceptions of Canadian Collaborative practice physiotherapists. Thus, although not all participants’ Compassion value responses precisely met our definition, we retained Equity them because they were inclusive and represented the Excellence opinions of Canadian physiotherapists. Honesty Innovative practice It is interesting to note that some of the values ulti- Integrity mately identified in this study aligned with some of the Patient-centred care professional behaviours published by MacDonald and Respect colleagues: lifelong learning, client centred, respect, Social responsibility empathy or sensitive practice, and evidence-based prac- tice.13 This confusion between values and behaviours will Table 5 Values Amalgamated to Achieve the Final List likely continue to challenge those conducting future research in this area, and it potentially highlights the lack Final value Values amalgamated of education about the meaning and role of values in the profession. These results should prompt action among Accountability Ethical practice educators, regulators, and those in our professional asso- Advocacy Stewardship ciation to consider strategies to address this issue. Altruism Advocacy Compassion/caring Going the extra mile The challenge of identifying core values and their asso- Equity Empathy ciated behaviours is not specific to physiotherapists prac- Excellence Justice tising in Canada. A prime example of how values and Evidence-based practice behaviour can be mistakenly interpreted as synonymous is Integrity Innovative practice evidenced by the research undertaken with Australian phy- Lifelong learning siotherapists.12 This qualitative study identified three over- Patient/client centredness Professional duty arching themes of values: the patient and the patient– Respect Quality care therapist partnership; PT knowledge, skills, and practice; Social responsibility Credibility and altruistic values. Within these themes, 22 values Honesty emerged.12 However, on further scrutiny, it becomes clear Truthfulness that a number of these proposed values represent value-as- Cultural competency sociated behaviour – for example, “being a professional,” Collaborative practice “having leadership,” and “being a good communicator.”12 Respect Although the Australian physiotherapists recognized “being Social responsibility a good communicator,” “practicing safely,” and “being edu- cators” as important values of their PT profession, these were not identified in the present study of Canadian physiotherapists. Also, McGinnis and colleagues noted that the discus- sion of values and associated behaviour was further com- plicated by the fact that some behaviour associated with

Boyczuk et al. Professional Values: Results of a Scoping Review and Preliminary Canadian Survey 141 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 one core value can also be affiliated with another core future nationwide survey of Canadian physiotherapists. value.6 There appears to be an important opportunity Although Canadian physiotherapists can consider the va- here for further studies that explore the commonalities lues identified by PT organizations in other countries, among and differences between national professional va- those values may not align with their own. Because it is lues and their associated behaviour. understood that the core values of a profession are the foundation for the development of professional beha- However, there are several similarities between the va- viours in practice,6 there are benefits to identifying those lues identified in our Canadian survey and those identi- values unique to Canadian physiotherapists. An agreed- fied by physiotherapists in the United States and on set of national, professional core values could be Australia. Our survey identified six of the seven APTA incorporated into entry-level and continuing education values – namely, accountability, altruism, compassion programmes to inform the professional socialization pro- and caring, excellence, integrity, and social responsibil- cess.28 Moreover, a well-defined list of values and asso- ity;11 professional duty was not among them. The most ciated behaviour could inform the practice of both represented values in our survey were caring and com- student and practising physiotherapists as well as the passion, integrity, and excellence (reported 26, 18, and actions of the CPA. 11 times, respectively), whereas social responsibility was identified by only one respondent. These findings are Although this study is the first to identify the values of similar to those reported in the recent study of American Canadian physiotherapists, several limitations should be physical therapists by McGinnis and colleagues6 and noted. First, the survey component was circulated to a serve to support the validity of our study’s results. small convenience sample of Canadian physiotherapists. With approximately 17,600 practising physiotherapists in Moreover, many of the values identified by the Cana- Canada,29 the responses represented only 0.005% of dian physiotherapists fit into the three themes identified all physiotherapists across the nation. Second, the by the Australian physiotherapists – that is, the values of majority of participants were from Ontario and British excellence, evidence-based practice, and lifelong learning Columbia; thus, their responses may not represent the correspond with several values listed under the Australian thoughts and opinions of physiotherapists across the survey’s theme of PT knowledge, skills, and practice: hav- country. However, these limitations are balanced by ing, mastering, and updating skills and knowledge and our thorough review of the primary and grey literature. having an evidence base.11,12 The Canadian physiothera- Thus, the results can be considered to be a comprehen- pists also identified several altruism- and integrity-related sive list of professional values for the international PT values that were identified by the Australian physiothera- profession and an appropriate starting point for estab- pists, such as honesty, respect, compassion, and empathy.12 lishing