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Background Behavior change is not simple, and the introduction of guidelines or protocols does not mean that they will be followed. As such, implementation strategies are vital for the uptake and sustainability of changes in medical protocols. Medical or mental emergencies may be life-threatening, especially in children due to their unique physiological needs. In emergency departments (EDs), where timely decisions are often made, practice change requires thoughtful considerations regarding the best approaches to implementation. As there are many studies reporting on a wide variety of implementation strategies in the emergency management of children in EDs, we aim to identify and map the characteristics of these studies. Methods We will conduct a scoping review to identify various implementation strategies in the emergency management of children using the Arksey and O’Malley framework. We will search MEDLINE (Ovid), Embase (Ovid), Cochrane Central (Wiley), and CINAHL (Ebsco), from inception to May 29, 2019, for implementation studies among the pediatric population (≤ 21 years) in a pediatric emergency setting. Two pairs of reviewers will independently select studies for inclusion and extract the data. We will perform a descriptive, narrative analysis of the characteristics of the identified implementation strategies. Discussion We will present specific characteristics and outcome measures of all included studies in a tabular form. The results of this review are expected to help identify and characterize successful implementation strategies in the emergency management of children in EDs. Systematic review registration Open Science Framework https://osf.io/h6jv2

Background Most implementation interventions in rehabilitation, including physiotherapy, have used passive, non-theoretical approaches without demonstrated effectiveness. The goal of this study was to improve an important domain of physiotherapy practice – reactive balance measurement – with a targeted theory-based multi-component intervention developed using the Theoretical Domains Framework. The primary objective was to determine documented reactive balance measure use in a 12-month baseline, during, and for three months post- intervention. Methods An uncontrolled before-and-after study was completed with physiotherapists at three urban adult rehabilitation hospitals in Ontario, Canada. The 12-month intervention included group meetings, local champions, and health record modifications for a validated reactive balance measure. The primary outcome was the proportion of records with a documented reactive balance measure when balance was assessed pre-, during- and post-intervention. Secondary outcomes were changes in use, knowledge, and confidence post-intervention, differences across sites, and intervention satisfaction. Results Reactive balance was not measured in any of 211 eligible pre-intervention records. Thirty-three physiotherapists enrolled and 28 completed the study. Reactive balance was measured in 31% of 300 eligible records during-intervention, and in 19% of 90 eligible records post-intervention (p

Background and Objectives Since the launch of Dublin City University’s Age-Friendly University (AFU) Initiative in 2012, relatively little empirical research has been published on its feasibility or implementation by institutions of higher learning. This article describes how collaborative citizen science—a research method where professional researchers and community members work together across multiple stages of the research process (e.g., data collection, analysis, and/or knowledge mobilization) to investigate an issue—was used to identify barriers and supports to university age-friendliness at the University of Manitoba (UofM) in Canada. Research Design and Methods Ten citizen scientists each completed 1 data collection walk around the UofM campus and used a tablet application to document AFU barriers and supports via photographs and accompanying audio commentaries. The citizen scientists and university researchers then worked together in 2 analysis sessions to identify AFU priority areas and brainstorm recommendations for institutional change. These were then presented to a group of interested university stakeholders. Results The citizen scientists collected 157 photos documenting AFU barriers and supports on campus. Accessibility, signage, and transportation were identified as being the most pressing issues for the university to address to improve overall age-friendliness. Discussion and Implications We suggest that academic institutions looking to complete assessments of their age-friendliness, particularly those exploring physical barriers and supports, could benefit from incorporating older citizen scientists into the process of collecting, analyzing, and mobilizing findings.

During the COVID-19 pandemic, in-person exercise programs for older people were temporarily closed, and some were replaced with online exercise. We explored the online exercise experiences of older people in Manitoba, Canada, using an online survey. We recruited a convenience sample (≥ 65 years), primarily through community organizations, and 745 people (57.5% female) consented. About 38.2% reported participating in online exercise during the pandemic. Most used pre-recorded classes (80.4%), from their local community (79.7%), and YouTube was the most used platform (57.4%). Almost all (82.7%) found the classes had the right variety and intensity. Of those who had participated in online exercise, 67.0% said they would participate in an online exercise class outside of a pandemic time. Participants like the following aspects better about online exercise: no transportation arrangements, it doesn’t matter what they wear, no travel time, and they like to exercise without others seeing them. However, they also miss being with and socializing with others, and they reported feeling unsafe when the instructor cannot see them. Of those who did not participate online, several reasons were given: they prefer to exercise with others in the same room, they prefer to exercise with an instructor directly present, no appropriate device, and their internet is not reliable. Many also provided examples of future circumstances when they might participate online, including: when the weather is not conducive to outdoor exercise, and if they can overcome technical issues. Lessons learned from this study can help those delivering online exercise in the future.

Walking is an important component of daily life requiring sensorimotor integration to be successful. Adding haptic input via light touch or anchors has been shown to improve standing balance; however, the effect of adding haptic input on walking is not clear. This scoping review systematically summarizes the current evidence regarding the addition of haptic input on walking in adults. Following an established protocol, relevant studies were identified using indexed data bases (Medline, EMBASE, PsychINFO, Google Scholar) and hand searches of published review articles on related topics. 644 references were identified and screened by a minimum of two independent researchers before data was extracted from 17 studies. A modified TREND tool was used to assess quality of the references which showed that the majority of studies were of moderate or high quality. Results show that adding haptic input changes walking behaviour. In particular, there is an immediate reduction in variability of gait step parameters and whole body stability, as well as a decrease in lower limb muscle activity. The effect of added haptic input on reflex modulation may depend on the limb of interest (i.e., upper or lower limb). Many studies did not clearly describe the amount and/or direction of haptic input applied. This information is needed to replicate and/or advance their results. More investigations into the use and design of the haptic tools, the attentional demands of adding haptic input, and clarity on short-term effects are needed. In addition, more is research needed to determine whether adding haptic input has significant, lasting benefits that may translate to fall prevention efforts.

Purpose: This study was conducted to determine the balance assessment practices of physiotherapists in Saskatchewan. Methods: Practising physiotherapists who assess and treat adults with balance and mobility impairments were eligible to participate in this cross-sectional, online survey. The questions investigated the use of balance assessment measures, the balance components assessed, and practice area. Results: Of the 72 respondents, most reported regularly assessing five or more of the nine balance components listed. Movement observation was the most commonly reported measure used, followed by the Berg Balance Scale, single-leg stance test, and tandem standing/walking. Conclusions: Most physiotherapists in Saskatchewan use a variety of tools to assess balance. Gaps in practices related to fall prevention were noted in the mismatch between the tools used and the components reportedly assessed.

Background The concept of patient engagement in health research has received growing international recognition over recent years. Yet despite some critical advancements, we argue that the concept remains problematic as it negates the very real complexities and context of people’s lives. Though patient engagement conceptually begins to disrupt the identity of “researcher,” and complicate our assumptions and understandings around expertise and knowledge, it continues to essentialize the identity of “patient” as a homogenous group, denying the reality that individuals’ economic, political, cultural, subjective and experiential lives intersect in intricate and multifarious ways. Discussion Patient engagement approaches that do not consider the simultaneous interactions between different social categories (e.g. race, ethnicity, Indigeneity, gender, class, sexuality, geography, age, ability, immigration status, religion) that make up social identity, as well as the impact of systems and processes of oppression and domination (e.g. racism, colonialism, classism, sexism, ableism, homophobia) exclude the involvement of individuals who often carry the greatest burden of illness — the very voices traditionally less heard in health research. We contend that in order to be a more inclusive and meaningful approach that does not simply reiterate existing health inequities, it is important to reconceptualize patient engagement through a health equity and social justice lens by incorporating a trauma-informed intersectional analysis. Summary This article provides key concepts to the incorporation of a trauma-informed intersectional analysis and important questions to consider when developing a patient engagement strategy in health research training, practice and evaluation. In redefining the identity of both “patient” and “researcher,” spaces and opportunities to resist and renegotiate power within the intersubjective relations can be recognized and addressed, in turn helping to build trust, transparency and resiliency — integral to the advancement of the science of patient engagement in health research.

