PHYSIOTHERAPY CANADA

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 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 68  Number 2  Spring 2016 Highlights Sixth Issue in a Special Series on Education GUEST EDITORAL in Physiotherapy What is Evidence-Based Physiotherapy? / La physiothérapie fondée sur les données probantes : une définition Second Issue in a Special Series on Global ARTICLES Health, Disability, and Rehabilitation: Perceptions of Leadership: Comparing Canadian and Irish Implications for Physiotherapy Physiotherapists’ Views by E. McGowan, G. Martin, and E. Stokes OA Go Away: Development and Preliminary Validation of a Self- Management Tool to Promote Adherence to Exercise and Physical Activity for People with Osteoarthritis of the Hip or Knee by G. Paterson, K. Toupin April, C. Backman, and P. Tugwell Evidence of Reliability, Validity, and Practicality for the Canadian Physiotherapy Assessment of Clinical Performance by B. Mori, K. E. Norman, D. Brooks, J. Herold, and D. E. Beaton Official Journal of the Canadian Physiotherapy Association Revue officielle de l’Association canadienne de physiothérapie

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https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Physiotherapy Advancing health through scientific inquiry and knowledge translation CANADA Pour l’avancement de la sante´ par l’enqueˆ te scientifique et la transmission du savoir VOLUME 68 NUMBER 2 SPRING 2016 ISSN-0300-0508 E-ISSN-1708-8313 TABLE OF CONTENTS GUEST EDITORIAL 95 What Is Evidence-Based Physiotherapy? ORIGINAL ARTICLES Mirella Veras, Dahlia Kairy, and Nicole Paquet EDUCATION 96 La physiothe´rapie fonde´e sur les donne´es probantes : une de´finition Mirella Veras, Dahlia Kairy, and Nicole Paquet 99 Effects of Three Weeks of Whole-Body Vibration Training on Joint-Position Sense, Balance, and Gait in Children with Cerebral Palsy: A Randomized Controlled Study Myung-Sook Ko, Yon Ju Sim, Do Hyun Kim, and Hye-Seon Jeon 106 Perceptions of Leadership: Comparing Canadian and Irish Physiotherapists’ Views Emer McGowan, Gillian Martin, and Emma Stokes 114 Clinician’s Commentary Martine Quesnel 116 SenseWearMini and Actigraph GT3X Accelerometer Classification of Observed Sedentary and Light-Intensity Physical Activities in a Laboratory Setting Lynne M. Feehan, Charles H. Goldsmith, April Y. F. Leung, and Linda C. Li 124 OA Go Away: Development and Preliminary Validation of a Self-Management Tool to Promote Adherence to Exercise and Physical Activity for People with Osteoarthritis of the Hip or Knee Gail Paterson, Karine Toupin April, Catherine Backman, and Peter Tugwell 133 Learning Curves Observed in Establishing Targeted Rate of Force Application in Pressure Pain Algometry Alicia J. Emerson Kavchak, Josiah D. Sault, and Ann Vendrely 141 An Exploration of Canadian Physiotherapists’ Decisions about Whether to Supervise Physiotherapy Students: Results from a National Survey Mark Hall, Cheryl Poth, Patricia Manns, and Lauren Beaupre 149 Clinician’s Commentary Robyn Davies 151 Examining the Need for a New Instrument to Evaluate Canadian Physiotherapy Students during Clinical Education Experiences Mark Hall, Patricia Manns, Cheryl Poth, and Lauren Beaupre

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 GLOBAL HEALTH 156 Evidence of Reliability, Validity, and Practicality for the Canadian Physiotherapy Assessment of Clinical Performance COCHRANE COLLABORATION Brenda Mori, Kathleen E. Norman, Dina Brooks, Jodi Herold, and Dorcas E. Beaton BOOK REVIEW 170 Clinician’s Commentary Peggy L. Proctor 172 Physiotherapy Students’ Attitudes toward Psychiatry and Mental Health: A Cross-Sectional Study Joanne Connaughton and William Gibson 179 Interviewers’ Experiences with Two Multiple Mini-Interview Scoring Methods Used for Admission to a Master of Physical Therapy Programme Ina van der Spuy, Angela Busch, and Julia Bidonde 186 Clinician’s Commentary Sharon Switzer-McIntyre 188 Standing on the Precipice: Evaluating Final-Year Physiotherapy Students’ Perspectives of Their Curriculum as Preparation for Primary Health Care Practice Sinead McMahon, Grainne O’Donoghue, Catherine Doody, Geraldine O’Neill, Terry Barrett, and Tara Cusack 197 Ethics and Community-Based Rehabilitation: Eight Ethical Questions from a Review of the Literature Stephen Clarke, Jessica Barudin, and Matthew Hunt 206 Clinician’s Commentary Sudha R. Raman and Graziella Van den Bergh 208 What Does the Cochrane Collaboration Say about Rehabilitation Interventions for Shoulder Dysfunction? 209 Practical Management of Pain, 5th ed. Judith P. Hunter

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Physiotherapy SCIENTIFIC EDITOR CANADA Dina Brooks, PT, PhD INTERNATIONAL ADVISORY BOARD Professor, Canada Research Chair, Department of Physical Therapy, University of Toronto, Toronto, ON Rik Gosselink, PhD, PT Professor, Department of Rehabilitation Sciences, Katholieke ASSOCIATE EDITORS Universiteit Leuven, Leuven University, Belgium Denise Connelly, PhD, BScPT Karen Grimmer-Somers, PhD, MMedSci, BPhty, Associate Professor, School of Physical Therapy, University of CertHealthEc, LMusA Western Ontario, London, ON Professor, School of Health Sciences Director, Centre for Allied Health Evidence, University of South Australia, Australia Je´roˆme Frenette pht, PhD Professeur titulaire, Programme de Physiothe´rapie, De´partment Meg E. Morris, BAppSC(Physio), MAppSc, Grad Dip(Geron), de Re´adaptation, Pavillon Ferdinand-Vandry, Universite´ Laval, PhD, FACP Que´bec, QC Professor and Chair, School of Physiotherapy, University of Melbourne, Australia Isabelle Gagnon, pht, PhD Assistant Professor , School of Physical and Occupational Kenneth J. Ottenbacher, OT, PhD Therapy, McGill University, Montre´al, QC Russel Shearn Moody Distinguished Chair in Neurological Rehabilitation, Senior Associate Dean for Graduate Research S. Jayne Garland, PhD, PT Education, School of Allied Health Sciences, University of Professor and Department Head, Department of Physical Texas Medical Branch, USA Therapy, University of British Columbia, Vancouver, BC Carol L. Richards, PhD, PT, FCAHS Barbara Gibson, PhD, PT Professor and Canada Research Chair in Rehabilitation, Associate Professor, Department of Physical Therapy, Department of Rehabilitation Medicine, Laval University, University of Toronto, Toronto, ON Quebec City, QC Marilyn MacKay-Lyons, BSc(PT), MSc(PT), PhD Peter Rosebaum, MD, CM, FRCP(C) Associate Professor, School of Physiotherapy, Dalhousie Professor, Department of Pediatrics, McMaster University University, Halifax, NS Hamilton, ON Stephanie Nixon Julius Sim, BA, MSc(Soc), MSc(Stat), PhD Associate Professor, Department of Physical Therapy, Primary Care Musculoskeletal Research Centre, Keele University of Toronto, Toronto, ON University, UK Christine B. Novak, BSc(Kin), BSc(PT), MSc, PhD STATISTICAL CONSULTANT Associate Professor, Department of Surgery, University of Toronto / Toronto Rehab-UHN and Research Associate, Paul Stratford, PT, MSc University Health Network, Toronto, ON Professor, School of Rehabilitation Science, McMaster University, Hamilton, ON Tom Overend, PhD, BSc(PT) Associate Professor, School of Physical Therapy, University of PUBLISHER Western Ontario, London, ON Canadian Physiotherapy Association Marco Pang, BScPT, PhD 955 Green Valley Crescent, Suite 270, Ottawa, ON Assistant Professor, Department of Rehabilitation Sciences, K2C 3V4 Canada The Hong Kong Polytechnic University, Kowloon, Hong Kong Tel.: 613-564-5454 or 800-387-8679, Fax: 613-564-1577 E-mail: [email protected] EDITORIAL OFFICE www.physiotherapy.ca University of Toronto Press – Journals Division Competing Interest Statements for Physiotherapy Canada 5201 Dufferin St., North York, ON, M3H 5T8 Canada Editorial Board members are available online at Tel.: 416-667-7810, Fax: 416-667-7881 http://www.utpjournals.com/Physiotherapy-Canada.html. E-mail: [email protected], www.utpjournals.com

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 STATEMENT OF PURPOSE OBJECTIF Physiotherapy Canada is the official, scholarly, refereed journal of Physiotherapy Canada est la publication scientifique officielle re´vise´e the Canadian Physiotherapy Association, giving direction to excellence en profondeur de l’Association canadienne de physiothe´rapie. Son in clinical science and reasoning, knowledge translation, therapeutic objectif est de fournir des orientations a` l’excellence en sciences et skills and patient-centred care. en raisonnement clinique, transmission du savoir, compe´tences the´rapeutiques et soins centre´s sur le patient. Recognized as one of the top five evidence-based journals of physiotherapy worldwide, Physiotherapy Canada publishes the Reconnu comme l’un des cinq grands journaux de physiothe´rapie results of qualitative and quantitative research including systematic reposant sur des faits scientifiques dans le monde, Physiotherapy reviews, meta analyses, meta syntheses, public/health policy research, Canada publie les re´sultats de recherches qualitatives et quantitatives, clinical practice guidelines, and case reports. Key messages, clinical notamment des revues syste´matiques, des me´ta-analyses, des commentaries, case studies, evidence-based practice articles, brief me´tasynthe`ses, des recherches en politiques de la sante´ ou en reports, and book reviews support knowledge translation to clinical politiques publiques, des directives en pratique clinique et des practice. e´tudes de cas. Ses messages cle´s, commentaires cliniques, e´tudes de cas, articles fonde´s sur des faits scientifiques, re´sume´s de discussions Founded in 1923, Physiotherapy Canada meets the diverse needs of et comptes-rendus de livres favorisent la transmission du savoir a` la national and international readers and serves as a key repository of pratique clinique. inquiries, evidence and advances in the practice of physiotherapy. Fonde´e en 1923, Physiotherapy Canada re´pond aux divers besoins de Physiotherapy Canada (ISSN 0300-0508) is published four times per lecteurs canadiens et e´trangers et se positionne comme un ve´ritable year in spring, summer, fall and winter by the University of Toronto recueil sur la recherche, les faits scientifiques et les progre`s dans la Press for the Canadian Physiotherapy Association. pratique de la physiothe´rapie. EDITORIAL SUBMISSIONS PRE´ SENTATIONS D’ARTICLES Physiotherapy Canada welcomes manuscripts reporting results of Physiotherapy Canada accepte les articles qui font e´tat de re´sultats qualitative or quantitative research. Systematic reviews, meta analyses de recherche qualitative ou quantitative. Les examens syste´matiques, (quantitative), meta syntheses (qualitative), public/health policy research, les me´ta-analyses (quantitatives), les me´tasynthe`ses (qualitatives), clinical practice guidelines, case reports (quantitative), case studies les recherches sur les politiques publiques et de sante´, les guides de (qualitative), evidence-based practice articles and brief reports are pratique clinique, les rapports de cas (quantitatifs), les e´tudes de cas also welcomed. Submissions are now being accepted online via (qualitatives), les articles sur la pratique factuelle et les rapports de Physiotherapy Canada’s online peer-review system PRESTO. To log in me´moire sont aussi les bienvenus. Vous pouvez pre´senter vos articles or see submission guidelines, please go to http://bit.ly/PTCPRESTO. en ligne graˆce au syste`me e´lectronique d’examen par les pairs PRESTO For technical support information or questions regarding the editorial de Physiotherapy Canada. Pour ouvrir une session ou pour connaˆıtre process please contact us at [email protected]. les lignes directrices sur la pre´sentation d’un article, consultez la page http://bit.ly/PTCPRESTO. Pour obtenir un soutien technique ou des Physiotherapy Canada is indexed by Allied and Complementary re´ponses a` vos questions concernant le processus re´dactionnel, Medicine Database (AMED), China Education Publications Import & veuillez communiquer avec nous a` [email protected]. Export Corporation (CEPIEC), CrossRef, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EJS EBSCO Electronic Journals Physiotherapy Canada est indexe´e par Allied and Complementary Service, Google Scholar, ISI Web of Knowledge, PEDro, PubMed Medicine Database (AMED), China Education Publications Import Central (PMC), and Scopus. & Export Corporation (CEPIEC), CrossRef, l’index cumulatif des publications sur les soins infirmiers et les soins parame´dicaux (CINAHL), The statements and opinions in this journal are solely those of the le Service de journaux e´lectroniques EJS EBSCO, Google Scholar, ISI contributors and not those of the publisher or of the Canadian Web of Knowledge, PEDro, PubMed Central (PMC) et Scopus. Physiotherapy Association. Les opinions publie´es dans cette revue sont celles des contributeurs COPYRIGHT et ne repre´sentent pas les opinions de l’e´diteur ou de l’Association 6 Canadian Physiotherapy Association, 2016. All rights reserved. No canadienne de physiothe´rapie. part of this material may be reproduced, stored in a retrieval system, or transcribed in any form or by any means, electronic, mechanical, DROIT D’AUTEUR photocopying, recording, or otherwise, without written permission 6 Association canadienne de physiothe´rapie, 2016. Tous droits from the Canadian Physiotherapy Association and its publisher, re´serve´s. Aucune partie de la pre´sente publication ne peut eˆtre University of Toronto Press. reproduite, emmagasine´e dans un syste`me de recherche documentaire, ou transcrite, d’aucune fac¸on que ce soit ou par quelque moyen Requests should be made to Permissions Coordinator, Journals e´lectronique ou me´canique que ce soit – photocopie, enregistrement Division, University of Toronto Press, journal.permissions@utpress. ou autre – sans l’autorisation e´crite de l’Association canadienne de utoronto.ca, Fax 416-667-7881. physiothe´rapie (ACP) et de son e´diteur, les Presses de l’Universite´ de Toronto. SUBSCRIPTIONS Individual and institutional subscriptions are available at Les demandes doivent eˆtre adresse´es au coordonnateur des www.utpjournals.com. autorisations, Division des pe´riodiques de University of Toronto Press, [email protected], nume´ro de te´le´copieur : ADVERTISING 416 667 7881. Physiotherapy Canada is distributed nationally and internationally to more than 11,300 individuals. For advertising rates and contracts, ABONNEMENTS contact the Canadian Physiotherapy Association at advertising@ Les particuliers et les e´tablissements peuvent s’abonner a` l’adresse physiotherapy.ca. http://physiotherapy.ca/Advertise-with-Us suivante : www.utpjournals.com. The appearance of an advertisement in the journal is not a warranty, PUBLICITE´ endorsement, or approval of the product(s) or service(s) offered, or of Physiotherapy Canada est distribue´e dans tout le pays et a` l’e´tranger a` their effectiveness, quality, or safety. The publisher and Canadian plus de 11 300 personnes. 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GUEST EDITORIAL / E´ DITORIALISTES INVITE´ ES https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 What Is Evidence-Based Physiotherapy? Mirella Veras, PhD, BScPT;* Dahlia Kairy, PhD, pht;* Nicole Paquet, PhD, pht† Evidence-based physiotherapy (EBP) is an emerging specific topic or field. There is an intrinsic connection and increasing theme in rehabilitation and physiother- between research and study, in that study is always part apy. Although it is increasingly used worldwide, a precise of research, but research, or the action of doing research, and appropriate definition has not been agreed on among is not necessarily included in study. The reason for clinicians and researchers. including both study and research as elements in our definition of EBP is to motivate critical thinking among The World Confederation for Physical Therapy (Euro- physiotherapists, who should feel comfortable question- pean region) has defined EBP as ‘‘a commitment to use ing the quality of the scientific evidence. In this way, the best available evidence to inform decision-making physiotherapy professionals can be agents of transfor- about the care of individuals that involves integrating mation and participate in the production of science physiotherapist practitioners and individual professional rather than merely be followers of new paradigms. judgement with evidence gained through systematic re- search.’’1(p.1) This definition is based on Sackett and It is important to highlight EBP as a field of study and colleagues’ definition of evidence-based medicine (EBM), research in which physiotherapists can collect relevant published in 1996 by BMJ (formerly British Medical information, use a variety of research methods to pro- Journal).2 duce scientific evidence on topics related to patient eval- uation and interventions in physiotherapy, and assess In 2000, Sackett and colleagues published a revised the quality of the scientific evidence already available. definition of EBM as ‘‘the integration of best research Several authors have criticized EBM methods, which evidence with clinical expertise and patient values.’’3(p.1) they see as an attempt to monopolize science for stand- This definition showed some progress because it now ardizing methods and research tools around a unique included research, clinical practice, and the values of scientific truth.4–6 Every health discipline should reflect the patient. However, it did not yet include all the ele- on its practices and goals to construct a pertinent defini- ments that characterize EBM or EBP. For instance, it did tion of evidence-based practice. not include ethical principles of autonomy, beneficence, non-maleficence, and justice, which are of utmost im- The arguments of these critics of EBM are supported portance in evidence-based clinical decisions and go mainly by the theories of Thomas Kuhn and Michel Fou- beyond patient values. Therefore, we propose defining cault. Kuhn held that a scientific revolution occurs when EBP as follows: an area of study, research, and practice in a new paradigm—a theory or perspective that dominates which clinical decisions are based on the best available the science and is generally accepted by all members of evidence, integrating professional practice and expertise the scientific community—replaces an old paradigm, with ethical principles. Although the terms study and and two theories cannot coexist. Foucault’s theory of research are often used as synonyms, for our purposes epistemological ruptures in knowledge production follows study (or knowledge acquisition) is defined as the act of a similar path.4–6 devoting time to learning about any topic or area of knowledge. On one hand, to study is to learn a topic or The fundamentals that support including clinical de- some knowledge that has already been discovered and cision making based on the best available evidence and revealed; it can stimulate the eager to investigate, go the integration of professional practice expertise with deeper in their studies, and perhaps originate an innova- ethical principles (including, but not limited to, patient tion on existing knowledge; in this case, research skills values) in the definition of EBP are already accepted would be needed to systematize the new knowledge and in the Kuhnian sense of a paradigm that is scientifically make it coherent and acceptable for the academic field. accepted. The great vision of this integration is the rec- On the other hand, research (or knowledge creation) goes ognition of evidence-based practice with a commitment beyond the study of existing knowledge and requires to consider all the ethical pillars in clinical decisions so a complex set of skills to develop new knowledge in a that the patient and society are included from beginning to end in the clinical decision-making process. From the: *E´ cole de re´ adaptation, Universite´ de Montre´ al, CRIR-site IRGLM du CIUSSS centre sud de l’Ile de Montre´ al; †E´ cole des sciences de la re´ adaptation, Universite´ d’Ottawa. Correspondence to: Mirella Veras, E´ cole de re´ adaptation, Universite´ de Montre´ al, 600 Rue Darling, Montre´ al, QC H1W 2V9; [email protected]. 95

96 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Incorporating patients’ values, beliefs, and prefer- REFERENCES ences in clinical decisions is a challenge. The failure to include these components in clinical decisions has com- 1. World Confederation for Physical Therapy—European Region. Evi- monly received much criticism. However, to build a dence based physiotherapy [Internet]. Brussels: The Confederation; science or a practice based on evidence, we must go 2015. [cited 2015 Mar 24]. Available from: http://www.erwcpt.eu/ beyond the narrow walls of individual patients’ values to education/evidence_based_physiotherapy_evidence_and_research. consider all the ethical principles that should shape a fair and progressive clinical practice in contemporary society. 2. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: Thus, clinicians might discuss evidence-based treatment what it is and what it isn’t. BMJ. 1996;312(7023):71–2. http:// options with their patients, thus opening the door to dx.doi.org/10.1136/bmj.312.7023.71. Medline:8555924 ethical discussions in which the benefits and risks of interventions are presented to patients so that they can 3. Sackett DL, Strauss SE, Richardson WS. Evidence-based medicine: participate in clinical decisions.7 how to practice and teach EBM. London: Churchill-Livingstone; 2000. CONCLUSION Our definition of evidence-based physiotherapy con- 4. Holmes D, Murray SJ, Perron A, et al. Nursing best practice guide- lines: reflecting on the obscene rise of the void. J Nurs Manag. tributes to a clarification of the term’s meaning and scope. 2008;16(4):394–403. http://dx.doi.org/10.1111/j.1365- We have offered some arguments for including new ele- 2834.2008.00858.x. Medline:18405255 ments to better define EBP as an area of study, research, and practice, adding the essential component of ethical 5. Samarkos MG. The philosophy of evidence-based medicine. Hosp principles. We welcome discussion and debate regarding Chronicles. 2006;1:27–35. this definition, with the ultimate goal of reaching some consensus on this important and emergent concept for 6. Solomon M. Just a paradigm: evidence-based medicine in episte- the physiotherapy field. mological context. Eur J Philos Sci. 2011;1(3):451–66. http:// dx.doi.org/10.1007/s13194-011-0034-6. 7. Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision making. JAMA. 2014;312(13):1295–6. http://dx.doi.org/10.1001/jama.2014.10186. Medline:25268434 DOI:10.3138/ptc.68.2.GEE La physiothe´rapie fonde´e sur les donne´es probantes : une de´finition Mirella Veras, PhD, BScPT;* Dahlia Kairy, PhD, pht;* Nicole Paquet, PhD, pht† La physiothe´rapie fonde´e sur les donne´es probantes medicine, ou EBM) publie´e par Sackett et collaborateurs (evidence-based physiotherapy, ou EBP) est une me´thode en 1996 dans la revue The BMJ (anciennement le British de pratique qui prend de l’ampleur en re´adaptation et en Medical Journal ).2 physiothe´rapie. Bien qu’elle soit de plus en plus adopte´e partout dans le monde, il reste encore aux praticiens En 2000, Sackett et collaborateurs ont publie´ une et aux chercheurs a` formuler une de´finition pre´cise et de´finition re´vise´e de l’EBM, la de´crivant comme l’« inte´- exacte. gration des meilleures donne´es issues de la recherche a` l’expertise clinique et aux valeurs du patient ».3(p.1) Cette La division europe´enne de la Confe´de´ration mondiale dernie`re de´finition marque un certain progre`s, puisqu’elle pour la the´rapie physique (WCPT) de´finit l’EBP comme re´unit la recherche, la pratique clinique et les valeurs du suit : patient. Il y manque encore cependant certains e´le´ments caracte´risant l’EBM ou l’EBP, a` savoir notamment les Engagement a` fonder ses de´cisions de soins au patient principes e´thiques d’autonomie, de bienfaisance, de non- sur les meilleures donne´es probantes existantes en inte´- malveillance et de justice, lesquels transcendent les grant l’expe´rience des physiothe´rapeutes praticiens et leur valeurs du patient et sont d’une importance critique avis professionnel aux donne´es probantes issues de la dans la prise de de´cisions cliniques fonde´es sur des recherche me´thodique.1(p.1) donne´es probantes. Nous proposons donc de de´finir l’EBP comme « un champ d’e´tude, de recherche et de Cette de´finition s’appuie sur la de´finition de la me´de- pratique dans le cadre duquel les de´cisions cliniques cine fonde´e sur des donne´es probantes (evidence-based * E´ cole de re´ adaptation, Universite´ de Montre´ al, CRIR-site IRGLM du CIUSSS du Centre-Sud-de-l’Iˆle-de-Montre´ al †E´ cole des sciences de la re´ adaptation, Universite´ d’Ottawa. Correspondance a` : Mirella Veras, E´ cole de re´ adaptation, Universite´ de Montre´ al, 600 Rue Darling, Montre´ al, QC H1W 2V9 ; [email protected].

