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Supplemental Digital Content is Available in the Text. Background: The leading cause of injuries among older adults in the United States is unintentional falls. The American Geriatrics Society/British Geriatrics Society promote fall risk management in primary care; however, this is challenging in low-resource settings. Local Problem: Archer Family Health Care (AFHC), an Advanced Practice Registered Nurse (APRN)–managed and federally designated rural health clinic, identified a care gap with falls adherence to guidelines for patients at higher risk for falls. Methods: The aim of this quality improvement effort was to integrate an evidence-based fall risk management tool in a rural nurse-managed primary care practice. A standardized fall risk management process with a new brief paper-based clinical decision support (CDS) tool was developed and tested in two phases. Intervention: Phase 1 focused on developing a fall risk management CDS tool, identifying the primary care visit workflow, communicating the workflow patterns to the AFHC staff, and collaborating with the staff to identify when and who should implement the tool. Phase 2 focused on implementation of the fall risk management CDS tool into standard practice among older adults aged 65 years and older. Results: We found that integrating the tool did not disrupt the workflow of primary care visits at AFHC. The most common recommended intervention for patients at risk of falling was daily vitamin D supplementation. Conclusion: This project revealed that it is feasible to introduce a brief fall risk management decision support tool in an APRN-managed rural primary care practice. [ABSTRACT FROM AUTHOR]

The important goals of Magnet® hospitals are to create supportive professional nursing care environments. A recently published paper found little difference in work environments between Magnet and non-Magnet hospitals. The aim of this study was to determine whether work environments, staffing, and nurse outcomes differ between Magnet and non-Magnet hospitals. A secondary analysis of data from a 4-state survey of 26,276 nurses in 567 acute care hospitals to evaluate differences in work environments and nurse outcomes in Magnet and non- Magnet hospitals was conducted. Magnet hospitals had significantly better work environments (t = -5.29, P < .001) and more highly educated nurses (t = -2.27, P < .001). Magnet hospital nurses were 18% less likely to be dissatisfied with their job (P <.05) and 13% less likely to report high burnout (P < .05). Magnet hospitals have significantly better work environments than non-Magnet hospitals. The better work environments of Magnet hospitals are associated with lower levels of nurse job dissatisfaction and burnout. [ABSTRACT FROM AUTHOR]

INTRODUCTION Ankle-foot orthoses (AFOs) are commonly prescribed to treat a range of lower-limb deficits by providing ankle support during walking. Current prescription standards provide general guidelines for choosing between AFO types but are limited in terms of guiding specific design parameter choices. AFO design parameters; e.g., trimlines, thickness, and material type, affect the AFO’s torsional stiffness (Major, 2004). In order to prescribe the best designs for their patients, clinicians need to know if and how stiffness affects patient outcomes. Therefore, the purpose of this literature review was to determine the impact of AFO torsional stiffness on walking performance. METHOD A literature search was conducted during February 2018 using three databases (Pubmed, Engineering Village, and Web of Science), PRISMA guidelines (Moher, 2009), and the following search terms: (ankle-foot orthosis OR AFO OR ankle foot orthosis) AND (stiffness OR resistance OR compliance OR rigidity OR flexibility OR energy storage OR energy return) AND (gait OR walking OR outcomes OR performance). Potentially relevant articles were screened against the following exclusion criteria: (1) no experimental subject data was presented; (2) the study did not include an AFO/AFO-like device; (3) no comparisons were drawn across stiffness conditions or only one stiffness was tested for each subject; (4) the intervention applied powered assistance and not passive resistance at the ankle; (5) AFO stiffness varied (was not constant) within a single stiffness condition; and (6) the study did not include a walking activity. The remaining articles were further analyzed, and their quality was assessed by three independent reviewers using a 10-point modified PEDro scale (Tyson, 2013). Each was scored by reviewer consensus. RESULTS After applying the exclusion criteria, 26 of 287 potential articles were included. A majority of the studies had low to moderate quality scores (i.e., below 7/10); the highest rating received was 8/10. Only one study ensured subjects were blinded to the test conditions, only three included sufficient participant eligibility criteria, and 11 papers failed to perform between-group statistical analyses. The included papers tested a variety of stiffnesses (0.02 to 8.17 Nm/ deg), covered several populations (healthy, post-stroke, cerebral palsy, Charcot-Marie-Tooth, and lower-limb salvage and trauma), and reported a variety of outcome measures. Nineteen of 26 studies measured stiffness experimentally. Measurement methods differed between studies. Ankle kinematics parameters were the most frequently reported and consistently affected measures. Greater stiffnesses generally resulted in decreased peak ankle plantar flexion, dorsiflexion, and range of motion, as well as increased initial contact ankle angle. At the knee, increased stiffness caused reduced peak knee extension during stance, increased peak knee flexion during stance, and increased knee flexion at initial contact. There was low evidence for the effect of stiffness on hip or pelvis kinematics. Stiffness did not affect hip kinetics, and there was low evidence for its effects on ankle and knee kinetics, muscle activity, metabolics, ground reaction force pattern, and gait spatiotemporal parameters. There were no generalizable trends for the impact of stiffness on user preference. DISCUSSION Drawing comparisons between the studies proved difficult due to differences in stiffness reporting and measurement, and the low number of participants for each subject population. Others have also highlighted the lack of established standards for reporting AFO design variables (Malas, 2011) and patient deficits (Chisholm, 2012). Nonetheless, stiffness consistently affected distal joint kinematics. CONCLUSION AFO torsional stiffness is a key factor influencing ankle movement. Clear reporting standards for AFO design parameters, as well as additional higher quality research is needed with larger sample sizes and different clinical populations to ascertain the true effect of stiffness on gait. [ABSTRACT FROM AUTHOR]