ObjectivesExamine the characteristics of patient engagement (PE) practices in exercise-based randomized trials in type 1 diabetes (T1D), and facilitate T1D stakeholders in determining the top ten list of priorities for exercise research.DesignTwo methodological approaches were employed: a scoping review and a modified James Lind Alliance priority-setting partnership.MethodsPublished (Medline, Embase, CINAHL, and Central databases) and grey literature (www.clinicaltrials.gov) were searched to identify randomized controlled trials of exercise interventions lasting minimum four weeks and available in English. We extracted information on PE and patient-reported outcomes (PROMs) to identify if patient perspectives had been implemented. Based on results, we set out to determine exercise research priorities as a first step towards a patient-engaged research agenda. An online survey was distributed across Canada to collect research questions from patients, caregivers and healthcare providers. We qualitatively analyzed submitted questions and compiled a long-list that a twelve-person stakeholder steering committee used to identify the top ten priority research questions.ResultsOf 9,962 identified sources, 19 published trials and 4 trial registrations fulfilled inclusion criteria. No evidence of PE existed in any included study. Most commonly measured PROMs were frequency of hypoglycemia (n=7) and quality of life (n=4). The priority-setting survey yielded 194 submitted research questions. Steering committee rankings identified 10 priorities focused on lifestyle factors and exercise modifications to maintain short-term glycemic control.ConclusionRecent exercise-based randomized trials in T1D have not included PE and PROMs. Patient priorities for exercise research have yet to be addressed with adequately designed clinical trials.

Background People after stroke often have postural impairments that can increase their risk of falling. Anticipatory postural adjustments (APAs) are changes in the activity of postural muscles prior to a voluntary movement in order to maintain vertical equilibrium. Previous research suggests that improving APAs leads to better postural control and reduces the risk of falls. Despite the importance of APAs and their impairment among people post-stroke, studies that aim to investigate methods for improving APAs are limited. Consistent evidence supports that an external focus of attention compared to an internal focus of attention, yields superior performance of motor skills that include postural control. Research question What are the effects of adopting different foci of attention on measures of APAs and movement parameters when performing a lower extremity Fitts’ task among people post-stroke? Methods Twelve individuals post-stroke performed a lower extremity stepping movement (Fitts’ task) while adopting an external focus or an internal focus of attention in a within-subject design. A motion capture system was used to record participants’ movement data. Custom software derived movement time (MT), peak velocity (PV), time to peak velocity (ttPV) and variability at endpoint (SDT). Electromyography was used to measure muscle activity and determine APAs onset and magnitude. For all dependent variables separate repeated measures ANOVAs were conducted to compare performance between foci of attention. Results The results showed that an external focus of attention yielded significantly better performance on all outcome measures. The improvement in performance was seen in shorter MT, higher PV, shorter ttPV, smaller SDT, earlier APAs onset and more efficient APAs magnitude. Significance The changes in outcome measures suggest that adopting an external focus of attention during postural tasks could be an effective strategy for improving balance control among people post-stroke.

BACKGROUND There is a documented need to build capacity for theory- and evidence-informed knowledge translation (KT) and patient engagement (PE) practice in health research. Dissemination of foundational content online coupled with social media promotion may build capacity by increasing awareness, knowledge, and positive attitudes. OBJECTIVE This retrospective study sought to (1) describe exposure and engagement of the KnowledgeNudge KT and PE dissemination strategy (online blog and Twitter profile) over 2 years and (2) identify and compare characteristics of individual posts with the most and least exposure and reach. METHODS Exposure was assessed by blog site views per month and Twitter profile impressions per month. Engagement was assessed by Twitter profile interactions per month. Descriptive statistics were calculated for 6-month blocks and compared using one-way analysis of variance or Student t test. Individual post exposure was assessed by average post views per week. Individual post reach was assessed by average post reads per week. High- and low-profile blog posts with the highest and lowest 10th percentile for exposure and reach were identified. RESULTS A total of 99 posts and 755 tweets were published during the study period. There was a significant increase in exposure (P=.004) and reach (PP=.003). There were no other significant differences between posts. CONCLUSIONS The increases in KnowledgeNudge exposure and engagement offer preliminary evidence in support of this dissemination strategy for the practice of KT and PE. Variation in individual post exposure and reach warrants further exploration to tailor content to user needs. Future work will include a prospective evaluation strategy to explore the effect of KnowledgeNudge on awareness, knowledge, attitudes, and behavior.

Background Medication reviews are a structured clinical intervention with the general goals of improving patient drug knowledge and detecting and resolving drug-related problems in an individual patient's medication regimen. A variety of barriers entrenched in the traditional drug distribution and dispensing model of pharmacy business has continued to challenge the implementation efforts of medication review services worldwide in the community pharmacy setting. Main objectives i) Characterize original research studies that sought to enhance medication review service implementation in community pharmacy settings. ii) Categorize the broader corpus of scientific literature (beyond original implementation studies) on medication review service implementation in community pharmacy settings. Methods A broad systematic search strategy was applied to ovid MEDLINE, Embase, CINAHL and Cochrane Library to create an over-arching view and extensively ordered bibliography of the diverse research publication types dealing with the topic of medication review service implementation in the community pharmacy setting. A scoping review was subsequently conducted on original research studies that utilized various strategies to enhance the implementation of this service in community pharmacies. Data-charting evaluated the location of implementation studies, the strategies undertaken, the scale of implementation strategies, the use of DII (Dissemination, Implementation and Improvement) science theory, sample sizes, and DII outcomes. Results Of 5947 records screened, 419 fulfilled the inclusion criteria (from abstract screening) to be deemed suitable for categorization and inclusion into the broader survey on this topic. Of these 419 publications, only 75 were original research specifically focused on enhancing the implementation of medication reviews in community pharmacy. A large majority of the publications were qualitative studies (n = 203). The remaining articles were improvement studies (n = 36), descriptive observational studies (n = 49), reviews (n = 69) and methodology papers (n = 16). Twenty-nine of these articles were deemed suitable for inclusion in more than one category. After full-text screening, 41 of the 75 implementation publications, representing 40 original studies, published between 1999 and 2019, were eligible for data-charting. The majority of these studies occurred in North America (n = 30), used some form of education as the most common implementation strategy (n = 22) and measured ‘adoption’ (extent or frequency of medication reviews delivered) most frequently as an implementation outcome (n = 30). Just over half of the studies used a multi-faceted implementation strategy (n = 21). Only 9 studies used a theory, model or framework at any point in the research process to test hypotheses or explain empirical findings. Conclusions There is an abundance of publications addressing various issues surrounding medication review implementation in community pharmacies. However, the literature appears disproportionately represented by qualitative studies. There is also a need for more rigorously conducted implementation studies on medication review services in community pharmacy.

Background Effective fall prevention exercise for community-dwelling older adults requires (i) challenging balance exercise, (ii) offered at least 3 hrs/ week, and (iii) on an ongoing basis, to reduce falls. Community exercise programs are a potential implementation strategy for fall prevention exercise; however, the extent to which they address balance and include effective fall prevention exercise is unknown. Study objectives were to describe program delivery, exercise design, and assessment characteristics of older adult community exercise programs in Winnipeg, Canada; determine if they included effective fall prevention exercise; determine the balance challenge and components of postural control addressed in the most- and least-frequently reported exercises. Methods A public inventory of older adult community exercise programs served as the sampling frame for cross-sectional telephone questionnaires exploring program, exercise, and assessment characteristics. Exercises were coded independently by two investigators for balance challenge level and components of postural control. Programs were categorized by number of effective fall prevention exercise components established by evidence-based recommendations. Descriptive statistics were calculated. Results Thirty-three eligible programs were identified and nine individuals participated. Most programs (n = 5, 56%) identified as general exercise, and two (22%) as fall prevention exercise. Most programs (n = 5, 56%) were offered two or more times/ week and reported exercise intensity as somewhat challenging. Exercise time offered ranged between 1 and 3 h/ week. Assessments were conducted in two programs (22%). Only one program (general exercise) included all components of effective fall prevention exercise. Two programs (22%) included the component of being offered at least 3 hrs/ week. Three programs (33%) included the component of being offered on an ongoing basis. Seven programs (78%) prescribed mostly moderate challenge balance exercise, and one program (11%) prescribed mostly high challenge exercise. Most of the 19 most-frequently prescribed exercises (n = 17, 89%) targeted static stability and none targeted reactive postural control. Conclusions Most of the older adult community exercise programs participating in this study did not focus on fall prevention, and did not include all components of effective fall prevention exercise. Future studies should focus on fall prevention programs and explore factors influencing implementation of effective fall prevention exercise components to facilitate planning. Electronic supplementary material The online version of this article (10.1186/s12877-019-1224-x) contains supplementary material, which is available to authorized users.

