Knowledge to practice in developmental coordination disorder: impact of an evidence-based online module on physical therapists' self-reported knowledge, skills, and practice.

Physical & Occupational Therapy in Pediatrics, Early Online(00):1–15, 2015 C 2015 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/potp DOI: 10.3109/01942638.2015.1012318

Phys Occup Ther Pediatr Downloaded from informahealthcare.com by Kainan University on 04/03/15. For personal use only.

ARTICLE

Knowledge to Practice in Developmental Coordination Disorder: Impact of an Evidence-Based Online Module on Physical Therapists’ Self-Reported Knowledge, Skills, and Practice Chantal Camden, Lisa Rivard, Nancy Pollock, & Cheryl Missiuna CanChild, McMaster University, Hamilton, Ontario, Canada

ABSTRACT. Aims: To evaluate the impact of an evidence-based online module on Developmental Coordination Disorder (DCD) on self-reported physical therapist (PT) knowledge, skills, and practice. Methods: Fifty PTs completed a questionnaire before and after the completion of the online module, with 41 PTs completing the same questionnaire 2 months later. The questionnaires included items rated using a 7-point Likert Scale and short open-ended questions. Results: There was a significant effect of Time for 17 out of 18 items on self-reported knowledge, and all 19 items for self-reported skills. Post-hoc analyses indicated that mean scores at Time 2 and Time 3 were higher than the mean scores at Time 1. Forty-six (92%) participants reported an increase in their confidence to provide evidence-based services. Forty-three (86%) participants indicated their intentions to modify their evaluative practices (e.g., involving children in goal setting) and their management of DCD (e.g., using the best practice principles, providing resources to families). At the 2-month follow-up, 19 (46%) participants had returned to the module to review information (e.g., video, resources) or to download handouts. Conclusions: The online DCD module appears to be an effective knowledge translation strategy to increase PTs’ self-reported knowledge and skills, and to support evidence-informed practice. KEYWORDS. Developmental coordination disorder, evidence-based practice, knowledge translation, physical therapy, web-based resource

Developmental coordination disorder (DCD) is characterized by poor learning and coordination of motor skills that significantly impacts the performance of age-appropriate everyday activities, and affects academic performance, employment, leisure, and play (American Psychiatric Association, 2013). Physical therapists (PTs) are one of the many health care professionals that can help children and Address correspondence to: Dr Chantal Camden, CanChild, McMaster University, 1400 Main Street West, Room 408, Hamilton, Ontario L8S 1C7, Canada (E-mail: [email protected]). (Received 9 February 2014; accepted 18 January 2015)

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families to successfully manage DCD. However, as outlined in Rivard et al. (2015) there is an evidence-to-practice gap in the PT management of children with DCD, with an emphasis on changing underlying motor impairment (Niemeijer et al., 2007; Watemberg et al., 2007). This approach is likely to be ineffective in long term, as it fails to incorporate the motor learning processes that are necessary for the transfer and generalization of learned motor skills to natural contexts (Banks et al., 2008; Hillier, 2007). In fact, in a recent meta-analysis, task-oriented approaches focusing directly on functional skills were reported to be more effective in improving motor performance than process-oriented interventions addressing children’s impairments (Smits-Engelsman et al., 2013). Knowledge translation (KT) is thus needed to support PTs’ implementation of DCD evidence-based practice (EBP). Knowledge translation is defined as “a dynamic and iterative process that includes synthesis, dissemination, exchange, and ethically sound application of knowledge to improve the health of [individuals], provide more effective health services and products, and strengthen the health care system” (Canadian Institutes of Health Research, 2012). Training PTs in research methods, and developing and disseminating short reports are popular KT strategies; however, these strategies have been reported as having a limited impact on changing practice when used as the sole KT intervention (Ketelaar et al., 2008; Schreiber et al., 2009). KT interventions that foster exchange between clinicians and researchers (e.g., collaborative research studies, knowledge brokering) have interactive components (e.g., backand-forth discussions among participants and the instructor, blogs, communities of practice), and use of a variety of strategies and components have been reported to be more useful than passive KT strategies such as research reports (David et al., 2012; Ketelaar et al., 2008; Rivard et al., 2010; Russell et al., 2010; Zidarov et al., 2013). There is a growing interest in the use of the Internet as a platform for KT and exchange. Perceived advantages include easy access to information whenever (and wherever) clinicians need it, opportunities to proceed through materials at a selfdetermined pace, the use of multimedia for illustration, and the potential to engage participants in discussion (Curran and Fleet, 2005; David et al., 2012). Elearning refers to using the Internet to learn more in-depth information about a particular topic, while online KT resources are e-learning products that seek to translate evidence-based knowledge into practice by disseminating information, increasing awareness, and/or stimulating practice change (Levac et al., in press). Most evaluation of online KT resources targets users’ feedback, but there is a need to evaluate change in practice and outcomes on clients/patients (Curran and Fleet, 2005). Evaluation of outcomes is one of the final steps in the Knowledge-to-Action (KTA) framework (Graham et al., 2006) (Figure 1), which is a useful tool to guide the development of KT projects. The KTA framework clearly illustrates that the “action cycle” (i.e., using the knowledge or implementing best practice) should start with identifying the problem and reviewing the knowledge, adapting this knowledge to a particular context, and assessing barriers that challenge the use of the knowledge in the identified context. These steps then lead to selecting, tailoring, and implementing interventions to foster use of knowledge. Monitoring knowledge