INTRODUCTION Cerebral palsy (CP) has been identified as the most common motor disability in childhood. Lower-limb orthoses are frequently worn by this population with the general treatment objectives of improving function and maintaining or increasing range of motion (Wingstrand, 2014). Unfortunately, inadequate descriptions of both the participating subjects and the AFOs utilized in clinical trials, as well as frequent heterogeneity in both patient presentation and device design have precluded high-level conclusive evidence (systematic review and meta-analysis) related to comparative efficacy between AFO design variants. However, comparative efficacy between the use and nonuse of AFOs has become increasingly established (Neto, 2012; Bourseul, 2016; Aboutorabi, 2017; Lintanf, 2018). The purpose of this guideline is to identify and present in greater detail the established indications, benefits, and shortcomings that have been observed and validated in systematic reviews and metaanalyses related to the use of AFOs in the management of children with CP. METHOD A systematic review was conducted to identify systematic reviews and meta-analyses summarizing primary literature reporting upon the impact of lower-limb orthoses in children with CP. RESULTS Four systematic reviews/meta-analyses were identified. These reviews reported upon an average of 18 trials (range, 7–31) (Neto, 2012; Bourseul, 2016; Aboutorabi, 2017; Lintanf, 2018) inclusive of an average of 837 patients (range, 490–1129) (Bourseul, 2016; Aboutorabi, 2017; Lintanf, 2018). Individual reviews used a range of search engines. Methodologic quality assessments were performed using the PEDro scale (Neto, 2012; Aboutorabi, 2017) and a modified PEDro scale (Bourseul, 2016; Lintanf, 2018). Only those papers graded at a quality of “moderate evidence” were considered. Evidence statements relating to comparative efficacy (AFO vs no AFO), benefits and potential harms were extracted from each systematic review/meta-analysis. Observations and considerations related to potential benefits included gross motor function, temporospatial gait considerations, key kinematic variables, kinetic observations, and metabolic considerations. Potential harms were confined to potential compromise to peak power generation associated with the use of most orthoses. DISCUSSION The following recommendations were synthesized from the identified secondary knowledge sources and their extracted evidence statements as clinical practice guidelines regarding the indications, observed benefits, and shortcomings associated with the use of AFOs in children with CP. Recommendation #1: Among children with CP, AFOs are indicated to increase gross motor function (Aboutorabi, 2017; Lintanf, 2018). Recommendation #2: Among children with spastic CP and equinus, AFOs are indicated to increase stride length and gait speed and decrease cadence, with greater impacts observed in children with hemiplegia than in diplegia (Bourseul, 2016; Aboutorabi, 2017; Lintanf, 2018). Recommendation #3: Among children with spastic CP and equinus, AFOs are indicated to increase ankle dorsiflexion during swing phase and at initial contact (Bourseul, 2016; Aboutorabi, 2017; Lintanf, 2018). Recommendation #4: AFOs may have an effect on ankle power generation during ambulation (Bourseul, 2016; Lintanf, 2018). CONCLUSION While additional research is needed to determine which patient types are most likely to attain the desired benefits associated with an AFO and which AFO design variants are most appropriate across this range of patient presentations, a number of general indications and benefits have been observed at the level of systematic review and meta-analysis. [ABSTRACT FROM AUTHOR]