Background Research partnership approaches, in which researchers and stakeholders work together collaboratively on a research project, are an important component of research, knowledge translation, and implementation. Despite their growing use, a comprehensive understanding of the principles, strategies, outcomes, and impacts of different types of research partnerships is lacking. Generating high-quality evidence in this area is challenging due to the breadth and diversity of relevant literature. We established a Coordinated Multicenter Team approach to identify and synthesize the partnership literature and better understand the evidence base. This review protocol outlines an innovative approach to locating, reviewing, and synthesizing the literature on research partnerships. Methods Five reviews pertaining to research partnerships are proposed. The Coordinated Multicenter Team developed a consensus-driven conceptual framework to guide the reviews. First, a review of reviews will comparatively describe and synthesize key domains (principles, strategies, outcomes, and impacts) for different research partnership approaches, within and beyond health (e.g., integrated knowledge translation, participatory action research). After identifying commonly used search terminology, three complementary scoping reviews will describe and synthesize these domains in the health research partnership literature. Finally, an umbrella review will amalgamate and reflect on the collective findings and identify research gaps and future directions. We will develop a collaborative review methodology, comprising search strategy efficiencies, terminology standardization, and the division of screening, extraction, and synthesis to optimize feasibility and literature capture. A series of synthesis and scoping manuscripts will emerge from this Coordinated Multicenter Team approach. Discussion Comprehensively describing and differentiating research partnership terminology and its domains will address well-documented gaps in the literature. These efforts will contribute to and improve the quality, conduct, and reporting of research partnership literature. The collaborative review methodology will help identify and establish common terms, leverage efficiencies (e.g., expertise, experience, search and protocol design, resources) and optimize research feasibility and quality. Our approach allows for enhanced scope and inclusivity of all research user groups and domains, thereby contributing uniquely to the literature. This multicenter, efficiency and quality-focused approach may serve to inspire researchers across the globe in addressing similar domain challenges, as exist in this rapidly expanding field. Electronic supplementary material The online version of this article (10.1186/s13643-018-0879-2) contains supplementary material, which is available to authorized users.

Anticipatory postural adjustments (APAs) are an integral part of standing balance. Previous research with balance control has shown that adopting an external focus of attention, compared to an internal focus of attention, yields better performance during motor skills. Despite the importance of APAs, especially among older adults, and the potential benefits of adopting an external focus of attention, studies investigating methods for improving APAs are limited. The aim of this study was to compare behavioral, kinematic and APAs measures while adopting different foci of attention among young and older adults when performing a lower extremity Fitts’ task. Ten young adults (mean age 24 years ± 4.37) and ten older adults (mean age 75 years ± 5.85) performed a lower-extremity reaching task (Fitts’ task) while adopting an external focus (focus on target) and an internal focus (focus on limb) in a within-subject design. A motion capture system was used to record participants’ movement data. Custom software derived movement time (MT), peak velocity (PV), time to peak velocity (ttPV) and variability at target (SDT). Electromyography (EMG) was used to determine APAs onset and magnitude. The findings showed that an external focus of attention led to significantly shorter MT, higher PV, shorter ttPV and more accuracy when reaching the target (SDT) for both age groups. Also, EMG results showed that, with an external focus, APAs onset occurred earlier and APAs magnitude was more efficient. As predicted by Fitts’ Law, participants spent more time executing movements to targets with higher indices of difficulty. Older adults compared to young adults were more adversely affected by the increase of difficulty of the Fitts’ task, specifically, on measures of APAs. In conclusion, adopting an external focus of attention led to better overall movement performance when performing a lower extremity Fitts’ task. The task used in the present study can distinguish between APAs for older and young adults. We recommend that future studies expand on our findings in order to establish a performance-based objective measure of APAs to assess clinical interventions for postural control impairment.

Background Systematic reviews have established that exercise reduces falls in older adults, however the most effective types of exercise are not known. This secondary analysis determined the comparative effectiveness of fall prevention exercise approaches. Method All fall prevention exercise interventions for older adults were identified from an existing search from inception until April 2017. Interventions were coded using a framework of 25 exercise types. Two reviewers independently screened studies, extracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis (NMA) were conducted. P-scores were used to rank exercise combinations. Results One hundred and sixty-nine studies were included. NMA was conducted on 73 studies (30,697 participants) for the outcome of number of fallers. The exercise combination ranked with the greatest likelihood of being most effective relative to no exercise was: anticipatory control, dynamic stability, functional stability limits, reactive control and flexibility (p-score = 0.95). This exercise combination also significantly reduced number of fallers compared to 16 other combinations. No exercise combination had a significantly greater effect on reducing number of fallers more than this combination. Conclusion This analysis identified components of effective fall prevention exercise. The results can inform evidence-informed exercise recommendations and be used to design effective programs.

Background Educating people with stroke about community-based exercise programs (CBEPs) is a recommended practice that physical therapists are well positioned to implement. Objective The aim of this study was to evaluate the provision of education about CBEPs to people with stroke, barriers to providing education, and preferences for resources to facilitate education among physical therapists in neurological practice. Design A cross-sectional e-survey of physical therapists treating adults with stroke in Ontario, Canada, was conducted. Methods A link to the questionnaire was emailed to physical therapists in a provincial stroke network, a provincial physical therapy association, and on hospital and previous research lists. Results Responses from 186 physical therapists were analyzed. The percentage of respondents who reported providing CBEP education was 84.4%. Only 36.6% reported typically providing education to ≥7 out of 10 patients with stroke. Physical (90.5%) and preventative (84.6%) health benefits of exercise were most frequently discussed. Therapists reported most commonly delivering education at discharge (73.7%). Most frequently cited barriers to educating patients were a perceived lack of suitable programs (53.2%) and a lack of awareness of local CBEPs (23.8%). Lists of CBEPs (94.1%) or brochures (94.1%) were considered to be facilitators. The percentage of physical therapists providing CBEP education varied across acute, rehabilitation, and public outpatient settings. Limitations The percentage of physical therapists providing education may have been overestimated if respondents who deliver CBEP education were more likely to participate and if participants answered in a socially desirable way. Conclusions Even though a high proportion of physical therapists provide CBEP education, education is not consistently delivered to the majority of patients poststroke. Although a CBEP list or brochure would facilitate education regarding existing CBEPs, efforts to implement CBEPs are needed to help overcome the lack of suitable programs.

Objective To explore exercise professionals’ perspectives on technology integration for balance and mobility assessment practices in retirement and long-term care. Setting A private residential care organization in Ontario, Canada, with 18 sites providing accommodation and services for older adults. Design A qualitative descriptive approach was used including semistructured focus group interviews. Open-ended questions explored perceptions of technology integration along with factors influencing its adoption. Analysis involved preliminary coding based on research questions, review and discussion of emerging themes, and final, resultant coding for each category. Participants Exercise professionals (kinesiologists and exercise therapists) (N=18). Interventions Not applicable. Main Outcome Measures Not applicable. Results All participants felt that technology could enhance their practice by supporting programming, communication, and/or information management. Potential barriers to technology integration related primarily to the need to accommodate the broad range of complex health conditions present among clients, which would impact (1) their ability to engage with the technology and (2) relevance of technology-derived outcomes. Specific concerns related to individuals with significant cognitive and/or functional impairment. Solutions to these barriers emphasized the need for flexible technology and appropriate normative data to maximize the potential for uptake. Conclusions The participating exercise professionals working in a retirement and long-term care setting saw technology as a potentially effective addition to current clinical practice. To increase the likelihood for clinical uptake, technology must be maximize flexibility in order to accommodate a wide range of physical and cognitive abilities and meet specific needs related to setting and job responsibilities. The findings emphasize the need for continuous dialogue between technology producers and end users for successful development and implementation.

Background Falls are a common occurrence and the most effective quality improvement (QI) strategies remain unclear. Methods We conducted a systematic review and network meta-analysis (NMA) to elucidate effective quality improvement (QI) strategies for falls prevention. Multiple databases were searched (inception-April 2017). We included randomised controlled trials (RCTs) of falls prevention QI strategies for participants aged ≥65 years. Two investigators screened titles and abstracts, full-text articles, conducted data abstraction and appraised risk of bias independently. Results A total of 126 RCTs including 84,307 participants were included after screening 10,650 titles and abstracts and 1210 full-text articles. NMA including 29 RCTs and 26,326 patients found that team changes was statistically superior in reducing the risk of injurious falls relative to usual care (odds ratio [OR] 0.57 [0.33 to 0.99]; absolute risk difference [ARD] -0.11 [95% CI, -0.18 to -0.002]). NMA for the outcome of number of fallers including 61 RCTs and 40 128 patients found that combined case management, patient reminders and staff education (OR 0.18 [0.07 to 0.47]; ARD -0.27 [95% CI, -0.33 to -0.15]) and combined case management and patient reminders (OR, 0.36 [0.13 to 0.97]; ARD -0.19 [95% CI, -0.30 to -0.01]) were both statistically superior compared to usual care. Conclusions Team changes may reduce risk of injurious falls and a combination of case management, patient reminders, and staff education, as well as case management and patient reminders may reduce risk of falls. Our results can be tailored to decision-maker preferences and availability of resources. Systematic review registration PROSPERO (CRD42013004151).