Impact of an Evidence-based Online DCD PT Module

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FIGURE 1. Knowledge to Action (KTA) process framework (Graham et al., 2006).

use, evaluating outcomes, and sustaining knowledge use are the final steps of the action cycle. The KTA framework was used to develop the DCD PT module, an online KT resource providing evidence-based information about effective PT management of children with DCD (http://dcd.canchild.ca/en/dcdresources/workshops.asp). The module comprises five sections: (a) Identification; (b) Planning interventions and goals; (c) Evidence-based practice; (d) Management; and (e) Resources. Clinical case scenarios, videos, and links to internal and external resources are included in the module. Rivard et al. (2015) described the development and perceived utility of this module, describing aspects of the KTA framework that relate to knowledge creation/contextualization, tailoring and implementation of the knowledge, and the users’ feedback. The objectives of this study were to evaluate whether the online DCD module had an impact over time on PTs’ self-reported (a) DCD knowledge and skills, and (b) practice. A mixed methods, pre-/post-/follow-up, design was used. Data were

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collected at three time-points–before, immediately after, and 2 months following the completion of the module to document and compare over time aspects of PT DCD knowledge and skills related to the content of the module. Self-reported modifications in practice were measured following completion of the module to document changes in the use of evidence-based practice by PTs. We did not define “evidence-based practice” generally or specific to children with DCD. The DCD PT module synthesized current evidence relevant to DCD PT practice, and we were particularly interested in determining whether PTs would report increased use of validated measures for diagnosis of DCD, resources to explain DCD to children, families, and teachers, and motor learning-, task-oriented- and cognitive approaches for intervention. METHODS The Hamilton Integrated Research Ethics Board (HIREB) for Hamilton Health Sciences and McMaster University approved this study. Participants Fifty PTs working with children at the time of this study were recruited to participate. Experience in providing services to children with DCD was not a requirement for eligibility. Pediatric PTs from across Canada were recruited between February and April 2013 by e-mail using four different approaches. We contacted: (a) individual pediatric rehabilitation centers in Ontario (administrators then invited center PTs to participate); (b) members of the Canadian Physiotherapy Association’s pediatric section; (c) PTs who had previously contacted our research center with queries regarding information on DCD; and (d) we asked participants to forward the study invitation to PT colleagues who might be interested in the study. We estimate that these communication approaches reached approximately 500 Canadian PTs working with children with DCD (the recruitment numbers can only be estimated because no easily accessible, published registry of Canadian PTs working with children [including those with DCD] exists). We collected sample demographic characteristics (work setting, number of children with DCD seen each week) by way of an electronic pre-questionnaire. PTs consented to participate through an electronic survey posted on Survey Monkey. All but one of the 50 participants worked primarily as a clinician (one participant worked primarily in research). PTs worked in different clinical contexts, varied in the number of years of clinical experience (mean: 18 years; SD: 11 years), and the number of years working with children (mean: 13 years; SD: 9 years) (a flow chart providing details of participant recruitment as well as the socio-demographic data of the 50 participants are presented in another manuscript found in this issue [Rivard et al., 2015]). Fourteen PTs completed the pre-questionnaires but did not complete the post-questionnaires. Analysis revealed that these 14 PTs tended to have lower pre-questionnaire mean scores for self-reported knowledge and skills than those completing the post-questionnaire, but no statistical differences were found between the groups. Since no statistical differences were found, subsequent analyses were completed with the 50 PTs who completed both questionnaires, with the exception of two participants who did not complete the skills questions (n = 48),



