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Objective To develop a cross-professional model framing the concept and practice of person-centered rehabilitation (PCR) in adult populations, based on a scoping review and thematic analysis of the literature. Data Sources Key databases (PubMed, Scopus, Cumulative Index to Nursing and Allied Health), snowballing searches, and experts’ consultation were the data sources for English-language empirical or conceptual articles published from January 2007-February 2020. Study Selection Two independent reviewers selected adult-based articles addressing at least 1 of the 6 categories of PCR-related content, a priori specified in the published review protocol. From 6527 unique references, 147 were finally included in the analysis. Of those, 26 were exclusively conceptual articles. Data Extraction Two independent reviewers extracted textual data on what PCR entails conceptually or as a practice. No quality appraisals were performed as is typical in scoping reviews. Data Synthesis A thematic analysis produced thematic categories that were combined into an emergent model (the PCR Model), which was reviewed by 5 external experts. PCR was framed as a way of thinking about and providing rehabilitation services “with” the person. PCR is embedded in rehabilitation structures and practice across 3 levels: (1) the person-professional dyad; (2) the microsystem level (typically an interprofessional team, involving significant others); and (3) a macrosystem level (organization within which rehabilitation is delivered). Thematic categories are articulated within each level, detailing both the conceptual and practice attributes of PCR. Conclusions The PCR Model can inform both clinical and service organization practices. The PCR Model may benefit from further developments including obtaining wider stakeholders’ input, determining relevance in different cultural and linguistic groups, and further operationalization and testing in implementation projects.

Human movement is complex, presenting clinical and research challenges regarding how it is described and investigated. This paper discusses the commonalities and differences on how human movement is conceptualized from neuroscientific and clinical perspectives with respect to postural control; the limitations of linear measures; movement efficiency with respect to metabolic energy cost and selectivity; and, how muscle synergy analysis may contribute to our understanding of movement variability. We highlight the role of sensory information on motor performance with respect to the base of support and alignment, illustrating a potential disconnect between the clinical and neuroscientific perspectives. The purpose of this paper is to discuss the commonalities and differences in how movement concepts are defined and operationalized by Bobath clinicians and the neuroscientific community to facilitate a common understanding and open the dialogue on the research practice gap.

Background To explore the movement patterns utilized by persons post stroke from the simultaneous perspective of pelvic and limb loading with the path of centre of mass during the movement transitions sit to stand and stand to sit. Methods A descriptive pilot study where kinetic and kinematic data were collected and compared between the contribution made by the less affected versus more affected lower limb and trunk during sit to stand and stand to sit following stroke. Movement analysis was undertaken using force-plates and a 3D VICON motion capture system. Findings Data were successfully collected on nine subjects of whom four presented with left side more affected and eight were male. Two patterns were demonstrated for pelvic loading, four patterns for limb loading and five patterns for deviation of centre of mass. There were no consistent patterns of movement demonstrated dependent upon the more or less affected side. There was no consistent relationship between pelvic and limb loading and deviation of centre of mass throughout the movement phases. Interpretation In contrast to assumptions often made with respect to limb loading, we found large variability in movement patterns utilized by person's with a hemiparetic presentation during sit to stand and stand to sit. The findings suggest that movement problems encountered by persons post-stroke are complex and identifies limitations with respect to current measurement techniques.

Purpose: This study's purpose was to gain insight into physiotherapists' perspectives on the perceived barriers and facilitators of integrating physiotherapists into primary health care (PHC) teams. Method: A qualitative descriptive approach consisting of semi-structured face-to-face or telephone interviews was used. Interviews were audio recorded, transcribed verbatim, and checked by the interviewers to ensure trustworthiness. Data were analyzed using Braun and Clarke's six steps to thematic analysis. Results: Eight participants were interviewed, representing physiotherapists from diverse demographics and geographical regions in Ontario. Common themes discussed were the orientation process, their experiences of integrating the physiotherapist's role into the organization, programme development compared with one-to-one care, the characteristics of the physiotherapist and the interdisciplinary team, and the resources available in the organization. Our key findings of influential factors for integration were (1) the diversity and novelty of new physiotherapists' role, (2) team members' understanding of the physiotherapists' role, and (3) physiotherapists' actions and values regarding PHC. Conclusions: The integration process is affected by factors ranging from individual to system levels. The integration of physiotherapists into PHC would be enhanced by a greater understanding of the role of physiotherapy in PHC by physiotherapists, other health care professionals, and system planners.

Objective(s) To frame the concept and practice of Person-Centered Rehabilitation (PCR) in adult physical rehabilitation, derived from a scoping review and thematic synthesis of the literature. Data Sources English-language empirical or conceptual papers, published from January 2007 to February 2020, were found through searches in databases (PubMed, Scopus, CINAHL), snowballing searches, and experts’ consultation. Study Selection Two independent reviewers selected papers with PCR-related content, using the criteria in the published review protocol. From 6527 unique references, 147 were used in the analysis, 18% of them exclusively conceptual. Data Extraction Textual data on the PCR concepts or practices were extracted by two independent reviewers. Data Synthesis The thematic analysis and experts’ consultation gave rise to the Person-Centered Rehabilitation Model (PCR Model): a cross-professional model for the concept and practice of PCR in adult physical rehabilitation settings. At the person-professional dyad, PCR was framed as: a respectful of and tailored to the person; reflexive and adaptive to the situation; compassionate and caring; focused on strengths and hopes - beyond deficits, and empowering and collaborative - toward a co-constructed rehabilitation. At the team level, a PCR approach includes significant others, is delivered in a welcoming and secure environment, and is articulated through a PCR team. At the organization level, PCR approaches are inclusive of clients and staff in service evaluation and improvement, create the context (e.g. provides training opportunities) for PCR to occur, and is organized for coordinated and tailored approaches. Conclusions PCR occurs at clinical and service organization practices, which are articulated through the PCR Model. The PCR model offers a conceptualization of PCR applicable in clinical and service settings and may assist in the implementation of PCR principles. Disclosures No conflicts of interest declared.