Veras et al. What Is Evidence-Based Physiotherapy? 97 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 sont fonde´es sur les meilleures donne´es probantes exi- les ruptures e´piste´mologiques dans la production de stantes, et inte`grent la pratique et l’expertise profession- connaissances suit une tangente similaire.4–6 nelles aux principes e´thiques. » Bien que les termes e´tude et recherche soient souvent employe´s de fac¸on inter- Les principes voulant qu’on inclue dans la de´finition changeable, e´tude (soit l’acquisition de connaissances) de l’EBP la prise de de´cisions fonde´e sur les meilleures renvoie aux pre´sentes a` l’action de consacrer du temps donne´es probantes et l’expertise des praticiens profes- a` s’informer sur un sujet ou un domaine de la connais- sionnels inte´gre´e aux principes e´thiques (comprenant, sance. E´ tudier, c’est explorer un sujet ou un e´le´ment sans s’y limiter, les valeurs du patient) sont de´ja` accepte´s de savoir qui a de´ja` e´te´ de´couvert et re´ve´le´. Pratique´e au sens kuhnien d’un paradigme admis par la commu- se´rieusement, l’e´tude peut eˆtre pousse´e plus loin et naute´ scientifique. L’objectif principal de cette inte´gra- amener a` formuler de nouveaux concepts relativement tion est de faire en sorte que la pratique fonde´e sur des au savoir existant. Dans ce cas, des compe´tences en re- donne´es probantes s’accompagne d’un engagement a` cherche sont ne´cessaires pour syste´matiser ces nouvelles tenir compte de tous les piliers e´thiques dans les de´ci- notions et en faire un tout cohe´rent et acceptable pour sions cliniques, afin que le patient et la socie´te´ soient le milieu de la recherche. La recherche (ou cre´ation de inclus du de´but a` la fin du processus de prise de de´ci- connaissances), quant a` elle, de´passe le cadre de l’e´tude sions cliniques. des connaissances existantes et fait appel a` un ensemble de compe´tences pousse´es ne´cessaires a` l’e´laboration de Tenir compte des valeurs, des croyances et des pre´fe´- nouveaux concepts relativement a` un sujet ou a` un rences du patient dans les de´cisions cliniques pose un domaine particuliers. Un lien intrinse`que unit recherche de´fi. On a d’ailleurs beaucoup critique´ les manquements et e´tude, cette dernie`re faisant ne´cessairement partie de a` cet e´gard dans la prise de de´cisions. Toutefois, pour tout travail de recherche, mais il est possible d’e´tudier e´tablir une science ou une pratique fonde´es sur des sans pour autant faire de la recherche. donne´es probantes, il nous faut franchir les limites e´troites impose´es par les valeurs du patient pour tenir Si nous avons choisi d’inclure a` la fois l’e´tude et la compte de tous les principes e´thiques qui devraient recherche dans notre de´finition de l’EBP, c’est pour re- modeler une pratique clinique contemporaine e´quitable fle´ter la pense´e critique qui devrait animer les physiothe´- et progressiste. Les praticiens pourraient par exemple rapeutes. Ceux-ci ne devraient pas he´siter a` e´prouver discuter avec leur patient des traitements possibles la qualite´ des donne´es scientifiques. C’est ainsi qu’ils fonde´s sur les donne´es probantes, e´changes qui ouvri- peuvent eˆtre des agents de transformation et participer raient la porte a` des discussions e´thiques ou` les avantages a` la construction du savoir, plutoˆt que d’absorber sim- et les risques des interventions seraient pre´sente´s au plement les nouveaux paradigmes. patient pour qu’il puisse participer a` la prise de de´ci- sions cliniques.7 Il est important de pre´senter l’EBP comme un domaine d’e´tude et de recherche auquel les physiothe´rapeutes CONCLUSION peuvent contribuer en recueillant des donne´es pertinen- Notre de´finition de la physiothe´rapie fonde´e sur des tes, en utilisant diverses me´thodes de recherche pour produire des donne´es scientifiques sur des sujets lie´s donne´es probantes contribue a` clarifier le sens et la aux e´valuations de patient et aux traitements de physio- porte´e de ce terme. Nous avons avance´ quelques argu- the´rapie, et en e´valuant la qualite´ des donne´es scien- ments en faveur de l’inclusion de nouveaux e´le´ments tifiques existantes. Plusieurs auteurs ont critique´ les pour mieux de´finir l’EBP en tant que domaine d’e´tude, me´thodes de l’EBM, qu’ils voient comme une tenta- de recherche et de pratique, ajoutant la composante tive d’accaparement de la science pour conformer les essentielle que sont les principes e´thiques. Nous invitons me´thodes et les outils de recherche a` une ve´rite´ scien- la communaute´ a` discuter et a` de´battre de cette de´fini- tifique unique.4–6 Chaque science de la sante´ devrait tion, dans l’objectif ultime d’arriver a` un consensus rela- re´fle´chir a` ses pratiques et objectifs afin d’e´laborer une tivement a` cet important concept e´mergent dans le de´finition pertinente de ce qu’est la pratique fonde´e sur domaine de la physiothe´rapie. des donne´es probantes. RE´ FE´ RENCES Les arguments des de´tracteurs de l’EBM reposent surtout sur les the´ories de Thomas Kuhn et de Michel 1. World Confederation for Physical Therapy—European Region. Evi- Foucault. Kuhn soutenait qu’une re´volution scientifique dence based physiotherapy [Internet]. Brussels: The Confederation; se produit lorsqu’un nouveau paradigme—une the´orie 2015 [cite´ le 24 mars 2015]. Disponible au : http://www.erwcpt.eu/ ou un point de vue dominant les sciences et ge´ne´rale- education/evidence_based_physiotherapy_evidence_and_research. ment accepte´ par les membres des milieux scientifi- ques—remplace un ancien, et qu’il ne peut y avoir co- 2. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: existence de deux the´ories. La the´orie de Foucault sur what it is and what it isn’t. BMJ. 1996;312(7023):71–2. http:// dx.doi.org/10.1136/bmj.312.7023.71. Medline:8555924 3. Sackett DL, Strauss SE, Richardson WS. Evidence-based medicine: how to practice and teach EBM. London: Churchill-Livingstone; 2000.

98 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 4. Holmes D, Murray SJ, Perron A, et al. Nursing Best Practice Guide- 7. Hoffmann TC, Montori VM, Del Mar C. The connection between lines: reflecting on the obscene rise of the void. J Nurs Manag. evidence-based medicine and shared decision making. JAMA. 2008;16(4):394–403. http://dx.doi.org/10.1111/j.1365- 2014;312(13):1295–6. http://dx.doi.org/10.1001/jama.2014.10186. 2834.2008.00858.x. Medline:18405255 Medline:25268434 5. Samarkos MG. The philosophy of evidence-based medicine. Hosp DOI:10.3138/ptc.68.2.GEF Chronicles. 2006;1:27–35. 6. Solomon M. Just a paradigm: evidence-based medicine in episte- mological context. European Journal of Philosophy of Science. 2011;1(3):451–66. http://dx.doi.org/10.1007/s13194-011-0034-6.

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 ARTICLE Effects of Three Weeks of Whole-Body Vibration Training on Joint-Position Sense, Balance, and Gait in Children with Cerebral Palsy: A Randomized Controlled Study Myung-Sook Ko, MSc, PT;*† Yon Ju Sim, MSc, PT;*‡ Do Hyun Kim, MSc, PT;§ Hye-Seon Jeon, PhD, PT * ABSTRACT Purpose: To observe the effects of whole-body vibration (WBV) training in conjunction with conventional physical therapy (PT) on joint-position sense (JPS), balance, and gait in children with cerebral palsy (CP). Methods: In this randomized controlled study, 24 children with CP were randomly selected either to continue their conventional PT or to receive WBV in conjunction with their conventional PT programme. Exposure to the intervention was intermittent (3 min WBV, 3 min rest) for 20 minutes, twice weekly for 3 weeks. JPS, balance, and gait were evaluated before and after treatment. Results: Ankle JPS was improved after 3 weeks of WBV training (p ¼ 0.014). Participants in the WBV group showed greater improvements in speed (F1,21 ¼ 5.221, p ¼ 0.035) and step width (F1,21 ¼ 4.487, p ¼ 0.039) than participants in the conventional PT group. Conclusion: Three weeks of WBV training was effective in improving ankle JPS and gait variables in children with CP. Key Words: cerebral palsy; gait; postural balance; proprioception; whole-body vibration. RE´ SUME´ Objectif : Observer les effets de l’entraıˆnement par vibration de tout le corps (VTC) conjugue´ a` la physiothe´ rapie conventionnelle sur la sensation de la position de l’articulation (SPA), l’e´ quilibre et la de´ marche chez les enfants atteints de paralysie ce´ re´ brale (PC). Me´ thodes : Au cours de cette e´ tude controˆ le´ e randomise´ e, 24 enfants atteints de PC ont e´ te´ choisis au hasard pour continuer leur physiothe´ rapie (PT) conventionnelle ou recevoir un entraıˆnement par VTC conjugue´ a` leur programme de PT conventionnelle. L’exposition a` l’intervention e´ tait intermittente (3 min. VTC, 1 min. repos) pendant 20 minutes, deux fois par semaine pendant trois semaines. On a e´ value´ la SPA, l’e´ quilibre et la de´ marche avant et apre` s le traitement. Re´ sultats : La SPA au niveau de la cheville s’est ame´ liore´ e apre` s trois semaines d’entraıˆnement par VTC (p ¼ 0,014). Les participants du groupe VTC ont montre´ des ame´ liorations plus importantes aux niveaux de la vitesse (F ¼ 5,221, p ¼ 0,03) et de la longueur du pas (F ¼ 4,487, p ¼ 0,039) comparativement aux participants du groupe suivant une physiothe´ rapie conventionnelle. Conclusion : Trois semaines d’entraıˆnement par VTC ont re´ ussi a` ame´ liorer la SPA au niveau de l’articulation de la cheville et les variables de la de´ marche chez les enfants atteints de PC. Cerebral palsy (CP) is a sensory-motor disorder asso- ception in children who have decreased ability to self- ciated with pathology of the normal postural reflex correct posture. mechanism and the sensory input system.1 Propriocep- tion, the receipt of information about changes in joint Whole-body vibration (WBV) was recently introduced position, is closely associated with control of gait and as a novel way to improve proprioceptive sense, bone posture;2 according to Wingert and colleagues,3 children density, balance, and motor skills.4 Vibration may directly who have CP with gait disturbance show a reduced pro- stimulate muscle spindles and Golgi tendon organs.5 prioceptive sense compared with typically developing Increases in proprioceptive sense have been observed in children. There may be important differences between healthy young adults after WBV exercise.6 According to a therapeutic approaches aimed at enhancing proprio- systematic review by del Pozo-Cruz and colleagues,7 the immediate effects of WBV include observed increases in From the: *Department of Physical Therapy, The Graduate School, Yonsei University; ‡Department of Rehabilitation Medicine, Wonju Medical Center, Wonju; †Department of Occupational Therapy, College of Health and Welfare, Woosong University, Daejeon; §HIP&MAL Laboratory, Department of Rehabilitation Science, Inje University, Gimhae, Republic of Korea. Correspondence to: Hye-Seon Jeon, Department of Physical Therapy, Yonsei University, 1 Yonseidae-gil, Wonju City, Gangwon-do 220–710, Republic of Korea; [email protected]. Contributors: All authors designed the study; collected, analyzed, and interpreted the data; drafted or critically revised the article; and approved the final draft. Competing interests: None declared. This work was supported by a National Research Foundation of Korea grant (NRF-2013S1A5B8A01055336), funded by the Korean government. Physiotherapy Canada 2016; 68(2);99–105; doi:10.3138/ptc.2014-77 99

100 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Table 1 Participant Characteristics Mean (SD)* Characteristic WBV group Control group p-value (n ¼ 12) (n ¼ 12) Basic demographics 0.53 Age, y 9.37 (2.69) 9.52 (2.16) 0.23 Sex, M:F 5:7 5:7 0.53 Height, cm 122.31 (18.73) 133.95 (15.22) Weight, kg 27.99 (9.90) 30.50 (11.14) 0.04† Mobility status 5/2/5 8/4/0 GMFCS stage, no. at I/II/III 85.77 (9.59) 92.82 (5.33) GMFM–88 score 8 6 CP type 4 (2:2) 6 (3:3) Diplegia, no. Hemiplegia, no. (R:L) *Except where otherwise indicated. † p < 0.05. WBV ¼ whole-body vibration; GMFCS ¼ Gross Motor Functional Classification System; GMFM–88 ¼ Gross Motor Function Measure; CP ¼ cerebral palsy. oxygen consumption, muscle temperature, blood flow, device, based on Gross Motor Function Classification and muscle power. Although del Pozo-Cruz and collea- System (GMFCS) criteria for Levels I–III.13 gues also suggested that muscle strength, balance, and osseous tissue content could be improved after extended Potential participants were excluded if they had re- WBV therapy,7 another group of studies reported no ceived botulinum toxin injection within the previous 6 long-term benefits in balance, mobility, or bone density months, had undergone selective dorsal rhizotomy or associated with WBV therapies.8,9 Similarly, Gerodimos orthopaedic surgery within the previous 12 months, had and colleagues10 found that strength, power, and balance moderate to severe intellectual disability, or had expe- remained unchanged, and de Ruiter and colleagues11 ob- rienced a seizure episode within the past 12 months. served a decrease in these measures after a single session Participants were randomly assigned to either the WBV of WBV. training group (n ¼ 14) or the control group (n ¼ 12). Both groups received traditional physical therapy (PT) For a person with CP, proprioception is more pro- twice per week. Originally, the WBV training group had foundly impaired in the more pathologically affected 14 participants, but 2 dropped out, 1 because of nausea limb. Current studies9,12 of people with CP have sug- and the other because of schedule conflicts with another gested that long-term WBV training (8–24 wk) is an therapy. Table 1 summarizes participants’ general char- effective therapy, but long-term intervention is not real- acteristics, most of which were not significantly different istic for children attending school. The aim of our study, between groups; the exception was pre-intervention Gross therefore, was to investigate the therapeutic efficacy of Motor Function Measure score, an indicator of mobility 3-week WBV training for children with CP in terms of status, which was significantly higher in the control group proprioception, balance, and gait parameters. than in the WBV group. METHODS Therapeutic protocol Approval for the study was obtained from the Ethical Participants Before recruiting participants for this study, we per- Review Board of the Ministry of Health and Welfare, Republic of Korea. Both groups participated in a training formed a power analysis using G*Power version 3.1.5 programme twice per week for 3 weeks and received a (Heinrich-Heine-Universita¨t, Du¨sseldorf, Germany), based 30-minute conventional PT session that included passive on the results of a pilot study involving five participants stretching of the lower limb muscles followed by techni- and assuming an effect size of 0.54, a probability of 0.05, ques to reduce spasticity and facilitate normal patterns and 80% power. Because the estimated target sample of movement while also working on motor functions. size was 23, we recruited 24 participants for this experi- Participants in the WBV group also received 9 minutes ment. Inclusion criteria were diagnosis of CP by a paedi- of WBV per session. The Galileo System vibration unit atric neurologist; between 7 and 13 years old; ability to (Novotec Medical, Pforzheim, Germany) was used for understand and follow researchers’ instructions; and WBV training. Participants stood on the device with ability to walk independently or with an assistive mobility bare feet, with knees slightly flexed about 30 from full

Ko et al. Three Weeks of Whole-Body Vibration Training on Joint-Position Sense, Balance, and Gait in Children with CP 101 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 extension, and the vibrator generated side-to-side alter- reliability has been confirmed,16 allowing the system to nating vertical sinusoidal vibrations, with vibration fre- be widely used for both assessment and rehabilitation in quency set to 20–24 Hz and amplitude set to 1–2 mm. different groups in previous studies.17 Interactive postur- Participants were instructed to avoid holding onto the ography was assessed by vertical pressure fluctuations support rail if possible, although they were allowed to produced while standing upright on four independent do so if necessary. They were asked to focus on standing pressure-sensitive platforms. Participants were asked to with equal weight on both legs. look at a fixed target placed 1 m in front of them. The peak-to-peak displacement to which the feet are The Tetrax device also measures a parameter called exposed during WBV increases with the distance of the general stability. The concept of postural stabilization is feet from the centre line of the vibrating board. Two characterized by body oscillations, reflected by centre- positions are indicated on the Galileo System’s vibrating of-mass horizontal acceleration, which changes con- board, marked 1 and 2, corresponding to peak-to-peak tinuously. Posture is not a stationary phenomenon; it displacements of 1 mm and 2 mm. Training intensity can alternate phases on the basis of changing postural was increased throughout the 3-week training period by performance indexes. These indexes are correctly, objec- increasing the vibration amplitude (1 mm for training tively, and efficiently measureable by means of com- sessions 1–4, 2 mm for sessions 5 and 6). The goal was puterized posturography. The stability index (SI), an in- to increase vibration frequency to 24 Hz and peak-to- dicator of overall steadiness, measures the participant’s peak displacement to 2 mm (as determined for the ability to control postural balance and is independent of middle toe of each foot); these target settings correspond the participant’s weight and height. A low SI value indi- to a peak acceleration of approximately 3.8 g. Each WBV cates high stability. training session consisted of 3 minutes of vibration stim- ulation and 3 minutes of rest (during which participants Gait analysis were asked to stand upright), performed twice, followed Our gait analysis used the two-dimensional OptoGait by a final 3 minutes of vibration. In total, each partici- pant underwent 9 minutes of vibration.14 System (Bolzano, Italy), a rectangular opto-electrical mea- surement system consisting of transmitting and receiving Outcome measures bars that create a two-dimensional measurement area. Variables for motor function observation included Each bar is 1 m long and contains 100 LEDs that trans- mit continuously to one other so that any break in the proprioceptive sense (knee and ankle), balance (balance connection can be measured and timed. Walking pattern distribution between the two feet), and several gait vari- was monitored at 1000 Hz to allow us to collect both ables. Participants were evaluated before treatment and spatial and temporal gait data. The OptoGait System has three weeks after treatment. demonstrated high discriminant and concurrent validity with a validated electronic walkway (GAITRite, Sparta, Joint-position sense NJ), in both orthopaedic patients and healthy controls.18 We evaluated joint-position sense (JPS) of the knee Participants wore their own footwear while walking at a self-selected speed along an instrumented 10 m walk- and ankle by estimating the position–reposition error of way, beginning and ending each walk a minimum of 2 the dominant leg. Joint angle was measured using Tilt- m beyond the walkway to allow sufficient distance for meter, an iPhone application with an interrater reliability acceleration and deceleration. Each participant performed of 0.96 and concurrent validity of 0.83.15 The therapist three trials; we analyzed three-trial averages for gait speed, manually moved the participant’s knee flexion angle step length, and step width. from 90 to 100 or from 90 to 80, where it was main- tained for 5 seconds, and then brought the knee pas- Statistical analysis sively back to 90; the participant was then asked to We used the Kolmogorov–Smirnov test to test for reposition the knee at the previously positioned angle as accurately as possible, and the therapist measured the normal distribution among all measured variables, and difference between the two repositionings.6 Position– independent-samples t-tests to compare baseline values reposition error of the ankle was assessed in a similar for each dependent variable between the control and way, with ankle movement starting at a neutral position WBV groups (JPS ankle, p ¼ 0.014; speed, p ¼ 0.005; step and then repositioned to either 10 plantar flexion or 10 length, p ¼ 0.021; step width, p ¼ 0.002; but not JPS knee dorsiflexion. or SI). Postural balance test To compare the effect of training on JPS, balance, and We used the Tetrax Interactive Balance System (Tetrax gait parameters (gait speed, step length, and step width), we used a separate 2 Â 2 mixed-model analysis of co- System, Jerusalem, Israel) to assess changes in vertical variance with repeated measures, using pre-intervention pressure under the feet while the participant remained values of each dependent variable as covariates. Paired standing, using two different conditions: solid surface, t-tests were used to compare pre- and post-treatment eyes open, and solid surface, eyes closed. The system’s