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and one participant who did not complete the questions regarding the module’s utility in increasing DCD knowledge and skills, and ability to provide evidence-based practice (n = 49). Ninety-two percent (92%) of the participants reported working with children they suspected to have DCD; however, only 70% of those PTs reported working with children who had a formal diagnosis of DCD. Only 18% of PTs reported working with children with DCD at least once a week; 40% said they might work with a child with DCD approximately once a month, and 42% said they worked with children with DCD infrequently (less than once a month). Forty-one participants (82%) completed the 2-month follow-up questionnaire. Thirty-one of the 41 PTs (76%) had worked with 1 to 10 children with DCD within this period, and 19 PTs (46%) reported having returned to the online module. One of the primary reasons noted for returning to the module was to address specific needs of a client with DCD (e.g., to prepare a report, to plan an evaluation, and to download resources). Not having clients and/or not having the time were the reasons noted for not having returned to view the module. Questionnaires Physical therapists were invited to complete three separate questionnaires. The first questionnaire included 37 close-ended (scaled) items and four open-ended questions related to self-reported knowledge, skills, and practice. Items evaluating DCD PT self-reported knowledge and skills were adapted from questionnaires used in a previous study (Missiuna et al., 2012) that evaluated similar attributes reported by occupational therapy clinicians (items and wording were reviewed and adapted to the current study objectives). The questionnaire contained 18 items evaluating DCD knowledge and 19 evaluating DCD skills, all of which used a 7-point Likert Scale for responses (Tables 1 and 2). The same wording was used for items evaluating knowledge (i.e., “Please rate the extent to which you agree with the following statements”) and for items evaluating skills (i.e., “Please rate your level of competence with the following skills”). Open-ended questions were used to document different aspects of PT practice and influencing factors (e.g., “Are you confident in your ability to provide evidence-based practice for children with DCD? Please explain.”). The second and third questionnaires included the same questions about self-reported knowledge and skills but also added questions about PTs’ perception of the usefulness of the module to their practice (results reported in Rivard et al., 2015) and practice change. The second and third questionnaires had 56 and 46 close-ended (scaled) items, and 13 and 12 open-ended questions respectively. Procedure The first questionnaire, referred to as the pre-questionnaire, was completed before reviewing the module; the second and third, referred to as the post- and follow-up questionnaires, were completed by the participant immediately after completing the online module (post-) and then 2 months later (follow-up), respectively. The questionnaires were hosted on the private “intranet” site of the CanChild Centre for Childhood Disability Research (www.dcd.canchild.ca). Following electronic consent to participate, participants were automatically directed to the online pre-questionnaire, and then they were directed to the module itself. Once PTs had

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∗p < .05.

I know what the typical characteristics of DCD are. I believe that I can provide evidence-based services to children with DCD. I am aware of DCD resources that I can use to support my practice. I have a good understanding of DCD as a health condition. I am knowledgeable about how coordination difficulties may impact upon children’s functioning and participation: • at home • at school • during leisure I am familiar with the secondary psychosocial/health issues that commonly develop in children with coordination difficulties over time. I am familiar with current evidence regarding interventions for children with coordination difficulties. I am familiar with the key features of: • task-oriented approach • motor learning approach • cognitive approach I believe that the following can learn to support/manage children’s needs: • teachers • parents • community partners and coaches I believe that PT intervention can help children with coordination difficulties by changing their: • motor impairments • functional activities • participation

Self-reported dcd knowledge

TABLE 1. Changes in Self-Reported DCD Knowledge

5.9 (0.8) 5.5 (1.1) 6.0 (0.9) 5.8 (0.9)

5.9 (0.8) 6.0 (0.8) 6.0 (0.8) 5.8 (1.0)

5.6 (1.0)

5.5 (1.0) 5.5 (1.0) 5.5 (1.0)

5.7 (1.1) 5.9 (1.0) 5.60 (1.12)

4.2 (1.4) 5.8 (0.8) 5.9 (0.8)

4.7 (1.2) 4.0 (1.4) 4.5 (1.5) 4.4 (1.4)

4.9 (1.2) 5.0 (1.2) 5.0 (1.2) 4.4 (1.5)

4.1 (1.4)

3.8 (1.2) 4.1 (1.1) 3.9 (1.4)

5.4 (1.2) 5.6 (1.1) 5.34 (1.12)

3.8 (1.3) 5.3 (1.2) 5.5 (1.2)

Mean (SD)

Pre-module Post-module (n = 50) (n = 50)

4.2 (1.5) 5.7 (0.8) 5.9 (0.8)

5.9 (0.9) 6.0 (0.9) 5.46 (1.19)

5.3 (1.0) 5.3 (0.9) 5.3 (1.0)

5.4 (1.1)

5.9 (0.9) 5.9 (1.0) 5.9 (0.9) 5.8 (1.1)

5.8 (1.0) 5.7 (1.1)

5.6 (0.9) 5.3 (1.1)

2-month follow-up (n = 41)

3.6 (0.03)∗ 6.5 (0.00)∗ 4.5 (0.01)∗

3.1 (0.05)∗ 3.5 (0.04)∗ 1.4 (0.25)

79.2 (0.00)∗ 44.5 (0.00)∗ 62.0 (0.00)∗

47.3 (0.00)∗

34.5 (0.00)∗ 37.2 (0.00)∗ 36.0 (0.00)∗ 44.4 (0.00)∗

39.2 (0,00)∗ 52.4 (0,00)∗

37.7 (0.00)∗ 42.0 (0.00)∗

F-value (p-value)


T1 vs. T3 +0.9∗ +1.3∗ +1. 3∗ +1.3∗ +1.0∗ +0.9∗ +0.9∗ +1.4∗ +1.3∗ +1.5∗ +1.2∗ +1.4∗ +0.4∗ +0.4∗ N/A