Rationale, aims, and objectives Movement, a core aspect of physiotherapy practice, and integral to the clinical reasoning process has undergone limited theoretical development. Instead, research has focused on intervention effectiveness embedded within the positivist paradigm. The purpose of this study was to explore how expert neurorehabilitation therapists conceptualize movement as part of their clinical reasoning. Method A qualitative interpretive descriptive approach consisting of stimulated recall using video-recorded treatment sessions and in-depth interviews was used. Theoretical sampling was used to recruit members of the International Bobath Instructors Training Association (IBITA) who are recognized experts in neurorehabilitation. Interview transcripts were transcribed verbatim. Data analysis was progressive, iterative, and inductive. Results Twenty-two IBITA instructors from 7 different countries volunteered to participate. They ranged in clinical experience from 12 to 40 years and instructor experience from 1 to 35 years. The conceptualization of movement by the IBITA instructors involves the following elements: (1) movement comprises the whole person and the whole body, not just individual body segments; (2) active alignment of body segments is integral to movement performance; and (3) efficient movement requires the relative integration of postural control/stability and selective movement/mobility. Conclusions The IBITA instructors conceptualize movement from a person-centred perspective. The integration of postural control and selective movement, with alignment and variability as key components, forms the foundation of their understanding of movement. Further investigation into the role of postural control in movement recovery post central nervous system lesion is required. Likewise, the dimensions of movement critical to the conceptualization of movement are not well understood from the perspective of the physiotherapist or persons with neurological impairments.

Rationale, aims, and objectives Clinical reasoning is an essential aspect of clinical practice, however is largely ignored in the current rehabilitation sciences evidence base. Literature related to clinical reasoning and clinical expertise has evolved concurrently although rehabilitation reasoning frameworks remain relatively generic. The purpose of this study was to explicate the clinical reasoning process of Bobath instructors of a widely used neuro-rehabilitation approach, the Bobath concept. Methods A qualitative interpretive description approach consisting of stimulated recall using video-recorded treatment sessions and in-depth interviews. Purposive sampling was used to recruit members of the International Bobath Instructors Training Association (IBITA). Interview transcripts were transcribed verbatim providing the raw data. Data analysis was progressive, iterative, and inductive. Results Twenty-two IBITA instructors from 7 different countries participated. Ranging in clinical experience from 12 to 40 years, and instructor experience from 1 to 35 years. Three themes were developed, (a) a Bobath clinical framework, (b) person-centered, and (c) a Bobath reasoning approach, highlighting the role of practical wisdom, phronesis in the clinical reasoning process. In particular the role of visuospatial-kinesthetic perception, an element of technical expertise, was illuminated as an integral aspect of clinical reasoning in this expert group. Conclusions This study provides an interpretive understanding of the clinical reasoning process used by IBITA instructors illustrating an inactive embodied view of clinical reasoning, specifically the role of phronesis, requiring further investigation in nonexpert Bobath therapists, as well as in novice and experienced therapists in other specialty areas.

Purpose: To describe the amount, range, and key characteristics (e.g., publication years, methods, topics) of the person-centered rehabilitation literature in adults with physical impairments. Method: Following the published scoping review protocol, papers were identified through: three major databases, snowball searches and expert consultation. Two independent reviewers have identified English-language papers on adult person-centered rehabilitation according to six pre-defined inclusion categories – theoretical, quantitative and qualitive research papers are included; and then have extracted their key characteristics (e.g., aims, methods, participants). Descriptive statistics, regression and content analyses were used to synthesize the results. Results: Of 5912 deduplicated records initially screened, 170 papers were included: 136 empirical, including 13 systematic reviews. Empirical papers had data from 15264 clients and 4098 providers, in total. Yearly publications grew significantly from 2009 to 2018 (r2 = 0.71; b = 1.98: p < 0.01). Publications were unevenly distributed by countries (e.g., United States’ publications per population was 44 times lower than New Zealand’s). Most papers focused in more than one profession, setting-type or health conditions. Finally, many empirical papers (n = 67) studied implementation of person-centered rehabilitation approaches, including its effect. Conclusion: This scoping review synthesizes key characteristics and publication trends in the person-centered rehabilitation literature on adults with physical impairments, a growing but unchartered territory thus far. This large and diverse body of literature can ground further person-centered rehabilitation practices and research, including toward building a transdisciplinary, trans-service model of person-centered rehabilitation.Implications for rehabilitationThe person-centered rehabilitation literature on adults with physical impairments, especially the empirical one, has been growing significantly over time, despite inequitably distributed per countries.Rehabilitation stakeholders, including practitioners, have a growing amount of literature in which they can rely for the operationalization and implementation of person-centered rehabilitation approaches into routine practice.Based on our work, person-centered rehabilitation emerges as a practice requirement that cuts across professional and other rehabilitation silos. The person-centered rehabilitation literature on adults with physical impairments, especially the empirical one, has been growing significantly over time, despite inequitably distributed per countries. Rehabilitation stakeholders, including practitioners, have a growing amount of literature in which they can rely for the operationalization and implementation of person-centered rehabilitation approaches into routine practice. Based on our work, person-centered rehabilitation emerges as a practice requirement that cuts across professional and other rehabilitation silos.

Introduction : Designing appropriate studies for evaluating complex interventions, like eHealth solutions to support integrated care, remains a methodological challenge. Although randomized control trials RCTs persist as the gold standard, they may not always be appropriate. Identification of contexts and mechanisms that can influence outcomes of an intervention typical in realist evaluations can help to identify appropriate methods for subsequent evaluation studies. Exploratory trials can be used to uncover these determinants, occurring at macro policy/system, meso organizational/team and micro person/provider levels in complex interventions prior to designing a full evaluation plan. Methods : An exploratory trial of the electronic Patient Reported Outcome ePRO tool was conducted to uncover contexts, mechanisms and relevant outcomes prior to full-scale evaluation. ePRO is a mobile application and portal designed to support goal-oriented care in inter-disciplinary primary health care practices. The four month trial was conducted in two practices in Toronto, Canada. Patients were randomized into control and intervention groups and compared pre and post on outcome measures quality of life and activation. Semi-structured interviews were conducted with providers and patients in the intervention group to capture relevant contexts, mechanisms and outcomes. Results : Eight providers and 16 patients 7-control, 9-intervention participated in the study. Outcomes were captured using the AQoL-4D and PAM surveys; analyzed using descriptive statistics. Interview transcripts were analyzed using interpretive descriptive methods. There was little change in outcome measures, with a high baseline, suggesting patients were higher-functioning than anticipated. Qualitative data highlighted factors for study consideration. Micro level factors included: participant characteristics, comfort with technology, training, and patient-provider relationship. Meso level factors included: provider workflows and norms, and organizational resources and culture. Macro level factors included: the technology policy environment, and system structure. Notably the research context and processes themselves were also influential. Enabling mechanisms occurred mainly at the micro level around motivation and readiness to set goals, and feelings regarding technology. Discussion : Multiple contextual variables and mechanisms were found to be potentially influential on study outcomes. Identifying relevant theories has been suggested as a way to address context and mechanisms in large scale control studies. In the ePRO example, we see the potential for dozens of potentially relevant theories ranging from individual level behaviour change theories, to organizational level innovation adoption theories. Conclusion : The number of complex, overlapping influencing variables suggests that complex interventions like ePRO may not be well suited to controlled evaluation designs. Realist, mixed-methods, and case studies which adopt ethnographic and narratives approaches may be more appropriate. Lessons Learned : Context variables and mechanisms can occur at multiple levels and may change over time of the intervention. Limitations : Although our analysis methods were informed by realist approaches, the study was not set up as a realist evaluation. Opportunities for observation and follow-up that would have allowed for more in-depth exploration may have been missed. Suggestions for future research : Studies of complex interventions, liked eHealth enabled models of integrated care, should consider alternatives to RCT approaches when “controlling” all relevant variables is unlikely. A case-study ethnographic approach will be taken as part of the next phase of ePRO evaluation.