102 Physiotherapy Canada, Volume 68, Number 2 Table 2 Comparison of JPS (Degree) Covariance (ANCOVA) https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Mean (SD) Between groups group  time p-value Pre Post for paired Variable F p-value F p-value t-test JPS knee 3.877 0.06 1.160 0.305 WBV 0.30 Control 4.05 (3.78) 2.77 (2.97) 1.604 0.22 0.001 0.97 0.30 6.30 (2.81) 5.66 (2.69) 0.014* JPS ankle 0.84 WBV 10.94 (8.34) 5.08 (3.81) Control 4.48 (1.82) 4.43 (1.67) p-value for paired *Significant at p < 0.025. ANCOVA ¼ analysis of covariance; JPS ¼ joint position sense; WBV ¼ whole-body vibration. t-test Table 3 Balance Test Comparisons (Hertz) 0.50 0.68 Covariance (ANCOVA) 0.77 0.67 Mean (SD) Between groups group  time Pre Post SI F p-value F p-value Eyes open 0.073 0.79 0.527 0.48 WBV Control 74.05 (28.61) 70.20 (29.52) 0.086 0.77 0.073 0.79 56.46 (24.21) 54.81 (26.66) Eyes closed WBV 87.05 (24.15) 85.36 (32.00) Control 63.10 (27.74) 61.48 (25.21) ANCOVA ¼ analysis of covariance; SI ¼ stability index; WBV ¼ whole-body vibration. outcome measures for each group. All statistical analyses was observed for speed (F1,21 ¼ 5.221, p ¼ 0.035) and were conducted using IBM SPSS Statistics version 15 step width (F1,21 ¼ 4.487, p ¼ 0.039; see Table 4), which (IBM Corp., Armonk, NY), with the threshold for statis- indicates that the improvement in these two gait varia- tical significance set at p < 0.05. However, because of bles was greater for the WBV group than for the control concerns with multiple comparisons, the a value for the group. We found no statistically significant differences t-tests was adjusted to p < 0.025 (0.05/2 comparisons). between pre- and post-intervention measures of any gait parameter in the control group, but gait speed (p ¼ 0.005), RESULTS step length (p ¼ 0.021), and step width (p ¼ 0.002) im- proved significantly post-intervention in the WBV group Joint-position sense (position–reposition error) (see Table 4). We found no significant group  time interactions in DISCUSSION JPS of either the knee or the ankle. There was a trend Despite a growing body of literature supporting WBV toward a decrease in reposition error of the knee and ankle in both groups; however, only ankle JPS im- for the rehabilitation of patients with various condi- proved significantly after intervention for the WBV group tions,6,7,19–21 its use in CP has received little attention. (p ¼ 0.014; see Table 2). The between-groups difference Our study was designed to evaluate the effectiveness of in magnitude of improvement in JPS did not reach statis- WBV training, applied in conjunction with conventional tical significance (p > 0.05; see Table 2). PT for 3 weeks, in producing changes in proprioception, postural balance, and gait parameters in children with Balance test CP. The results indicate that WBV treatment in addition Static postural balance had a tendency to increase to PT produced superior outcomes in gait speed and step width relative to conventional PT; proprioception of the more after the WBV interventions, but the changes were ankle joint and step length improved significantly only not statistically significant either the WBV or the control in the WBV group. group (p > 0.05; see Table 3). Before intervention, the mean ankle joint–position Gait parameters errors of the participants with CP were 10.94 (SD 8.34) We found no significant group  time interactions for any gait parameters. A significant main effect by group

Ko et al. Three Weeks of Whole-Body Vibration Training on Joint-Position Sense, Balance, and Gait in Children with CP 103 Table 4 Gait Variable Comparison Covariance (ANCOVA) https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Mean (SD) Between groups group  time p-value Pre Post for paired Variable F1,21 p-value F1,21 p-value t-test Gait speed, cm/s 5.221 0.035* 0.931 0.35 WBV 0.005† Control 0.44 (0.26) 0.54 (0.29) 0.032 0.87 0.169 0.69 0.11 0.70 (0.27) 0.77 (0.21) Step length (cm) 4.487 0.039* 0.008 0.92 0.021† WBV 32.77 (8.00) 40.89 (11.05) 0.32 Control 38.56 (11.83) 42.08 (15.99) 0.002† Step width, cm 15.83 (5.89) 11.27 (5.42) 0.17 WBV 11.78 (7.17) 18.93 (13.03) Control *Significant between-groups interaction (ANCOVA, p < 0.05). † Significant (paired t-test, p < 0.025). ANCOVA ¼ analysis of covariance; WBV ¼ whole-body vibration. for the WBV group and 4.48 (SD 1.82) for the control of thought, long-term proprioceptive impairments may group. Compared with the joint-position error of indi- lead people with CP to develop compensatory gait changes, viduals without disability reported in a previous study and improved ankle proprioception induced by WBV could (0 –3),6 the participants with CP demonstrated decreased contribute to better acquisition or adaptation of skilled proprioceptive function, concurring with the results of movement.26 previous studies that reported a deficiency in proprio- ception and errors in body positional sense in people In our study, participants in both groups showed with CP.3,19 The proprioception deficits observed in CP slight and statistically non-significant improvements in most likely result from primary central nervous system balance, as measured by the SI with eyes open and eyes lesions, which affect all known proprioceptive inputs to closed; improvement on the SI was not significantly dif- the cortex arising from muscle spindles, Golgi tendon ferent between the two groups. In contrast, Mikhael and organs, and sensory afferent innervation of the joints colleagues27 reported increases in lower extremity muscle and skin.3 Furthermore, because spastic muscle fibres strength and postural balance when WBV stimulation was are stiffer and sarcomeres are shorter in people with CP used for geriatric patients, and Olama and Thabit’s14 than in people with normal muscles, muscle changes comparative study with people with hemiplegic CP found caused by spasticity may impair JPS by shortening and that balance improved in both the WBV training group stiffening muscle tissue, affecting the relationship be- and the body weight–supported treadmill training group tween muscles and joints as well as disrupting muscle after 6 weeks of intervention. These inconsistent findings spindle sensitivity.22 In general, proprioceptive sense may be partly due to differences in study populations and (JPS) is used to perceive the movement of the joints and procedures, including frequency of vibration and duration plays an important role in gait and postural control.23 of treatment. In particular, ankle JPS is known to contribute signifi- However, participants in the WBV group significantly cantly to gait velocity and step width, although the rela- improved their gait speed and step width after a 3-week tionship is indirect, and people with decreased proprio- training period, whereas those in the control group ception tend to walk more slowly.2 Ankle JPS should be showed no significant improvement. Other studies with taken into account in clinical decision making about the training periods lasting 8 weeks,12 24 weeks,9 and 12 necessity of changing gait patterns in children with CP. months20 have found improvements in 10 m gait speed Clinically, patients who report not knowing where their for WBV groups relative to controls. In another study foot is tend to walk more slowly and take smaller steps. with a 6-month trial period, children with cerebral palsy Changes in gait patterns, including slower speed and who had received vibration therapy increased their walk- smaller step length, have been observed in healthy peo- ing speed in the 10 m walk.21 ple with experimentally induced proprioceptive changes around the ankle joint.24 Changes in locomotor strat- Although we combined WBV therapy with traditional egies, including slower walking speed, can be chosen by PT intervention for a relatively short period (3 weeks), patients with neuropathy to compensate for sensory we did observe some positive outcomes in propriocep- loss and maintain walking stability.25 Following this line tion and gait in children with CP. Therefore, we suggest WBV as a possible treatment option in physical therapy for CP. However, the small sample size and lack of

104 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 randomization are potential limitations of this study. 7. del Pozo-Cruz B, Adsuar JC, Parraca JA, et al. Using whole-body Many of the statistically non-significant parameters in vibration training in patients affected with common neurological this study did not reach sufficient statistical power. Fur- diseases: a systematic literature review. J Altern Complement Med. thermore, we only included children with diplegic and 2012;18(1):29–41. http://dx.doi.org/10.1089/acm.2010.0691. hemiplegic CP with level I, II, or III gross motor function Medline:22233167 on the GMFCS; therefore, any generalization of these results beyond these CP subtypes and gross motor func- 8. Broekmans T, Roelants M, Alders G, et al. Exploring the effects of a tion levels should be undertaken with caution. Further 20-week whole-body vibration training programme on leg muscle investigation is needed to determine the most effective performance and function in persons with multiple sclerosis. J type and frequency of vibration for achieving improve- Rehabil Med. 2010;42(9):866–72. http://dx.doi.org/10.2340/ ment in gait, postural balance, and proprioception. 16501977-0609. Medline:20878048 CONCLUSION 9. Ruck J, Chabot G, Rauch F. Vibration treatment in cerebral palsy: Three weeks of WBV training was shown to be effec- a randomized controlled pilot study. J Musculoskelet Neuronal Interact. 2010;10(1):77–83. Medline:20190383 tive in improving ankle JPS and several gait variables in CP children. Further long-term follow-up studies are 10. Gerodimos V, Zafeiridis A, Karatrantou K, et al. The acute effects needed to provide therapeutic evidence that WBV im- of different whole-body vibration amplitudes and frequencies on proves JPS and balance in young CP patients. This study flexibility and vertical jumping performance. J Sci Med Sport. suggests that WBV is a safe and minimally time-consuming 2010;13(4):438–43. http://dx.doi.org/10.1016/j.jsams.2009.09.001. therapy option for children with CP. Medline:19853506 KEY MESSAGES 11. de Ruiter CJ, van der Linden RM, van der Zijden MJ, et al. Short-term effects of whole-body vibration on maximal voluntary isometric What is already known on this topic knee extensor force and rate of force rise. Eur J Appl Physiol. Whole-body vibration (WBV) can be applied easily and 2003;88(4):472–5. http://dx.doi.org/10.1007/s00421-002-0723-0. Medline:12527980 safely to achieve therapeutic or physical performance goals for people with various conditions, including cere- 12. Lee BK, Chon SC. Effect of whole body vibration training on mobility bral palsy (CP). in children with cerebral palsy: a randomized controlled experi- menter-blinded study. Clin Rehabil. 2013;27(7):599–607. http:// What this study adds dx.doi.org/10.1177/0269215512470673. Medline:23411791 We studied the changes in strength, balance, and gait 13. Rosenbaum PL, Palisano RJ, Bartlett DJ, et al. Development of the after long-term application of WBV with pediatric patients Gross Motor Function Classification System for cerebral palsy. Dev with CP. The investigation demonstrated that WBV train- Med Child Neurol. 2008;50(4):249–53. http://dx.doi.org/10.1111/ ing had a positive impact on improving ankle joint–posi- j.1469-8749.2008.02045.x tion sense and several other gait variables. This study suggests that WBV is a safe and minimally time-consuming 14. Olama KA, Thabit NS. Effect of vibration versus suspension therapy therapy option for children with CP. on balance in children with hemiparetic cerebral palsy. Egypt J Med Hum Genet. 2012;13(2):219–26. http://dx.doi.org/10.1016/ REFERENCES j.ejmhg.2011.11.001. 1. Bly L. A historical and current view of the basis of NDT. Pediatr Phys 15. Williams CM, Caserta AJ, Haines TP. The TiltMeter app is a novel Ther. 1991;3(3):131–5. http://dx.doi.org/10.1097/00001577- and accurate measurement tool for the weight bearing lunge test. J 199100330-00005. Sci Med Sport. 2013;16(5):392–5. http://dx.doi.org/10.1016/ j.jsams.2013.02.001. Medline:23491138 2. Damiano DL, Wingert JR, Stanley CJ, et al. Contribution of hip joint proprioception to static and dynamic balance in cerebral palsy: a 16. LaPorte JA, Broeder CE. Test-retest reliability of the Tetrax balance case control study. J Neuroeng Rehabil. 2013;10(1):57. http:// system in frail seniors. 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Ko et al. Three Weeks of Whole-Body Vibration Training on Joint-Position Sense, Balance, and Gait in Children with CP 105 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 24. Courtine G, Pozzo T, Lucas B, et al. Continuous, bilateral Achilles’ 26. Kawato M, Wolpert D. Internal models for motor control. Novartis tendon vibration is not detrimental to human walk. Brain Res Bull. Found Symp. 1998;218:291–304, discussion 304–7. Medline:9949827 2001;55(1):107–15. http://dx.doi.org/10.1016/S0361-9230(01)00504- 4. Medline:11427345 27. Mikhael M, Orr R, Amsen F, et al. Effect of standing posture during whole body vibration training on muscle morphology and function 25. Dingwell JB, Cavanagh PR. Increased variability of continuous over- in older adults: a randomised controlled trial. BMC Geriatr. ground walking in neuropathic patients is only indirectly related to 2010;10(1):74. http://dx.doi.org/10.1186/1471-2318-10-74. sensory loss. Gait Posture. 2001;14(1):1–10. http://dx.doi.org/ Medline:20946685 10.1016/S0966-6362(01)00101-1. Medline:11378419

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 ARTICLE Perceptions of Leadership: Comparing Canadian and Irish Physiotherapists’ Views Emer McGowan, BSc;* Gillian Martin, PhD;† Emma Stokes, PhD* ABSTRACT Purpose: To contribute to the growing body of research on leadership in physiotherapy by comparing leadership-related perceptions of physiotherapists in Ireland and in Canada. Methods: This article compares the results of a survey of Canadian physiotherapists with those of the same survey administered to Irish physiotherapists. The results of both studies have previously been reported and are used here to allow a cultural comparison of the perceptions of physiotherapists. The present study used two-portion Z-tests to compare the percentage of physiotherapists in Ireland who self-declared as a leader with the percentage of physiotherapists in Canada who did so. Results: Physiotherapists in both Ireland and Canada most often rated communication and professionalism as extremely important characteristics. Physiotherapists in Canada were more likely than those in Ireland to perceive themselves as leaders (Z ¼ 2.67, p < 0.05; 95% CI: 1.33, 9.87). Factors associated with self-declaration as a leader differed between the two countries. Conclusion: Physiotherapists in Canada and Ireland showed both similarities and differences in their perceptions of leadership characteristics. Results from this study may aid the development of future leadership training programmes specifically targeted at physiotherapists. Key Words: cross-cultural comparison; leadership. RE´ SUME´ Objectif : Contribuer a` la masse croissante de donne´ es de recherche sur le leadership en physiothe´ rapie en comparant les perceptions lie´ es au leadership chez les physiothe´ rapeutes en Irlande et au Canada. Me´ thodes : Cet article compare les re´ sultats d’un sondage des physiothe´ rapeutes du Canada a` ceux du meˆ me sondage administre´ a` des physiothe´ rapeutes en Irlande. Les re´ sultats des deux e´ tudes ont de´ ja` fait l’objet de rapports et servent a` e´ tablir une comparaison culturelle des perceptions relatives aux physiothe´ rapeutes. Au cours de la pre´ sente e´ tude, on a utilise´ des tests-Z bilate´ raux pour comparer le pourcentage des physiothe´ rapeutes en Irlande qui se sont autode´ clare´ s chefs de file a` celui des physiothe´ rapeute au Canada qui ont fait de meˆ me. Re´ sultats : Les physiothe´ rapeutes tant en Irlande qu’au Canada ont cote´ le plus souvent la communication et le professionnalisme comme caracte´ ristiques « extreˆ mement importantes ». Les physiothe´ rapeutes du Canada e´ taient plus susceptibles que ceux de l’Irlande de se percevoir comme des chefs de file (Z ¼ 2,67, p < 0.05; IC a` 95%, 1,33 a` 9,87). Les facteurs associe´ s a` l’autode´ claration comme chefs de file diffe´ raient entre les deux pays. Conclusion : Les physiothe´ rapeutes au Canada et en Irlande ont montre´ a` la fois des similitudes et des diffe´ rences au niveau de leur perception des caracte´ ristiques du leadership. Les re´ sultats de cette e´ tude peuvent aider a` e´ laborer de futurs programmes de formation en leadership destine´ s spe´ cialement aux physiothe´ rapeutes. Leadership is required of all health care providers to the Canadian Physiotherapy Association (CPA) Descrip- make the effective and lasting changes needed to in- tion of Physiotherapy in Canada 2012,4 and the 2014 crease quality of care and lower costs in health care.1 In Strategic Plan of the American Physical Therapy Associa- physiotherapy, leaders are needed to raise the profile of tion.5 Nonetheless, there is a lack of published infor- the profession and address the changes necessary for a mation on leadership and leadership development pro- sustainable future in the evolving health service environ- grammes in physiotherapy.6 ment.2 Although some aspects of leadership are universally The need for leadership in physiotherapy has been endorsed, it is important to remember that people in articulated in several policy statements around the world, different cultures have different criteria for defining including the Description of Physical Therapy policy state- effective leaders.7 Leadership theories and practices can ment of the World Confederation for Physical Therapy,3 be difficult to transfer across cultures: What works in From the: *Department of Physiotherapy and †Department of Germanic Studies, Trinity College Dublin, Ireland. Correspondence to: Dr. Emma Stokes, Department of Physiotherapy, School of Medicine, Trinity Centre for Health Sciences, St James’s Hospital, Dublin 8, Ireland; [email protected]. Contributors: All authors designed the study; collected, analyzed, and interpreted the data; drafted or critically revised the article; and approved the final draft. Competing interests: None declared. Acknowledgements: The authors thank Laura Desveaux for granting permission to use the survey instrument. Physiotherapy Canada 2016; 68(2);106–113; doi:10.3138/ptc.2014-95 106