+0.4∗ +0.4∗ +0.4

T1 vs. T2 +1.2∗ +1.5∗ +1.5∗ +1.4∗ +1.0∗ +1.0∗ +1.0∗ +1.4∗ +1.5∗ +1.7∗ +1.4∗ +1.6∗ +0.3 +0.3 N/A

+0.4 +0.5∗ +0.4∗

Post-hoc analysis

0.0 –0.1 –0.0

–0.2 +0.1 N/A

–0.2 –0.2∗ –0.2

–0.2

0.0 –0.1 –0.1 0.0

–0.2 –0.1

–0.30∗ –0.2∗

T2 vs. T3

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5.0 (1.2) 5.4 (1.0) 5.3 (1.0) 5.2 (1.1)

5.2 (1.1) 5.3 (1.1) 5.2 (1.1) 5.0 (1.2) 5.8 (0.9) 5.8 (0.9) 5.8 (0.9) 5.5 (1.13) 5.7 (1.1) 5.5 (1.1) 5.4 (1.0) 5.4 (1.0) 5.3 (1.1)

3.4 (1.6) 4.0 (1.6) 3.9 (1.7) 3.7 (1.8)

3.6 (1.4) 3.7 (1.5) 3.6 (1.6) 3.4 (1.6) 5.4 (1.1) 5.3 (1.1) 5.0 (1.2) 4.3 (1.5) 4.8 (1.6) 4.4 (1.6) 3.6 (1.4) 3.9 (1.4) 3.7 (1.6)

∗p < .05. Graham et al. (2006).

5.7 (1.0) 5.3 (1.2)

4.4 (1.5) 4.0 (1.5)

Mean (SD)

Recognize typical characteristics of DCD. Communicate information to parents to facilitate a diagnosis of DCD. Explain DCD to: • children • parents • teachers • community partners and coaches Support the following groups in managing DCD • Children • Parents • Teachers • Community partners and coaches Assess a child’s: • motor impairments • functional activities • participation Involve the child in goal setting. Use validated tools to: • assess a child with DCD • evaluate outcomes During intervention, apply principles of: • task-oriented approach • motor learning approach • cognitive approach

Post (n = 50)

Pre (n = 50)

Self-reported DCD skills (Perceived level of competence with the following skills)

TABLE 2. Changes in Self-Reported DCD Skills

5.2 (1.1) 5.2 (1.0) 5.0 (1.1)

5.9 (1.2) 5.8 (1.2)

6.1 (1.0) 5.8 (1.0) 5.7 (1.1) 5.4 (1.4)

5.3 (1.0) 5.4 (1.0) 5.4 (1.0) 5.1 (1.1)

5.2 (1.2) 5.4 (1.1) 5.3 (1.2) 5.2 (1.3)

5.6 (1.0) 5.4 (1.1)

Follow-up (n = 41)

72.0 (0.00)∗ 39.2 (0.00)∗ 44.7 (0.00)∗

20.6 (0.00)∗ 26.7 (0.00)∗

8.5 (0.00)∗ 9.2 (0.00)∗ 17.3 (0.00)∗ 23.3 (0.00)∗

56.0 (0.00)∗ 52.6 (0.00)∗ 45.5 (0.00)∗ 49.4 (0.00)∗

60.3 (0.00)∗ 50.1 (0.00)∗ 52.3 (0.00)∗ 37.5 (0.00)∗

40.1 (0.00)∗ 42.9 (0.00)∗

F-value (p-value)

T1 vs. T3 +1.2∗ +1.4∗ +1.8∗ +1.4∗ +1.4∗ +1.5∗ +1.7∗ +1.7∗ +1.7∗ +1.7∗ +0.7∗ +0.5∗ +0.7∗ +1.1∗ +1.1∗ +1.4∗ +2.0∗ +1.3∗ +1.3∗

+1.3∗ +1.3∗ +1.6∗ +1.4∗ +1.4∗ +1.5∗ +1.6∗ +1.6∗ +1.6∗ +1.6∗ +0.4∗ +0.5∗ +0.8∗ +1.2∗ +0.9∗ +1.1∗ +1.8∗ +1.5∗ +1.6∗

Post-hoc analysis T1 vs. T2


–0.2∗ –0.2∗ –0.3∗

+0.2 +0.3

+0.3 0.0 –0.1 –0.1

+0.1 +0.1 +0.1 +0.1

+0.2 0.0 0.0 0.0

–0.1 +0.1

T2 vs. T3

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completed each of the five sections of the online module, in any order, an invitation to complete the post-questionnaire appeared at the top of their screen (two reminder e-mails were also sent as needed). Two months following the completion of the pre-questionnaire, a research assistant sent an e-mail to participants with a direct link to the follow-up questionnaire. If participants had not yet completed the questionnaire within 1 week of the first e-mail, the research assistant sent a reminder e-mail.