Background: Designing appropriate studies for evaluating complex interventions, such as electronic health solutions to support integrated care, remains a methodological challenge. With the many moving parts of complex interventions, it is not always clear how program activities are connected to anticipated and unanticipated outcomes. Exploratory trials can be used to uncover determinants (or mechanisms) to inform content theory that underpins complex interventions before designing a full evaluation plan. Objective: A multimethod exploratory trial of the electronic patient-reported outcome (ePRO) tool was conducted to uncover contexts, processes and outcome variables, and the mechanisms that link these variables before full-scale evaluation. ePRO is a mobile app and portal designed to support goal-oriented care in interdisciplinary primary health care practices (clinical-level integration). This paper offers evaluation findings and methodological insight on how to use exploratory trial data to identify relevant context, process, and outcome variables, as well as central (necessary to achieving outcomes) versus peripheral (less critical and potentially context dependent) mechanisms at play. Methods: The 4-month trial was conducted in 2 primary health care practices in Toronto, Canada. The patients were randomized into control and intervention groups and compared pre and post on quality of life and activation outcome measures. Semistructured interviews were conducted with providers and patients in the intervention group. Narrative analysis was used to uncover dominant mechanisms that inform the intervention’s content theory (how context and process variables are linked to outcomes). Results: Overall, 7 providers, 1 administrator, and 16 patients (7-control, 9-intervention) participated in the study. This study uncovered many complex and nuanced context, process, and outcome variables at play in the intervention. Narrative analysis of patient and provider interviews revealed dominant story lines that help to tease apart central and peripheral mechanisms driving the intervention. Provider and patient story lines centered around fitting the new intervention into everyday work and life of patients and providers and meaningfulness of the intervention. These themes were moderated by patient-provider relationships going into and throughout the intervention, their comfort with technology, and the research process. Conclusions: Identifying dominant story lines using narrative analysis helps to identify the most relevant context and process variables likely to influence study outcomes. Normalization process theory emerges as a useful theory to uncover underlying mechanisms because of its emphasis on the social production and normalization of technological, processual, and social aspects of work; all found to be critical to our intervention. The number of complex, overlapping influencing variables suggests that complex interventions such as ePRO require us to pay careful attention to central versus peripheral mechanisms that will influence study outcomes. The narrative methods presented here are shown to be useful in uncovering these mechanisms and help to guide subsequent larger evaluation studies.

BACKGROUND Designing appropriate studies for evaluating complex interventions, such as electronic health solutions to support integrated care, remains a methodological challenge. With the many moving parts of complex interventions, it is not always clear how program activities are connected to anticipated and unanticipated outcomes. Exploratory trials can be used to uncover determinants (or mechanisms) to inform content theory that underpins complex interventions before designing a full evaluation plan. OBJECTIVE A multimethod exploratory trial of the electronic patient-reported outcome (ePRO) tool was conducted to uncover contexts, processes and outcome variables, and the mechanisms that link these variables before full-scale evaluation. ePRO is a mobile app and portal designed to support goal-oriented care in interdisciplinary primary health care practices (clinical-level integration). This paper offers evaluation findings and methodological insight on how to use exploratory trial data to identify relevant context, process, and outcome variables, as well as central (necessary to achieving outcomes) versus peripheral (less critical and potentially context dependent) mechanisms at play. METHODS The 4-month trial was conducted in 2 primary health care practices in Toronto, Canada. The patients were randomized into control and intervention groups and compared pre and post on quality of life and activation outcome measures. Semistructured interviews were conducted with providers and patients in the intervention group. Narrative analysis was used to uncover dominant mechanisms that inform the intervention’s content theory (how context and process variables are linked to outcomes). RESULTS Overall, 7 providers, 1 administrator, and 16 patients (7-control, 9-intervention) participated in the study. This study uncovered many complex and nuanced context, process, and outcome variables at play in the intervention. Narrative analysis of patient and provider interviews revealed dominant story lines that help to tease apart central and peripheral mechanisms driving the intervention. Provider and patient story lines centered around fitting the new intervention into everyday work and life of patients and providers and meaningfulness of the intervention. These themes were moderated by patient-provider relationships going into and throughout the intervention, their comfort with technology, and the research process. CONCLUSIONS Identifying dominant story lines using narrative analysis helps to identify the most relevant context and process variables likely to influence study outcomes. Normalization process theory emerges as a useful theory to uncover underlying mechanisms because of its emphasis on the social production and normalization of technological, processual, and social aspects of work; all found to be critical to our intervention. The number of complex, overlapping influencing variables suggests that complex interventions such as ePRO require us to pay careful attention to central versus peripheral mechanisms that will influence study outcomes. The narrative methods presented here are shown to be useful in uncovering these mechanisms and help to guide subsequent larger evaluation studies.