Background The Balance Evaluation Systems Test (BESTest) and its two abbreviated versions (mini-BESTest and briefBESTest) are functional balance tools that have yet to be validated in middle aged and elderly people living in the community. Objective Determine the construct validity of the three BESTest versions by comparing them with commonly-used measures of balance, balance confidence and physical activity, and examining their ability to discriminate between groups with respect to falls and fall risk. Methods This was a secondary analysis of data from 79 adults (mean age 68.7 ± 10.57 years). Pearson correlation coefficients were used to examine the relationships between each BESTest measure and the Activities-Specific Balance Confidence (ABC) scale, the Physical Activity Scale for the Elderly (PASE), the Timed Up and Go (TUG) and the Single Leg Stance (SLS) test. Independent t-tests were used to examine differences in balance between fallers (≥1 fall in previous year) and non-fallers and individuals classified at low versus high fall risk using the Elderly Falls Screening Test (EFST). Results The BESTest measures showed moderate associations with the ABC scale and TUG (r = 0.62–0.67 and −0.60 to −0.68 respectively), fair associations (r = 0.33–0.40) with the PASE and moderate to high associations (r = 0.67–0.77) with the SLS. Fallers showed a trend (p = 0.054) for lower scores on the original BESTest, and people at high risk for falls had significantly lower scores on all BESTest versions. Conclusions These findings support the construct validity of the BESTest, mini-BESTest and briefBESTest in adults over 50 years old.

Background and PurposeKnowledge translation (KT) is an emerging discipline with a focus on implementing health evidence in decision making and clinical practice. Knowledge translation theories provide conceptual frameworks that can direct research focused on optimizing best practice. The objective of this case report is to describe one prominent KT theory—the knowledge-to-action (KTA) framework—and how it was applied to research on balance and gait assessment in physical therapist practice.Case DescriptionValid and reliable assessment tools are recommended to evaluate balance and gait function, but gaps in physical therapy practices are known. The KTA framework's 2-pronged approach (knowledge creation phase and action cycle) guided research questions exploring current practices in balance and gait assessment and factors influencing practice in Ontario, Canada, with the goal of developing and evaluating targeted KT interventions.OutcomesResults showed the rate at which therapists use standardized balance and gait tools was less than optimal and identified both knowledge-to-practice gaps and individual and organizational barriers to implementing best assessment practices. These findings highlighted the need for synthesis of evidence to address those gaps prior to the development of potential intervention strategies.DiscussionThe comprehensive KTA framework was useful in guiding the direction of these ongoing research programs. In both cases, the sequence of the individual KTA steps was modified to improve the efficiency of intervention development, there was a need to go back and forth between the 2 phases of the KTA framework, and additional behavior change and barrier assessment theories were consulted. Continued research is needed to explicitly evaluate the efficacy of applying KT theory to best practice in health care.

Background The importance of effective translation of health research findings into action has been well recognized, but there is evidence to suggest that the practice of knowledge translation (KT) among health researchers is still evolving. Compared to research user stakeholders, researchers (knowledge producers) have been under-studied in this context. The goals of this study were to understand the experiences of health researchers in practicing KT in Manitoba, Canada, and identify their support needs to sustain and increase their participation in KT. Methods Qualitative semi-structured interviews were conducted with 26 researchers studying in biomedical; clinical; health systems and services; and social, cultural, environmental and population health research. Interview questions were open-ended and probed participants’ understanding of KT, their experiences in practicing KT, barriers and facilitators to practicing KT, and their needs for KT practice support. Results KT was broadly conceptualized across participants. Participants described a range of KT practice experiences, most of which related to dissemination. Participants also expressed a number of negative emotions associated with the practice of KT. Many individual, logistical, and systemic or organizational barriers to practicing KT were identified, which included a lack of institutional support for KT in both academic and non-academic systems. Participants described the presence of good relationships with stakeholders as a critical facilitator for practicing KT. The most commonly identified needs for supporting KT practice were access to education and training, and access to resources to increase awareness and promotion of KT. While there were few major variations in response trends across most areas of health research, the responses of biomedical researchers suggested a unique KT context, reflected by distinct conceptualizations of KT (such as commercialization as a core component), experiences (including frustration and lack of support), and barriers to practicing KT (for example, intellectual property concerns). Conclusions The major findings of this study were the continued variations in conceptualization of KT, and persisting support needs that span basic individual to comprehensive systemic change. Expanding the study to additional regions of Canada will present opportunities to compare and contrast the state of KT practice and its influencing factors. Electronic supplementary material The online version of this article (10.1186/s12913-017-2573-9) contains supplementary material, which is available to authorized users.

There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers.Study design: overview of reviews.MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015).two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language.two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors' conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.).Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change.Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change.

Objective To identify measures of standing balance validated in pediatric populations, and to determine the components of postural control captured in each tool. Data Sources Electronic searches of MEDLINE, Embase, and CINAHL databases using key word combinations of postural balance / equilibrium , psychometrics / reproducibility of results / predictive value of tests , and child/pediatrics ; gray literature; and hand searches. Study Selection Inclusion criteria were measures with a stated objective to assess balance, with pediatric (≤18y) populations, with at least 1 psychometric evaluation, with at least 1 standing task, with a standardized protocol and evaluation criteria, and published in English. Two reviewers independently identified studies for inclusion. There were 21 measures included. Data Extraction Two reviewers extracted descriptive characteristics, and 2 investigators independently coded components of balance in each measure using a systems perspective for postural control, an established framework for balance in pediatric populations. Data Synthesis Components of balance evaluated in measures were underlying motor systems (100% of measures), anticipatory postural control (72%), static stability (62%), sensory integration (52%), dynamic stability (48%), functional stability limits (24%), cognitive influences (24%), verticality (9%), and reactive postural control (0%). Conclusions Assessing children's balance with valid and comprehensive measures is important for ensuring development of safe mobility and independence with functional tasks. Balance measures validated in pediatric populations to date do not comprehensively assess standing postural control and omit some key components for safe mobility and independence. Existing balance measures, that have been validated in adult populations and address some of the existing gaps in pediatric measures, warrant consideration for validation in children.

Background There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers. Methods Study design: overview of reviews. Data source: MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015). Study selection: two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language. Data extraction and synthesis: two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors’ conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.). Results Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change. Conclusions Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0538-8) contains supplementary material, which is available to authorized users.

BackgroundBalance is a composite ability requiring the integration of multiple systems. The Balance Evaluation Systems Test (BESTest) and 2 abbreviated versions (the Mini-BESTest and the Brief-BESTest) are balance assessment tools that target these systems. To date, no normative data exist for any version of the BESTest.ObjectiveThe purpose of this study was to determine the age-related normative scores on the BESTest, Mini-BESTest, and Brief-BESTest for Canadians who are healthy and 50 to 89 years of age.DesignA cross-sectional study design was used.MethodsSeventy-nine adults who were healthy and aged 50 to 89 years (mean age=68.9 years; 50.6% women) participated. Normative scores were reported by age decade.ResultsMean BESTest scores were 95.7 (95% confidence interval [CI]=94.4–97.1) for adults who were aged 50 to 59 years, 91.4 (95% CI=89.8–93.0) for those who were aged 60 to 69 years, 85.4 (95% CI=82.5–88.2) for those who were aged 70 to 79 years, and 79.4 (95% CI=74.3–84.5) for those who were aged 80 to 89 years. Similar results were obtained for the Mini-BESTest and the Brief-BESTest, and all 3 tests showed statistically significant differences in scores among the age cohorts.LimitationsBecause only adults who were 50 to 89 years of age were tested, there are still no normative data for people outside this age range. Also, the scores presented may not be generalizable to all countries.ConclusionsThese normative data enhance the clinical utility of the BESTest, Mini-BESTest, and Brief-BESTest by providing clinicians with reference points to guide treatment.