Data Analysis SPSS Statistics software (PASW 18.0) was used to describe participants’ demographic information as well as the questionnaire item ratings. The data of the 50 participants who completed the background information questions and, at a minimum, all the questions relating to self-reported knowledge of DCD in the preand post-questionnaires were included in the analysis. For each item in the questionnaires, mean scores at pre-test, post-test, and follow-up were compared using one-way repeated measures ANOVA. For items where there was an effect of time, post-hoc analyses were computed. Principles of thematic analysis (Braun and Clarke, 2010) guided the analysis of the open-ended questions. Specifically, for each question, the first author reviewed the data, assigning codes to each statement. Codes were then collated to identify principal themes for each open-ended question. Quotes and codes were reviewed to ensure that identified themes captured the collected data. Themes and quotes which reflect qualitative findings are presented.

RESULTS Self-Reported Knowledge and Skills Mean scores for the 37 items evaluating self-reported DCD knowledge and skills are presented in Tables 1 and 2. There was a significant effect for Time for 17 out of 18 items (94%) for self-reported knowledge, and on all the 19 items for selfreported skills (Tables 1 and 2). Post-hoc analyses indicated that mean scores at Time 2 and Time 3 were higher than mean scores at Time 1. Immediately after completing the module (Time 2), participants’ perceptions of the usefulness of the module in increasing their knowledge and skills were high, with mean scores of 6.0 (SD = 1.1) and 5.5 (SD = 1.0), respectively. Self-Reported Practice Before completing the module (Time 1), 18 (36%) PTs reported that they were confident in providing evidence-based practice to children with DCD. PTs perceived, there were a number of factors influencing their confidence in providing evidencebased practice, including the following identified themes: (a) experience with children with DCD, (b) access to knowledge, evidence-based practice resources, colleagues, and training opportunities, and (c) opportunities/constraints of the service delivery model in which they worked. The citations below illustrate their comments following module completion:


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Although I am aware of [the] definition, [and] current assessments to help facilitate a diagnosis, I feel I am not fully informed regarding evidence-based interventions, management strategies for the DCD population. (PT #20, did not complete data regarding clinical and pediatric experience) [I] feel as though I have not had enough training/exposure to fully understand and treat DCD. (PT #29, did not complete data regarding clinical experience; 3 years pediatric experience)


I feel I have the general knowledge but because I have just started, I need practice. (PT #34, 1-year clinical experience, and 1-year pediatric experience) The treatment of DCD ends up being a lower priority than higher needs children. [I] feel I have the knowledge but not the resources to treat these kids with such a large caseload. (PT #37, 15 years clinical experience, and 15 years pediatric experience) Immediately after completing the module (Time 2), participants’ perceptions of the usefulness of the information and resources contained within the module in supporting them in providing evidence-based practice were high, with a mean score of 6.2 (SD = 0.8). Forty-six (92%) participants reported feeling more confident in providing evidence-based practice. The quality and comprehensiveness of the information, and the resources provided were among the reasons they reported as influencing their confidence. They indicated that the module saved them time looking for information, and that it provided them with tools for assessing children, as well as planning intervention and evaluating outcomes, which they felt would help promote positive change in the lives of children with DCD and their families. PTs indicated that more experience working with children with DCD would now be necessary to reinforce their knowledge base, and they reported that the module videos provided were useful to help them to move their knowledge into practice. Many felt better equipped to help families in spite of limited resources. Others, on the other hand, reported persistent challenges in (a) gaining commitment from families, (b) changing their clinical management from impairment-focused to activity-focused, and (c) the time required to implement evidence-based practice. I knew already about the best evidence but struggled a little as to how to apply these principles. I feel the videos provided a great resource to this application. (PT #34, 1-year clinical experience, 1-year pediatric experience) It is really helpful to actually see [the approaches] in practice on the videos. I just could not get a great understanding of how to put them in practice from reading about them. (PT #38, 8 years clinical experience, 8 years pediatric experience) The module assisted me in realizing that more can be done, even with our limited availability for this group of children. (PT #37, 15 years clinical experience, 15 years pediatric experience)