BackgroundGiven the complex and evolving needs of individuals with multimorbidity, the adoption of mHealth tools to support self-management efforts is increasingly being explored, particularly in primary care settings. The electronic patient-reported outcomes (ePRO) tool was codeveloped with patients and providers in an interdisciplinary primary care team in Toronto, Canada, to help facilitate self-management in community-dwelling adults with multiple chronic conditions. ObjectiveThe objective of study is to explore the experience and expectations of patients with multimorbidity and their providers around the use of the ePRO tool in supporting self-management efforts. MethodsWe conducted a 4-week pilot study of the ePRO tool. Patients’ and providers’ experiences and expectations were explored through focus groups that were conducted at the end of the study. In addition, thematic analyses were used to assess the shared and contrasting perspectives of patients and providers on the role of the ePRO tool in facilitating self-management. Coded data were then mapped onto the Individual and Family Self-Management Theory using the framework method. ResultsIn this pilot study, 12 patients and 6 providers participated. Both patients and providers emphasized the need for a more explicit recognition of self-management context, including greater customizability of content to better adapt to the complexity and fluidity of self-management in this particular patient population. Patients and providers highlighted gaps in the extent to which the tool enables self-management processes, including how limited progress toward self-management goals and the absence of direct provider engagement through the ePRO tool inhibited patients from meeting their self-management goals. Providers highlighted proximal outcomes based on their experience of the tool and specifically, they indicated that the tool offered valuable insights into the broader patient context, which helps to inform the self-management approach and activities they recommend to patients, whereas patients recognized the tool’s potential in helping to improve access to different providers in a team-based primary care setting. ConclusionsThis study identifies a more explicit recognition of the contextual factors that influence patients’ ability to self-manage and greater adaptability to accommodate patient complexity and provider workflow as next steps in refining the ePRO tool to better support self-management efforts in primary care ahead of its application in a full-scale randomized pragmatic trial.

Purpose: To describe the perspectives of people with stroke and their physiotherapists on the use of biomechanics technology to assess balance and mobility. Methods: This qualitative study used semi-structured interviews with patients with stroke and a focus group with their physiotherapists. Coding of interview and focus-group data used a line-by-line inductive approach, with qualitative software to develop codes into themes. Results: The quantitative data from the assessment were seen as beneficial to providing patients with insight into balance and mobility problems. Physiotherapists found that the assessment confirmed clinical reasoning and aided in precise evaluation of progress but expressed mixed opinions as to whether treatment choice was influenced. Patients would have liked more communication regarding the purpose of the assessment. Patients also stated that trust in their physiotherapists helped them overcome anxieties and that confidence was gained through exposure to more challenging balance assessments. Physiotherapists advocated for the use of a harness system to safely incorporate reactive balance control assessment and training into practice. Conclusion: Both patients and therapists saw value in the quantitative data provided by the assessment. Regardless of the technology used, patients value a strong physiotherapist–patient relationship. Ongoing collaboration between clinicians and researchers should guide the evolution of technology into clinically useful tools.

BACKGROUND Given the complex and evolving needs of individuals with multimorbidity, the adoption of mHealth tools to support self-management efforts is increasingly being explored, particularly in primary care settings. The electronic patient-reported outcomes (ePRO) tool was codeveloped with patients and providers in an interdisciplinary primary care team in Toronto, Canada, to help facilitate self-management in community-dwelling adults with multiple chronic conditions. OBJECTIVE The objective of study is to explore the experience and expectations of patients with multimorbidity and their providers around the use of the ePRO tool in supporting self-management efforts. METHODS We conducted a 4-week pilot study of the ePRO tool. Patients’ and providers’ experiences and expectations were explored through focus groups that were conducted at the end of the study. In addition, thematic analyses were used to assess the shared and contrasting perspectives of patients and providers on the role of the ePRO tool in facilitating self-management. Coded data were then mapped onto the Individual and Family Self-Management Theory using the framework method. RESULTS In this pilot study, 12 patients and 6 providers participated. Both patients and providers emphasized the need for a more explicit recognition of self-management context, including greater customizability of content to better adapt to the complexity and fluidity of self-management in this particular patient population. Patients and providers highlighted gaps in the extent to which the tool enables self-management processes, including how limited progress toward self-management goals and the absence of direct provider engagement through the ePRO tool inhibited patients from meeting their self-management goals. Providers highlighted proximal outcomes based on their experience of the tool and specifically, they indicated that the tool offered valuable insights into the broader patient context, which helps to inform the self-management approach and activities they recommend to patients, whereas patients recognized the tool’s potential in helping to improve access to different providers in a team-based primary care setting. CONCLUSIONS This study identifies a more explicit recognition of the contextual factors that influence patients’ ability to self-manage and greater adaptability to accommodate patient complexity and provider workflow as next steps in refining the ePRO tool to better support self-management efforts in primary care ahead of its application in a full-scale randomized pragmatic trial.

The study's purpose was to describe the range of knowledge pertaining to the Bobath (NDT) concept in adult neurological rehabilitation, synthesizes the findings, identify knowledge gaps and develop empirically based recommendations for future research.A scoping review of research and non-research articles published from 2007 to 2012. Two independent reviewers selected studies based on a systematic procedure. Inclusion criteria for studies were electronically accessible English language literature with Bobath and/or Neurodevelopmental Therapy as the subject heading in the title/keyword/abstract/intervention comparison with respect to adult neurological conditions. Data were abstracted and summarized with respect to study design, theoretical framework, clinical application including population representation, study fidelity, intervention comparison, duration of care, measurement and findings.Of the 33 publications identified 17 were intervention studies (11 RCT's/1 prospective parallel group design/5 N-of-1). One other paper was a systematic review.The intervention studies, primarily RCT designs, have serious methodological concerns particularly related to study/treatment fidelity and measurement resulting in no clear clinical direction. Aspects such as theoretical framework, therapist skill, quality of movement measurement and individualized interventions require careful consideration in the design of Bobath studies. Implications for Rehabilitation Future intervention studies should be based on the current Bobath theoretical framework and key aspects of clinical practice. Study and treatment fidelity issues need to be carefully considered when interpreting the results of existing RCT's evaluating the Bobath concept. N-of-1 randomized, observational, factorial and mixed method study designs should be considered as alternative study options.

This commentary focuses on patient-reported measures as tools to support patient-centered care for patients with multiple chronic conditions (MCCs). We argue that those using patient-reported measures in care management or evaluation of services for MCC patients should do so in recognition of the challenges involved in treating them. MCC patient care is challenging because (1) it is difficult to specify the causes of particular symptoms; (2) assessment of many important symptoms relies on subjective report; and (3) patients require care from a variety of providers. Due to the multiple domains of health affected in single individuals, and the large variation in needs, care that is holistic and individualized (i.e. patient-centered) is appropriate for MCC patients. However, due to the afore-mentioned challenges, it is important to carefully consider what this care entails and how practical contexts shape it. Patient-centered care for MCC patients implies continuous, dialogic patient-provider relationships, and the formulation of coherent and adaptive multi-disciplinary care protocols. We identify two broadly defined contextual influences on the nature and quality of these processes and their outputs: (1) busy practice settings and (2) fragmented information technology. We then identify several consequences that may result from inattention to these contextual influences upon introduction of patient-reported measure applications. To maximize the benefits, and minimize the harms of patient-reported measure use, we encourage policy makers and providers to attend carefully to these and other important contextual factors before, during and after the introduction of patient-reported measure initiatives.