a list of core professional values for Canadian physiotherapists. One must be cautious when interpreting the fre- quency of survey responses because we had a small sam- Third, the results of the survey were limited by the par- ple, and participants were asked to list only two values. ticipants’ responses, requiring interpretation and recod- Thus, a participant’s response did not necessarily include ing. Although we may have misinterpreted a participant’s all the values that guide their practice. In addition, intended response, this limitation highlights the impor- because the responses were collected at one time (during tance of undertaking a national project to identify the core a conference), the participants may have been under a professional values of Canadian physiotherapists. time constraint and may therefore have been more likely to respond with the first value that came to mind, such as CONCLUSION the more commonly used terms of caring and compas- This is the first study to identify prevalent professional sion as opposed to less frequently used terms such as professional duty and social responsibility. values from the perspective of Canadian physiotherapists. Although many of the respondents’ values aligned with Although the results of this study align well with the value statements previously published by APTA11 and re- available literature, both reveal the ambiguity and ongo- ported by practising therapists in the United States6 and ing discourse about the definition and understanding of Australia,12 a number of unique responses were identified: value. This lack of understanding emphasizes the need advocacy, empathy, ethical practice, evidence-based prac- for increased awareness and knowledge translation about tice, quality care, lifelong learning, stewardship, and hard values and how they guide PT practice. This study’s find- work. The results of this study are an important first step ings suggest a need for a more explicit approach to edu- in the process of identifying the core professional values cating practising and student physiotherapists about the and associated behaviour of Canadian physiotherapists role of core values, and their associated behaviours, both and will inform future research. in individual practice and in the profession. The results of this study will be used to inform future research by incorporating the values it identified into a

142 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 KEY MESSAGES 14. Bartlett DJ, Lucy SD, Bisbee L. Item generation and pilot testing of the Comprehensive Professional Behaviours Development Log. What is already known on this topic J Allied Health. 2006;35(2):89–93. Medline: 16848372. Core values are an integral aspect of professionalism, 15. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the and they guide professional behaviour. To date, a set of methodology. Implementation Science. 2010;5(1):69. https://doi.org/ core professional values has not been identified by Cana- 10.1186/1748-5908-5-69. Medline: 20854677 dian physiotherapists. 16. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res What this study adds Psych. 2006;3(2):77–101. https://doi.org/10.1191/ We identified 10 values relevant to physiotherapists by 1478088706qp063oa. conducting a scoping review of the primary and grey lit- 17. Hsieh HF, Shannon SE. Three approaches to qualitative content erature and a survey of participants attending the 2016 analysis. Qual Health Res. 2005;15(9):1277–88. https://doi.org/ Canadian Physiotherapy Association Congress. This list is 10.1177/1049732305276687. Medline: 16204405 an important starting point for a national initiative to identify the core professional values of the Canadian 18. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic physiotherapy profession. analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398–405. https://doi.org/10.1111/ REFERENCES nhs.12048. Medline: 23480423 1. Davis C. Patient practitioner interaction. Thorofare, NJ: Slack; 2011. 19. Aguilar A, Stupans I, Scutter S, King S. 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Boyczuk et al. Professional Values: Results of a Scoping Review and Preliminary Canadian Survey 143 APPENDIX 1: SOURCES OF VALUE STATEMENTS IN THE GREY LITERATURE https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Country Province, State, or Jurisdiction Country Province, State, or Jurisdiction Australia Canada n/a United Kingdom New Mexico Alberta* South Africa New York* Hong Kong British Columbia* North Carolina Australia Manitoba* North Dakota New Zealand New Brunswick Ohio Republic of Ireland Newfoundland and Labrador Oklahoma* United States Northwest Territories Oregon Nova Scotia Pennsylvania Nunavut Rhode Island Ontario South Carolina Prince Edward Island South Dakota Quebec* Tennessee Saskatchewan Texas Yukon Utah* n/a Vermont n/a Virginia n/a Washington* n/a West Virginia* Alabama Wisconsin Alaska Wyoming Arizona England Arkansas Scotland California* Northern Ireland Colorado* Wales Connecticut n/a Delaware* Florida *The Web site(s) of this region’s regulatory board or college or its association Georgia* set out a value statement or list of values. Hawaii n/a = not applicable. Idaho Illinois Indiana Iowa* Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi* Missouri Montana* Nebraska Nevada New Hampshire New Jersey