McGowan et al. Perceptions of Leadership: Comparing Canadian and Irish Physiotherapists’ Views 107 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 one culture may not work in another.8 For this reason, Our primary objective was to compare Irish and leadership perceptions and practices across different Canadian physiotherapists’ perceptions of the skills and cultures should be investigated to identify leadership attributes that are important for effective leadership in etics (findings universal to all cultures) and emics (findings the workplace, in the health care system, and in society. unique to individual cultures) specific to physiotherapy. A secondary objective was to compare the proportion of physiotherapists in Ireland and in Canada who perceive Cross-cultural comparison of leadership in health themselves as leaders and to compare the factors asso- care is a poorly researched area. A brief review of the ciated with this self-declaration in each country. literature performed by the first author retrieved only two studies on this topic. In the first, Posner9 examined METHODS how culture affects health care leaders’ behaviour and Desveaux and colleagues11 and Desveaux and Verrier2 their effectiveness as leaders. Reproductive health leaders in Ethiopia, India, Pakistan, and the Philippines com- surveyed Canadian physiotherapists on their perceptions pleted a 360-degree leadership instrument, and each of leadership. McGowan and Stokes12 used the same also asked eight of their constituents to complete an ob- questionnaire in a subsequent study of Irish physio- server’s version of the survey. Posner9 found that leader- therapists. Below we compare and discuss the previously ship practices varied between countries but that their reported results of these surveys. impact within countries was the same. In the second, Zittel and colleagues10 reported on the insights gained Methodology of the original surveys by an international group of nurse leaders who attended To permit comparison of the results, the Irish study the Global Nursing Leadership Institute in 2010, which provided an opportunity for senior- and executive-level followed the same distribution and analysis methodology nursing leaders from around the world to acquire new used in the Canadian study, as described in the original knowledge and skills about national and global leader- articles.11,12 Briefly, an online survey was distributed by ship. Nursing leaders representing Australia, Bhutan, email via a gatekeeper to members of the national physio- Lebanon, Lesotho, Thailand, and the United States dis- therapy professional organizations in Canada and Ireland. cussed ways in which health care challenges and nursing converged and diverged in their respective countries.10 At Survey instrument present, there are no cross-cultural comparative studies of The questionnaire was developed by Desveaux and leadership in physiotherapy. colleagues11 using information obtained through a litera- To date, only three publications (two from Canada ture review of leadership characteristics described in and one from Ireland) have reported on physiothera- business and health care settings. The first section eli- pists’ perceptions of leadership.2,11,12 The purpose of cited respondents’ personal and workplace demographics. Desveaux and colleagues’11 study was to explore the The second section listed 15 key attributes consistently concept of leadership from the perspective of physio- identified as important to leadership in business and therapists in Canada; Desveaux and Verrier2 aimed to health care settings and asked participants to rate how compare Canadian physiotherapists’ perspectives on the important they perceived each characteristic to be to leadership characteristics required in the workplace and successful leadership across three different settings—the those required in society. McGowan and Stokes12 incor- workplace, the health care system, and society—on a 5- porated both of these aims, investigating leadership point Likert-type scale. Society, for the purposes of the from the perspective of Irish physiotherapists and com- survey, was defined as ‘‘the global environment in which paring the importance they place on leadership charac- the community functions,’’ encompassing the public’s teristics in the workplace and in society. views and perceptions of the physiotherapy profession and what it can offer the wider community. To reduce In the study reported here, we undertook a cross- the risk of differences in interpretation, working defini- cultural comparison using previously presented results tions of the terms used in the questionnaire were pro- from the Canadian and Irish studies. Our study repre- vided and remained visible to respondents throughout sents the first step toward taking an international view the survey. The final question asked participants, ‘‘Do of leadership in physiotherapy; cross-cultural comparisons you perceive yourself to be a leader?’’ help to facilitate international collaboration, education, professional development, and mobility for physiotherapy Survey modifications professionals and students. The present study is part of a McGowan and Stokes12 adapted the original question- larger research project investigating similarities and dif- ferences in perceptions of leadership in physiotherapy naire to make it applicable to participants in the Irish across a range of different cultures. Data from this and study, including rewording the question on work envi- subsequent studies will inform the development of a ronment to make it compatible with the structure and definition of leadership appropriate to physiotherapy inter- types of workplace in the Irish health care system. As nationally. in Canada, physiotherapists in Ireland are autonomous health care practitioners who work in a range of set- tings.13 (The types of workplaces named in the Canadian

108 Physiotherapy Canada, Volume 68, Number 2 Table 1 Demographic Characteristics of Canadian and Irish Respondents settings,11,12 and percentages were sorted in descending order from most to least likely to be rated as extremely No. (%) of respondents important. https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Demographic characteristic Canada Ireland Chi-square analyses were performed to investigate whether an association existed between working in pri- No. of responses/no. sent survey 1,875/6,156 615/2,787 vate practice and rating business acumen as important; (n ¼ no. of fully completed surveys) (n ¼ 1,511) (n ¼ 525) the threshold for statistical significance was set at Gender p < 0.05, with the assumption that no association exists. 241 (15.9) 93 (17.7) In both studies, the authors obtained frequency distribu- Male 1,270 (84.1) 432 (82.3) tions and percentages for the leadership variable and Female performed w2 analyses comparing leadership declaration Leader 1,203 (79.6) 387 (74)* status to demographic variables (gender, supervisory Self-identified as a leader 308 (20.4) 136 (26)* status, highest degree attained, and workplace). Did not self-identify as a leader Supervisory status 833 (55.1) 247 (47.3)† The Irish study and the more recent of the two Cana- Supervises students 678 (44.9) 275 (52.7)† dian studies compared the importance ratings of leader- Does not supervise students ship characteristics by setting,2,12 using Mann–Whitney Practice setting 586 (38.8) 194 (37.0)‡ U tests to compare the ratings of characteristics between Private practice 343 (22.7) 0 (0)‡ the workplace and society. General hospital Public hospital 0 (0) 165 (31.4)‡ Statistical analyses in this study Private hospital 0 (0) 38 (7.3)‡ In our study, to compare the percentage of physio- Rehab hospital 133 (8.8) 0 (0)‡ Community 98 (6.5) 85 (16.2)‡ therapists in Ireland who self-declared as leaders with Long-term care 89 (5.9) 0 (0)‡ the percentage of physiotherapists in Canada who did Education 90 (6.0) 39 (7.4)‡ so, we performed two-portion Z-tests using the Statisti- Other 172 (11.4) 89 (17.0)‡ cal Package for the Social Sciences (SPSS), version 21 Level of education (IBM Corp., Armonk, NY), and calculated 95% CIs for Certificate 57 (3.8) 0 (0)§ the difference between the two proportions. Diploma 0 (0) 49 (9.5)§ Bachelor’s degree 861 (57.0) 277 (53.7)§ RESULTS Master’s degree 412 (27.3) 175 (33.9)§ The Canadian study’s response rate was 30% (n ¼ 1,875); Doctoral degree 64 (4.2) 11 (2.1)§ Other degree 117 (7.7) 0 (0)§ that of the Irish study was 22% (n ¼ 615).11,12 Table 1 shows Doctor of Physical Therapy 0 (0) 4 (0.8)§ the demographic characteristics of respondents from each country. * n ¼ 523. † n ¼ 522. Leadership characteristics ‡ In the Irish survey, some participants indicated that they worked in more than Table 2 shows the proportions of physiotherapists one setting type; therefore, the total exceeds n of 524. § n ¼ 516. who rated each characteristic as extremely important. In the Canadian study, communication, professionalism, and Irish surveys are listed in Table 1.) The leadership and credibility were the three characteristics most often characteristic contingent reward was changed to adapt- rated as extremely important in all three settings.11 For ability, based on feedback from physiotherapists in Ire- physiotherapists in Ireland; communication and profes- land who had completed the survey as part of a pilot sionalism were the top two characteristics in all three study to test its clarity and readability. The definition of settings,12 but the third most highly rated characteristic the term provided to respondents was the same as that varied by setting: in the workplace, ability to motivate; used in the Canadian study. in the health care system, active management; and in society, empathy.12 Statistical analysis This study compares the published results of the The characteristic least often rated as extremely im- portant varied by setting in the Canadian study: in the Canadian studies2,11 with the results reported in the Irish workplace, social dominance; in the health care system, study.12 Statistical analyses conducted in the original extraversion; and in society, the ability to delegate.11 In studies and in this study are briefly described. Ireland, however, social dominance was the characteristic least often rated as extremely important in all three Statistical analyses in the original studies settings.12 Analyses conducted in the Irish study were the same Mann–Whitney U tests demonstrated that both Irish as those conducted in the two Canadian studies.2,11 In and Canadian physiotherapists were more likely to rate each study, frequency distributions and percentages were obtained for the leadership characteristics in the three

McGowan et al. Perceptions of Leadership: Comparing Canadian and Irish Physiotherapists’ Views 109 Table 2 Proportion of Physiotherapists Who Rated Each Characteristic as Extremely Important: Canada and Ireland % of respondents https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Workplace Health care system Society Leadership characteristic Canada Ireland Canada Ireland Canada Ireland Communication 75.1 79.0 68.1 71.0 50.9 58.1 Professionalism 64.0 67.4 60.7 66.2 40.6 49.2 Credibility 58.9 64.5 54.2 52.1 37.2 34.2 Active management 48.9 61.8 44.4 56.7 24.7 34.6 Ability to motivate 48.7 66.7 32.1 53.3 24.8 39.2 Self regulation 46.2 46.8 37.1 38.6 29.6 30.8 Contingent reward/adaptability 43.3 60.7 43.7 56.4 27.5 37.1 Social skills 43.1 55.6 30.1 39.4 29.3 40.6 Empathy 39.5 57.8 26.4 44.3 24.6 44.6 Ability to delegate 36.5 58.9 30.9 50.4 13.8 28.4 Vision 34.5 43.1 50.8 53.5 33.6 30.4 Self-awareness 25.2 33.1 18.3 28.3 17.9 24.9 Extraversion 22.3 39.7 16.5 33.0 15.9 25.9 Business acumen 22.0 34.7 37.7 43.7 16.0 21.2 Social dominance 20.2 27.0 20.8 27.0 16.4 18.4 leadership characteristics as extremely important in the consideration when comparing the perceptions of health workplace than in society,2,12 and this difference was sta- care professionals in different countries. tistically significant for all 15 leadership characteristics (p < 0.001 in the Canadian study; p < 0.01 in the Irish The Global Leadership and Organisational Behaviour study).2,12 Physiotherapists working in private practice Effectiveness (GLOBE) Research Program, a major proj- were more likely to rate business acumen as extremely ect investigating the interrelationships among societal important in the workplace, both in Canada (12 ¼ 12.44, culture, organizational culture, and leadership18 that in- p < 0.001) and in Ireland (22 ¼ 18.971, p < 0.001).11,12 volved close to 150 management scholars and social scien- tists from 61 cultures studying 17,300 middle managers, Declaration as a leader found that although leadership attributes and behaviours Table 1 shows the proportion of respondents from varied by culture, certain implicit leadership traits (e.g., team oriented, charismatic) had universal endorsement. each country who self-declared as leaders. In Desveaux and colleagues’11 study, 79.6% of respondents self-declared The GLOBE Research Program placed Canada and as leaders; in the Irish study, 74.0% of respondents did so.12 Ireland in the same cultural cluster, the ‘‘Anglo cluster.’’ We investigated these sample proportions and found a According to Gupta and colleagues’19 description of the small but statistically significant difference between the development of these clusters, countries in the Anglo two countries: Canadian physiotherapists were more cluster are said to have three important characteristics: likely than Irish physiotherapists to perceive themselves English is their predominant national language, they as leaders (Z ¼ 2.67, p < 0.05; 95% CI: 1.33, 9.87). were once part of the British Empire, and they have de- veloped Western economies.20 These countries share Factors associated with self-declaration as a leader similar dominant value orientations, as manifested in We observed several differences between countries in the cultural dimension scores identified by GLOBE.20 Because countries in the same cultural cluster are more the factors associated with self-declaration as a leader. In similar to each other than to countries outside the Canada, male gender, supervising students, and working cluster,21 perceptions of effective leadership in physio- in private practice or education were associated with therapy might be expected to be similar between Canada self-declaration as a leader;11 in Ireland, by contrast, and Ireland. the highest qualification a physiotherapist had attained was the only factor associated with self-declaration as a Indeed, the results from the Canadian and Irish sur- leader.12 veys that we analyzed for this study demonstrated many similarities in the leadership perceptions of physiothera- DISCUSSION pists working in Ireland and those of physiotherapists The cultural, ethical, and religious backgrounds of working in Canada. In both countries, communication and professionalism were the two characteristics most health care providers have a significant impact on health often rated as extremely important across all three care and on health care decision making.14–17 Societal settings, which suggests that physiotherapists from both cultural values are therefore an important contextual

110 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 countries perceive communication and professionalism workplace: social dominance. For the purposes of the as fundamental to effective leadership in physiotherapy. survey, to exert social dominance was to ‘‘gain respect and attention of others, appear competent and have a These findings are not surprising; the importance of strong influence over others.’’ This unequal distribution effective communication to good leadership in health of power echoes the Power Distance cultural dimension care settings has been widely reported.22–24 Physiothera- in the GLOBE project, defined as ‘‘the degree to which pists rely on effective communication (both verbal and members of an organisation or society expect and agree nonverbal) between themselves and their clients, their that power should be unequally shared.’’18(p.4) Countries colleagues, and other health and social care workers.25 in the Anglo cluster scored low on Power Distance; Similarly, a high degree of professionalism—defined by the finding that social dominance was not highly rated Wilkinson and colleagues26 as incorporating adherence is therefore consistent with the results of the GLOBE to ethical practice principles, effective interactions with project. people working within the health system, effective inter- actions with patients and their families, reliability, and A characteristic of particular interest to Desveaux and commitment to autonomous maintenance or improve- colleagues11 was business acumen. Physiotherapists in ment of competence in oneself, others, and systems— both Canada and Ireland who worked in private practice among health care providers builds trust with the patient were more likely to rate business acumen as extremely and facilitates appropriate relationships with colleagues.27 important in the workplace than those who worked in other contexts. In the health systems of both countries, Physiotherapists in Ireland rated empathy as the third physiotherapy services are on the boundary between most important leadership trait in society, which may public and private; that is, they are funded sometimes reflect Ireland’s high score on the Humane Orienta- through public funds, sometimes through private funds, tion cultural dimension in the GLOBE study.28 Humane and, in certain circumstances, through a combination of societies are said to be founded on moral and civil both.33 Because physiotherapists, and health care profes- virtues such as honesty, fairness, sincerity, and empathy; sionals more generally, often consider business acumen they recognize the equality and dignity of each person.29 to be the domain of those working in the private sector Ability to motivate was the third most important leader- rather than of those working in the public or non-profit ship trait in the workplace for physiotherapists in Ire- sectors,34 it is unsurprising that physiotherapists work- land, which may reflect that these respondents view the ing in private practice were more likely to rate business ability to inspire and encourage others as an important acumen as extremely important. A business approach is leadership role in the workplace and is consistent with also important in the public and non-profit sectors, but a transformational leadership style.30 The third most increasing pressure to improve efficiency and operate in highly rated trait for a physiotherapist to demonstrate in a cost-effective manner has created a growing demand the health care system was active management. Active for health care leaders with business acumen.35 Yet de- management was defined as ‘‘actively monitor[ing] situa- spite the potential relevance of business skills to a wide tions and mak[ing] corrective interventions before situa- range of activities within physiotherapy, such skills are tions become problematic.’’ This finding suggests that not commonly included in physiotherapy curricula and these respondents recognize the importance of being are generally addressed only in continuing professional cognisant of potential problems in the health care sys- development activities run by special interest or employ- tem and of being assertive when intervening to address ment groups.34 them. As detailed by the Chartered Society of Physio- therapists (CSP)31 in the United Kingdom, physiotherapy Respondents in both Ireland and Canada were more leaders must take a central role in the redesign, delivery, likely to rate all characteristics as extremely important and sustainability of key patient services and pathways. in the workplace than to rate them as extremely im- portant in society. Desveaux and Verrier2 hypothesized For physiotherapists in Canada, however, the third that the decrease in perceived importance of leadership most highly rated leadership characteristic across all characteristics at the societal level may indicate that three settings was credibility, defined as being ‘‘up to physiotherapists are more focused on leadership in their date on continuing education, able to give guidance or immediate work environment than in the wider society. directions to find answers or solutions.’’ Credibility in The importance of leadership may be more readily ap- the physiotherapy profession is enhanced through evi- parent in the workplace than in society, where the con- dence-based practice (EBP);32 results from the Canadian cept of leadership may seem more abstract. survey suggested that physiotherapists in Canada recog- nize that demonstrating EBP and assisting colleagues Working at the point of care with patients across the with their own professional development are essential health care system, from home to community to hospital behaviours in demonstrating leadership to both health services, physiotherapists are ideally positioned to iden- care professionals and the general public. tify areas for improvement and lead efforts to bring change and innovation.31 Their long contact time with Respondents in Ireland and Canada agreed on the patients enables them to develop trusting relationships characteristic they perceived as least important in the

McGowan et al. Perceptions of Leadership: Comparing Canadian and Irish Physiotherapists’ Views 111 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 and thus to respond effectively to patients’ needs and leadership and has recently introduced leadership skill concerns. Recognizing the opportunities for physiothera- development programmes for physiotherapists.47 The pists to use their leadership skills in the wider societal ISCP, by contrast, does not have a leadership specialist context may be less obvious, however. We need to pro- interest group and does not offer leadership devel- mote physiotherapy services through modern marketing opment opportunities to all its members. The Chartered strategies to improve public awareness and confidence Physiotherapists in Management is an employment group in physiotherapy,36 which will require leadership at the of the ISCP that does offer leadership development oppor- societal level. Several such promotional campaigns are tunities to its members. However, to be a member of this currently being run by physiotherapy professional groups group a physiotherapist must be employed in a recog- around the world; National Physiotherapy Month in nized health or education sector management role. Canada37 aims to raise awareness of the physiotherapy profession in Canada and its many benefits for patients The leadership characteristics identified as important by engaging CPA members, patients, and the public in to physiotherapists in this study may form the basis for events and activities. In Australia, the ‘‘I W my Physio’’ developing leadership programmes for physiotherapists campaign38 invites members of the public to share their in a variety of countries; for example, the results of the stories of how their lives have improved with support Canadian survey have been used to inform the develop- from a physiotherapist. The CSP Council in the United ment of CPA’s leadership development curriculum.48 Kingdom supports Physiotherapy Works,39 a 3-year pro- When determining the content of leadership develop- gram aimed at increasing demand for physiotherapy ment, we must consider what definition of leadership services by communicating how physiotherapy can help will be used; the definition of a leader advocated by CPA’s people live better and longer. In Ireland, the Irish Society Leadership Division, as documented in their Framework of Chartered Physiotherapists (ISCP) has set up Move4- for Professional Development of Leadership Core Com- Health,40 a health promotion initiative that informs the petencies document,48(p.4–5) is someone who public of physiotherapists’ role as physical activity experts and highlights the contribution that physical activity can leads successful and sustainable change, holds multiple make in the treatment and prevention of many medical lenses and perspectives, strengthens and builds relation- conditions. ships, inspires and engages others to grow, leads across complex systems, asks questions and reflects on and The finding that more than 70% of physiotherapists in senses what is needed most in a system. both studies perceived themselves as leaders is en- couraging, particularly given the contrasting findings The research phases to follow this preliminary study in research on the nursing profession. For example, will aim to shed light on whether this definition is valid Sherman41 reported growing concern among nurse leaders in an international context or whether it will need to be about nurses’ lack of desire to advance to leadership refined. At present, leadership development programmes positions, and Bulmer42 found that only 12.5% of regis- in Canada focus on emotional intelligence, appreciative tered nurses aspire to leadership roles. Self-awareness of inquiry, and transformative leadership.48 Although our leadership capabilities is an essential step that will allow results highlight many similarities in Irish and Canadian physiotherapists to pursue leadership roles in the health physiotherapists’ perceptions of leadership, further re- care system.43 search is needed to decide whether the content of this Canadian programming is also appropriate for Irish Self-declaration as a leader was associated with male participants. gender for physiotherapists in Canada, but not for those in Ireland. Traditionally, men have predominated in Limitations leadership positions across most sectors of society,44 The limitations of the original studies also affect the and the stereotype that leaders are male is still com- mon.45 There is evidence that within the medical profes- comparisons and conclusions made in this article.11,12 sion, gender biases still hamper women’s success in their These limitations include the response rates in both pursuit of leadership.46 These stereotypes and biases studies (which may have led to a non-response bias), may have had an impact on study participants’ views of the fact that only members of the professional body their own leadership potential and may thus explain why (and not professionals who were not members) were sur- female physiotherapists in Canada were less likely than veyed, and the potential for differences in interpretation their male colleagues to perceive themselves as leaders. of the terms used. To mitigate potential differences in It is not clear why the Irish study did not find the same how the leadership terms were understood, the same association. definitions were used in both studies, and these defini- tions remained visible to the respondents while they We found a statistically significant difference between completed the survey. The social desirability of being a the two countries in the percentage of respondents who leader could also have led to a response bias in which a self-declared as leaders, but this difference was relatively higher percentage of respondents reported that they per- small. This finding may reflect the existence of CPA’s ceive themselves to be a leader than actually do consider Leadership Division, which fosters discussion around themselves a leader.