PURPOSE To describe participants in a cardiac rehabilitation program who were referred to an in-house musculoskeletal clinic and their cardiac rehabilitation and musculoskeletal outcomes. METHODS A retrospective chart review was done on 51 participants who were referred to the musculoskeletal clinic between February 1, 2009, and March 31, 2010. Data on demographics, clinical characteristics, and cardiac rehabilitation and musculoskeletal outcomes were collected. Analyses included descriptive statistics and nonparametric analysis of outcome measures. RESULTS Of the 51 participants, 88.2% reported preexisting musculoskeletal conditions. The most common region of diagnosed musculoskeletal conditions included knee(s) (45.1%), back (25.5%), and shoulder(s) (17.6%). For those who attended the musculoskeletal clinic and had pre-/postintervention data (n = 14), there was a significant improvement from initial to final mean Numerical Pain Rating Scale scores (P = .001) and peak oxygen uptake measures (P = .002). CONCLUSION A musculoskeletal clinic within a cardiac rehabilitation program could allow for musculoskeletal conditions to be addressed in an effective manner and potentially minimize their negative impact on cardiac rehabilitation participation and outcomes.

Background: Therapeutic emotion work is performed by health care providers as they manage their own feelings as well as those of colleagues and patients as part of efforts to improve the physical and psychosocial health outcomes of patients. It has yet to be examined within the context of traumatic brain injury rehabilitation. Objective: To evaluate the impact of a research-based theater intervention on emotion work practices of neurorehabilitation staff. Research Design: Data were collected at baseline and at 3 and 12 months postintervention in the inpatient neurorehabilitation units of two rehabilitation hospitals in central urban Canada. Subjects: Participants ( N = 33) were recruited from nursing, psychology, allied health, recreational therapy, and chaplaincy. Measures: Naturalistic observations ( N = 204.5 hr) of a range of structured and unstructured activities in public and private areas, and semistructured interviews ( N = 87) were conducted. Results: Preintervention analysis indicated emotion work practices were characterized by stringent self-management of empathy, suppression of client grief, adeptness with client anger, and discomfort with reactions of family and spouses. Postintervention analysis indicated significant staff changes in a relationality orientation, specifically improvements in outreach to homosexual and heterosexual family care partners, and support for sexual orientation and intimacy expression. No improvements were demonstrated in grief support. Conclusion: Emotion work has yet to be the focus of initiatives to improve neurorehabilitative care. Our findings suggest the dramatic arts are well positioned to improve therapeutic emotion work and effect cultures of best practice. Recommendations are made for interprofessional educational initiatives to improve responses to client grief and potential intimate partner violence.

This paper explores the impact of outcome-based funding on service delivery within employment services for people with serious mental illness. It draws on a case study of a policy change in the provincial disability support program in Ontario, Canada where funding for employment programs and services was changed from a fee-for-service to an outcome-based model. The findings highlight that the financial imperative for programs to meet employment targets in order to secure their funding has shifted the focus away from the provision of pre-employment supports to job development and job placements. However, there remains little attention to job matching and career development, and there is concern about access to services among those with complex barriers to employment. There is a need to reconcile tensions between the goals of outcome-based funding and on-the-ground service delivery to promote ongoing innovation in employment services for people with serious mental illness.

For individuals providing care for older people the issue of risk is a well-established concern, especially in the context of the older person's declining functional abilities and cognitive skills....

To illustrate the application of geographic information systems (GIS) as a tool to assess rehabilitation service delivery by presenting results from research recently conducted to assess demand and provision for community rehabilitation service delivery in Ontario, Canada.Secondary analysis of data obtained from existing sources was used to establish demand and provision profiles for community rehabilitation services. These data were integrated using GIS software.A number of descriptive maps were produced that show the geographical distribution of service provision variables (location of individual rehabilitation health care providers and location of private and publicly funded community rehabilitation clinics) in relation to the distribution of demand variables (location of the general population; location of specific populations (i.e., residents age 65 and older) and distribution of household income).GIS provides a set of tools for describing and understanding the spatial organization of the health of populations and the distribution of health services that can aid the development of health policy and answer key research questions with respect to rehabilitation health services delivery. Implications for Rehabilitation It is important to seek out alternative and innovative methods to examine rehabilitation service delivery. GIS is a computer-based program that takes any data linked to a geographically referenced location and processes it through a software system that manages, analyses and displays the data in the form of a map, allowing for an alternative level of analysis. GIS provides a set of tools for describing and understanding the spatial organization of population health and health services that can aid the development of health policy and answer key research questions with respect to rehabilitation health services delivery.

