Mobility as the 6th Vital Sign?

Will be fashioning this vision as we progress through the PMC project, so consider this just getting the thinking juices flowing.  Some readers will be aware of the American Pain Society's 'Pain as the 5th vital sign' initiative that was introduced in the mid-90s and ramped up in earnest in the early and mid-2000's.  The intention was to elevate pain and its management to the level of other vital body functions that are routinely assessed in medical contexts, along with temperature, heart rate, blood pressure and respiration rate.  It's hard to objectively say how well it actually worked, with evidence generally indicating that patients were having their pain assessed more frequently, but that pain management was still inadequate.  Of course, many of you will also know that there have been recent calls to remove the pain as the 5th vital sign owing to the ongoing public and political movements around the so-called 'opioid crisis'.  So, hard to say at this time what that initiative will end up looking like, but at least I would say the spirit of the initiative was in the right place.

So on to mobility.  I'll cop to the fact that I've often said that physical therapy doesn't save lives, but it gives lives back.  And I thought that was a very admirable and supportive thing to say about my profession.  But as we're traveling across Canada to better understand the concept of mobility, I'm realizing that I was very likely wrong - adequate mobility may well save lives.  I'm going to have to tiptoe slightly around the precise nature of the qualitative narratives I've been capturing as they are part of an ongoing research study, but I can say it has become clear that without adequate mobility (and the 'adequate' word is intentional here as it differs by person and context, more on that in a later post) the lives of many may well be at risk.  Consider the fishing villages in the Atlantic provinces, at which residents must work HARD during the summer months to ensure they have enough food and supplies to last what are often fairly harsh winters.  No one else is going to do it for them if they can't.  Consider our military personnel for whom mobility (defined broadly and in different ways) is what may save the lives of you, your squad mates and the people you're trying to protect in active combat zones.  Just today I see that the province of British Columbia has issued a state of emergency and has evacuated thousands from the province's interior due to raging wildfires.  Those who are immobile must rely on the aid of others or perish.  And then there were even more unexpected things that have emerged through these conversations, from more than one physio patient, who have stated that their mobility is such a key aspect of their personal identity that without it, they were in danger of losing the will to live.  

So, what would a 'mobility as the 6th vital sign' initiative look like?  Could we adequately argue for mobility as a basic function of human life?  What would that mean for nursing staff on inpatient wards - they were trained to assess pain better, could they be trained to conduct basic mobility assessment?  Does that then mean increased demand for physiotherapy services?  Would that mean mobility intervention would have to become a publicly funded service in our socialized health care system?  Does that then lead to more physios in primary care and preventative roles?  Would that mean physios are required on all inpatient wards in hospitals?  Long term care facilities?  Does the public then get an annual 'mobility check up' in the same vein as annual physicals or dental checkups?  Could there be any potential fallout, as per the pain as 5th sign initiative?  Is this all taking the concept too far?

I don't yet have a clear vision of what this can or should be, or if it's even worth pursuing, but one has a lot of time to think when driving for several hours at a stretch, so consider this little more than a musing at this time.  Would love to hear your comments though.

Cross-Cultural Validation of PROs is more than language translation

A fairly late night and long day today, so missed our chance for a good video update as the sunlight burned off quickly.  We've spent the day in Twillingate Newfoundland, a historic city of just over 2,000 permanent residents originally settled by the french.  It's gone through several hundred years of ups and downs and according to the local residents, is currently experiencing a bit of a down in terms of economy and jobs especially for younger people.  In wandering around this town not only have I been awestruck by my first experience seeing icebergs (they are STUNNING!), but it also got me thinking about the way we use patient-reported outcomes (PROs) to measure mobility issues in our patients.  Some of you will be familiar with common physio PROs like the Lower Extremity Functional Scale (LEFS) or the Upper Extremity Functional Index (UEFI).  My mind immediately went to some of the questions on the LEFS, in particular ones asking about difficulty walking a block, walking a mile, or running on even or uneven ground.  While having a wander round Twillingate I tried to imagine how residents of this quaint fishing town with its homes shoved literally into the side of some of the hills around the area would answer those questions.  There are no 'blocks' here, so a question about difficulty walking a block would have no meaning.  I doubt many of the residents I've seen run all that often, yet in some cases the 'simple' act of walking from their home to their outbuildings is likely biomechanically and energetically speaking just as difficult as running (at least running on even ground), so they may indicate they don't run on even ground, yet mobility-wise are likely very capable - perhaps moreso than those of us who run on even ground.  And then there was the story of a patient who described the mechanism of her lower extremity injury to her doctor as 'I jumped off my bridge' to which her doctor (not a local) responded with concern about her clear suicidality.  As it turns out, your 'bridge' in newfoundland-ish is the front step of your house.