Purpose: Balance is a critical modifiable risk factor for falls in older adults. The purpose of this study was to identify the physiotherapy assessment tools used to evaluate balance in clinical practice and to determine the components of balance assessed through the use of standardized and/or other measures. Methods: A retrospective chart review was performed on 250 patients aged 65 and older undergoing in-patient rehabilitation with a clinical diagnosis associated with a balance impairment (stroke, musculoskeletal conditions, lower limb amputation, deconditioning, or cardiac surgery) at a rehabilitation hospital in Ontario. Results: All patients received at least one assessment that incorporated a balance component. Standardized balance measures were performed for 73% of patients; the timed up-and-go test (48%) and Berg Balance Scale (36%) were most commonly used for this assessment. Reactive movement strategies and cognitive processing were the least commonly assessed components of balance. Balance was assessed least often among people with cardiac surgery. Conclusions: Considerable variation exists in the assessment of balance, and the data suggest that not all relevant components are equally considered. Future research should be conducted in other clinical settings and should include other health care practitioners' assessments to develop a more complete understanding of current balance assessment procedures.

Reactive postural control, the ability to recover from an external perturbation to stability, ultimately determines whether an individual will fall following a loss of balance and should be routinely incorporated in balance assessment. The purpose of this study was to identify (1) methods used to assess reactive postural control in clinical practice and (2) factors associated with regular assessment of reactive postural control. A cross-sectional survey was conducted. Three hundred and fifty-seven physiotherapists in Ontario, Canada who treated adults with balance impairments answered questions about the components of balance they assess and how they assess reactive control in their practice. Of the 273 respondents who assessed reactive postural control at least some of the time, 15.4% used a standardized measure, 79.1% used a non-standardized approach, and 5.5% used both. Forty-five methods of assessing reactive control were reported. The most common methods used were non-standardized perturbations (43.5%; 104/239 respondents) and movement observation (18.8%; 45/239). The remaining 43 methods were each used by less than 8% of respondents. Practice area had the strongest association with regular assessment of reactive postural control (>60% of the time), and respondents working with neurological disorders were more likely to regularly evaluate reactive control than those working with people with orthopedic conditions. Despite the availability of valid standardized measures to evaluate reactive postural control, respondents relied primarily on non-standardized approaches and observational assessment. Future work should examine the factors influencing choice of reactive control assessment tools and awareness of standardized measures for reactive postural control.

BACKGROUND: Effective balance reactions are essential for avoiding falls, but are not regularly measured by physical therapists. Physical therapists report wanting to improve reactive balance assessment, and theory-based approaches are recommended as the foundation for the development of interventions. This article describes how a behavior change theory for health care providers, the theoretical domains framework (TDF), was used to develop an intervention to increase reactive balance measurement among physical therapists who work in rehabilitation settings and treat adults who are at risk of falls. CASE DESCRIPTION: We employed published recommendations for using the TDF-guided intervention development. We identified what health care provider behavior is in need of change, relevant barriers and facilitators, strategies to address them, and how we would measure behavior change. In this case, identifying strategies required selecting both a reactive balance measure and behavior change techniques. Previous research had determined that physical therapists need to increase reactive balance measurement, and identified barriers and facilitators that corresponded to 8 TDF domains. A published review informed the selection of the Balance Evaluation Systems Test (Reactive Postural Responses Section) as addressing the barriers and facilitators, and existing research informed the selection of 9 established behavior change techniques corresponding to each identified TDF domain. OUTCOMES: The TDF framework were incorporated into a 12-month intervention with interactive group sessions, local champions, and health record modifications. Intervention effect can be evaluated using health record abstraction, questionnaires, and qualitative semistructured interviews. SUMMARY: Although future research will evaluate the intervention in a controlled study, the process of theory-based intervention development can be applied to other rehabilitation research contexts, maximizing the impact of this work.Video Abstract is available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A123). Language: en

For older adults with osteoporosis, a fall resulting in hip fracture is a life-changing event from which only one-third fully recover. Current best evidence argues strongly for elderly patients to bear weight on their repaired hip fracture immediately after their surgery to maximize their chances of full or nearly full recovery. Patient stakeholders in Canada have argued that some surgeons fail to issue "weight-bearing-as-tolerated" (WBAT) orders in all eligible cases, protecting their bony repair but contributing to increased mortality and long-term disability rates. In collaboration with a national stakeholder organization, Bone and Joint Canada, we interviewed 20 orthopedic surgeons across Canada who perform hip fracture repair surgery, with the aim of understanding their attitudes and behavior toward patient management regarding weight bearing. Qualitative content analysis, in which themes are identified and agreed by multiple coders, suggested that both patient characteristics and surgeon factors influence surgeons' postoperative weight-bearing orders. While almost all respondents agreed that weight bearing as tolerated is indeed therapeutic for most hip fracture repair or replacement patients, surgeons also described certain patient characteristics that would diminish the value of immediate weight bearing, including poor bone quality and certain types of fracture pattern. Surgeon factors that affect postoperative mobilization orders include choice of construct, previous experience of construct failure, and lack of local audit data regarding past weight-bearing decisions and patient outcomes. Thus, although familiar with best practice guidelines, surgeons also have "rules to break the rules." In an era when "good" medicine leans toward science rather than art, the role of individual experience in decision making with regard to hip fracture care continues to be important and would benefit from being discussed openly.

Although balance deficits are increasingly recognized in COPD, little is known regarding the disordered subcomponents underlying the control of balance. We aimed to determine the specific components of balance that are impaired in COPD and to investigate the association among balance, peripheral muscle strength, and physical activity.Balance, physical activity, and lower extremity muscle strength were assessed in 37 patients with COPD and 20 age-matched healthy control subjects using the Balance Evaluation Systems Test (BESTest), the Physical Activity Scale for the Elderly, and an isokinetic dynamometer, respectively. A subset of subjects (20 patients with COPD and 20 control subjects) underwent a second testing session in which postural perturbations were delivered using a lean-and-release system.Subjects with COPD (age, 71 ± 7 years; FEV(1), 39% ± 16% predicted) exhibited significantly lower scores than did control subjects (age, 67 ± 9 years) on all of the BESTest subscales (all P.001). In response to anterior perturbations, subjects with COPD showed a longer time to foot-off (P = .027) and foot contact (P = .018), and a longer duration anticipatory phase (P = .008) compared with control subjects. Muscle strength (P = .008) and self-reported physical activity (P = .033) explained 35% of the variance in balance in subjects with COPD.Individuals with COPD exhibit impairments in all balance subcomponents and demonstrate slower reaction times in response to perturbations. Deficits in balance are associated with reduced physical activity levels and skeletal muscle weakness.

Wong R, Sibley KM, Hudani M, Roeland S, Visconti M, Balsano J, Hill K, Brooks D. Characteristics of people with chronic lung disease who rest during the six-minute walk test. Objectives To examine the incidence of resting during the 6-minute-walk test (6MWT) in patients with chronic lung disease (CLD) and to explore differences in functional exercise capacity and response to pulmonary rehabilitation (PR) between resters and nonresters. Design Retrospective chart review. Setting Inpatient PR program. Participants Individuals (N=211) who performed the 6MWT at admission and discharge from PR. Interventions Not applicable. Main Outcome Measures Primary outcomes were total distance walked (6-minute walk distance [6MWD]) and rest frequency and duration. Secondary outcomes were walking speed, end-test dyspnea, and the Chronic Respiratory Questionnaire (CRQ). Results At admission, 45 people (21%) rested 1 to 4 times during the 6MWT (total duration, 105±80s) and 166 people walked continuously. At discharge, 9 people continued to rest (total duration, 28±55s). At admission, nonresters walked 315±93m, whereas resters walked 197±83m ( P P P P =.01). Resters' end-test dyspnea scores decreased from 5.7±0.3 to 4.3±0.2 from admission to discharge, whereas nonresters' end-test dyspnea scores did not significantly change from 4.5±0.2 to 4.2±0.2 at discharge (interaction P Conclusions One in 5 individuals with CLD rest during the 6MWT. Decreasing rest duration or increasing walking speed reflects different strategies used to improve 6MWD after rehabilitation, both suggesting a positive effect of PR. This may be related to improvements in an individual's sense of control over dyspnea. Future work should investigate potential factors related to resting during the 6MWT.

Recent work has demonstrated that postural instability evokes an electrodermal response (EDR) that is temporally coupled to perturbation onset. The purpose of this study was to determine whether arousal linked to balance recovery is associated with the size of the perturbation (stimulus-dependent variations); and/or the challenge of executing a motor response to recover stability (context-dependent task variations). Twelve healthy subjects received whole-body perturbations while seated in a tilting chair that required a compensatory upper limb reaction to regain balance following instability. The influence of perturbation amplitude (stimulus-dependent challenge- slow vs. fast perturbations) and task condition (context-dependent challenge- unrestricted vs. restricted movement) on EDR timing and magnitude parameters were examined. While EDR latency was consistent across conditions with onset occuring approximately 2 s after the perturbation, peak-to-peak EDR amplitude was influenced by both stimulus-dependent and context-dependent challenges and also mirrored postural response amplitude. Compared to the Slow condition, EDR amplitude was 27 ± 6% larger in the Fast condition ( p = 0.0004). Similarly, EDR amplitude was 244 ± 86% larger in the Restricted task condition relative to the Unrestricted task condition ( p = 0.006). Context-dependent EDR modulation suggests that autonomic reactivity is associated with some higher level of processing independent of the degree of challenge related to stimulus characteristics. This work has potential implications for understanding determinants of central nervous system reactivity among individuals with impaired limb control where the recovery challenge is uniquely linked to the context.