Introduction: People experiencing complex chronic disease and disability (CCDD) face some of the greatest challenges of any patient population. These individuals struggle to manage their many health conditions, which may be exacerbated by psychological and social challenges. Primary care providers working in integrated interdisciplinary teams also find it difficult to manage these patients’ multiple discordant conditions and symptoms, and their often complex social challenges. The electronic Patient Reported Outcome (ePRO) tool is designed to overcome some of these challenges through supporting goal-oriented primary care delivery. Using the tool patients and providers collaboratively develop health care goals on a portal which is linked to a mobile device to help patients track goal progress. Multiple providers on the patients care team can view patient goals and work together to care for patients. Theory/Methods: This study tested the usability and feasibility of adopting the ePRO tool into a single inter-disciplinary primary care practice in Toronto, Canada. We used the Fit between Individuals, Task and Technology (FITT) framework to guide our feasibility and usability assessment to explore whether the ePRO tool is, 1) feasible for adoption in inter-disciplinary primary care practices and, 2) usable from both the patient and provider perspective. This usability and feasibility pilot is part of a broader user-centred design strategy that is guiding development of the ePRO tool. We conducted a 4-week pilot study in which patients and providers used the ePRO tool to collaboratively set health related goals that patients then monitored using a mobile device. Providers and patients were separately trained to use the tool. Patients and providers set up goals on the system during an initial visit, and had at least one follow-up visit at the end of the 4-week pilot to discuss goal progression. Focus groups and interviews were conducted with patients and providers to capture usability and feasibility measures. Data from the ePRO system was extracted to provide information regarding how the tool was used. Results: A total of 6 providers and 11 patients participated in the study. Three patients dropped out within the first two weeks due to health issues, and in one case, due to increased anxiety caused by using the ePRO tool. The tool was used heavily by patients, with 8 individuals completing 210 monitoring protocols, which included over 1300 total questions. Providers and patients accessed the portal an average of 10 and 1.5 times respectively over the course of the pilot. Patients and providers found the system easy to use. Some patients reported that using the tool helped in their ability to self-manage, catalyzed a sense of responsibility over their care, and improved patient-centred care delivery. Some providers saw the tool as helping to focus conversations on goal-setting. However, the tool did not fit well with provider workflows and current processes, in particular the monitoring questions were not adequately tailored to individual patient needs, and monitoring became tedious and time consuming for patients. Discussion: Heavy tool use may be attributable to the ease of use of the tool, the noted impact on patient self-management and patient-centred care delivery, as well as the potential for the tool to improve patients’ sense of responsibility over their care. Providers were equally positive about the potential of the tool to improve efficiency and patient-centredness at the point of care, particularly if suggested changes were to be implemented. However, our assessment indicates that overall usability and feasibility of the ePRO tool was low. Concerns regarding the impact on patient-provider relationships, the repetitive nature of questions, and an inability of the system to connect with other monitoring activities that they were already completing (e.g. physical activity monitoring using other apps/devices), were among the more notable issues identified by patients. For providers they experienced difficulty integrating the ePRO tool into their daily workflow, what was exacerbated by the lack of inter-operability between the ePRO tool and the providers’ electronic medical record, which are common challenges in eHealth tool adoption. Conclusion: While our study suggests relatively low usability and feasibility of the ePRO tool, we are encouraged by the early impact on patient outcomes as well as the generally positive response from patients and providers regarding the importance, and potential of the tool to improve care delivery for patients with CCDD in integrated multi-disciplinary primary care settings. As is consistent with our user-centred design development approach, we have modified the tool based on user feedback to improve usability and feasibility and are now testing the re-developed tool through an exploratory trial.

Purpose: Student-run clinics (SRCs) provide a unique opportunity for inter-professional education; they prepare health care students for a collaborative future by enabling them to interact with other such students in a clinical setting focused on inter-professional learning and collaboration. Physical therapy (PT) students are increasingly being included in SRCs; however, most research on student experiences in SRCs has been carried out with medical students. This qualitative study explores the perceived benefits of the PT experience in an SRC through the lens of PT students and their preceptors. Method: A qualitative interpretive–descriptive approach consisting of face-to-face, semi-structured interviews was used. Interviews were audiotaped and transcribed verbatim. Data were analyzed using a constant comparative approach. Results: Seven PT students and eight preceptors who volunteered at the SRC between September 2013 and May 2015 participated in the study. Three themes emerged from the interviews: (1) exposure to marginalized patient populations, (2) learning through inter-professional interactions, and (3) experience with different patient care approaches. Conclusions: Participating in an SRC enhances PT students' understanding of their and other health care professionals' roles. Students gained an appreciation for the social determinants of health and improved their knowledge of inter-professional collaboration. The knowledge gained from this study has the potential to inform PT professional development, SRCs, and PT education.

Background Timely access to effective treatments for arthritis is a priority at national, provincial and regional levels in Canada due to population aging coupled with limited health human resources. Models of care for arthritis are being implemented across the country but mainly in local contexts, not from an evidence-informed policy or framework. The purpose of this study is to examine existing models of care for arthritis in Canada at the local level in order to identify commonalities and differences in their implementation that could point to important considerations for health policy and service delivery. Methods Semi-structured key informant interviews were conducted with 70 program managers and/or care providers in three Canadian provinces identified through purposive and snowball sampling followed by more detailed examination of 6 models of care (two per province). Interviews were transcribed verbatim and analyzed thematically using a qualitative descriptive approach. Results Two broad models of care were identified for Total Joint Replacement and Inflammatory Arthritis. Commonalities included lack of complete and appropriate referrals from primary care physicians and lack of health human resources to meet local demands. Strategies included standardized referrals and centralized intake and triage using non-specialist health care professionals. Differences included the nature of the care and follow-up, the role of the specialist, and location of service delivery. Conclusions Current models of care are mainly focused on Total Joint Replacement and Inflammatory Arthritis. Given the increasing prevalence of arthritis and that published data report only a small proportion of current service delivery is specialist care; provision of timely, appropriate care requires development, implementation and evaluation of models of care across the continuum of care. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1634-9) contains supplementary material, which is available to authorized users.

BACKGROUND: Older adults experiencing multiple chronic illnesses are at high risk of hospitalization and health decline if they are unable to manage the significant challenges posed by their health conditions. Goal-oriented care approaches can provide better care for these complex patients, but clinicians find the process of ascertaining goals "too complex and too-time consuming," and goals are often not agreed upon between complex patients and their providers. The electronic patient reported outcomes (ePRO) mobile app and portal offers an innovative approach to creating and monitoring goal-oriented patient-care plans to improve patient self-management and shared decision-making between patients and health care providers. The ePRO tool also supports proactive patient monitoring by the patient, caregiver(s), and health care provider. It was developed with and for older adults with complex care needs as a means to improve their quality of life.OBJECTIVE: Our proposed project will evaluate the use, effectiveness, and value for money of the ePRO tool in a 12-month multicenter, randomized controlled trial in Ontario; targeting individuals 65 or over with two or more chronic conditions that require frequent health care visits to manage their health conditions.METHODS: Intervention groups using the ePRO tool will be compared with control groups on measures of quality of life, patient experience, and cost-effectiveness. We will also evaluate the implementation of the tool.RESULTS: The proposed project presented in this paper will be funded through the Canadian Institute for Health Research (CIHR) eHealth Innovation Partnerships Program (eHIPP) program (CIHR-348362). The expected completion date of the study is November, 2019.CONCLUSIONS: We anticipate our program of work will support improved quality of life and patient self-management, improved patient-centered primary care delivery, and will encourage the adoption of goal-oriented care approaches across primary health care systems. We have partnered with family health teams and quality improvement organizations in Ontario to ensure that our research is practical and that findings are shared widely. We will work with our established international network to develop an implementation framework to support continued adaptation and adoption across Canada and internationally.