112 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 An additional limitation of our study was that our KEY MESSAGES comparisons between the two countries used only the published data from the Canadian studies and not their What is already known on this topic raw data. The differences in response rate and total Perceptions of leadership are influenced by culture. number of participants are also a limitation to consider when interpreting the results of this comparison. Another Physiotherapists in Canada perceive communication, possible limitation relates to the comparison between professionalism, and credibility to be the most important our study results and those of the GLOBE project: The leadership characteristics for physiotherapists to demon- Canadian sample in the GLOBE project consisted of strate. A high proportion of physiotherapists in Canada English-speaking Canadians only, whereas the Canadian perceive themselves as leaders. sample in our study included physiotherapists from both Anglophone and Francophone regions of Canada. For What this study adds these reasons, our conclusions should be interpreted This study is the first cross-cultural comparison of with caution because they may not be generalizable to the wider physiotherapy populations in Canada and leadership perceptions among physiotherapists. Physio- Ireland. therapists in Canada and Ireland have similar percep- tions of the leadership characteristics that are important Future research for effective leadership, but Canadian physiotherapists The next phase of this research will investigate whether may be more likely to perceive themselves to be a leader than physiotherapists in Ireland. 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A blueprint to assess profession- alism: results of a systematic review. Acad Med. 2009;84(5):551–8. 45. Koenig AM, Eagly AH, Mitchell AA, et al. Are leader stereotypes http://dx.doi.org/10.1097/ACM.0b013e31819fbaa2. Med- masculine? A meta-analysis of three research paradigms. Psychol line:19704185 Bull. 2011;137(4):616–42. http://dx.doi.org/10.1037/a0023557. Medline:21639606 27. Brehm B, Breen P, Brown B, et al. An interdisciplinary approach to introducing professionalism. Am J Pharm Educ. 2006;70(4):81. 46. Jagsi R. Women’s leadership in the development of medicine. In: http://dx.doi.org/10.5688/aj700481. Medline:17136200 O’Connor K, editor. Gender and women’s leadership: a reference handbook. Vol. 2. Thousand Oaks (CA): Sage; 2010. p. 720–7. 28. Keating M, Martin G. Leadership and culture in the Republic of Ireland. In: Chhokar J, Brodbeck F, House R, editors. Culture and 47. Canadian Physiotherapy Association. Leadership Division [Internet]. leadership across the world. New York: Lawrence Erlbaum; 2008. Ottawa: The Association; 2015 [cited 2015 Jan 6]. Available from: p. 361–96. http://www.physiotherapy.ca/Divisions/Leadership 29. Gupta V, House R. Leading in high growth Asia: Managing relation- 48. Canadian Physiotherapy Leadership Division. Framework for pro- ship for teamwork and change. In: Tjosvold D, Leung K, editors. fessional development of leadership core competencies [Internet]. Understanding leadership in diverse cultures: implications of project Ottawa: The Association; 2012 [cited 2015 Jan 6]. Available from: GLOBE for leading international ventures. Singapore: World Scien- http://www.physiotherapy.ca/getmedia/62c59938-be84-4062-bcc8- tific; 2004. p. 13–54. http://dx.doi.org/10.1142/9789812562135_0002. 939145698b98/CPA-Leadership-Education-Report-FINAL.pdf.aspx 30. Bass BM, Riggio RE. Transformational leadership. 2nd ed. Mahwah (NJ): Lawrence Erlbaum; 2006.

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Clinician’s Commentary on McGowan et al.1 Leadership is a universal phenomenon;2 however, how it is ing leadership efforts and recognizing the importance of ini- practised varies around the world. Leadership in health care is tiatives, yet there continues to be a scarcity of research on widely recognized as a requirement of professionals working in leadership and development programmes in PT.8 The World evolving and complex health care systems so that they can make Confederation for Physical Therapy has recognized the need for sustainable changes and provide effective and efficient care.3 the development of leadership skills and is ideally positioned to We know that in physiotherapy (PT), leadership is necessary to address this with a strategic planning campaign called ‘‘Look respond to emerging health care trends and increase the profile Forward Together.’’9 Physiotherapists are being challenged to of the profession,1 but questions remain about how socio- understand the dynamics of health care systems in complex cultural factors influence the enactment of leadership in PT geopolitical and socio-cultural contexts, and this is an oppor- around the world. Exploring cross-cultural perceptions of leader- tune time to develop cross-cultural frameworks and establish ship is a necessary first step in facilitating global collabora- standards for global leadership initiatives. Such collaboration tion and educational initiatives that target the development of will require cultural competence and an in-depth understanding leadership skills in the profession. I commend McGowan and of leadership practices in different countries to build strategic colleagues1 for their study, which is the first to examine cultural alliances, adopt a unified vision for change, and raise the inter- comparisons of leadership in the field of PT. Gaining an interna- national profile of the PT profession, thereby ensuring that tional view of leadership has significant implications for physio- it has a global impact. We need leaders who can adapt their therapists across health care systems, both here in Canada and leadership styles in cross-cultural encounters to positively en- around the world. gage physiotherapists in different contexts and encourage them to be agents of change in client care. There is currently no consensus on the definition of leader- ship, and adding a cross-cultural component increases the For Canadians to actively participate in this global collabora- complexity of the task.4 Despite this challenge, McGowan and tion, our educational curriculum must incorporate leadership as colleagues1 defined key characteristics of leadership and, in a competency. The revised CanMEDS 2015, an internationally an important step, recognized socio-cultural influences on adopted framework that informs the Essential Competency Pro- the expression of key traits of successful leaders. Their findings file for Physiotherapists in Canada, newly identifies ‘‘leader’’ as revealed that both Irish and Canadian physiotherapists reported an essential competency, one that physiotherapists need so communication and professionalism as key attributes of leader- that they can develop a vision of high-quality health care and ship. However, factors associated with self-declaration as a institute change to advance the health care system.10 Leadership leader differed significantly. Canadian physiotherapists were training must be part of the curriculum for health care pro- more likely to self-declare as leaders, and they associated the fessionals, and PT programmes need to foster leadership skills male gender, student supervision, and working in private prac- during entry-level PT training. tice as influential; Irish physiotherapists, however, reported the highest degree attained as the sole factor. These findings rein- Continuing competence in leadership is also necessary. The force the idea that leadership manifests itself in various ways; Canadian health care system is rapidly evolving, as are trends what is effective in one context may not be so in another.5 in PT.11 New models of care and service delivery require in- Despite the fact that Ireland and Canada belong to the same creased accountability;8,11 physiotherapists at all levels must cultural cluster5 and physiotherapists receive substantially equiv- assume leadership responsibilities, which will require leadership alent training for autonomous practice,6 similarities and differ- training.11 The Canadian Physiotherapy Association has devel- ences in leadership perceptions remain. oped a programme to build leadership capacity in the profes- sion,12 and all physiotherapists need to take this training so These similarities and differences underscore the need to in- that they can become competent clinicians and leaders. This vestigate traits that are universally endorsed and fundamentally programme will also encourage physiotherapists to solidify their important to leadership and to identify those that are unique role and advance the profession while shaping PT services and to individual cultures.1 Further research must also explore the making progressive improvements in Canadian health care.13 perceptions of leadership held by physiotherapists around the Physiotherapists need to adopt roles beyond their clinical duties globe with varying training, professional scopes, and practice to effectively steward and lead change in fluctuating contexts. models in different geopolitical and socio-economic contexts.1 The impact of leadership is powerful,7 and programmes must be More and more physiotherapists are moving around the tailored to build key leadership attributes that are appropriate to world to work, so this study by McGowan and colleagues1 is a country’s PT practice.1 McGowan and colleagues1 have taken very timely. In Canada, between 600 and 800 skilled interna- the first step toward creating a definition of leadership that is tionally educated physiotherapists (IEPTs) seek to join the appropriate to PT around the world, a definition that is cul- profession every year.6 Understanding varying expressions of turally sensitive and meaningful for a variety of countries but leadership will enable bridge training programmes to design adaptable to the context. This first step forms the basis for leadership curricula that address learning needs, build on skills, an international framework that will provide coherence to PT and target the development of key attributes for effective leader- leadership research, development programmes, and outcome ship in the Canadian context. Because IEPTs have an appre- measurement. ciation for differing worldviews, they can play a pivotal role in assisting Canadian physiotherapists with global collaboration. This study has important implications for the profession on an international level. PT associations across the globe are prais- McGowan and colleagues1 bring to light the need to further explore cross-cultural perceptions of leadership, investigate various 114

Clinician’s Commentary on McGowan et al. 115 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 leadership styles, develop programmes to nurture leadership 5. House R, Javidan M, Hanges P, et al. Understanding cultures and skills, and measure the outcomes of programming. It is time for implicit leadership theories across the globe: an introduction to physiotherapists around the world to have the skills required to project GLOBE. J World Bus. 2002;37(1):3–10. http://dx.doi.org/ respond to radical health care system changes in an evolving 10.1016/S1090-9516(01)00069-4. profession and in an ever-changing landscape. Although per- ceptions of leadership in PT may not be universal, striving to 6. Canadian Alliance of Physiotherapy Regulators. Setting the course: be better has no borders. 2014 annual report [Internet]. Toronto: The Alliance; 2014 [cited 2015 Nov 17]. Available from: http://www.alliancept.org/pdfs/ Martine Quesnel, BSc, MScPT annual_report_2014.pdf. Academic Coordinator of Clinical Education and Lecturer, Ontario Internationally Educated Physical 7. Posner BZ. It’s how leaders behave that matters, not where they are from. Leadersh Organ Dev J. 2013;34(6):573–87. http://dx.doi.org/ Therapy Bridging Program, Department of 10.1108/LODJ-11-2011-0115. Physical Therapy, University of Toronto; 8. McGowan E, Stokes EK. Leadership in the profession of physical Physiotherapist, Collaborative Academic Practice, therapy. Phys Ther Rev. 2015;20(2):122–31. http://dx.doi.org/ Toronto Rehabilitation Institute 10.1179/1743288X15Y.0000000007. REFERENCES 9. World Confederation for Physical Therapy. Policy document: description of physical therapy. London: The Confederation; 2011. 1. McGowan E, Martin G, Stokes E. Perceptions of leadership: com- paring Canadian and Irish physiotherapists’ views. Physiother Can. 10. Royal College of Physicians and Surgeons of Canada. CanMEDS 2015 2016;68(2):106–13. http://dx.doi.org/10.3138/PTC.2015.95. [Internet]. The College; 2015 [cited 2015 Nov 16]. Available from: http://www.royalcollege.ca/portal/page/portal/rc/canmeds/ 2. Bass BM. Does the transactional–transformational leadership canmeds2015 paradigm transcend organizational and national boundaries? Am Psychol. 1997;52(2):130–9. http://dx.doi.org/10.1037/0003- 11. Jones J, Norman K, Saunders S. The state of the union: trends and 066X.52.2.130. drivers of change in physiotherapy in Ontario in 2014 [Internet]. Kingston (ON): Queen’s University; 2014 [cited 2015 Oct 29]. Avail- 3. Trastek VF, Hamilton NW, Niles EE. Leadership models in health able from: http://qspace.library.queensu.ca/handle/1974/12616. care – a case for servant leadership. Mayo Clin Proc. 2014;89(3):374– 81. http://dx.doi.org/10.1016/j.mayocp.2013.10.012. 12. Canadian Physiotherapy Association, Leadership Division. Frame- Medline:24486078 work for professional development of leadership core competencies [Internet]. Ottawa: The Association; 2012 [cited 2015 Oct 29]. 4. Dickson MW, Den Hartog DN, Mitchelson JK. Research on leader- Available from: http://www.physiotherapy.ca/getmedia/62c59938- ship in a cross-cultural context: Making progress, and raising new be84-4062-bcc8-939145698b98/cpa-leadership-education-report- questions. Leadersh Q. 2003;14(6):729–68. http://dx.doi.org/10.1016/ final.pdf.aspx. j.leaqua.2003.09.002. 13. Desveaux L, Nanavaty G, Ryan J, et al. Exploring the concept of leadership from the perspective of physical therapists in Canada. Physiother Can. 2012;64(4):367–75. http://dx.doi.org/10.3138/ ptc.2011-42. Medline:23997391 DOI:10.3138/ptc.2015-95-CC

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 ARTICLE SenseWearMini and Actigraph GT3X Accelerometer Classification of Observed Sedentary and Light-Intensity Physical Activities in a Laboratory Setting Lynne M. Feehan, PhD;*† Charles H. Goldsmith, PhD;*‡ April Y. F. Leung, MPT;* Linda C. Li, PhD*† ABSTRACT Purpose: To compare the ability of SenseWear Mini (SWm) and Actigraph GT3X (AG3) accelerometers to differentiate between healthy adults’ observed sedentary and light activities in a laboratory setting. Methods: The 22 participants (15 women, 7 men), ages 19 to 72 years, wore SWm and AG3 monitors and performed five sedentary and four light activities for 5 minutes each while observed in a laboratory setting. Performance was examined through comparisons of accuracy, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. Correct identification of both types of activities was examined using area under the receiver operating characteristic curve (AUC). Results: Both monitors demonstrated excellent ability to identify sedentary activities (sensitivity > 0.89). The SWm monitor was better at identifying light activities (specificity 0.61–0.71) than the AG3 monitor (specificity 0.27–0.47) and thus also showed a greater ability to correctly identify both sedentary and light activities (SWm AUC 0.84; AG3 AUC 0.62–0.73). Conclusions: SWm may be a more suitable monitor for detecting time spent in sedentary and light-intensity activities. This finding has clinical and research relevance for evaluation of time spent in lower intensity physical activities by sedentary adults. Key Words: accelerometer; physical activity; sedentary behaviour. RE´ SUME´ Objectif : Comparer la capacite´ des acce´ le´ rome` tres Sensewear Mini (SWm) et Actigraph GT3X (AG3) de distinguer les activite´ s se´ dentaires et d’intensite´ le´ ge` re d’adultes en bonne sante´ observe´ s en laboratoire. Me´ thodes : Les 22 participants (15 femmes), aˆ ge´ s de 19 a` 72 ans, ont porte´ des moniteurs SWm et AG3 et se sont livre´ s a` cinq activite´ s se´ dentaires et quatre activite´ s d’intensite´ le´ ge` re pendant cinq minutes dans chaque cas sous observation en laboratoire. On a analyse´ le rendement des appareils en comparant leur exactitude, sensibilite´ , spe´ cificite´ et leurs valeurs pre´ dictives positive et ne´ gative et ratios de probabilite´ positif et ne´ gatif. On a examine´ la de´ termination correcte des deux types d’activite´ s au moyen de la zone situe´ e sous les courbes des caracte´ ristiques ope´ rationnelles du re´ cepteur (ZSC). Re´ sultats : Les deux moniteurs ont de´ montre´ une excellente capacite´ de de´ terminer les activite´ s se´ dentaires (sensibilite´ > 0,89). Le moniteur SWm e´ tait meilleur pour de´ terminer les activite´ s d’intensite´ le´ ge` re (spe´ cificite´ variant de 0,61 a` 0,71) que le moniteur AG3 (spe´ cificite´ variant de 0,27 a` 0,47) et a donc montre´ une plus grande capacite´ de de´ terminer correctement les activite´ s se´ dentaires et les activite´ s d’intensite´ le´ ge` re (ZSC: SWm ¼ 0,84; AG3: variant de 0,62 a` 0,73). Conclusions : Le moniteur SWm peut convenir mieux pour de´ tecter le temps consacre´ a` des activite´ s se´ dentaires et d’intensite´ le´ ge` re. Cette constatation pre´ sente une pertinence clinique et de recherche pour l’e´ valuation du temps consacre´ aux activite´ s physiques de plus faible intensite´ par des adultes se´ dentaires. The World Health Organization1 has identified physi- important message ‘‘sit less’’ is not so well known, de- cal inactivity as the fourth leading risk factor for global spite the emerging evidence of additional health benefits mortality, responsible for an estimated 3.2 million deaths from a less sedentary lifestyle.4–6 per year. As a result, the message ‘‘exercise more,’’ with the goal of meeting weekly physical activity guidelines Clinicians and researchers supporting sedentary adults for aerobic moderate to vigorous physical activity (MVPA), to be less sedentary need measurement tools that can dis- has been widely disseminated.2,3 However, the equally criminate between sedentary and light-intensity physical activities.7 An accelerometer is a tool that provides an From the: *Arthritis Research Canada, Richmond; †Department of Physical Therapy, University of British Columbia, Vancouver; ‡Faculty of Health Sciences, Simon Fraser University, Burnaby, B.C. Correspondence to: Lynne M. Feehan, Milan Ilich Arthritis Research Centre, 5591 No. 3 Rd., Richmond, BC V6X 2C7; [email protected]. Contributors: All authors designed the study; collected, analyzed, and interpreted the data; drafted or critically revised the article; and approved the final draft. Competing interests: None declared. Acknowledgements: The authors thank their colleagues Cynthia MacDonald, Jenny Leese, and Erin Carruthers from Arthritis Research Canada (Richmond, B.C.) for their assistance with participant recruitment and data collection. Physiotherapy Canada 2016; 68(2);116–123; doi:10.3138/ptc.2015-12 116

Feehan et al. SenseWearMini and Actigraph GT3X Accelerometer Classification of Observed Sedentary and Light-Intensity Physical Activities 117 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 objective measurement of a person’s motion in space intensity physical activities by healthy ambulatory adults or a kinematic measure of physical activity, measuring in a laboratory setting. Our objectives were, first, to com- energy expenditure and time spent in activities of differ- pare the ability of the SWm and the AG3 to accurately ent intensity. However, accelerometers were designed identify and differentiate between observed sedentary primarily to measure higher intensity activities.8 Acti- activities and light-intensity activities in a laboratory graph (AG) accelerometers (Actigraph LLC, Pensacola, setting and, second, to explore how categorization of FL) are those most frequently used in research, with the sedentary and light activity differed between the two Actigraph GT3X (AG3), the monitor used in this study, monitors. being a later triaxial model.9 They are usually worn at the waist during waking hours and provide output that METHODS includes measures of number of steps (similar to pedom- Our study was approved by the University of British etry) and number of activity counts (ACs) generated from the different motion axes of the accelerometer Columbia Clinical Research Ethics Board. Volunteers over a predefined measurement period (e.g., at 1-minute were recruited from the Greater Vancouver Regional Dis- intervals).10 Several validated data-reduction methods trict metropolitan area and were eligible if they were at have been used to define AC cut-points associated with least 19 years old, lived independently in the community, different intensities of activity and estimates of energy and were able to walk without the use of a mobility aid. expenditure,7,9–15 but the accuracy of these data-reduc- We excluded from the study those who could not provide tion methods for estimations of time spent in sedentary written informed consent or who answered ‘‘yes’’ to any activities has often been questioned.9,11–15 question on the Physical Activity Readiness Question- naire.31 With institutional permission, we distributed SenseWear (SW) accelerometers (BodyMedia/JawBone, study recruitment fliers through direct posting, email Inc., Pittsburgh, PA) are a newer design of multi-sensor notification, and website posting in selected health care monitors. SW monitors use proprietary pattern-recogni- and academic locations associated with the primary tion algorithms to integrate accelerometry measures with authors’ affiliations. Interested volunteers contacted the physiological sensors (heat flux, galvanic skin response, study centre by phone and were screened for eligibility. skin temperature, and near-body ambient temperature) Eligible participants provided informed consent before and personal demographic data (age, sex, height, weight, enrolment in the pilot study. and smoking status) to provide estimates of steps, energy expenditure (EE), and metabolic equivalent tasks (METs) Participants attended a 2-hour evaluation session. per unit of time.16 The SW Mini (SWm) is a triaxial model Height (in cm) and weight (in kg) were measured using that can be worn 24 hours a day against the skin on the standard techniques. The SWm was placed on the skin upper arm. SW monitors have been extensively evaluated over the triceps muscle, and the AG3 was worn at the for validity of measures of EE, with several recent studies waist at the mid-axillary line, with both monitors placed using the SWm.16–22 To our knowledge, only Reece and on the dominant-arm side (Figure 1). The SWm was colleagues19 specifically explored SWm measures of time configured using handedness, smoking status, age, sex, spent in lower intensity activity; their study reported very height, and weight. The AG3 was initialized to collect high accuracy (89%) for SWm measures of time spent triaxial data, with the low-frequency filter turned off. across a spectrum of sedentary, light, and moderate Both monitors were synchronized to the second with activities. Greenwich Mean Time and were set to collect data at 1- minute intervals. A few studies have compared SWm and AG3 monitors’ measures of EE.23–30 In two recent and related studies, Before testing, we demonstrated nine simulated lower Calabro and colleagues29 and Lee and colleagues30 deter- intensity daily activities to the participants, who were mined that SWm monitors provided more accurate mea- then given the chance to ask questions and practice the sures of EE during light- to moderate-intensity activities activity. We selected these nine activities from among in laboratory and free-living settings than the AG3 and common activities listed in the 2011 Compendium of three other activity monitors. However, neither study Physical Activities32 as sedentary (non-adjusted MET esti- specifically compared SWm and AG3 monitors’ measures mates a1.5) or light (non-adjusted MET estimates >1.5 of time spent in lower intensity activity. Two other studies and <3.0). The selected activities included three stand- compared measures of time spent in MVPA by older SW ing, three sitting, and three lying activities; one activity and AG monitor models and had inconsistent findings, in each body posture involved moving the upper extrem- with one study each showing both monitors to either ities, one involved moving the lower extremities, and one underestimate23 or overestimate24 time spent in MVPA. required no extremity motion (see Table 1). For two To our knowledge, no previous study has specifically activities (walking on a treadmill and cycling on sta- compared SWm and AG3 monitors’ measures of time tionary bike), we asked participants to stay within a rec- spent in lower intensity activities. ommended range for speed (1.5–2 mph [2.4–3.2 km/h] and 30–50 rotations per minute, respectively). For one The purpose of this study was to compare SWm and other activity (knee range of motion activity while lying AG3 measures of time spent in sedentary and light- down), we asked participants to use a pace similar to