Clinician’s Commentary on Boyczuk et al.1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Boyczuk and colleagues1 present an interesting, multifaceted Boyczuk and colleagues1 proposed, on the basis of work done examination of the values applicable to or identified by practis- by others, that articulating values may promote unity and coher- ing physiotherapists and physiotherapy students in Canada. ence in the profession. The profession should also examine its They describe their study as a first step in informing plans for beliefs and their compatibility with physiotherapists’ espoused future research, and they provide recommendations on the values and societal contribution, and they should focus on rele- importance of values for educators, regulatory bodies, and pro- vance at least as much as on unity. For example, early codes of fessional associations. conduct for physiotherapists explicitly prohibited providing treatment to patients without medical referral.7,8 Physiothera- The distinctions among beliefs, values, and behaviours may pists’ professional forebears were evidently united in believing in remain fuzzy despite all intelligent efforts to draw sharp lines. and valuing physicians’ supervision and direction, in contrast to Neuroscientific and behavioural research do not bear out the the profession’s current unity about the value of autonomy and notion that the distinctions are sharp or that people’s behaviour direct access.9 Physiotherapists who led this transition in values is always determined by their stated values.2 Moreover, there are needed to be willing to challenge unity.10 constructs for which a person’s thinking may go straight from belief to behaviour: for example, a person may believe that all Examining beliefs as well as values may help physiotherapists people deserve respect, and a person’s behaviour may show identify different things. Considering values may lead to a strong respect to people with whom that person interacts. What else to focus on morals and ethics – arguably shared by members of call the intervening value but respect? It may not reflect confusion many other professions – whereas it may be easier to think of be- about values and behaviours but rather an economy of language. liefs that are more strongly held by physiotherapists than by In research on values, researchers should embrace the thinking members of other professions. This wider lens may help us see that they are intricately connected with beliefs and behaviours. what unites us and also what can impede us if it is not ad- dressed. For example, Nicholls has argued that physiotherapists Boyczuk and colleagues1 make an interesting point, grounded hold strongly to a belief system about the body as machine and in the literature, that core values may be less susceptible to that they must critically examine their strong beliefs in biome- change than other values. It may not be good use of curricular chanical explanations and solutions as paramount if physiother- time to have university educators try to teach certain core values, apy is to remain a highly relevant profession for society.11,12 such as altruism, compassion, and integrity. Many of them are embedded in All I Really Need to Know I Learned in Kindergarten,3 Boyczuk and colleagues1 have provided an important first and they may be deeply ingrained in people who have arrived at step in articulating the values of physiotherapists in Canada. I university to become a health professional.4 Rather than designing join them in hoping that it fosters a national conversation and education that views students’ minds as blank slates or empty of further research on this important topic. core values, we should design education to guide students to op- erationalize their core values in their professional conduct. Educa- Kathleen E. Norman, BScPT, PhD tors can do this through explicit teaching or role modelling of how Associate Professor and Associate Director, Research and to interact with patients, co-workers, and others. These processes are part of the professional socialization that helps to form profes- Post-Professional Programs, School of Rehabilitation sional identity, as Boyczuk and colleagues describe.1 For example, Therapy, Faculty of Health Sciences, Queen’s University, if we start from the premise that students entering physiotherapy education already place some value on compassion, we can guide Kingston, Ontario; [email protected]. them to reflect on how a practitioner’s behaviour in a clinical sce- nario demonstrated compassion or to consider stories that prompt REFERENCES them to feel and reflect on compassion.5 1. Boyczuk AM, Deloyer JJ, Ferrigan KF, et al. Professional values: results Further research on values should consider combining survey from a scoping review and preliminary Canadian survey. Physiother methods with other methods. Even respondents to an anony- Can. 2018;71(2):xxx–xx. https://doi.org/10.3138/ptc.2017-70. mous survey can show social desirability bias, for example en- dorsing altruism because it feels immoral not to. Boyczuk and 2. Ariely D. The honest truth about dishonesty. London: HarperCollins; colleagues identified “patient/client centredness” as a value; this 2012. is a prevailing message in health care, and physiotherapists may want to think well of themselves for endorsing it without neces- 3. Fulghum R. All I really need to know I learned in kindergarten. New sarily behaving in a fully patient-centred way. Using an auto- York: Villard Books; 1988. ethnographic method, Mudge and colleagues showed that, at least for two physiotherapists in New Zealand but also grounded 4. Collier R. Professionalism: can it be taught? 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Clinician’s Commentary on Boyczuk et al. 145 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 7. Barclay J. In good hands: the history of the Chartered Society of 10. Kruger J. Patient referral and the physiotherapist: three decades later. Physiotherapy 1894–1994. Oxford, UK: Butterworth Heinemann; J Physiother. 2010;56(4):217–18. https://doi.org/10.1016/s1836-9553 1994. (10)70001-1. Medline:21091408 8. Linker B. The business of ethics: gender, medicine, and the 11. Nicholls DA. The end of physiotherapy. Abingdon, UK: Routledge; professional codification of the American Physiotherapy Association, 2018. 1918–1935. J Hist Med Allied Sci. 2005;60(3):320–54. https://doi.org/ 10.1093/jhmas/jri043. Medline:15917259 12. Nicholls DA, Gibson BE. The body and physiotherapy. Physiother Theory Pract. 2010;26(8):497–509. https://doi.org/10.3109/ 9. World Confederation for Physical Therapy. Policy statement: direct 09593981003710316. Medline:20795873 access and patient/client self-referral to physical therapy [Internet]. London: The Confederation; 2017 [cited 2018 Oct 10]. Available from: DOI:10.3138/ptc.2017-70-cc https://www.wcpt.org/policy/ps-direct-access.