Clinical reasoning is an essential aspect of clinical practice, however is largely ignored in the current rehabilitation sciences evidence base. Literature related to clinical reasoning and clinical expertise has evolved concurrently although rehabilitation reasoning frameworks remain relatively generic. The purpose of this study was to explicate the clinical reasoning process of Bobath instructors of a widely used neuro-rehabilitation approach, the Bobath concept.A qualitative interpretive description approach consisting of stimulated recall using video-recorded treatment sessions and in-depth interviews. Purposive sampling was used to recruit members of the International Bobath Instructors Training Association (IBITA). Interview transcripts were transcribed verbatim providing the raw data. Data analysis was progressive, iterative, and inductive.Twenty-two IBITA instructors from 7 different countries participated. Ranging in clinical experience from 12 to 40 years, and instructor experience from 1 to 35 years. Three themes were developed, (a) a Bobath clinical framework, (b) person-centered, and (c) a Bobath reasoning approach, highlighting the role of practical wisdom, phronesis in the clinical reasoning process. In particular the role of visuospatial-kinesthetic perception, an element of technical expertise, was illuminated as an integral aspect of clinical reasoning in this expert group.This study provides an interpretive understanding of the clinical reasoning process used by IBITA instructors illustrating an inactive embodied view of clinical reasoning, specifically the role of phronesis, requiring further investigation in nonexpert Bobath therapists, as well as in novice and experienced therapists in other specialty areas.

Background: Many mHealth technologies do not meet the needs of patients with complex chronic disease and disabilities (CCDDs) who are among the highest users of health systems worldwide. Furthermore, many of the development methodologies used in the creation of mHealth and eHealth technologies lack the ability to embrace users with CCDD in the specification process. This paper describes how we adopted and modified development techniques to create the electronic Patient-Reported Outcomes (ePRO) tool, a patient-centered mHealth solution to help improve primary health care for patients experiencing CCDD. Objective: This paper describes the design and development approach, specifically the process of incorporating qualitative research methods into user-centered design approaches to create the ePRO tool. Key lessons learned are offered as a guide for other eHealth and mHealth research and technology developers working with complex patient populations and their primary health care providers. Methods: Guided by user-centered design principles, interpretive descriptive qualitative research methods were adopted to capture user experiences through interviews and working groups. Consistent with interpretive descriptive methods, an iterative analysis technique was used to generate findings, which were then organized in relation to the tool design and function to help systematically inform modifications to the tool. User feedback captured and analyzed through this method was used to challenge the design and inform the iterative development of the tool. Results: Interviews with primary health care providers (n=7) and content experts (n=6), and four focus groups with patients and carers (n=14) along with a PICK analysis—Possible, Implementable, (to be) Challenged, (to be) Killed—guided development of the first prototype. The initial prototype was presented in three design working groups with patients/carers (n=5), providers (n=6), and experts (n=5). Working group findings were broken down into categories of what works and what does not work to inform modifications to the prototype. This latter phase led to a major shift in the purpose and design of the prototype, validating the importance of using iterative codesign processes. Conclusions: Interpretive descriptive methods allow for an understanding of user experiences of patients with CCDD, their carers, and primary care providers. Qualitative methods help to capture and interpret user needs, and identify contextual barriers and enablers to tool adoption, informing a redesign to better suit the needs of this diverse user group. This study illustrates the value of adopting interpretive descriptive methods into user-centered mHealth tool design and can also serve to inform the design of other eHealth technologies. Our approach is particularly useful in requirements determination when developing for a complex user group and their health care providers. [JMIR Res Protoc 2016;5(1):e28]

To examine the experience of normalization through rehabilitation for persons growing upgrowing older with lifelong physical impairment (cerebral palsy [CP]).A qualitative methodology consisting of narrative inquiry informed by the Life Course Perspective. Multiple (3-4), in-depth interviews were completed with each participant in order to co-construct their life stories. Data were systematically compared for themes and categories, as well as the central plot that weaves the participants' experiences together.Nine community-dwelling individuals (three men; six women), aged 26-70, with mild to severe CP participated. Their common narrative involved intensive rehabilitation in childhood that focused on "normalizing" movement, particularly walking. In adolescence they were deemed to have achieved their functional potentials and "nothing further could be done". After transitioning out of pediatric health services many start to lose the gains they achieved in rehabilitation (particularly around walking). In their 30's and 40's they begin to slow down and lose functional abilities but no longer have access to rehabilitation to help them manage their aging bodies.Many of the assumptions that underlie the organization and delivery of rehabilitation services for people with long term impairments may contribute to difficulties encountered in adulthood and old age by focusing on normalizing physical function at the expense of learning to manage their bodies across the life course.• The way that rehabilitation services are organized and delivered for people with lifelong impairments needs to be re-considered. • Frontloading rehabilitation in childhood does not meet the long term needs of children growing up and growing older with physical impairments. As they grow up and grow older, they lose many of the gains they achieved in rehabilitation yet they have nowhere to turn to receive rehabilitation for their aging bodies. • The focus on normalizing function in childhood may only serve to emphasize the child’s lack of ablebodiedness to the detriment of their sense of self and wellbeing.

Purpose: Our purpose was to determine advanced manual and manipulative physiotherapists' (AMPTs') current use and awareness of continuing education (CE) opportunities; to establish their perceived CE needs by identifying facilitators and barriers to participation; and to explore the association of demographics with CE needs. Methods: A questionnaire was e-mailed to 456 registered members of the Canadian Academy of Manipulative Physiotherapy. Data analyses using frequencies and percentages of total responses and t-tests for group comparisons were performed. Results: One hundred thirty-three (29.2%) participants responded. Most lived in an urban region and worked predominantly in direct patient care. More respondents reported engaging in informal CE than in formal CE. Hands-on or practical workshops were the preferred CE format. Common barriers to CE included professional commitments and cost and time of travel; facilitators included interest in the topic and increasing knowledge and competency. AMPTs with less physical therapy experience found cost to be a greater barrier and were more interested in mentorship programs and CE as a means to obtain credentials. Conclusions: AMPTs' preferred CE formats are inconsistent with the CE opportunities in which they participate. CE initiatives for AMPTs should include hands-on training and should account for time and cost to make CE opportunities more readily available to them.