118 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Figure 1 The SenseWear Mini (SWm) accelerometer is worn on the skin sure used in this study was verification of the timing, over the triceps muscle on the upper arm, and the Actigraph GT3X (AG3) is type, and quality of activities performed through direct worn at the waist at the mid-axillary line. observation by a trained observer. The trained observer provided direct oral feedback if participants varied from how they would move their legs if they were walking the recommended performance parameters; if necessary, slowly around a grocery store. For all other activities, we the task was stopped, instructions were repeated, and asked participants to perform the task at a pace that they the participant was allowed to practice the activity again considered similar to how they would typically perform before repeating it. Lyden and colleagues33 have shown that activity in their normal living environment. We did direct observation of physical activity behaviours to be a not ask participants to rate their perceived exertion dur- valid criterion measure for estimating physical activity ing any activity. and sedentary behaviours. Participants performed all nine activities in a random We processed the raw SWm data using the SenseWear order for 5 continuous minutes each. The criterion mea- Professional software (version 7; BodyMedia/JawBone, Inc., Pittsburgh, PA) and the raw AG3 data using the Acti- life software (version 5; ActiGraph, LLC, Pensacola, FL) and then exported them to Microsoft Excel (version 14; Microsoft Corp., Redmond, WA) for coding and analysis. The SWm data were recoded into sedentary METs (a1.5) and non-sedentary METs (>1.5); the AG3 ACs were recoded using three sedentary cut-point criteria: (1) single vertical axis (VA) <100 ACs per minute,11,12 (2) VA <25 AC/minute,15 and (3) triaxial vector magnitude (VM) <200 AC/minute.15 We then extracted the recoded data from the middle 3 minutes of each 5-minute activity for further analysis to ensure that all included minutes had a full 60 seconds of the observed activity. We compared sensitivity (i.e., correctly identified as a sedentary activity) and specificity (i.e., correctly identi- fied as a light activity) and the proportion of sedentary or light minutes measured by each monitor and con- firmed through observation as sedentary (e.g., positive predictive value [PPV]) or light (e.g. negative predictive value [NPV]) and also determined the positive likelihood ratio (LRþ) and negative likelihood ratio (LRÀ), using Minitab statistical analysis software (version 16; Minitab Inc., State College, PA). We also gauged the relative ability of the SWm and AG3 monitors to correctly classify both sedentary and light activities by examining the relation- ship between true positive (sensitivity) and true negative (1—specificity) rates, as evaluated via area under the receiver operating characteristic curve.34 These analyses used IBM SPSS statistical analysis software (version 19; IBM Corp., Armonk, NY). All our analyses were conducted using two definitions of sedentary: (1) a sedentary activity, defined as an activity estimated at 1.5 METs or less, performed in any posture (lying, sitting, or standing),2 and (2) a sedentary be- haviour, defined by the Sedentary Behavioural Research Network (SBRN) as an activity estimated at 1.5 METs or less, performed in either a sitting or a lying posture (i.e., excluding low-intensity standing activities).35 These different definitions affected the categorization of two tasks: standing still texting and sitting on a swivel office chair doing active upper extremity computer workstation tasks (see Table 1).

Feehan et al. SenseWearMini and Actigraph GT3X Accelerometer Classification of Observed Sedentary and Light-Intensity Physical Activities 119 Table 1 Nine Common Daily Activities Simulated in the Controlled Laboratory Setting Motion condition Standing Sitting Lying (supine) https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Lower extremity motion Treadmill, slow (2.4–3.2 km/h Stationary bike, slow (30–50 rpm), Slow, self-paced, alternating knee Upper extremity motion [1.5–2 mph]), self-paced walking, self-paced cycling, no resistance range of motion over pillow no incline (CPA: ~3.0 METs)* (CPA: ~3.0 METs)* (CPA: ~1.3 METs)†‡ Reading magazines Washing, drying, and putting away Swivel chair, repetitive, light effort, (CPA: ~1.3 METs)†‡ dishes (CPA: ~2.5 METs)* office workstation tasks (i.e., setting up a laptop, moving files and papers, and Lying still, relaxing, and listening to No lower or upper Standing still, text messaging on a typing; CPA: ~1.6 METs)*‡ music (CPA: ~1.3 METs)†‡ extremity motion handheld mobile device (CPA: ~1.3 METs)*† Sitting still, comfortable chair, watching TV (CPA: ~1.3 METs)†‡ Note: CPA28 estimated METs value for daily activities similar to these simulated activities. *Light-intensity activity (estimated 1.5 < METs < 3.0).2 † Sedentary activity (estimated a1.5 METs any posture).2 ‡Sedentary behaviour (estimated a1.5 METs sitting of lying postures).8 mph ¼ miles per hour; CPA ¼ 2011 Compendium of Physical Activity; METs ¼ metabolic equivalent tasks; rpm ¼ rotations per minute. RESULTS Table 2 Cross-Tabulations Comparing SWm and AG3 Measures of We recruited 22 community-dwelling adults (15 women, Sedentary and Light Activities with Observed Light and Sedentary Activities 7 men), aged 19 to 72 years (mean age 35.7 [SD 13.9] y), in a Controlled Laboratory Setting with a median BMI of 24.2 kg/m2 (Q1 ¼ 21.3, Q3 ¼ 31.7). Of 594 minutes retained for analysis (3 min from each Observed activity of nine simulated daily activities from 22 participants), 330 were from five sedentary activities and 264 were Accelerometer condition Sedentary Light Total from four light activities. Table 2 shows the cross-tabula- and measured activity tions for SWm and AG3 measures of sedentary and light activities compared with the observed sedentary and SWm (A) light activity categorization, comparing the sedentary activity and sedentary behaviour definition conditions. Sedentary 322 76 398 The SWm and AG3 monitors both demonstrated ex- Light 8 188 196 cellent ability to correctly identify observed sedentary activities in the controlled laboratory setting, with sensi- Total 330 264 594 tivity varying from 0.89 (SWm, sedentary behaviour) to 0.98 (SWm, sedentary activity) to 0.99 (AG3, all three SWm (B) sedentary cut-point conditions). The SWm sedentary activity condition and all three AG3 sedentary cut-point Sedentary 295 103 398 conditions rarely misidentified a light activity as seden- tary (i.e., false negative); false negative rates varied from Light 35 161 196 4% for the SWm sedentary behaviour condition to less than 2% for the three AG3 sedentary cut-point con- Total 330 264 594 ditions. Thus, with the marginal exception of the SW sedentary behaviour condition (NPV 0.82; LRÀ 0.17), AG3 VM < 200/min (A&B) both monitors showed very high NPV, varying from 0.96 for the SW sedentary activity condition to 0.99 for all Sedentary 327 141 468 three AG3 sedentary cut-point conditions, and a very low LRÀ (<0.04) for the SWm sedentary activity condi- Light 3 123 126 tion and for all three AG3 sedentary cut-point conditions (see Table 3). Total 330 264 594 With respect to correctly identifying light activity AG3 VA < 25/min (A&B) 329 178 507 minutes (i.e., specificity), the SWm sedentary activity con- Sedentary dition (specificity 0.71) performed notably better than the SWm sedentary behaviour (0.61) and all three AG3 seden- Light 1 86 87 tary cut-point conditions (varying from 0.47 [VM < 200] to 0.27 [VA < 100]). The SWm sedentary activity condi- Total 330 264 594 AG3 VA < 100/min (A&B) Sedentary 329 192 521 Light 1 72 73 Total 330 264 594 Note: Actigraph results are the same for both sedentary-activity and sedentary- behaviour conditions as both activities were measured 100% of the time as sedentary in all three cut-point conditions. A:2 a 1.5 METs any posture2 (e.g., standing texting ¼ observed sedentary; active computer workstation activities ¼ observed light). B:8 a 1.5 METs sitting or lying postures only8 (e.g., standing texting ¼ observed light; active computer workstation activities ¼ observed sedentary). SWm ¼ SenseWear Mini; AG3 ¼ Actigraph GT3X; A ¼ sedentary activity; B ¼ sedentary behaviour; VM ¼ vector magnitude; VA ¼ vertical axis; METs ¼ metabolic equivalent tasks. tion miscategorized a light activity as sedentary (i.e., false positive) 19% of the time, whereas the SWm seden- tary behaviour and all three AG3 sedentary cut-point

120 Physiotherapy Canada, Volume 68, Number 2 Table 3 Summary of Results Examining the Comparative Ability of SWm and AG3 Monitors to Differentiate between Observed Sedentary and Light Activities in a Laboratory Setting https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Mean (95% CI) Statistic SWm (A) SWm (B) AG3 VM < 200 (A&B) AG3 VA < 25 (A&B) AG3 VA < 100 (A&B) Sensitivity (0–1) 0.98 (0.95, 0.99) 0.89 (0.86, 0.93) 0.99 (0.97, 0.99) 0.99 (0.98, 0.99) 0.99 (0.98, 0.99) Specificity (0–1) 0.71 (0.65, 0.77) 0.61 (0.55, 0.67) 0.47 (0.40, 0.53) 0.33 (0.27, 0.40) 0.27 (0.22, 0.33) PPV (0–1) 0.81 (0.77, 0.85) 0.74 (0.70, 0.78) 0.70 (0.65, 0.74) 0.65 (0.62. 0.69) 0.63 (0.59, 0.67) NPV (0–1) 0.96 (0.92, 0.95) 0.82 (0.76, 0.87) 0.99 (0.93, 0.99) 0.99 (0.94, 0.99) 0.99 (0.93, 0.99) LRþ (b1) 3.40 (2.80, 4.10) 2.29 (1.96, 2.68) 1.86 (1.66, 2.08) 1.48 (1.36, 1.61) 1.37 (1.27, 1.48) LRÀ (<1) 0.04 (0.02, 0.07) 0.17 (0.12, 0.24) 0.02 (0.01, 0.06) 0.01 (0.01, 0.07) 0.01 (0.01, 0.08) ROC (AUC; 0.5–1) 0.84 (0.81, 0.88) 0.75 (0.71, 0.79) 0.73 (0.69, 0.77) 0.67 (0.62, 0.71) 0.64 (0.60. 0.68) Note: A: a1.5 METs (any posture).2 B: a1.5 METs (lying or sitting postures only).8 A vs B definitions only affect standing texting and sitting computer workstation categorizations. Notably, all AG cut-points categorized both the standing texting and sitting computer workstation activities as sedentary 100% of the time, so the AG results were the same for both sedentary definition conditions. SWm ¼ SenseWear Mini; AG3 ¼ Actigraph GT3X; A ¼ sedentary activity; B ¼ sedentary behavior; VM ¼ vector magnitude cut-point/minute; VA ¼ vertical axis cut-point/minute; PPV ¼ positive predictive value; NPV ¼ negative predictive value; LRþ ¼ positive likelihood ratio; LRÀ ¼ negative likelihood ratio; ROC ¼ receiver operating characteristics; AUC ¼ area under the curve; METs ¼ metabolic equivalent tasks. conditions were more likely to make this error (false activity, compared with an AG3 accuracy that varied positive rates varying from 26% [SWm sedentary behav- from 20% (VA < 25 and < 100) to 50% (VM < 200). iour] to 37% [AG3 VA < 100]). Thus, the SWm sedentary activity condition showed the best PPV (0.81) and LRþ DISCUSSION (3.4); PPVs varied from 0.74 for the SW sedentary be- Our study extends the literature on the use of acce- haviour condition to 0.61 for the AG3 VA < 100 condi- tion, and LRþ varied from 2.29 for the SWm sedentary lerometry for the objective measurement of time spent behaviour condition to 1.37 for the AG VA < 100 condi- in lower intensity physical activities by examining the tion. The SWm was also better able than the AG3 monitor comparative ability of the SWm and AG3 monitors to dif- to correctly identify both sedentary and light activities: ferentiate observed sedentary and light-intensity physical AUC was 0.84 for the SWm sedentary activity condition activity in a laboratory setting. We deliberately focused and 0.75 for the SW sedentary behaviour condition, on measures of lower intensity activity because accuracy whereas AUC for the three AG3 sedentary cut-point con- in differentiating time spent in sedentary and light physi- ditions varied from 0.74 (VM < 200) to 0.64 (VA < 100; cal activities is an important measurement characteristic see Table 3). to consider, especially in clinical and research situations focused on reducing time spent in sedentary lifestyle Both monitors, under all conditions, correctly identi- activities. fied all activities in lying position as sedentary. The two monitors also performed very similarly in terms of cor- Our results show that, compared with the AG3 monitor, rectly identifying 97% or more of all minutes sitting still the SWm monitor was much better able to distinguish and more than 90% (SWm 91%; all AG3 100%) of minutes between observed sedentary and light-intensity activities standing still as sedentary, assuming that standing still is in the controlled laboratory setting. These differences are a sedentary activity on the basis of the sedentary activity likely because the AG3 monitor uses only triaxial acce- definition.2 Both monitors were also very likely to identify lerometry measures (i.e., measures of three-dimensional slow treadmill-walking activities as light, varying from body motions in space) to define intensity of activity. more than 98% (SWm and AG3 VA < 25 and VM < 200) Whereas the SWm monitor integrates triaxial accelero- to 89% (AG3 VA < 100). The primary difference between metry with additional physiological data (e.g., skin the two monitors was that the SWm monitor was mark- temperature and sweating with activity) and personal edly more accurate in correctly identifying standing or demographic data (e.g., age, sex, BMI), using proprietary sitting activities that involved upper extremity motion algorithms, to define intensity of activity. Differences as light activity. SWm identified 97% of dishwashing may also be related to where on the body the monitors minutes and 50% of computer workstation minutes were designed to be worn during activity (i.e., the SWm as light activity, whereas the AG3’s best performance monitor is designed to be worn on the arm; the AG3 (VM < 200) identified 0% of dishwashing minutes and monitor, at the waist). Positioning the SWm monitor on 35% of computer workstation minutes as light activity. the arm provides a mechanical advantage in detecting Similarly, the SWm monitor identified 60% of minutes upper extremity motions when the rest of the body is spent in slow pedalling with no resistance as a light not moving in space. These technological advantages of SWm are an important consideration, given the SWm

Feehan et al. SenseWearMini and Actigraph GT3X Accelerometer Classification of Observed Sedentary and Light-Intensity Physical Activities 121 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 monitor’s additional practical advantage in terms of more accurate identification of the time in a person’s providing a more comprehensive 24-hour picture of a day when he or she is performing many common light- person’s sleep, wakeful physical activity patterns, and intensity standing or sitting activities of daily living in- off-body times than the AG3 monitor, which is intended volving the upper extremity—a large portion of the day to be worn only while a person is awake.36 that the AG monitor would, in contrast, potentially iden- tify as sedentary time. We also found that the sedentary cut-points for the AG3 monitor of VM < 200 AC/minute and single Our finding that the SWm monitor more accurately VA < 25 AC/minute better differentiated between seden- measures time spent in lower intensity activity is consis- tary and light activities than the more commonly used tent with the findings of Calabro´ and colleagues (2014)29 sedentary cut-point of single VA < 100 AC/minute.11,12,15 and Lee and colleagues,30 who also found that the SWm This finding, which is consistent with those of Aguilar- was more accurate than the AG3 for measuring EE from Far´ıas,15 suggests that an AG3 VM cut-point of less than lower intensity activity. Together, these findings suggest 200 AC per minute may be a better sedentary cut-point that any direct comparison between time spent in, or EE when using a triaxial AG3 monitor or, alternatively, using from, lower intensity activities as captured by SWm and a VA cut-point of <25 AC/minute as a sedentary cut- AG3 monitors should be made with caution, because point rather than the more commonly used VA < 100 values for these metrics will differ markedly depending AC/minute sedentary cut-point. not only on the type of accelerometer used7,38 but also on the definition of a sedentary activity2,35 and the seden- Our study also found that results vary depending on tary cut-point used with the AG3 monitor.11,15 how sedentary is defined. The SBRN definition of seden- tary behaviour35 (i.e., wakeful sitting or lying activities of LIMITATIONS 1.5 METs or less) excludes any standing activity; in our Our study has several limitations. First, our sample study, by contrast, both SWm and AG3 monitors identi- fied standing still while texting as a sedentary activity, was a small cohort of 22 ambulatory adult volunteers which may be more consistent with Bailey and Locke’s37 aged 19–72 years. Our findings therefore cannot be recent findings that ‘‘standing breaks’’ (breaks in sitting generalized to non-ambulatory adults, adults living with to stand still for 2 min) did not confer the same cardio- gait deficits, or adults who use a walking aid; generaliza- metabolic benefits as light activity breaks (breaks con- tion to adults living with chronic health conditions may sisting of 2 min of light-intensity walking). Bailey and also be limited because some systemic chronic health Locke’s findings suggest that standing still for short periods, conditions may affect SWm physiological sensor data.39 similar to sitting still, could also be considered a sedentary We did not screen specifically for chronic health condi- behaviour. tions in any of our participants, so we are not able to comment on how living with chronic disease may or That said, identifying standing still as either a seden- may not have affected the findings in this study. tary or a light activity will not generally produce a marked over- or underestimation of time spent in seden- Second, we simulated activities in a controlled labo- tary activity, because most people do not typically spend ratory setting, which may not replicate the movement prolonged periods standing still with minimal upper ex- pattern of similar activities as they would have been per- tremity motion during the day. However, some people formed by participants in their own environment. Third, may stand for longer periods, with minimal use of their we did not select activities on the basis of an age- or arms, as part of their normal daily activities—for example, body-mass-adjusted estimate of METs, which may have if they use a standing desk or perform other occupational led to underestimation of EE for older participants and activities that require prolonged periods of standing still. those with higher BMI.40 This limitation is partially ad- Therefore, it is important to consider exploring how these dressed by the SWm monitor, whose proprietary algo- types of unique contextual standing-still activities might rithms do adjust for age, sex, and BMI; this adjustment affect specific research or clinical use of these monitors. may help explain the better performance of the SWm monitor. More likely to make a marked difference in measures of time spent in sedentary or light activity for most Fourth, we used direct observation as our criterion people is the SWm’s greater ability to identify sitting or measure for defining each minute as a sedentary or light non-ambulatory standing activities that involve upper activity, rather than using indirect calorimetry for com- extremity motion. As mentioned previously, better per- parative measures of EE during the activity. Direct obser- formance by the SWm monitor, compared with the AG3 vation of a person’s activity has been shown by Lyden monitor, in identifying light activities that involve upper and colleagues33 to be a valid criterion measure for iden- extremity motion is explained in part by the fact that the tifying different intensities of physical activity. Notably, SWm monitor and its accompanying analysis software the intent of our study was not to examine the monitors’ were designed for the monitor to be worn on the arm, measures of EE, which has been the primary focus of whereas the AG3 monitor is intended to be worn at the many other studies, but to examine their ability to detect waist. As such, the SWm monitor will likely provide a differences in body motions occurring in different body

