Brain Health—Attitudes—Behavior—Education

This April, the journal brings you 5 original research reports that represent areas of concern in our field. Does cardiovascular function influence brain health even when there are no overt neurological signs or symptoms? What are the attitudes of physical therapists and physical therapy students and how can they change in regard to regular screening of blood pressure and recommendation of physical therapy? How do we best prepare future physical therapists for the growing complexity of practice? Reading through these articles reminds me of a recent experience. In an effort for our Doctor of Physical Therapy (DPT) program to continue to move toward its mission, we offered free on-sight educational workshops to some local practice settings. Given my background and experience, one natural set of workshops would involve the cardiovascular and pulmonary systems, but also given my background and experience this would not be exclusive or at the expense of consideration of the full reality of an integrated human performing purposeful movement and activity. Not only have I studied such integration as a physical therapist, but also this was a core principle in my doctoral field of study of ergonomics and human factors. One of the responses was rather perplexing to me. The setting is looking to expand on its neurological education offerings, and so cardiovascular was just not a current priority. This situation left me wondering about what can be performed to close the gap and change attitudes that create such dichotomous thinking given the clear anatomical, physiological, and growing evidential connection between brain health (neurological function) and cardiovascular as well as pulmonary function. It has me considering proposing an entirely new set of workshops largely based on the growing and excellent body of work from Dr. Sandra Billinger and her colleagues reported in this issue.1 The aim of this study was to evaluate the relationship of cardiovascular disease on middle cerebral artery blood flow velocity at rest and during exercise. The authors conclude that in cognitively normal older adults, higher atherosclerotic risk was associated with blunted resting and exercise middle cerebral blood flow velocity and lower language processing performance. There are clear implications from such a finding in terms of the need for risk management to maintain optimal brain health. In addition, based on my experiences, there seem to be clear implications regarding the need to assess attitudes and consider the use of education to highlight the importance of considering the fully integrated human during movement. An area of concern that clearly demonstrates the impact of attitudes on practice behavior is that of blood pressure measurement in outpatient settings.2 Arena and Peterson3 report on a study using an observational pre-test and post-test study design to describe the impact of a blood pressure educational initiative on the attitude, practice behaviors, and knowledge of outpatient physical therapists. Quite favorably, they demonstrated that an educational initiative resulted in positive changes to therapists' attitude, immediate practice behavior, and knowledge. The authors do point out some limitations including that all the physical therapists were from one, clearly open and willing, health system. The strategy needed included education, but also pre-education. The authors provide an excellent explanation based on phases of engagement not just for preparation of an educational intervention, but as part of the educational intervention. Changing attitudes and resultant behaviors requires more than an hour as these authors demonstrate. Readers of this journal do not question the need for physical therapists to promote physical activity. And like most behaviors, attitudes tend to be a guide. Pathare et al4 report on the physical activity level, knowledge, attitudes, and role perceptions about promotion of physical activity in a cross section of DPT students. The study methods provide readers with an excellent example of combining research and education, allowing the researchers to learn about the attitudes, knowledge, and role perceptions of a cohort of DPT students, while educating the students as research participants (not explicitly) in these topics through participation. Replication of this study across the country and in collaboration would result in a data set capable of assessing regional variations, and repeating the study annually would result in a data set of longitudinal trends. It is quite pleasing that most DPT students in this cohort engaged in and know about the recommended levels of physical activity and value their role to give patients advice about physical activity. In many ways, this finding confirms what we would expect in a society that understands the role of physical therapists as professionals, even if this understanding has started with a group of individuals that have spent more time learning about the profession. Any hope of such an understanding spreading through society starts with a group. And the eventual practice and interactions of that group in the profession and society recursively contributes to the spread of understanding. In addition to attitudes influencing behavior, it is quite reasonable to suspect that level of competence influences behavior, which then frames attitudes.5 Propositionally, competence influences what someone will do and what someone does sets boundaries on experiences which then create frames for attitudes. Continuing such experience without reflection tends to generate small networks of thinking and reasoning in practice whereby heuristics and biases grow and closed patterned behaviors perpetuate.6 How do we prevent this from occurring when students are entering the profession? How do we prepare students for the technologically complex and rigorous demands of practice in our field, and our subfield, of physical therapy? How much competence and reflection is required to prevent the above proposed negative cascade with experience? A straightforward and pragmatic answer is as much as possible. The aim of all educators is to pass on as much competence, skill, and reflection as possible to their students, which we hope results in comfort and confidence.7 Bartlett and Smith8 introduce readers to the use of a mobile-learning application (app) to evaluate its effect on student skills in assessing blood pressure, heart rate, and pedal pulses. They report that students demonstrated improved competency when provided with a mobile app combined with traditional approaches. They propose that future research should include a multisite design and validation of a clinical competency instrument; I encourage readers to reach out and engage these authors if you're interested in being part of such design and validation. Such activities are necessary as we build intellectual capacity.9 As we prepare students to enter practice with competence that leads to behaviors that tend to recursively improve competence, there is a necessary first step as we consider complex environments and complex tasks working with patients who have complex presentations. With doctoral preparation in human factors and ergonomics, I do not use the term “complex” lightly. I do so with considerable understanding of the various information theoretic definitions of what is meant by complex, be it through Shannon's entropy, Kolmogorov's algorithmic information, or Dembski's specified complexity. Although we are not at the point in our profession of quantifying the complexity of the environments, tasks, or patient presentations with bits or bytes, we do feel we have a qualification of complexity in a critical illness environment. To prepare students for such environments to avoid stress and overload during their first experiences, the use of simulation has been proposed. In this issue, Cunningham and Cunningham10 report on a study that examined the influence of a simulation experience, using standardized patients, on physical therapy students' perceptions of comfort with early mobilization of patients in a critical care environment. I believe an underlying assumption of mine when reading such a study is that competence and comfort are associated, but comfort is assessed subjectively through the questioning of participants, whereas competence would be assessed objectively. Please keep in mind that I am not saying this to give greater weight to either the subjective experiences of participants or to objective evaluation of competence. These are simply different but related ontological concepts. As a critical realist, I believe that ontology determines epistemology which means, how things are determines how we can know about them.11 Although competence is important and it is what instructors assess in their students, in many ways, comfort (and confidence) as a subjective concept also determines practice behavior, attitudes, and response to challenges. When I initiated new practice patterns in an intensive care unit (ICU) of a small community hospital, it was my competence, comfort, and confidence that empowered me to propose such change despite having the least amount of years of experience in the PT department. What I had was the right experience including reflection in action. If I had accepted that position right out of PT school, I may never have proposed change. But spending time at a major medical center in the ICU provided the competence, comfort, and confidence. Not all students or new graduates have that opportunity. So, we need to look into DPT programs to empower through competence, comfort, confidence, and reflection. To this end, Cunningham and Cunningham demonstrate that standardized patients can be used to accurately portray patients in critical care units, and the use of standardized patients allows for the unrestricted ability to mobilize the patient and the ability to practice such skills. Most importantly, students reported increased comfort, a truly hopeful situation for the future of their professional attitudes and behaviors.