Importance Falls result in substantial burden for patients and health care systems, and given the aging of the population worldwide, the incidence of falls continues to rise. Objective To assess the potential effectiveness of interventions for preventing falls. Data Sources MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Ageline databases from inception until April 2017. Reference lists of included studies were scanned. Study Selection Randomized clinical trials (RCTs) of fall-prevention interventions for participants aged 65 years and older. Data Extraction and Synthesis Pairs of reviewers independently screened the studies, abstracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis were conducted. Main Outcomes and Measures Injurious falls and fall-related hospitalizations. Results A total of 283 RCTs (159 910 participants; mean age, 78.1 years; 74% women) were included after screening of 10 650 titles and abstracts and 1210 full-text articles. Network meta-analysis (including 54 RCTs, 41 596 participants, 39 interventions plus usual care) suggested that the following interventions, when compared with usual care, were associated with reductions in injurious falls: exercise (odds ratio [OR], 0.51 [95% CI, 0.33 to 0.79]; absolute risk difference [ARD], −0.67 [95% CI, −1.10 to −0.24]); combined exercise and vision assessment and treatment (OR, 0.17 [95% CI, 0.07 to 0.38]; ARD, −1.79 [95% CI, −2.63 to −0.96]); combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30 [95% CI, 0.13 to 0.70]; ARD, −1.19 [95% CI, −2.04 to −0.35]); and combined clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (eg, comprehensive geriatric assessment), calcium supplementation, and vitamin D supplementation (OR, 0.12 [95% CI, 0.03 to 0.55]; ARD, −2.08 [95% CI, −3.56 to −0.60]). Pairwise meta-analyses for fall-related hospitalizations (2 RCTs; 516 participants) showed no significant association between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care (OR, 0.78 [95% CI, 0.33 to 1.81]). Conclusions and Relevance Exercise alone and various combinations of interventions were associated with lower risk of injurious falls compared with usual care. Choice of fall-prevention intervention may depend on patient and caregiver values and preferences.

Objective To determine whether electrodermal responses (EDRs) evoked by postural perturbations were sensitive to the context of compensatory balance control, or simply reflected sensory or motor components of the reaction. Methods Thirteen participants were perturbed backwards in an upright chair and (1) performed compensatory reach-to-grasp movements to a handhold to recover balance (COMP); (2) received the perturbation only and the chair stopped via mechanical support (SENS); and (3) performed rapid self-initiated reach-to-grasp movements without perturbation (MOT). Results EDRs were most frequent and largest in the COMP task, observed in 100% of trials (1.42±0.16μS), compared to 39% of SENS trials (0.31±0.12μS, p p =0.073). EDRs in the MOT task followed two patterns across individuals, leading to post-hoc division of subjects into groups (smaller EDRs than COMP task, n =7, versus equivalent EDRs to COMP task, n =6). Motor patterns were equivalent in both groups, indicating that EDRs did not co vary with efferent drive. Conclusions Perturbation-evoked EDRs are not a direct reflection of sensory input or motor drive. Significance These findings suggest that evoked autonomic activity may play a functional role in compensatory postural control.

While much is understood about somatic contributions to postural control, there is less consideration for the potential involvement of the autonomic nervous system (ANS) as integral for maintenance of stability. The purpose of this study was to examine autonomic responses, as measured through electrodermal recordings, evoked in response to whole-body perturbations to standing balance. We hypothesized that phasic electrodermal responses (EDRs) would be consistently observed in response to evoked perturbations and that response amplitude would depend on the capacity to predict perturbation timing. Temporally unpredictable and self-initiated (predictable) backward perturbations evoked in healthy participants (n=15) elicited compensatory feet-in-place reactions with tibialis anterior activation 125.1+/-60.2 ms following perturbation onset. EDRs were consistently observed starting 1883.6+/-329.1 ms after perturbation and reaching their peak at 4016.6+/-896.9 ms. Amplitude was significantly larger in the unpredictable task (1.1+/-0.84 micromho) compared to the predictable task (0.45+/-0.55 micromho, P0.001). Amplitude was largest in the first block of five trials (P0.0001), then remained constant for subsequent trials in each condition. Post-hoc analysis indicated that trials with an unplanned compensatory step (3.5%) were 137.0+/-176.6% larger than feet-in-place reactions (P=0.02). Elevated EDRs during initial trials and unanticipated reactions suggest that these measures could be used to assess the perceived 'novelty' of applied perturbations, having implications for interpreting characteristics of the evoked somatic reactions. The persistence of perturbation-evoked EDRs even after thirty trials may also highlight an important role for phasic ANS responses in compensatory postural control.

Purpose: The purposes of this study were to characterize the cardiorespiratory capacity of individuals on admission to inpatient rehabilitation following stroke and to examine the relationship between measures of cardiorespiratory capacity and standard indices of neurological deficit and functional status. Methods: We recruited 45 patients within the first 10 days of admission to rehabilitation. We performed measures of aerobic fitness (VO2peak), functional status (Functional Independence Measure [FIM] and Clinical Outcomes Variable Score [COVS]), and neurological deficit (National Institutes of Health Stroke Scale [NIHSS] and Chedoke-McMaster Stroke Assessment scale [CMSA]). Results: Nineteen women and 26 men with a mean (SD) age of 65.2 (14.5) years were admitted to rehabilitation 16.2 (11.9) (minimum 3, maximum 62) days post-stroke. Average VO2peak was less than half the value expected in age-matched healthy individuals at 11.1 (3.1) ml/kg/min. The associations between VO2peak and FIM, NIHSS, and COVS were weak (r = 0.25, -0.12, and 0.26 respectively, p = 0.12, 0.46, and 0.10 respectively). There were no differences in VO2peak in higher-functioning individuals with CMSA leg scores of 5 and 6 compared to lower-functioning individuals with scores of 3 and 4 (p = 0.30). Conclusion: Cardiorespiratory capacity is extremely low in individuals during the first 3 months after stroke. Alternative measures of functional or clinical status do not adequately reflect this cardiorespiratory state; thus, routine measurement of cardiorespiratory capacity should be considered, along with a risk-factor profile.

Neuromuscular dyscontrol during gait following stroke may be further compromised by increased susceptibility to fatigue. Our purpose was to examine how extended effortful activity affected spatio-temporal gait parameters after stroke. The influence of sub-maximal exercise was assessed among 26 stroke survivors who performed the Six-Minute Walk Test with distance recorded every 2 min. Walking distance decreased 5.8 (S.D. 6.9) m in the second 2-min interval and another 2.3 (S.D. 9.9) m in the final 2 min (p = 0.0005). Secondly, we evaluated spatio-temporal gait parameters prior to and immediately following a standardized maximal exercise test on a cycle ergometer in 36 stroke survivors. In contrast to the expected reduction in walking speed, maximal exercise led to a 5.5 (S.D. 11.5) cm/s increase in preferred gait speed (p = 0.007) and a 4.5 (S.D. 7.7) steps/min increase in cadence (p = 0.0004), but did not affect gait symmetry. Subsequent division of participants by preferred pedaling cadence revealed that individuals with lower preferred cadence had the greatest increase in preferred speed, cadence and paretic leg step length (p < 0.01). These unexpected results suggest that potential fatigue-induced effects on gait may have been masked by immediate positive influences of movement rate on walking speed. Such activity-specific effects may have clinical applications for stroke patients and other populations with gait deviations.