122 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 postures associated with common light and sedentary What this study adds activities. We consider this an important distinction be- This study adds to the literature by demonstrating cause it is important to have measurement tools that are sensitive to changes in subtle body motion patterns that the SenseWear Mini accelerometer was better able associated with common sedentary and light activities. to differentiate between observed sedentary and light- intensity activities in a laboratory setting than the more Fifth, both monitors have technical limitations in commonly used Actigraph GT3X accelerometer. The terms of accurately detecting the number of steps at Actigraph GT3X monitor performed better using a vector slower walking speeds.41,42 The intent of this pilot study magnitude cut-point of less than 200 activity counts was not to explore the accuracy of the number of steps (ACs) per minute or the single vertical axis cut-point of identified during slow walking. It is important to note, less than 25 AC per minute for sedentary activity than however, that this physical limitation of both monitors with the more commonly used single vertical axis cut- did not seem to affect either monitor’s ability to correctly point for sedentary activity of less than 100 AC per minute. identify slow treadmill walking as a light activity, be- cause both showed very high accuracy. REFERENCES Finally, we did not examine the comparative accuracy 1. World Health Organization. Global recommendations on physical of the SWm and AG3 monitors using newly evolving AG3 activity for health [Internet]. 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https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 ARTICLE OA Go Away: Development and Preliminary Validation of a Self-Management Tool to Promote Adherence to Exercise and Physical Activity for People with Osteoarthritis of the Hip or Knee Gail Paterson, BSc PT;* Karine Toupin April, BSc OT, PhD;†‡ Catherine Backman, PhD, FCAOT;§¶ Peter Tugwell, OC, MD, MSc, FRCPC, FCAHS**††‡‡§§ ABSTRACT Purpose: To determine the face and content validity, construct validity, and test–retest reliability of the OA Go Away (OGA), a personalized self- management tool to promote adherence to exercise and physical activity for people with osteoarthritis (OA) of the hip or knee. Methods: The face and content validity of OGA version 1.0 were determined via interviews with 10 people with OA of the hip or knee and 10 clinicians. A revised OGA version 2.0 was then tested for construct validity and test–retest reliability with a new sample of 50 people with OA of the hip or knee by comparing key items in the OGA journal with validated outcome measures assessing similar health outcomes and comparing scores on key items of the journal 4–7 days apart. Face and content validity were then confirmed with a new sample of 5 people with OA of the hip or knee and 5 clinicians. Results: Eighteen of 30 items from the OGA version 1.0 and 41 of 43 items from the OGA version 2.0 journal, goals and action plan, and exercise log had adequate content validity. Construct validity and test–retest reliability were acceptable for the main items of the OGA version 2.0 journal. The OGA underwent modifications based on results and participant feedback. Conclusion: The OGA is a novel self-management intervention and assessment tool for people with OA of the hip or knee that shows adequate preliminary measurement properties. Key Words: exercise; hip; knee; osteoarthritis; patient compliance. RE´ SUME´ Objectif : De´ terminer l’apparence et la validite´ de contenu, la validite´ de concept et la fiabilite´ test-retest de l’outil OA Go Away (OGA), un outil personnalise´ d’autogestion visant a` promouvoir l’observance aux exercices et a` l’activite´ physique chez les personnes qui ont de l’arthrose de la hanche ou du genou. Me´ thodes : L’apparence et la validite´ de contenu de l’outil OGA version 1.0 ont e´ te´ de´ termine´ es au moyen d’entrevues mene´ es aupre` s de 10 personnes vivant avec l’arthrose de la hanche ou du genou et de 10 cliniciens. Une version re´ vise´ e 2.0 a ensuite fait l’objet de tests visant a` de´ terminer la validite´ de concept et la fiabilite´ test-retest au moyen d’un nouvel e´ chantillon de 50 personnes vivant avec l’arthrose de la hanche ou du genou en comparant des e´ le´ ments cle´ s du journal de l’outil OGA avec des mesures de re´ sultats valide´ es e´ valuant des e´ le´ ments semblables et comparant les scores attribue´ s a` des e´ le´ ments cle´ s du journal a` des intervalles de 4 a` 7 jours. On a ensuite confirme´ l’apparence et la validite´ de contenu en utilisant un nouvel e´ chantillon de cinq personnes vivant avec l’arthrose de la hanche ou du genou et de cinq cliniciens. Re´ sultats : Dix-huit des 30 questions de la version 1.0 de l’outil OGA et 41 des 43 questions de la version 2.0 du Journal, Buts, Plan d’action et Registre des exercices pre´ sentaient un contenu d’une validite´ ade´ quate. La validite´ de concept et la fiabilite´ test-retest e´ taient acceptables pour les principaux e´ le´ ments de la version 2.0 du Journal de l’outil OGA. L’outil OGA a subi des modifications base´ es sur les re´ sultats et les commentaires des participants. Conclusion : L’outil OGA est un nouvel outil d’intervention et d’e´ valuation en autogestion qui s’adresse aux personnes atteintes d’arthrose de la hanche ou du genou et qui affiche des caracte´ ristiques de proprie´ te´ s me´ trologiques pre´ liminaires ade´ quates. Recent clinical practice guidelines for the manage- ening programmes improve pain, function, and quality ment of osteoarthritis (OA) of the hip and knee1,2 have of life; facilitate weight management; and may slow the strongly recommended that people with OA exercise progression of the disease.3,4 However, these benefits regularly, based on evidence that aerobic and strength- are only realized if exercise and physical activity (PA) From the: *The Arthritis Society, Eastern Region; †Children’s Hospital of Eastern Ontario Research Institute; ‡Department of Pediatrics; **Department of Medicine; ††School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa; ‡‡Clinical Epidemiology Program, Ottawa Hospital Research Institute; §§WHO Collaborating Centre for Knowledge Translation and Health Technology Assessment in Health Equity, Bruye` re Research Institute, Ottawa; §Occupational Science & Occupational Therapy, The University of British Columbia, Vancouver; ¶The Arthritis Research Centre of Canada, Richmond, B.C. Correspondence to: Gail Paterson, 20–2269 Riverside Dr., Ottawa, ON K1H 8K2; [email protected]. Contributors: All authors designed the study; collected, analyzed, and interpreted the data; drafted or critically revised the article; and approved the final draft. Competing interests: None declared. Physiotherapy Canada 2016; 68(2);124–132; doi:10.3138/ptc.2014-68 124

Paterson et al. Preliminary Validation of a Self-Management Tool to Promote Adherence to Physical Activity in OA 125 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 are practised consistently and become a lifelong habit.5–7 services. Ravaud and colleagues25 investigated a self- Unfortunately, adherence to prescribed exercise is low evaluation tool for people with OA of the hip or knee among the OA population,6,8 and the majority of people that included the use of an exercise log, a weekly self- with OA of the hip or knee do not meet the Health administered visual analogue scale, and the Western Canada–recommended guidelines for weekly PA for Ontario and McMaster Universities Osteoarthritis (dis- adults: at least 150 minutes of moderate or 75 minutes ability) Index to monitor symptoms during a trial of of vigorous aerobic PA per week (which can be split into home exercise. Adherence to exercise at 6 months was 10-minute segments); strengthening exercises on at least very low, perhaps because the standardized assessment 2 days per week; and PA to enhance balance and prevent measures did not always evaluate the specific outcomes falls for those older than age 65 years with poorer mobil- most relevant or important to each participant. ity.9–11 This lack of PA increases the potential for disease progression and greater morbidity and mortality.8,12 The two primary authors (GP, KTA) decided to create the OA Go Away (OGA), a self-regulation intervention Physiotherapists who simply prescribe exercise or PA that includes an exercise log, goal setting, and a person- to their clients with OA of the hip or knee seldom achieve alized rather than standardized self-assessment measure, lasting changes in behaviour, especially in clients dis- whereby individuals decide which OA symptoms or charged to independent home exercise programmes.13 outcomes are most problematic for them. Qualitative Additional motivational interventions for behaviour change studies have suggested that self-regulation efforts that need to be adopted to help bridge the gap between good assess personally meaningful health status outcomes at intentions and behaviour.2,3,8,14–16 Although some quali- intervals encourage people with OA to maintain exercise tative research has examined the factors that influence behaviour.8,26,27 The OGA is intended for people to the decision to adopt and maintain a regular exercise use independently at home, after brief coaching from a programme, the evidence is scant for interventions to physiotherapist. The OGA version 1.0 was developed promote adherence to exercise for people with OA. after performing a systematic search of the literature to identify relevant health outcomes for people with OA We identified 2 recent review articles6,8 that reviewed and obtaining feedback from 10 people with OA of the a total of 13 studies that included adherence among their hip or knee in clinical practice at the Arthritis Society evaluation criteria and 1 subsequent study7 that spe- office in Ottawa. cifically tested an intervention to promote adherence to exercise for people with OA of the hip or knee. The To our knowledge, the OGA is the first personalized adherence interventions studied, used alone or in com- adherence intervention incorporating SRT elements for bination, were exercise logs, goal setting, telephone calls, people with OA of the hip or knee to be validated. This booster sessions, pedometers, video-assisted exercises, article describes the three phases in the preliminary de- and self-evaluation tools. Only trials that included booster velopment and validation of the OGA and their respec- sessions in combination with goal setting, exercise logs, tive results. or telephone calls showed increased adherence after 6 months, and even in these trials, rates declined over METHODS time.7,17 These multi-component interventions were sup- ported in part by aspects of self-regulation theory Design (SRT),18,19 which posits that behaviour is goal directed Our three-phase study was guided by standard ap- and that by taking an active rather than a passive role in managing a chronic condition, patients can create their proaches to instrument validation28 and followed the own pathways to goal attainment through personal goal COSMIN (COnsensus-based Standards for the selection setting, action planning, self-monitoring, feedback, and of health Measurement INstruments) checklist.29 In phase relapse prevention. SRT suggests that self-efficacy may 1, we determined the face and content validity of OGA be increased because people perceive that they are able version 1.0, then revised it on the basis of these results to control or influence various aspects of their chronic to create OGA version 2.0. Phase 2 established the con- disease. The stronger one’s perceived self-efficacy, the struct validity and test–retest reliability of OGA version stronger and more proactive and persistent one’s efforts 2.0. In phase 3, we tested OGA version 2.0 for content will be.18 Self-regulation strategies have been shown to validity and then made further modifications to generate promote weight loss,20 increase PA in people with rheu- OGA version 3.0. All participants in each phase provided matoid arthritis,21 and increase adherence to exercise in informed consent, and our study protocol was reviewed the general population.22,23 and approved by the Ottawa Health Science Network Research Ethics Board. Although the use of goal setting and exercise logs is supported by SRT, the use of booster sessions may not Phase 1: face and content validity of OA Go Away version 1.0 be, because autonomous feedback (self-directed) is pre- ferred over feedback from an external source (physio- Participants therapist).24 Booster sessions are also very resource in- We recruited a convenience sample of 10 people with tensive, and many people have limited access to these OA of the hip or knee from Ottawa rheumatology clinics and the Arthritis Society’s Ottawa office via an informa- tion poster that invited volunteers to phone the research

126 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 assistant (RA). Participants were eligible if they had OA Phase 2: construct validity and test–retest reliability of OA Go of the hip or knee and could communicate in English. Away version 2.0 We also recruited a purposive sample of 10 rheumatology clinicians from the Canadian Arthritis Network (a national Participants centre of excellence) and from Ottawa rheumatology Using posters at Ottawa rheumatology offices and the practices. Clinicians who were judged by the research team to be experts in OA or self-management were in- Arthritis Society’s Ottawa office that invited volunteers to vited by the research team to participate via email. phone the RA, we recruited a new convenience sample of 50 people with OA of the hip or knee for phase 2. Inclu- Data collection sion and exclusion criteria were the same as for phase 1. The RA conducted in-person semi-structured qualita- Data collection tive interviews of participants with OA of the hip or knee; Participants completed a socio-demographic form, clinicians were interviewed by phone by one of two research team members (GP or KTA). Participants com- the Short-Form Health Survey (SF-36), the Pittsburgh pleted a socio-demographic form and then reviewed the Sleep Quality Index (PSQI), and an Intermittent and OGA version 1.0 journal and exercise log; their answers Constant Osteoarthritis Pain (ICOAP) questionnaire at to the questions on the face and content validity rating the Arthritis Society’s Ottawa office. They also completed form were recorded. the OGA version 2.0 journal at baseline and were given a blank journal page with instructions to complete it Measures at home 4–7 days later and return it by mail in a self- Socio-demographic form. Used in all three phases of addressed sealed envelope. the study, this form gathered information on the clini- Measures cian’s profession and years of experience and the percent- OA Go Away version 2.0 (see Appendix 2 online). This age of OA clients in the clinician’s practice; for partici- pants with OA, it elicited age, gender, ethnicity, level of version of the OGA contained a monthly journal, monthly education, and location and duration of OA (hip or knee goals and action plan, and a weekly exercise log whose and other joints). appearance and content were modified from version 1.0 on the basis of the phase 1 results. OA Go Away version 1.0 (see Appendix 1 online). The OGA version 1.0 monthly journal assessed the following SF-36. The SF-36 is a patient-based measure of gen- outcomes, using scales for level of difficulty or quality eral health status validated for chronic diseases, includ- and level of importance, as well as space for a personal ing OA. It assesses health-related quality of life and description of ‘‘challenges in my daily activities,’’ sleep, yields component scores for Physical Functioning, Role– mood, and energy. Other measures collected were ‘‘things Physical, Bodily Pain, General Health, Vitality, Social I am not doing because of my OA,’’ ‘‘I also notice’’ (other Functioning, Role–Emotional, and Mental Health sub- symptoms), pain, use of medications and other treat- scales.32 ments, food habits, score on the F.I.T. (a fitness measure adapted by clinicians from Karsi’s30 F.I.T. index that ICOAP. The ICOAP is a multidimensional OA-specific computes a fitness score based on the frequency, inten- measure designed to comprehensively evaluate the pain sity, and time of aerobic activity per week), resting heart experience of people with hip or knee OA—including rate, weight, waist circumference, body mass index (BMI), pain intensity; pain frequency; and impact on mood, and goals. The weekly exercise log monitored daily fre- sleep, and quality of life—independent of the effect of quency, time, and intensity of exercise; use of medica- pain on physical function.33 tions; and OA treatments. PSQI. The PSQI, a measure of sleep quality and distur- Face and content validity rating form. This form asked bances over 1 month, identifies good and poor sleepers in participants to rate the relevance of each item on a the general medical population; it consists of 19 self-rated three-item nominal scale (essential, useful but not essen- items, which are combined to form seven component tial, or not necessary). They were asked to suggest other scores.34 relevant items and to provide feedback on comprehen- siveness and clarity. Data analysis To determine construct validity, we calculated Pearson Data analysis To quantify the relevance of the items included in (for data with approximately normal distributions) or Spearman (for data with non-normal distributions) cor- OGA version 1.0, we calculated the content validity ratio relation coefficients to determine the direction and (CVR).31 CVR scores range from À1.0 to 1.0; a higher strength of the association between OGA scores (func- score indicates a higher percentage of raters who rated tion, pain, sleep, mood, and energy) and the relevant the item as essential. The minimum acceptable CVR SF-36 subscale, ICOAP, and PSQI scores. A correlation value for 20 participants is 0.42. of 0.80–1.0 was considered very strong; 0.60–0.79, strong; 0.40–0.59, moderate; 0.20–0.39, weak; and 0.00–0.19, very weak.35

Paterson et al. Preliminary Validation of a Self-Management Tool to Promote Adherence to Physical Activity in OA 127 To determine test–retest reliability, we compared OGA Table 1 Participant and Clinician Demographics journal scores from baseline to time 2 (4–7 days later) using k coefficients for categorical data (stiffness and No. (%) of participants with OA of hip or knee* swelling) and intra-class correlation coefficients (ICCs) https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 for continuous data (function, sleep, mood, energy, pain, Characteristic Phase 1 Phase 2 Phase 3 F.I.T., weight, waist circumference, BMI). The Rehabilita- (n ¼ 10) (n ¼ 50) (n ¼ 5) tion Measures Index recommends that instruments for individual decision making show excellent agreement Sex, female 6 (60) 39 (78) 4 (80) (i.e., ICC > 0.90; k > 0.81).36 Age, y, mean (SD) 59.5 (8.1) Location of OA 65.81 (10.0) 71.4 (6.2) Phase 3: face and content validity of OA Go Away version 2.0 Knee 4 (40) 25 (50) 3 (60) Participants Hip 3 (30) 7 (14) 1 (20) We recruited 5 new participants with hip or knee OA, Both hip and knee 3 (30) 18 (36) 1 (20) Duration of OA, y, mean (SD) 13.8 (12.0) 9.31 (7.2) 12.4 (15.6) using the same eligibility criteria as in phase 1, from Self-reported ethnic origin Ottawa rheumatology clinics and the Arthritis Society’s Canadian 9 (90) 38 (76) 4 (80) Ottawa office via an information poster that invited European 1 (10) 4 (8) 0 them to phone the RA; we also recruited 5 of the original Haitian 0 3 (6) 1 (20) clinicians via email. Asian 0 5 (10) 0 Level of education Data collection, measures, and analysis University graduate 7 (70) 28 (56) 3 (60) All phase 1 procedures were repeated in phase 3. We College graduate 0 10 (20) 2 (40) High school graduate 1 (10) 10 (20) 0 used the face and content validity rating form from <High school graduate 2 (20) 2 (4) 0 Phase 1, with OGA version 2.0 items inserted. The mini- mum acceptable CVR value for 10 participants is 0.62. No. (%) of clinicians* RESULTS Phase 1 Phase 3 (n ¼ 10) (n ¼ 5) Phase 1: face and content validity of OA Go Away version 1.0 Profession 2 (20) 1 (20) Baseline characteristics Rheumatologist 3 (30) 1 (20) All 10 people with hip or knee OA who contacted the PT researcher 2 (20) 1 (20) PT clinician 1 (10) 1 (20) RA were eligible to participate. Participants had a mean OT clinician 1 (10) 1 (20) age of 60 years and mean disease duration of 14 years; SW researcher 1 (10) 60% were female (see Table 1). We sent email invitations RN clinician 30 (7.4) 26 (6.0) to 20 clinicians, 10 of whom responded and participated 7 (70) 4 (80) in the study. Clinician participants, who reported a mean Time in practice, mean (SD) y 30 years’ experience, were 2 rheumatologists, 3 physio- Clients with OA > 50% of practice therapy researchers, 2 physiotherapy clinicians, 1 occu- pational therapy clinician, 1 social work researcher, and * Except where otherwise indicated. 1 nurse clinician. OA ¼ osteoarthritis; PT ¼ physiotherapy; OT ¼ occupational therapy; SW ¼ social work; RN ¼ registered nurse. All 20 participants completed the face and content validity rating form, on which there were 10 missing 18 of 30 items. On the basis of CVR results and com- values from eight different questions: One clinician did ments from participants, we revised OGA version 1.0 to not answer one question; 5 participants with OA did not create OGA version 2.0. Items with a CVR less than 0.42 answer one to three questions each; and ‘‘Mood level of were removed or modified to represent participants’ importance’’ and ‘‘Energy level of quality’’ each had 2 views; for example, the ‘‘I also notice’’ category was re- missing values, with 18 of 20 answers. We calculated placed with ‘‘my stiffness’’ and ‘‘my swelling.’’ If par- averages for each item using all available scores. ticipants with OA and clinician participants showed significant discrepancies in the items they identified as Face validity of OA Go Away version 1.0 essential, our decision to exclude or modify an item All participants understood the purpose of the OGA. favoured the priorities of participants with OA, along with a team consensus based on available information Some participants with hip or knee OA commented and the purpose of the tool. For example, most partici- that they intended to share their OGA with their health pants with OA but few clinicians felt that food habits care provider as evidence of their status and their self- was an essential item to include in the journal; we de- management efforts. cided to remove this item because it was not the main goal of the PA intervention. Similarly, the item ‘‘Things I Content validity of OA Go Away version 1.0 am not doing because of my OA’’ was rated as essential Table 2 shows CVR scores, which were adequate for by the majority of participants with OA but not by clini- cians, who offered comments such as ‘‘Patients do not need reminders of the activities they can no longer do, especially if it is unlikely they will resume these activi- ties.’’ We therefore removed this item and integrated