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Having only a few children out of the whole caseload with DCD, so to always stay up to date can sometimes be hard, taking the time to check. (PT #36, 8 years clinical experience, 4 years pediatric experience) Immediately after viewing the module, many PTs indicated they would refer back to the module to review the information, or, more specifically, if they had a client with DCD. Forty-three (86%) PTs reported that they intended to make changes in their practice. Practice change intentions were quite varied and included the following reasons: (a) Trying to better identify children who might have DCD; (b) use of assessment tools; (c) involving the family and the child more in goal setting; (d) changing their focus of intervention (e.g., participation instead of impairment, increasing capacity-building with teachers and community partners); and (e) sharing more information with families, colleagues, physicians, teachers, and community partners. Yes [will come back]. I don’t seem to be able to retain all of the pertinent information into long-term memory unless I review it a few times or especially in regards to a real-life client, in which case reviewing the information again would be helpful. (PT #31, 26 years clinical experience, 10 years pediatric experience) I will use a model to identify the child’s or parent’s goals/needs to form a more specific function-oriented plan. (PT #5, 35 years clinical experience, 23 years pediatric experience) [I] think that I will try to use the MABC-2 as my evaluation tool. I would also like to use some of the handouts for parents, educators, and coaches. And help families discuss concerns with their family physicians regarding DCD. (PT #26, 10 years clinical experience, 6 years pediatric experience) I will assess certain children specifically for DCD if I am concerned versus simply providing a clinical diagnosis [like] “gross motor delay.” (PT #27, 4 years clinical experience, 2 years pediatric experience) At my organization, we typically have not treated children diagnosed with DCD, but I realize now how many children we see who may have DCD, but are not diagnosed. (PT #46, 19 years clinical experience, 19 years pediatric experience) Two months following completion of the module, 14 (34%) participants reported having changed one or more aspects of their practice following module completion (e.g., starting to refer children for diagnosis, sharing more information and resources with teachers and families). Factors noted as influencing PTs’ ability to provide evidence-based practice included having access to resources such as evidence-based information, handouts, and site “champions.” When asked if a virtual community of practice would help them to provide evidence-based practice, 33 (80%) participants agreed, indicating this would help them to create a “bag of tricks” and to seek out other therapists’ perspectives on the best approaches. Those who were not particularly interested in being part of a virtual community of practice indicated that they already had access to knowledgeable colleagues, or that they were not active Internet users.


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Opportunities for additional continuous education, the provision of education to others involved in DCD management (e.g., pediatrician), and advocating/raising community awareness were themes also reported as being necessary to facilitate evidence-based practice. Having time, funding, research evidence, and service delivery models supporting evidence-based practice were also mentioned as being important. Finally, website resources, such as this module, were also perceived as positively contributing to evidence-based practice, as highlighted in the following quotes: Access to approved websites backed by academic studies (as opposed to the multitude of “blogs” and “opinions” on the Internet). (PT #5, 35 years clinical experience, 23 years pediatric experience) Having someone/organization who has done all the background work at gathering/organizing/structuring the information in such a useable way is a huge facilitator for providing evidence-based services to children. (PT #8, 19 years clinical experience, 19 years pediatric experience) Education, awareness. I didn’t realize that we could provide so much assistance for these children prior to this module. (PT #46, 19 years clinical experience, 19 years pediatric experience) Opportunities for therapists working with the children to be educated in the evidence-based practices. The online module was great because you could take it at home. (PT #26, 10 years clinical experience, 6 years pediatric experience) Referring to the module again. Increased awareness overall of all physiotherapists on this condition and how to treat it. Increased awareness and diagnosis from [medical doctors] and referral to physiotherapy. (PT #31, 26 years clinical experience, 10 years pediatric experience) DISCUSSION In this study, an online module providing synthesized, evidence-based DCD information and resources to support PTs was implemented and evaluated. Following module completion, participants reported an increase in their self-reported knowledge and skills relating to DCD, which was maintained 2 months later. Participants also reported feeling more confident in providing evidence-based practice for children with DCD, and in making specific changes to their clinical practice. These finding are important not only in encouraging PTs to use the best practice principles in DCD but also in advancing KT science. From a clinical perspective, study findings highlight how the module helped PTs to begin to shift their focus from impairment-based models toward an emphasis on functional activity and participation, noted to be a knowledge-to-practice gap in PT DCD management (Blank et al., 2012; Hillier, 2007; Rivard et al., 2012). In addition, PTs reported having used many of the module’s practical resources to start to build capacity among families, teachers, and the community, another important area of DCD management that has recently been recommended by international consensus guidelines (Blank et al., 2012). While the PTs’ qualitative comments highlighted


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a shift in clinical reasoning, it is not known whether such a shift in thinking will ultimately result in practice changes. However, changes in beliefs along with intentions to change practice are necessary first steps toward more permanent behavior changes (Ajzen, 1991). Further work aimed specifically at module implementation, and with follow-up over a longer period of time will help to determine whether the module can be successful in translating shifts in thinking into practice. From a KT science perspective, the DCD module has several advantageous. As a web-based resource, this evidence-based module was accessible to PTs when and where they needed it, allowing them to return as often as they required for continuing education and access to practical resources. Relatively few studies have explored the utilization of the web by PTs to address knowledgeto-practice gaps. Moreover, online resources are often used as part of a larger KT intervention such as a “community of practice,” where participants interact to increase their knowledge or solve practical problems such as implementing the best practice (e.g., David et al., 2012). This study is one of the first to evaluate an evidence-based online module as a “stand alone” KT strategy. The module is available to PTs and rehabilitation professionals worldwide at http://dcd.canchild.ca/en/dcdresources/workshops.asp. Next steps include posting a French version of the module and exploring opportunities for examining the long-term impact on practice and health outcomes for children with DCD. The literature on e-learning emphasizes the need for studies evaluating the impact of KT interventions on changes in practice and patient outcomes, in addition to satisfaction with the online product and changes in knowledge and skills (Curran and Fleet, 2005). This study documented self-reported changes in knowledge and skills as well as self-reported concrete clinical practice changes over a very short time period. In fact, the overall perception of participants regarding the module’s usefulness in supporting them in providing evidence-based practice was rated higher than its ability to increase their knowledge and skills. This is important, given that, in other KT studies, researchers have reported limited impact on practice change over longer periods of time (Ketelaar et al., 2008), and it is an important area for further research. There may be several reasons to explain the positive findings of our study. An effort was made during the development of the module to respond to PTs’ content and format preferences. In particular, participants reported that the concrete examples provided in the case scenario and accompanying videos were very supportive to them in their efforts to apply evidence to practice. Tailoring knowledge to endusers is noted as an important first step in the KTA Cycle framework (Graham et al., 2006). Our results highlight the importance of providing user-friendly practical tools and information to support action into practice, such as guides to interview families and handouts providing recommendations for patients, families, and community partners. Our findings suggest that by including end-user input throughout the process, online modules may facilitate implementation and result in clinical practice changes. Although online KT strategies have been used and might be helpful in a variety of settings and with different groups of participants, we believe that using online KT resources might be particularly useful in situations where (a) it would be difficult for PTs to come together in one location; (b) there is a need to increase