Background We have recently demonstrated the efficacy of balance training in addition to Pulmonary Rehabilitation (PR) at improving measures of balance associated with an increased risk of falls in individuals with Chronic Obstructive Pulmonary Disease (COPD). Few knowledge translation (KT) projects have been conducted in rehabilitation settings. The goal of this study was to translate lessons learnt from efficacy studies of balance training into a sustainable clinical service. Methods Health care professionals (HCPs) responsible for delivering PR were given an hour of instruction on the principles and practical application of balance training and the researchers offered advice regarding; prescription, progression and practical demonstrations during the first week. Balance training was incorporated three times a week into conventional PR programs. Following the program, HCPs participated in a focus group exploring their experiences of delivering balance training alongside PR. Service users completed satisfaction surveys as well as standardized measures of balance control. At six month follow-up, the sustainability of balance training was explored. Results HCPs considered the training to be effective at improving balance and the support provided by the researchers was viewed as helpful. HCPs identified a number of strategies to facilitate balance training within PR, including; training twice a week, incorporating an interval training program for everyone enrolled in PR, providing visual aids to training and promoting independence by; providing a set program, considering the environment and initiating a home-based exercise program early. Nineteen service users completed the balance training [ten male mean (SD) age 73 (6) y]. Sixteen patients (84 %) enjoyed balance training and reported that it helped them with everyday activities and 18 (95 %) indicated their wish to continue with it. Scores on balance measures improved following PR that included balance training (all p

ThisissueofJAMAPediatricsrepresentsaspecialfocusonimplementation science inpediatrichealth care. Implementation science refers to the study ofmethods to promote the systematic uptakeofclinical researchfindings intoroutinepractice.1 It isdescribed in a multitude of ways around the world (knowledge translation, transfer,mobilization, exchange, dissemination),2 but ultimately all terms share a similar goal: to close persistent knowledge-to-practicegaps inhealthcareanddecisionmaking inanefforttoimproveoutcomes.Real-worlduptakeofevidencebasedpractices isessential inpediatrichealthcaretoensurechildreneverywherebenefit fromeffective treatments, suchas the useof glucocorticoids for childrenwith croup thathas resulted inasubstantialandimportantdecrease inhospitalizationforthis condition.3 Although the field of implementation science has grown exponentially throughout the late 20th and early 21st centuries, examination of the evidence base for health care practices canbe traced to the 1800s,whenpractices suchasbloodletting were being called into question as medically sound.4 Around this time major advances were also being realized in thefieldofpediatricmedicine, spearheadedbyindividualssuch as Abraham Jacobi, MD, who received the first academic appointment inpediatrics in theUnitedStates (1860)andwasone of the foundingmembers and the first president of theAmerican Pediatric Society (1871).5,6 Jacobi is well known for advocating that children are not small adults in size or disease as well as for how he used data to advocate for changes in practices such as the institutionalization of children and to support andpromotepractices suchasbreastfeedingor theproper preparationofcow’smilkwhenbreastmilkwasnotavailable.5,6 The articles in this issue of JAMAPediatrics bring together the fieldsof implementation scienceandpediatrics, representingawiderangeofhealthissues,researchdesigns,andtherapeutic interventions.For example,Arduraet al7 evaluate theeffect of implementingnewhospital-basedprotocols for reducingcentral catheter–associated infections inhomesettings, illustrating complementarybut at timesoverlappinggoalsof implementation science and quality improvement. The systematic review andmeta-analysis byManja et al8 on target oxygen saturation ranges forpreterm infants is anexcellent exampleofoneof the cornerstonesof implementationscienceanddemonstrates that thereisnotalwaysanevidence-supportedbestpracticeonwhich to informimplementation.Theseapproacheshighlightnotonly theprogress thathasbeenmade inplacingnewresearchwithin thecontextofexistingevidencebutalsotheactivepursuitof tailoredmessagingand interventions tomoveevidence intopractice.So,wheredowegonext in implementationscience?Where dowe go next in pediatric implementation science? We suggest that to further advance pediatric implementation science, there must be a continued and persistent focuson the following: (1) theuseof conceptual frameworks and theories to provide guidance into the relevant factors influencing the implementation process; (2) evaluation of the efficacyof implementation interventions; (3) applicationandadvancement of research designs that are best suited for implementation science; and (4) coordinationof efforts tomobilize and scale up widespread change. Implementation research isoftencomplex, andas suchour recommendationsare in line with the Medical Research Council’s guidance on developingandevaluatingcomplex interventions,9 avaluable resource for implementation researchers. Conceptual frameworks are systems of concepts, assumptions, and theories organized graphically or narratively,10 and theories are defined as a coherent and noncontradictory set of statements, concepts, or ideas thatorganizes, predicts, andexplainsphenomena, events, andbehavior.11 They arepromoted in implementation science toguide the systematic adoptionof evidence inpracticeandarepostulatedtoprovidegeneralizable componentsfordevelopingresearchquestionsandinterventions, allowing for an incremental accumulation of knowledge.1 Severalconceptual frameworksfor implementationandknowledge translationhavebeenpublished,12 andasnonehavebeendemonstrated tobe superior to another, users cancurrently choose which bestmeet their needs. One commonly used framework developed in Canada and adopted internationally is the Knowledge-to-ActionFramework.13,14 It provides step-by-step guidance for implementationandhasbeenused inanumberof healthcontexts.15 It identifies2keyphases tomovefromknowledge production to implementation: the knowledge creation phase and the action cycle (Figure). ApplyingtheKnowledge-to-ActionFrameworktothearticles in thecurrent issue (Table) placeseachof the studiespresented hereinthecontextofthefull implementationprocess.Doingthis highlights theabsenceof studies rigorouslyaddressingbarriers andfacilitators toknowledgeuseandsustainingknowledgeuse in the current issue. The lackof studies examining the sustainmentofevidence-basedpractice isperhapsunsurprising, as incorporatingmechanismsforsustainedimplementationandlongterm tracking often falls outside the traditional research realm and fundingperiods, and this lack is a commoncriticism in the Opinion

BackgroundStanding balance is imperative for mobility and avoiding falls. Use of an excessive number of standing balance measures has limited the synthesis of balance intervention data and hampered consistent clinical practice.ObjectiveTo develop recommendations for a core outcome set (COS) of standing balance measures for research and practice among adults.MethodologyA combination of scoping reviews, literature appraisal, anonymous voting and face-to-face meetings with fourteen invited experts from a range of disciplines with international recognition in balance measurement and falls prevention. Consensus was sought over three rounds using pre-established criteria.Data sourcesThe scoping review identified 56 existing standing balance measures validated in adult populations with evidence of use in the past five years, and these were considered for inclusion in the COS.ResultsFifteen measures were excluded after the first round of scoring and a further 36 after round two. Five measures were considered in round three. Two measures reached consensus for recommendation, and the expert panel recommended that at a minimum, either the Berg Balance Scale or Mini Balance Evaluation Systems Test be used when measuring standing balance in adult populations.LimitationsInclusion of two measures in the COS may increase the feasibility of potential uptake, but poses challenges for data synthesis. Adoption of the standing balance COS does not constitute a comprehensive balance assessment for any population, and users should include additional validated measures as appropriate.ConclusionsThe absence of a gold standard for measuring standing balance has contributed to the proliferation of outcome measures. These recommendations represent an important first step towards greater standardization in the assessment and measurement of this critical skill and will inform clinical research and practice internationally.

Tang A, Sibley KM, Thomas SG, McIlroy WE, Brooks D. Maximal exercise test results in subacute stroke. Objectives To establish the feasibility and reliability of graded maximal exercise testing, suitability of standard indexes of maximum oxygen consumption (Vo 2 max), and evidence of trial-to-trial practice effects in subacute stroke. Design Descriptive, cross-sectional study. Setting Rehabilitation hospital. Participants Consecutive sample of 35 participants (mean age, 65.7±2.6y; mean days poststroke, 17.6±2.2d). Interventions Not applicable. Main Outcome Measures Graded maximal exercise test using semirecumbent cycle ergometry. A subset (n=20) performed repeated tests to determine test-retest reliability and presence of practice effects. Results Thirty-one (89%) participants completed the exercise test without symptomatic responses (mean peak level of oxygen consumed [Vo 2 peak], 10.7mL·kg −1 ·min −1 ; peak work rate, 39W). Twelve (34%), 15 (44%), and 3 (9%) participants achieved oxygen consumption per unit time (Vo 2 ) plateau, respiratory exchange ratio, and heart rate criteria, respectively. Although test-retest correlations were high (intraclass correlation coefficient range, .67–.87), higher Vo 2 peak (1.0mL·kg −1 ·min −1 , P =.04) and work rate (7.3W, P =.01) were observed with repeated testing, with no associated increase in reaching standard criteria for Vo 2 max. Conclusions This work has important implications for developing guidelines for measuring aerobic capacity early after stroke. Although maximal exercise testing using semirecumbent cycle ergometry is feasible, standard Vo 2 max criteria are not consistently appropriate. At least 1 practice trial is recommended before the actual evaluation is performed.