128 Physiotherapy Canada, Volume 68, Number 2 Table 2 Face and Content Validity of OA Go Away Version 1.0 OGA exercise log into the different types of exercise and removed medications and other treatment categories. https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Item from OA Go No. of participants No. of clinicians CVR total Away version 1.0 with OA who who rated it (n ¼ 20) Phase 2: construct validity and test–retest reliability of OA Go rated it as as essential Away version 2.0 essential Baseline characteristics OA Go Away journal Of 51 people with hip or knee OA who contacted the Challenges 10 10 1.0 RA, 1 was ineligible to participate because of an inability LOD 9 10 0.90 to communicate in English. The 50 participants had a LOI 9 9 0.80 mean age of 66 years and mean disease duration of 9 9 3 0.20 years; 78% were female (Table 1). All 50 participants Things I am not doing 10 10 1.0 completed all outcome measures and the OGA version Sleep 9 9 0.80 2.0 journal at baseline, but 4 participants (8%) did not 8 4 0.20 return their second journal, leaving 46 participants for LOQ 8 10 0.89 the analysis of test–retest reliability. Participants took an LOI 7 8 0.57 average of 30 minutes to complete their first OGA journal Mood 7 3 À0.29 with help from the RA. LOQ 8 8 0.68 LOI 6 8 0.55 Construct validity of OA Go Away version 2.0 Energy 6 40 The results of the construct validity analysis are LOQ 7 5 0.20 LOI 10 10 1.0 shown in Table 3. OGA version 2.0 pain scores were I also notice 10 9 0.90 moderately to strongly associated with SF-36 Bodily Pain Pain 10 7 0.70 sub-scale scores and ICOAP total pain scores (Pearson Meds 9 0 À0.10 rs ranged from 0.55 to 0.75) and showed weak to moderate Other treatment 6 6 0.20 correlations with ICOAP intermittent or constant pain Food habits 4 5 À0.10 scores (Pearson rs ranged from 0.36 to 0.45). OGA ver- F.I.T. score 9 9 0.80 sion 2.0 sleep, mood, and energy scores were strongly Resting HR 4 5 À0.10 correlated with their respective PSQI and SF-36 sub- Weight 8 9 0.70 scale comparators (Pearson rs ranged from 0.66 to 0.69 BMI 7 10 0.70 and Spearman r was 0.78). OGA version 2.0 function Waist scores showed weak correlations with all SF-36 subscales Goals (Pearson rs ranged from 0.25 to 0.38). OA Go Away ex log Test–retest reliability of OA Go Away version 2.0 Table 4 shows the results of the test–retest analysis. Ex/activity 10 10 1.0 Only one item (weight) had an ICC or k value more than Min/int. 10 10 1.0 0.90; seven (energy, function, pain knee and hip, sleep, waist, stiff knee) had values between 0.70 and 0.90, and Meds 6 2 À0.20 three (mood, stiff hip, swelling) had values between 0.40 and 0.70. Two items (BMI, F.I.T.) with ICCs below 0.20 Other treatment 6 1 À0.30 were removed; the mean ICC or k of all remaining items was 0.72. Comments 8 10 0.80 Because most participants considered it essential to Ex routine log 2 6 À0.10 include a simple fitness measure in the journal, we added the Health Canada guidelines for aerobic PA and OA ¼ osteoarthritis; CVR ¼ content validity ratio; LOD ¼ level of difficulty; strengthening exercises, to be used as exercise targets LOI ¼ level of importance; LOQ ¼ level of quality; F.I.T. ¼ frequency/intensity/ for users. We also added reminders of these targets to time measure of fitness; HR ¼ heart rate; BMI ¼ body mass index; the exercise log to help participants track their exercise Ex ¼ exercise; Int. ¼ intensity. toward these targets. it as a possibility in the instructions for ‘‘top 3 difficult Phase 3: face and content validity of OA Go Away version 2.0 activities.’’ Baseline characteristics The OGA version 2.0 journal was reorganized into four All 5 people with hip or knee OA who contacted the domains: ‘‘top 3 activities that are difficult due to my OA that I would like to improve,’’ ‘‘other possible impacts of RA were eligible to participate; they had a mean age of my OA’’ (sleep, mood, energy, pain, stiffness, swelling), 71 years and mean disease duration of 12 years, and ‘‘my fitness and weight measures’’ (F.I.T., BMI, weight, 80% were female (Table 1). Of the 7 original clinicians waist), and ‘‘treatment for my OA pain’’ (medications, other treatments). Most participants considered it essen- tial to include goals, but they preferred a separate goals and action plan, which we therefore created, with space to record three goals (related to functional difficulties), an exercise action plan, barriers, plans to overcome barriers, and a confidence scale. We reorganized the

Paterson et al. Preliminary Validation of a Self-Management Tool to Promote Adherence to Physical Activity in OA 129 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Table 3 Construct Validity Correlation Coefficients of OA Go Away Version 2.0 (n ¼ 50) Pearson r (95% CI) Constructs 0.75 (0.58, 0.86) 0.45 (0.17, 0.67) OGA pain knee vs ICOAP total knee 0.41 (0.12, 0.64) OGA pain knee vs ICOAP constant knee 0.64 (0.33, 0.83) OGA pain knee vs ICOAP intermittent knee 0.44 (0.05, 0.71) OGA pain hip vs ICOAP total hip 0.36 (À0.07, 0.67) OGA pain hip vs ICOAP constant hip À0.65 (À0.44, À0.80) OGA pain hip vs ICOAP intermittent hip À0.55 (À0.20, À0.78) OGA pain knee vs SF-36 Bodily Pain 0.66 (0.46, 0.79) OGA pain hip vs SF-36 Bodily Pain À0.69 (À0.51, À0.81) OGA sleep vs PSQI total À0.25 (À0.50, 0.03) OGA mood vs SF-36 Mental Health sub-scale À0.38 (À0.60, À0.11) OGA function vs SF-36 Physical Component summary measure À0.27 (À0.51, 0.02) OGA function vs SF-36 Physical Functioning sub-scale Spearman r (95% CI) OGA function vs SF-36 Social Functioning sub-scale À0.78 (À0.87, À0.64) OGA energy vs SF-36 Vitality sub-scale OGA ¼ OA Go Away; ICOAP ¼ Intermittent and Constant Osteoarthritis Pain questionnaire; SF-36 ¼ Short-form Health Survey; PSQI ¼ Pittsburgh Sleep Quality Index. Table 4 Test-Retest Reliability of OA Go Away Version 2.0 (n ¼ 46) scale, we removed these two items from the OGA version 2.0 goals and action plan because the majority of par- Item from OA Go Away version 2.0 ICC or k (95% CI) ticipants with OA felt that both elements would invite negative affect; listing barriers would foster excuses for Energy* 0.73 (0.57, 0.84) not being active, whereas a confidence scale would Function* 0.75 (0.57, 0.86) imply that they would not take action. However, partici- Mood* 0.67 (0.47, 0.80) pants also noted that a confidence scale may be useful Pain knee* 0.70 (0.50, 0.83) for health care providers to identify people who may Pain hip* 0.81 (0.59, 0.91) have set unrealistic goals. We therefore replaced both Sleep* 0.85 (0.75, 0.92) ‘‘barriers’’ and ‘‘ways to overcome barriers’’ with ‘‘how F.I.T. score 0.02 (À0.30, 0.34) will I make sure I follow my plan?’’ and added instruc- Weight* 0.94 (0.90, 0.97) tions for users to think about possible barriers and focus Waist* 0.72 (0.52, 0.85) on ways to overcome them. Intention to adopt a new BMI 0.10 (À0.22, 0.41) behaviour (as indicated on a confidence scale) has been Stiff hip† 0.53 (0.14, 0.78) shown to be far less powerful in predicting actual be- Stiff knee* 0.74 (0.56, 0.86) haviour change than implementation intentions.18 An Swelling 0.47 (À0.90, 1.00) ‘‘other’’ category was added for people who plan to do other things to help their OA in addition to exercise, *p < 0.001. such as losing weight. We made minor changes to the † p < 0.01. exercise log, adding descriptors for the different types of ICC ¼ intra-class correlation coefficient; F.I.T. ¼ frequency/intensity/time exercise. measure of fitness; BMI ¼ body mass index DISCUSSION who were invited to participate, 5 responded; they had a Most people with hip or knee OA are sedentary and mean 26 years’ experience. All 10 participants completed all questions on the face and content validity rating do not adhere to prescribed home exercise programmes, form. especially after discharge from active physiotherapist- supervised intervention. 15,37 The OGA was developed Content validity of OA Go Away version 2.0 to facilitate this transition to active independent self- CVR was adequate (ranging from 0.80 to 1.0) for 41 of management. Our overall goal in this study was to create a valid and reliable version of the OGA. 43 items (see Appendix 1 online). We made the following changes to create OGA version 3.0 (see Appendix 3 A major strength of this validation study is that it online): For the journal, we added a light aerobic activity followed the COSMIN checklist, a valid tool to rate category to the fitness measure to encourage people who studies reporting measurement properties of health status are inactive to take more realistic intermediate steps measurement instruments. Another strength is that the toward the Health Canada moderate or vigorous exercise OGA was developed and validated with the help of targets. Even though traditional goal and action plan setting includes the list of barriers and a confidence

130 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 national health care experts in the field of OA from a After each phase of the study, we revised the OGA on wide variety of disciplines: rheumatology, research, phys- the basis of measurement properties, results, and feed- iotherapy, occupational therapy, social work, and nursing. back from participants. OGA version 3.0 includes multi- Participants with hip or knee OA were somewhat repre- ple components that reflect the basic tenets of the SRT. sentative of the OA population in Canada. According to Adherence to PA and exercise may be promoted through a 2010 Health Canada survey,38 66% of Canadians with enhanced self-efficacy, which is the most powerful pre- OA are female, and 60% are younger than age 65 years; dictor of initiation and maintenance of health behaviour in our sample, 75% were female, and the mean age change in healthy populations18 and possibly in the OA was 66 years. Our sample was not very diverse, however, population as well.41 because 77% of participants were college or university educated, and only 14% identified themselves as being OGA version 3.0 may be a useful clinical tool tailored of another ethnic origin (European, Asian, Haitian). Thus, to people with OA who are motivated to become active the validity of this tool may differ when used with other through interaction with a physiotherapist who teaches or more diverse populations. them about the potential benefits of PA and prescribes individually tailored, evidence-based approaches to adopt- Construct validity scores comparing key items on the ing a physically active lifestyle regardless of their chronic OGA journal with validated outcome measures assessing condition. We hypothesize that if a physiotherapist similar health outcomes varied from weak to strong coaches them to use the OGA, they will learn the skills correlations. The weak association between OGA difficult to autonomously self-regulate and will subsequently activity (function) scores and SF-36 sub-scales was ex- maintain exercise behaviour. The OGA journal will en- pected, and we therefore did not remove this item; the able them, through self-observation, to create a personal journal is intended to focus on functional difficulties, synopsis of how OA is currently affecting their life in and the weak correlation simply supports the hypothesis terms of altered function, sleep, mood, energy, pain, that difficulties encountered in a single activity requiring stiffness, swelling, fitness, weight, and use of medica- hip or knee integrity do not correlate well with the tions and other treatments (with both personal descrip- cumulative score of several different general functions, tions and ratings). as measured by the SF-36. An interesting finding was that OGA pain scores showed either moderate or strong After completing the journal, users are invited to self- correlations with SF-36 Bodily Pain sub-scale scores and reflect and to use this information to establish realistic ICOAP total pain scores but were moderately or weakly goals of personal importance and to internalize advice correlated with ICOAP intermittent pain and constant from the physiotherapist into a personal action plan. pain scores. The contrast between the two sets of corre- This plan may include self-evaluation of their current ex- lations may be explained by the fact that the OGA pain ercise behaviour (fitness measure) relative to the current score stems from one item representing the total pain Health Canada guidelines. When completing the goals experience (thus similar to the total ICOAP score and and action plan, they should decide on specific, measur- SF-36), whereas the ICOAP intermittent and constant able, achievable, realistic, and timely (SMART) goals that pain scores evaluate two distinct aspects of the pain are linked with their altered function and create a per- experience. sonal action plan (with specifics as to what, how often, how much or how long, when, and where). They should The test–retest scores ranged from 0.02 to 0.94; 8 of reflect on possible barriers to their action plan and iden- the 13 items yielded scores greater than 0.70. According tify ways to overcome these barriers by documenting to experts,36,39 ICC scores should be 0.90 or higher and k strategies to make sure they carry out their plan. The scores should be 0.81 or higher to ensure sufficient in- journal will then help them self-monitor the physical strument stability for individual clinical decision making, activities they have listed in the exercise log. Using the although an ICC of 0.70 or more and a k of 0.61 or more journal every month will help users to think about their are adequate for between-groups research studies.40 gains and losses in outcomes and to determine which In our study, only one score (weight; ICC ¼ 0.94) was physical activities are the most beneficial to them. Ex- higher than 0.90 or 0.81. We removed the two items pecting better outcomes may motivate them to stay with the lowest scores (BMI and F.I.T., ICCs ¼ 0.10 and active.18 0.02, respectively) but retained sleep, pain, function, stiffness, swelling, mood, and energy (ICC or k ¼ 0.40– Our study has several limitations. First, the face and 0.85) because participants considered these items essen- content validity results may not be generalizable to other tial. We also argue that because OA symptoms can be people with hip or knee OA or may vary when patients highly variable from one day to the next, participants use the OGA for a period at home. Because participants may have experienced changes in their disease and viewed the tool only briefly before rating it, their percep- symptoms during the 4- to 7-day period between the tion of the different items may not reflect perceived rele- baseline assessment and the completion of the second vance to daily life over time. A second weakness, accord- OGA. ing to the COSMIN checklist, is that the environments in which the two measures of test–retest reliability were

Paterson et al. Preliminary Validation of a Self-Management Tool to Promote Adherence to Physical Activity in OA 131 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 performed were not the same: Participants completed ning, and an exercise log and has the potential to im- the OGA first at the Arthritis Society’s Ottawa office and prove adherence to exercise. then at home, which may have led to lower estimates of test–retest reliability. This was a pragmatic decision to REFERENCES teach participants to use the tool (during their first visit) but not inconvenience them by requiring them to return 1. Hochberg MC, Altman RD, April KT, et al.; American College of to the office a few days later. Third, the test–retest inter- Rheumatology. 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https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 ARTICLE Learning Curves Observed in Establishing Targeted Rate of Force Application in Pressure Pain Algometry Alicia J. Emerson Kavchak, DPT, PT, MS, OCS, FAAOMPT;* Josiah D. Sault, DPT, PT, OCS, FAAOMPT;* Ann Vendrely, DPT, EdD, PT † ABSTRACT Purpose: To determine whether learning curves can be observed with deliberate practice when the goal is to apply a consistent rate of force at 5 N/second during pressure pain threshold (PPT) testing in healthy volunteers. Methods: In this prospective study, 17 clinician participants completed PPT targeted rate-of-application testing with healthy volunteers using three different feedback paradigms. The resultant performances of ramp rate during 36 trials were plotted on a graph and examined to determine whether learning curves were observed. Results: Clinicians were not consistent in the rate of force applied. None demonstrated a learning curve over the course of 36 trials and three testing paradigms. Conclusion: The results of this study indicate that applying a consistent 5 N/second of force is difficult for practising clinicians. The lack of learning curves observed suggests that educational strategies for clinicians using PPT may need to change. Key Words: hyperalgesia; learning curve; pain measurement; pain perception; psychomotor performance. RE´ SUME´ Objectif : De´ terminer si une courbe d’apprentissage se de´ gage en re´ ponse a` un entraıˆnement de´ libe´ re´ visant a` appliquer un taux de force constant de 5 newtons par seconde (N/s) lors de tests du seuil de douleur a` la pression (PPT pour pressure pain threshold) aupre` s de participants en sante´ . Me´ thodes : Dans cette e´ tude prospective, 17 cliniciens ont re´ alise´ des tests sur des participants en sante´ au moyen de trois modes de re´ troaction. La variation du taux de force observe´ e sur 36 essais a e´ te´ repre´ sente´ e graphiquement afin de de´ terminer si une courbe d’apprentissage se de´ gageait chez les cliniciens. Re´ sultats : Le taux de force applique´ par les cliniciens n’e´ tait pas constant. Une courbe d’apprentissage n’a e´ te´ observe´ e chez aucun d’entre eux au cours des 36 essais, peu importe le mode de re´ troaction. Conclusion : Les re´ sultats de cette e´ tude indiquent qu’il est difficile pour les cliniciens praticiens d’appliquer un taux de force constant de 5 N/s. L’absence de courbe d’apprentissage donne a` penser qu’il pourrait y avoir lieu de revoir les strate´ gies de formation des cliniciens appele´ s a` mesurer le seuil de douleur a` la pression. For both physical therapists and occupational thera- automatic phase, performance demonstrates a steady pists, consistent psychomotor skills are a professional state of efficient and coordinated movement without necessity when completing clinical pain measures. feedback.3 Because this transition from performance to Health care educators have suggested focusing on de- learning is influenced by a wide variety of internal and liberate practice to develop essential psychomotor skills.1 external factors, deliberate practice with concurrent or Boe and colleagues2(p.309) have defined motor learning as terminal augmented feedback3 has been reported to be a ‘‘process where improvements in performance are seen imperative for psychomotor skill acumen to develop via over a series of discrete training sessions, and following a performance modification.1,4 delay and subsequent consolidation of the skill, similar levels of performance are observed on a retention test.’’ When the optimal amount of feedback and trials is Sigrist and colleagues3 have described three phases of unknown, deliberate practice has been mapped on a psychomotor skill acquisition. In the most cognitively learning curve, which is a graphical representation of demanding stage, the motor programme is developed; the change in performance over the number of practice in the second, or associative, phase, error recognition trials (see Figure 1).5 The initial flat line represents the and corrective attempts are noted; and, finally, in the cognitive stage, in which repeated trials produce mini- mal improvements in performance.5 The subsequent From the: *Department of Physical Therapy, University of Illinois Hospital and Health Science Systems, Chicago; †Department of Physical Therapy, College of Health and Human Sciences, Governor’s State University, University Park, Ill. Correspondence to: Alicia J. Emerson Kavchak, Department of Physical Therapy, University of Illinois Hospital and Health Science Systems, 1801 W. Taylor St., Outpatient Care Center, Suite 2C, Chicago, IL 60612; [email protected]. Contributors: All authors designed the study; collected, analyzed, and interpreted the data; drafted or critically revised the article; and approved the final draft. Competing interests: None declared. Physiotherapy Canada 2016; 68(2);133–140; doi:10.3138/ptc.2015-16 133

134 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Figure 1 Ideal learning curve.5 PPT. Early researchers recommended a consistent rate of force application,18,19 but only recently has a protocol upslope indicates movement into the associative stage,5 specified this rate to be 50 kPa/second (5 N/s).20 Other and the start of the second flat line indicates that the studies have found that the inability to maintain a associative phase of learning has been reached, with no consistent rate of force application influences terminal further improvement in performance. The number of PPT.18,19 In the temporal muscles of healthy participants, trials corresponding to this point on the curve is recorded mean terminal PPT varied from 115 (SD 122) kPa/cm2 as the recommended number.5 when the algometer was applied at a slow rate (0.07 N/s) to 253 (SD 155) kPa/cm2 when it was applied at a fast Interest in evaluating altered somatosensory pro- rate (0.68 N/s).19 In people with craniomandibular pain, cessing via quantitative sensory testing (QST) tools has the rate of force application significantly influenced the grown. Pressure pain threshold (PPT), defined as the final threshold.18 point when the intensity of the pressure algometer ‘‘be- comes linked with that of pain,’’6(p.637) has been studied The reliability of terminal PPT has generally been in various acute and chronic pain conditions, including reported to be good in a variety of clinical and research low back pain,7–9 jaw pain,10 patellar tendinopathy,11 settings.9,21–24 Intra-rater reliability has been reported knee osteoarthritis,12 whiplash-associated disorder,13 and to range from an intra-class correlation (ICC) of 0.94 neck pain.14 PPT is a method-of-limits test (i.e., the par- (standard error of measurement [SEM] 4.5) to 0.97 (SEM ticipant must respond to stop the application of the 18.2);21 in the same cohort of testers, interrater reliability test),15 which makes the participant’s response time an varied from an ICC of 0.79 (SEM 52.5) to 0.84 (SEM influencing variable.15 The neurophysiological changes 59.2),21 and in another cohort it reached a high of 0.91 that occur during musculoskeletal pain can also influ- (SEM 6.7).23 Finally, test–retest reliability ICCs have ence PPT; for example, temporal summation can occur ranged from 0.76 (SEM 48.9)21 to 0.9824 These findings in response to repeated application of a stimulus (i.e., meet the cutoff threshold for good reliability (ICC although a single application of the stimulus may not b0.75).25(p.595) However, the large SEMs reported limit be painful, the same stimulus repeated can result in precision and invite caution with this interpretation. increased pain).16 A study specific to PPT demonstrated a decreased threshold when the same force intensity was Two recent studies have examined the rate of force applied with less time allowed between applications.17 application.23,26 Rolke and colleagues26(p.40) found that the actual mean rate of force application, when ‘‘checked Clinically, a lowered PPT, or hyperalgesia, may sug- in a few subjects,’’ was 55 (SD 5) kPa/s. In one of the gest underlying sensitized peripheral nociceptors when most detailed descriptions of training, the participants found at a site local to the injury or central sensitization blinded to the rate of force application were considered when found at sites distal to the injury.16 PPT has also to have demonstrated reliable rate of force application been proposed to be helpful in clinical decision making when they applied a fixed-angle algometer at a rate of and prognosis:8,13 In people with whiplash-associated 5 N/second over 10 seconds in 5 consecutive trials.23 disorder, lowered PPT demonstrated distally in the leg ‘‘On the first attempt,’’23(p.762) all participants applied was predictive of increased self-reported disability.13 the algometer at the target rate of 5 N/second in five consecutive trials. Reliability is integral to the clinical interpretation of Previously identified methodological limitations include a lack of detail on rate of application and on tester train- ing.27 Interestingly, three of five studies9,22,24 did not report the amount of training, and the remaining two reported training to be 1 hour21 and a ‘‘single day.’’23(p.761) The lack of details on training in PPT testing is not consistent with other medical education for psychomotor skill learning.1 The currently reported training protocols for PPT test- ing21,23 may be insufficient for the psychomotor skill of applying targeted rate of force during PPT testing. Although practising clinicians need to learn how to use QST tools, the literature contains few descriptions of actual educational strategies for rate of force application. The purpose of our study, therefore, was to determine whether learning curves could be observed with deliberate practice when the goal was to apply a consistent rate of force of 5 N/second during PPT in healthy volunteers.