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general knowledge; (c) the evidence-based skills that need to be acquired relate to capacity-building and chronic disease management (rather than more direct handson skills); and (d) clinical resources are available to be shared virtually. Since new DCD knowledge and resources were available for PTs and their clients, using an online module was probably particularly suitable for KT. Our results must, however, be interpreted with caution. Self-reported changes in knowledge, skills, and practice were the primary source of data in this study. The validity of self-reports may not represent an accurate measure of actual change in knowledge and skills. However, it has been shown that a change in attitude assists with narrowing the gap between the best practice evidence and the evidence-based practice (Lang et al., 2007). In addition, in spite of our efforts to include a representative sample of all Canadian PTs, a self-selection bias may have also influenced our results, with those more interested in DCD and/or evidence-based practice being more likely to participate in our study. Participants may have had more DCD knowledge than the overall population of PTs working with pediatric clients. In spite of the fact that retention was high, it is possible that participants who were less knowledgeable about DCD were overwhelmed by the module content, and are thus less represented in our sample (as was seen by the higher mean scores in the group of PTs completing the post-questionnaire compared with those who completed the pre-questionnaire but did not complete the post-questionnaire). Other factors, such as previous experiences with e-learning, could have also influenced participant retention over the study period as well as our response rate. Finally, we were unable to monitor long-term reported changes, and we did not document the impact of knowledge uptake on client care. Nonetheless, our results are promising and support further research on the use of the Internet for knowledge transfer and facilitation of research into PT practice. Ketalaar et al. (2008) pointed out that most KT interventions are aimed at increasing awareness, understanding, and acceptance around research evidence, but that it is also critical for researchers to foster and maintain practice change. In light of the KT and e-learning research literature, and our study’s findings, including the factors identified by participants as impacting their ability to implement evidence-based practice, key steps for developing effective online KT strategies might involve the following: (a) Collaborating with end-users from the early development stages and throughout when developing online content; (b) synthesizing and summarizing the currently available research evidence to address end-user content needs, and developing concrete, “action-able” tools to supporting practice; (c) creating a network of supportive “champions,” and (d) developing service delivery models that support the implementation of research evidence into practice. The current study addressed the two first steps in this process. Future studies exploring how the online module could be used within a network of PT leaders having expertise in DCD to influence service delivery and ease the implementation of evidence-based practice will be necessary. CONCLUSIONS An online evidence-based PT DCD module increased PTs’ self-reported DCD knowledge and skills. Moreover, over a 2-month period, participants reported

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having modified some aspects of their practice to align better with the DCD best practice. The implementation and evaluation of an evidence-based PT DCD module contributes to the KT online resources that may help to narrow the evidence-topractice gap in the PT management of children with DCD. Results also provided information about factors influencing PTs’ ability to implement DCD evidence-based practice. Participants reported that the online DCD module developed in this study supported their evidence-based practice, as it contributed to the resources available to them in the management of children with DCD.