We asked what the role of the vestibular system is in adaptive control of locomotor trajectory in response to walking on a rotating disc. Subjects with bilateral vestibular loss (BVL) were compared to age- and gender-matched controls (CTRL). Subjects walked in place on the surface of a rotating disc for 15 min and then attempted to step in place without vision on a stationary surface for 30 min. CTRL subjects demonstrated podokinetic after-rotation (PKAR), involuntarily and unknowingly turning themselves in circles while attempting to step in place. PKAR in CTRLs was characterized by a rapid rise in turning velocity over the first 1-2 min, followed by a gradual decay over the remaining 28 min. Subjects with BVL also demonstrated PKAR and had no knowledge of their turning. However, PKAR in BVLs was characterized by an extremely rapid, essentially instantaneous rise. Subjects with BVL immediately turned at maximum velocity and exhibited a gradual decay throughout the entire 30 min period. Despite this difference in the initial portion of PKAR in BVLs, their responses were not significantly different from CTRLs during minutes 2 to 30 of the response. These results suggest that vestibular inputs normally suppress PKAR velocity over the first 1-2 min of the response, but do not greatly influence PKAR decay. PKAR is therefore a process mediated primarily by somatosensory information and vestibular inputs are not required for its expression. Additionally, the absence of vestibular inputs does not result in increased somatosensory sensitivity that alters podokinetic intensity or decay time constants.

The ability to maintain balance is critical for daily activities such as walking and fall avoidance. The contemporary models of postural control emphasize the central and somatic interactions engaged in maintaining balance; however, there is emerging evidence that the autonomic nervous system (ANS) - the sympathetic division, in particular - routinely participates in postural control. The purpose of this paper is to review the evidence demonstrating the autonomic interactions in postural control. These interactions are presented in two broad categories: those that conceptualize the maintenance of postural equilibrium as a component of bodily homeostasis and those that illustrate how changes in affective states link cognitive perceptions and physiological responses (in this case, balance). The shared commonalities between postural and autonomic pathways are presented, pointing to the areas of overlap and the potential sources of the interaction. Although the specific function of autonomic engagement in postural control remains unknown, the potential roles are explored and highlight the directions for continued study.

Rating of perceived exertion (RPE) is used to monitor or prescribe workload of exercise, but its utility among individuals with a stroke remains in question.To examine the validity of RPE at multiple percentages of peak aerobic capacity (Vo2peak) in individuals in the subacute stage of stroke recovery.Thirty-seven patients with stroke in the subacute stage of recovery from an inpatient rehabilitation institute completed a graded maximal exercise test on a semi-recumbent cycle ergometer. Respiratory gas exchange was monitored for analysis of Vo2, while heart rate and RPE (Borg CR10 Scale) were measured at the end of each minute. RPE was compared with expected ranges when at 60%, 70%, and 80% of Vo2peak. Post hoc analyses were performed to determine whether patient characteristics differed between participants who fell within and outside the expected RPE range at 80% of Vo2peak.Median (interquartile range) RPE at 60%, 70%, and 80% Vo2peak were 3.0 (3.0-3.5), 3.0 (3.0-5.0), and 4.75 (3.0-5.75), respectively; 76.2%, 69.0%, and 38.9% of participants fell into the expected RPE range at each intensity. Patient characteristics were similar between participants who fell within and outside the expected RPE range at 80% Vo2peak.RPE appears to be a reasonable indicator of exercise intensity after stroke at moderate (60%-70% Vo2peak) but not high-intensity exercise (80% Vo2peak). This conclusion is based on the high degree of between-subject variability in RPE at 80% Vo2peak. Future research should identify whether RPE can be adapted to accurately capture exertion during high-intensity exercise after stroke.

Background Falls and chronic disease are both important health issues in older adults. The objectives of this study were to quantify the prevalence of falls and multi-morbidity (≥2 chronic conditions) in Canadian older adults; examine associations between falls and number of chronic conditions; and explore whether certain patterns of chronic disease were associated with a greater risk of falling. Methods Data were derived from the Canadian Community Health Survey- Healthy Aging. Primary outcomes from 16,357 community-dwelling adults aged 65 years and over were self-reported falls in the previous 12 months and presence of 13 chronic conditions. Prevalence estimates were calculated with normalized sampling weights, and hierarchical cluster analysis was used to identify clusters based on chronic condition patterns, and tested for association to falls with logistic regression. Results Overall prevalence of falling and multi-morbidity were 19.8% and 62.0% respectively. Fall risk was significantly greater in individuals with one, two, four, five and six or more chronic conditions relative to those with none (all p

Background. Balance impairment is a significant problem for older adults, as it can influence daily functioning. Treating balance impairment in this population is a major focus of physical therapist practice. Objective. The purpose of this study was to document current practices in clinical balance assessment and compare components of balance assessed and measures used across practice areas among physical therapists. Design. This was a cross-sectional study. Methods. A survey questionnaire was mailed to 1,000 practicing physical therapists in Ontario, Canada. Results. Three hundred sixty-nine individuals completed the survey questionnaire. More than 80% of respondents reported that they regularly (more than 60% of the time) assessed postural alignment, static and dynamic stability, functional balance, and underlying motor systems. Underlying sensory systems, cognitive contributions to balance, and reactive control were regularly assessed by 59.6%, 55.0%, and 41.2% of the respondents, respectively. The standardized measures regularly used by the most respondents were the single-leg stance test (79.1%), the Berg Balance Scale (45.0%), and the Timed “Up & Go” Test (27.6%). There was considerable variation in the components of balance assessed and measures used by respondents treating individuals in the orthopedic, neurologic, geriatric, and general rehabilitation populations. Limitations. The survey provides quantitative data about what is done to assess balance, but does not explain the factors influencing current practice. Conclusions. Many important components of balance and standardized measures are regularly used by physical therapists to assess balance. Further research, however, is needed to understand the factors contributing to the relatively lower rates of assessing reactive control, the component of balance most directly responsible for avoiding a fall.

Postural instability evokes cortical and autonomic reactions in addition to the primary compensatory response, and it is hypothesized that these responses may be related to underlying affective influences such as tonic physiological arousal. The purpose of this study was to determine whether perturbation-evoked cortical potentials (N1 and P2) and electrodermal responses (EDRs) were related to each other or to tonic electrodermal level (EDL). Ten healthy individuals received sixty perturbations while standing at ground level (LOW) and at the edge of an elevated platform (HIGH), where an unsuccessful reaction could lead to a fall from a height of 160 cm. Postural responses, tonic EDLs and N1 potentials were all significantly larger (p ≤ 0.01) at the HIGH height relative to LOW. EDR amplitudes did not show a main effect of condition, but habituated less at the HIGH height (interaction p = 0.04). P2 potentials were not different between conditions (p > 0.05). There was no statistically significant relationship between the magnitude of change in N1 amplitude between conditions and the change in EDR amplitude between conditions (R = 0.25, p = 0.5), between magnitude of N1 change and magnitude of EDL change (R = −0.23, p = 0.25), or between magnitude of EDR change and EDL change (R = −0.51, p = 0.16). Altered cortical and autonomic responses at the HIGH height were independent of elevated physiological arousal. These findings have implications for understanding the role of cortical and autonomic responses in compensatory balance control, and alleviate concerns about the potential influence of underlying arousal on electrodermal reactivity.

Background Gait dysfunction and fatigue are common post-stroke, though it is unclear how extended walking activity, as would be performed during activities of daily living, may change over time. The purpose of this study was to examine if spatial and temporal gait variables deteriorate during an extended bout of walking in a test of functional capacity after stroke. Methods 24 community dwelling, independently ambulating individuals greater than 3 months after stroke performed the Six-Minute Walk Test (6MWT). Participants walked over a pressure-sensitive mat on each pass of the 30 m course which recorded spatial and temporal parameters of gait. Mean gait speed and temporal symmetry ratio during each two-minute interval of the 6MWT were examined. Additional post hoc analyses examined the incidence of rests during the 6MWT and changes in gait speed and symmetry. Results On average, participants demonstrated a 3.4 ± 6.5 cm/s decrease in speed over time (p= 0.02). Participants who rested were also characterized by increased asymmetry in the final two minutes (p= 0.05). 30% of participants rested at some point during the test, and if a rest was taken, duration increased in the final two minutes (p= 0.001). Examination of factors which may have been associated with resting indicated that resters had poorer balance (p= 0.006) than non-resting participants. Conclusion This study supports previous findings establishing that walking performance after stroke declines over relatively short bouts of functionally-relevant ambulation. Such changes may be associated with both cardiorespiratory and muscular fatigue mechanisms that influence performance. The findings also indicate that rest duration should be routinely quantified during the 6MWT after stroke, and consequently, further research is necessary to determine how to interpret 6MWT scores when resting occurs.