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 EDUCATION Essential Elements for Advancing Cultural Humility through a Community-Based Physical Therapy Practicum in a Métis Community Sarah Oosman, BScPT, MSc, PhD;*{ Liz Durocher, BSW;{x Thomas J. Roy;{x Jenna Nazarali, BSc, MPT;*{ Jadon Potter, BSc, MPT; *{ Linaya Schroeder, BSExSci, MPT;*{ Megan Sehn, BScKin, MPT;*{ Kirsten Stout, MPT;*{ Sylvia Abonyi, PhD{} ABSTRACT Purpose: This article reveals MPT practicum participant perceptions of the impact that a community-based practicum in a Métis community had on their learning in the area of cultural humility and cultural safety. Method: The impact of this community-based practicum intervention in a Métis community on MPT student education was explored using phenomenological descriptive methodology, with data gathered via exit interviews conducted on completion of the community-based practicum. Concepts of cultural humility and safety from the literature, along with themes emerging from practicum participant inter- views, informed the analysis and theme development. Results: Participants’ experiences were categorized into three themes: (1) realizing Métis community strengths; (2) learning from experiences and shaping future practice; and (3) prioritizing relationships. Findings support that participants demonstrated the practice of cultural humility as a result of engaging in the community-based practicum. Conclusions: Our results highlight the importance of (1) community engagement, (2) community-informed practicum design based on strong relationships, (3) a backbone of reflective practice, and (4) a base of community and student readiness to support practicum success. These essential elements support a cultural humility approach to implementing MPT practicums in Indigenous communities, as well as a practice in reconciliation. Key Words: cultural competence; experiential learning; Indigenous health; preceptorship; qualitative research. RÉSUMÉ Objectif : le présent article révèle les perceptions d’étudiants à la maîtrise en physiothérapie sur les retombées d’un stage en communauté métisse dans leur apprentissage de l’humilité culturelle et de la sécurité culturelle. Méthodologie : les chercheurs ont exploré les retombées de ce stage en communauté métisse sur la formation d’étudiants à la maîtrise en physiothérapie au moyen d’une méthodologie phénoménologique descriptive et ont récolté leurs don- nées lors d’entrevues à la fin du stage. Ils ont appuyé leur analyse et leurs thèmes sur les concepts d’humilité culturelle et de sécurité culturelle tirés des publications scientifiques ainsi que sur les sujets découlant des entrevues avec les participants. Résultats : Les chercheurs ont regroupé les expériences des participants en trois thèmes : 1) comprendre les forces de la communauté métisse, 2) apprendre des expériences, modeler les futures pratiques et 3) prioriser les relations. Les résultats confirment que les participants ont adopté des pratiques d’humilité culturelle après leur stage communautaire. Con- clusion : les résultats démontrent l’importance a) de l’engagement communautaire, b) d’un stage communautaire axé sur de solides relations, c) d’une structure de pratique réflexive et d) d’une certaine préparation de l’étudiant et de la communauté pour soutenir la réussite du stage. Ces éléments essen- tiels corroborent l’approche d’humilité culturelle pour instaurer des stages d’étudiants à la maîtrise dans les communautés autochtones, de même qu’une pratique de réconciliation. Racism and discrimination are rooted in Canada’s identifies as Aboriginal, the second highest proportion history of colonization, and they are prevalent in its health among all the provinces.4 Researchers expect that by 2036 care system. This situation makes it difficult for Indige- the proportion of Aboriginal peoples living in Saskatche- nous peoples to access appropriate, timely, respectful, cul- wan will increase to 22.7%.5 To provide culturally safe and turally responsive, and safe care.1,2 They often have fear responsive care to this growing demographic, physical and trepidation when accessing health care as a result of therapists require enhanced training and preparation that the experience of residential schools, systemic racism, and will develop their cultural safety skills. other traumatic impacts of colonization.3 In Saskatche- wan, approximately 15.6% of the population currently The Aboriginal population in Canada is made up of three distinct groups – First Nations, Inuit, and Métis, as From the: *School of Rehabilitation Science; }Department of Community Health and Epidemiology, College of Medicine; {Saskatchewan Population Health and Eval- uation Research Unit; {University of Saskatchewan, Saskatoon; xCommunity of Île-à-la-Crosse, Sask. Correspondence to: Sarah Oosman, School of Rehabilitation Science, University of Saskatchewan, 104 Clinic Pl., Health Science Bldg., Saskatoon, SK S7N 2Z4; [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 2019; 71(2);146–157; doi:10.3138/ptc.2017-94.e 146