ACKNOWLEDGMENT Two of the investigators (Dr Chantal Camden and Lisa Rivard) received funding support (post-doctoral and doctoral awards respectively) through the Canadian Institutes of Health Research (CIHR) as well as support from the Canadian Child Health Clinician Scientist Program (CCHCSP). Dr Chantal Camden is also funded ´ through the Fonds de Recherche du Quebec–Sant e´ (FRQ-S). We wish to thank the Physiotherapy Foundation of Canada (Ontario Physiotherapy Association (Kim Wolny) Research Grant) for financial support of this project as well as the PT clinicians who participated in this study. Our thanks also to Tiffany Guanlao, Nicole Walter, and Kathy Wlodarczyk, for their assistance with recruitment and data collection. Special thanks to the knowledge translation staff of CanChild Centre for Childhood Disability Research, including Affaf Ahistam, for their help with the web development of the DCD PT module, and to “Adam” and his mother, who graciously gave their time to develop the videos of case scenario. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. ABOUT THE AUTHORS Dr Chantal Camden, Lisa Rivard, Nancy Pollock, and Dr Cheryl Missiuna are affiliated with CanChild, McMaster University, Canada. Chantal is now an assistant ´ professor at Sherbrooke University, Quebec, Canada. REFERENCES American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM5TM . Arlington, VA: American Psychiatric Publishing. Ajzen I. (1991). The theory of planned behaviour. Organizational Behavior and Human Decision Processes 50:179–211. Banks R, Rodger S, Polatajko H. (2008). Mastering handwriting: How children with developmental coordination disorder succeed with CO-OP. OTJR: Occupation, Participation and Health 28:100–109. Blank R, Smits-Engelsman B, Polatajko H, Wilson P. (2012). European academy for childhood disability (EACD): Recommendations on the definition, diagnosis, and intervention of developmental coordination disorder (long version). Developmental Medicine and Child Neurology 54:54–93. Braun V, Clarke V. (2010). Using thematic analysis in psychology. Qualitative Research in Psychology 3:77–101.



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Canadian Institutes of Health Research. (2012). Guide to knowledge translation planning at CIHR: Integrated and end-of-grant approaches. Ottawa, ON: CIHR. Curran VR, Fleet L. (2005). A review of evaluation outcomes of web-based continuing medical education. Medical Education 39:561–567. David I, Poissant L, Rochette A. (2012). Clinicians’ expectations of web 2.0 as a mechanism for knowledge transfer of stroke best practices. Journal of Medical Internet Research 14: e121–e121. Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions 26:13–24. Hillier S. (2007). Interventions for children with developmental coordination disorder: A systematic review. The Internet Journal of Allied Health Sciences and Practice 5:1540–1580. Ketelaar M, Russell DJ, Gorter JW. (2008). The challenge of moving evidence-based measures into clinical practice: Lessons in knowledge translation. Physical & Occupational Therapy in Pediatrics 28:191–206. Lang ES, Wyer PC, Haynes RB. (2007). Knowledge translation: Closing the evidence-to-practice gap. Annals of Emergency Medicine 49:355–363. Levac D, Glegg S, Camden C, Rivard L, Missiuna C. (in press). Best practice guidelines for the development, implementation, and evaluation of online knowledge translation resources in rehabilitation. Physical Therapy (Special Issue on Knowledge Translation). Missiuna C, Pollock N, Campbell W, Bennett S, Hecimovich C, Gaines R, DeCola C, et al. (2012). Use of the medical research council framework to develop a complex intervention in pediatric occupational therapy: Assessing feasibility. Research in Developmental Disabilities 33:1433–1452. Niemeijer AS, Smits-Engelsman BCM, Schoemaker MM. (2007). Neuromotor task training for children with developmental coordination disorder: A controlled trial. Developmental Medicine & Child Neurology 49:406–411. Rivard L, Camden C, Missiuna C, Pollock N. (2015). Knowledge to practice in developmental coordination disorder: Utility of an evidence-based online module for physical therapists. Physical and Occupational Therapy in Pediatrics (Special Issue on Developmental Coordination Disorder). Rivard L, Missiuna C, Pollock N, David, K. (2012). Developmental coordination disorder. In Campbell SK, Orlin M, Palisano RJ, eds. Physical therapy for children. St Louis, MO: Saunders Elsevier, 498–538. Rivard LM, Russell DJ, Roxborough L, Ketelaar M, Bartlett DJ, Rosenbaum P. (2010). Promoting the use of measurement tools in practice: A mixed-methods study of the activities and experiences of physical therapist knowledge brokers. Physical Therapy 90:1580–1590. Russell DJ, Rivard LM, Walter SD, Rosenbaum PL, Roxborough L, Cameron D, et al. (2010). Using knowledge brokers to facilitate the uptake of pediatric measurement tools into clinical practice: A before-after intervention study. Implementation Science 5:92. Schreiber J, Stern P, Marchetti G, Provident I. (2009). Strategies to promote evidence-based practice in pediatric physical therapy: A formative evaluation pilot project. Physical Therapy 89:918–933. Smits-Engelsman BCM, Blank R, Van Der Kaay A, Mosterd-Van Meijs R, Vlugt-Van Den Brand E, Polatajko H, Wilson PH. (2013). Efficacy of interventions to improve motor performance in children with developmental coordination disorder: A combined systematic review and meta-analysis. Developmental Medicine & Child Neurology 55:229–237. Watemberg N, Waiserberg N, Zuk L, Lerman-Sagie T. (2007). Developmental coordination disorder in children with attention-deficit-hyperactivity disorder and physical therapy intervention. Developmental Medicine & Child Neurology 49:920–945. Zidarov D, Thomas A, Poissant L. (2013). Knowledge translation in physical therapy: From theory to practice. Disability & Rehabilitation 35:1571–1577.

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