Critical features of physical therapists specializing in stroke rehabilitation
culoskeletal or cardiovascular), or no specialization. The fourth
group consisted of undergraduate physical therapy students.
The SCT was web-based and available for completion by
the participants from February until June 2015. In addition,
participants completed a survey to identify demographic cha-
racteristics and clinical expertise. By participating, PTs could
obtain continuing education credits for the Dutch Central Qua-
lity Register for Physical Therapy. No incentive was available
for the physical therapy students.
Statistical analysis
Data for all participants were entered into a computer database
and analysed with the IBM SPSS statistical package (version
21.0). Descriptive statistics were used to present the characte-
ristics of the subjects and the SCT score.
Construct validity. Construct validity was defined as the
degree to which the scores (17) of the SCT were consistent
with our hypothesis that there are differences between the
4 groups, so that PTs specializing in neurology could be
distinguished by their higher SCT score. The construct
validity of the SCT was analysed with 1-way ANOVA to
estimate differences between subgroups with a Bonferroni
post-hoc analysis.
Identification of critical features of PTs specializing in stroke
rehabilitation. To identify physical therapy characteristics
associated with guideline-consistent clinical reasoning in
stroke rehabilitation, the optimized SCT score, expressed
as percentages of the total score, was used as the dependent
variable. To avoid random allocation of physical therapy
characteristics in the regression model, 10 hypotheses were
formulated based on the expertise of the project group and
development panel. It was hypothesized that the following
features of clinical competence would be related to a higher
SCT score:
• Higher level of guideline knowledge: defined as higher
self-reported clinical practice guideline knowledge, using a
numerical rating scale.
• Being acquainted with international clinical practice guideline(s)
in stroke rehabilitation. Acquaintance was positive when 1 or
more international clinical practice guideline(s) were mentioned
in response to the open-ended question.
• More years of employment within specialized physical therapy.
• Delivering care within a team, with teamwork defined as
working with at least 3 different healthcare professionals,
including structured multidisciplinary team meetings to
discuss patients’ treatment plans.
• A higher number of unique stroke patients treated in the last
12 months, as reported by the PT.
• A higher frequency of reading scientific literature about stroke
care per year, scientific literature being defined as international
peer-reviewed journals.
• University-level education, defined as having successfully
completed a research Master’s degree or a PhD programme.
• Having attended in-depth training on neurorehabilitation,
defined as successfully having completed the Dutch Neu-
rorehabilitation course.
• Participation in professional development activities, defined
as systematic participation in teaching on neurorehabilitation,
formalized community stroke networks, or case discussion
meetings or peer feedback groups for neurology of the Royal
Dutch Society for Physical Therapy.
421
Associations between physical therapy characteristics and SCT
score were first analysed in a bivariate regression analysis to
identify statistically significant independent determinants
(p < 0.1) of the SCT score. Subsequently, multicollinearity
was assessed, and only physical therapy characteristics with a
correlation coefficient > 0.7, VIF> 10 or Tolerance < 0.2 were
selected, to prevent over-parametrization of the prediction
model. Finally, the remaining characteristics were included
in a multivariate, forward-selection linear regression analysis
followed by a backwards selection method. standardized and
unstandardized coefficients (B) were estimated, with 95% con-
fidence intervals (95% CI) for the unstandardized coefficients.
Only physical therapy characteristics with a 2-tailed statistically
significant level with a p-value < 0.05 in both methods were
considered to make a significant contribution to the multivari-
able regression model.
RESULTS
Development of the content-valid script concordance
test
The SCT developed contained 59 items, using a fixed
questioning format, nested within 21 clinical scena-
rios. All criteria stated in the AMEE guideline (12)
were met and the items were sufficiently distributed
across the different domains of the test blueprint. An
example item is presented in Box 2. A reference panel
of 15 physical therapy experts on stroke rehabilitation
developed the scoring algorithm. After the quality as-
sessment, 12 items were assumed to perform poorly
and the development panel selected 9 of these 12 items
to be discarded. After this optimization procedure, 50
items in 21 clinical scenarios were used to calculate
the total SCT score for each participant, expressed as
a percentage of the maximum score.
Box 2. Script concordance test (SCT) example. Example item
from the SCT developed for physical therapy in stroke patients,
translated from the Dutch. This concerns the use of a measurement
instrument. The bold text represents the fixed format of the script
concordance question.
Case description: Mr Klaas was hospitalized with an ischaemic stroke in
the left hemisphere. There is no indication for further medical treatment.
The physician wants to discharge him home, and seeks your advice. Mr
Klaas lives with his partner in an apartment, accessible by stairs as well
as by elevator.
Clinical decision-making: Your initial advice is to discharge Mr Klaas
home, since he shows maximum scores on the measurement instruments
recommended in the clinical practice guideline, and he has no signs of
higher cortical impairments.
The following new information is available: Just before discharge, Mr Klaas
suffers a recurrent stroke with the same localization. The Motricity Index
score after this second stroke is 26/25/25 for his arm, and 33/25/25 for
his leg. Furthermore, specific problems of balance are seen and the Berg
Balance Score is 50. Mr Klaas is able to walk independently and safely at
the hospital department.
As a result, your initial advice becomes:
•
•
•
•
•
Unlikely
Less likely
No more nor less likely
More likely
Very likely
J Rehabil Med 51, 2019