Here's my point of this - many scales we use (or arguably should be using) have been tested for adequate properties of validity and reliability.  The good ones will then usually get picked up by people from other global regions but before then can be implemented they must be 'cross-culturally adapted'.  In every single case I can think of, cross-cultural adaptation has been in fact the process of a language translation, with the presupposition that people who speak the same language, or at least who live in the same country, must necessarily interpret the items in the scale the same way.  Yet this is the value of the firsthand experience I've already gained on this project - clearly this presupposition is incorrect.  Perhaps it's time we start looking at our tools, in particular in a country as geographically and culturally-diverse as Canada, as requiring cross-cultural 'validation' (or even translation) in the same language and within the same country.  I seriously can't think of a single time this has happened so correct me if you know of one, but I can tell you the good, hard-working folks here in Twillingate would have a rough time fully completing the LEFS, and I'm fairly certain the way they do respond would give their clinicians an inaccurate view of their actual mobility.

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Press Release: Physio Moves Canada

Western Researcher Traveling Across Canada to Better Understand Mobility

Dr. David Walton, an Associate Professor with the School of Physical Therapy at Western University, is preparing to head off on a cross-Canada road trip intended to collect information on how physiotherapists and their patients think about mobility and how the delivery of care for mobility problems differs across the provinces.  “Physiotherapists are considered leaders in the management of mobility problems, but the concept of mobility very likely holds different meaning for the maritime fisherman, the northern BC indigenous leader, and the downtown Toronto bike messenger” says Walton.  “The Physio Moves Canada project is the signature project of my sabbatical leave, and I really wanted to do something that was different than what I normally do but also very impactful.”

Officially kicking off at the end of June, the genesis of the idea for this ethnographic research project began a year ago, with the initial intention simply to reconnect with the clinical community.  “I consider myself a clinical researcher” says Walton, “but I’m also acutely aware that despite a 10-year clinical career, since having moved full time into academia I’m getting farther and farther from the realities of front-line daily practice.”  He reached out to the Canadian Physiotherapy Association, the national professional association representing over 13,000 physiotherapists in Canada, and they loved the idea immediately.  “From there it rounded into a fully-fledged qualitative research project that is intended to highlight the diversity and the similarities in the ways physiotherapists are currently optimizing mobility for their patients across this geographically and culturally-diverse country.”

Walton and his research team, including respected qualitative researcher and fellow Western Faculty of Health Sciences member Dr. Debbie Rudman and the study coordinator (and his wife and fellow physiotherapist) Amanda Walton performed a country-wide search for clinical sites that are harnessing unique or innovative strategies to improve access, engagement and/or outcomes for their patients.  They have identified 26 such sites (from over 70 responses to their request for submissions), 21 of which will be visited over a 49-day roadtrip spanning the country from St. John’s, Newfoundland to Whitehorse, Yukon Territories, with at least one site in every province.  An additional 5 sites in southern Ontario will be visited after his return when he can use Western as a home base for one- or two-day trips.  The sites represent a wide diversity of practice settings and populations, from an historic cottage-style hospital in Gros Morne National Park, Newfoundland, to an advanced Virtual Reality-based rehabilitation centre at the Ottawa General Hospital.  “Not surprisingly, physiotherapists in Canada are a tremendously innovative group, many of which are pushing the boundaries of physiotherapy into its next evolution” says Walton, “and innovation is not just occurring in major centres; we’ll be visiting a group of clinicians in Whitehorse who have provided iPads to several of the remote indigenous villages they service so that they can remain connected with their patients in between their regular monthly visits.” 

A secondary purpose of the project will be to hold a series of focus groups with clinicians in many of the cities and towns through which they’ll be passing in order to capture their perspectives on the future of physiotherapy, including both threats and opportunities that they see coming down the road.  “This part of the project is borne from a firm belief that it’s the front line clinician, the ones who are in the trenches day in and day out who are stationed at the best vantage point to see both threats to current practice, and opportunities for growth on the horizon.”  By engaging clinicians in this way, Walton also hopes he’ll hear about clinicians’ priorities for research that should be done now to ensure the profession is prepared for the future, and even recommendations for revising current training programs so that graduates of today are prepared for the practice of tomorrow.  “Truth be told, if you were to pluck Dave Walton from his physiotherapy training program in 1997 and plop him into a current program in 2017, he probably wouldn’t see a whole lot of difference in terms of the content.  Yet the world has clearly advanced so perhaps it’s time that physiotherapy takes a long hard look in the mirror and decides what it wants to become over the next 10-15 years”.  This trip is not only planned to coincide with Canada’s 150th anniversary of confederation, but also the upcoming Physio 2020 initiative which is currently being planned to celebrate the 100th anniversary of physiotherapy in Canada.  By collecting rich, firsthand information on the current state of physiotherapy in Canada, innovators and trendsetters that are pushing it forward, and its anticipate future state, Walton and his colleagues hope to arm clinicians, educators and researchers with the best possible vision of what physiotherapy can become and what needs to happen now to make sure it gets there.