Experienced Clinical Decision Making in Physical Therapist Management of Concussion: A Qualitative Study

OBJECTIVE

The recent publication of the Physical Therapy Evaluation and Treatment After Concussion Clinical Practice Guideline is intended to assist clinicians in their decision making specific to evaluation and intervention. Clinical practice guidelines are supported by best available evidence, though it is unknown what other factors drive clinical decision making in the realm of concussion management. The purpose of this study was to explore factors related to the process of clinical decision making of experienced physical therapists who treat individuals with concussion.

METHODS

This grounded theory approach utilized semi-structured interviews of physical therapists who have practiced concussion management ≥3 years and have treated ≥15 individuals for post-concussion symptoms in the last year. Following the inductive approach, deductive qualitative methodology was utilized to explore alignment with recent guidelines. Member checking was used to ensure trustworthiness.

RESULTS

Ten therapists' experience in treating concussion ranged from 5 to 20 years. Four overarching themes were identified that contribute to clinical decision making: expert practice behaviors through use of reflection in action, clinical reasoning, collaboration, and evidenced informed practice; therapeutic alliance building using individualized education, reassurance, and relationship building; adaptability in prioritizing, assessing, and responding to patient's needs; and listening and observing. Clinician decision making statements showed alignment with clinical practice guideline recommendations.

CONCLUSIONS

Experienced therapists demonstrate a consistent approach that parallels the current clinical practice guideline while building off clinical experience to tailor individualized care focusing on patient centeredness. These factors may assist more novice clinicians to develop and improve their management strategies for optimal outcomes.

IMPACT

Identified themes may broaden frameworks and guidelines for the management of individuals post-concussion specific to the field of physical therapy.

Using Mean Absolute Relative Phase, Deviation Phase and Point-Estimation Relative Phase to Measure Postural Coordination in a Serial Reaching Task

The objectives of this communication are to present the methods used to calculate mean absolute relative phase (MARP), deviation phase (DP) and point estimate relative phase (PRP) and compare their utility in measuring postural coordination during the performance of a serial reaching task. MARP and DP are derived from continuous relative phase time series representing the relationship between two body segments or joints during movements. MARP is a single measure used to quantify the coordination pattern and DP measures the stability of the coordination pattern. PRP also quantifies coordination patterns by measuring the relationship between the timing of maximal or minimal angular displacements of two segments within cycles of movement. Seven young adults practiced a bilateral serial reaching task 300 times over 3 days. Relative phase measures were used to evaluate inter-joint relationships for shoulder-hip (proximal) and hip-ankle (distal) postural coordination at early and late learning. MARP, PRP and DP distinguished between proximal and distal postural coordination. There was no effect of practice on any of the relative phase measures for the group, but individual differences were seen over practice. Combined, MARP and DP estimated stability of in-phase and anti-phase postural coordination patterns, however additional qualitative movement analyses may be needed to interpret findings in a serial task. We discuss the strengths and limitations of using MARP and DP and compare MARP and DP to PRP measures in assessing coordination patterns in the context of various types of skillful tasks. Key pointsMARP, DP and PRP measures coordination between segments or joint anglesAdvantages and disadvantages of each measure should be considered in relationship to the performance taskMARP and DP may capture coordination patterns and stability of the patterns during discrete tasks or phases of movements within a taskPRP and SD or PRP may capture coordination patterns and stability during continuous oscillating movement tasks.

Changes in standing postural control during acquisition of a sequential reaching task

Postural control acquired during learning functional reaching movements has not been well examined. Fourteen healthy adults practiced a serial reaching task 300 times. Task acquisition was examined considering two types of action-goals [1]: hand accuracy and consistency as the focal action-goals and control of equilibrium as the postural action-goal [2,3]. Hand accuracy and consistency were measured as absolute constant error and variable error. Postural control was measured by time to boundary (TtB). Improvements were expected in the focal goals and postural goal; however the timing of improvements might reflect explicit and implicit learning processes. Practice effects resulted in improvements for hand task accuracy, consistency and an increase in TtB values. Changes in postural control may reflect improved efficiency or improved perception-action coupling by the postural system within task performance.