Objective This article reports on the consequences of the revised policy for employment supports within the Ontario Disability Support Program, a disability benefit program administered by the provincial government in Ontario, Canada. The revised policy involves a change from a fee-for-service model to an outcome-based funding model. This revision has encouraged a shift from preemployment to job placement services, with a particular focus on rapid placement into available jobs. Method Using a qualitative case study approach, 25 key informant interviews were conducted with individuals involved in developing or implementing the policy, or delivering employment services for individuals living with mental illness under the policy. Policy documents were also reviewed in order to explore the intent of the policy. Analysis focused on exploring how the policy has been implemented in practice, and its impact on employment services for individuals living with mental illness. Results The findings highlight how employment support practices have evolved under the new policy. Although there is now an increased focus on employment rather than preemployment supports, the financial imperative to place individuals into jobs as quickly as possible has decreased attention to career development. Jobs are reported to be concentrated at the entry-level with low pay and little security or benefits. Conclusions and implications for practice These findings raise questions about the quality of employment being achieved under the new policy, highlight problems with adopting selected components of evidence-based approaches, and begin to explicate the influence that funding structures can have on practice.

The impetus for this letter to the Editor of Physiotherapy Canada comes from the recently released 2010 update of the Canadian Best Practices Recommendations for Stroke Care.1 Many of the recommendations made are a welcome addition to our stock of ammunition to advocate for effective stroke care for Canadians. However, we take issue with the recommendations for stroke rehabilitation, and in particular the recommendations for upper- and lower-limb management following stroke,1(p.109–24) on three points: first, the use of hierarchies of evidence that privilege a methodology originally designed for drug trials to evaluate complex interventions such as stroke rehabilitation; second, the use of phrases such as “rehabilitation of the upper limb”1(p.109) and “rehabilitation of the lower limb”1(p.109) in an era of client-centred and humanistic care; and, finally, the lack of understanding of the nature of neurodevelopmental therapy (NDT) / Bobath. We feel strongly that these three issues need to be discussed and debated in the rehabilitation and physical therapy community. We hope that the following comments will be taken in the spirit of debate and will generate discussions that will help to move the dialogue between clinicians and researchers forward to a more collegial exchange, whereby we can ensure that the “evidence” being used to evaluate practice is appropriate.

Purpose: To identify the perceived benefits of and barriers to clinical supervision of physical therapy (PT) students. Method: In this qualitative descriptive study, three focus groups and six key-informant interviews were conducted with clinical physical therapists or administrators working in acute care, orthopaedic rehabilitation, or complex continuing care. Data were coded and analyzed for common ideas using a constant comparison approach. Results: Perceived barriers to supervising students tended to be extrinsic: time and space constraints, challenging or difficult students, and decreased autonomy or flexibility for the clinical physical therapists. Benefits tended to be intrinsic: teaching provided personal gratification by promoting reflective practice and exposing clinical educators to current knowledge. The culture of different health care institutions was an important factor in therapists' perceptions of student supervision. Conclusions: Despite different disciplines and models of supervision, there is considerable synchronicity in the issues reported by physical therapists and other disciplines. Embedding the value of clinical teaching in the institution, along with strong communication links among academic partners, institutions, and potential clinical faculty, may mitigate barriers and increase the commitment and satisfaction of teaching staff.

Purpose: The purpose of this study was to gain an understanding of the opportunities and challenges involved in providing clinical inter-professional education (IPE) to physical therapy (PT) students in the acute-care setting from the perspective of PT clinical instructors (CIs). Methods: Focus groups were conducted in four acute-care hospitals in Toronto. Participants were recruited using a purposive and convenience sampling approach in order to enhance our understanding of the perceptions of acute-care PT CIs. Eighteen full-time PT CIs with an average of 11 years in practice participated. A constant comparative process was employed to identify recurrent issues and themes within and between groups. Results: Three main themes emerged from the focus groups: (1) Clinical IPE happens when inter-professional collaboration (IPC) occurs; however, IPC differs according to setting, access to other professions, time, support, and structure. (2) IPE is a lifelong learning process that applies to both CIs and students. (3) Student preparedness is a prerequisite for clinical IPE. Conclusions: IPC is an integral part of clinical IPE that requires ongoing commitment and reflection by CIs to ensure that they are ready to instruct students who have some preparation in formal IPE. More knowledge about providing clinical IPE in a structured manner, through academic and health institutions, will allow CIs to become role models for future generations of PT students.

Objective This study was developed as a consensus-building exercise within the International Bobath Instructors Training Association (IBITA) to develop a revised definition of the Bobath concept. Methods A three-phase design utilizing (a) focus groups, (b) survey methods, and, (c) real-time Delphi. This paper details Phase 1 and 2. Results Forty IBITA members participated in five focus groups. Eight broad themes were developed from the focus groups from which the survey statements were developed. There was a high level of agreement on all nine survey statements identifying overarching constructs and on 12 of the 13 statements identifying unique aspects of Bobath clinical practice. Lower scores were attributed to lack of understanding of the term humanistic, Bobath clinical practice addressing multiple domains such as impairments, activities, and participation and limited agreement on the description of the term "placing." Conclusion Focus groups and a web-based survey were successful in soliciting the opinions of IBITA members on themes and statements of importance for the development of a revised Bobath definition. The results of Phase 1 and 2 will inform Phase 3, a real-time Delphi, to gain consensus within IBITA on statements on which a revised Bobath definition is to be based.

Purpose. To examine the FIM TM as an outcome measure at follow-up following discharge from inpatient rehabilitation. Methods. Secondary analysis of the National Rehabilitation Reporting System (NRS) data from 13 facilities across Canada that collected follow-up data between 2001 and 2006. The study sample included all NRS records with a hospital length of stay of at least 3 days, for individuals 18 years and older. Outcomes included: mean total, motor and cognitive FIM TM scores at admission, discharge, and follow-up; change in FIM TM scores from admission to discharge and from discharge to followup; correlation between FIM TM scores at admission, discharge and follow-up, and predictors of the change in FIM TM scores between discharge and follow-up. Results. The majority of the change in FIM TM scores is seen between admission and discharge with the higher FIM scores maintained, if not increased slightly, between discharge and follow-up. Discharge and follow-up total FIM TM scores are highly correlated indicating that collection of the follow-up FIM TM may not provide additional information that justifies the expense of data collection after a patient has been discharged from inpatient rehabilitation. Conclusions. The use of more appropriate rehabilitation follow-up outcomes needs to be considered.

Background: Timely access to publicly funded health services is a priority issue across the healthcare continuum in Canada. The purpose of this study was to examine wait list management strategies for publicly funded ambulatory rehabilitation services in Ontario, Canada.

Purpose: The purpose of this study was to explore the perspectives of caregivers of persons with stroke with respect to their own physical activity. Methods: A qualitative, descriptive approach was used to study 10 caregivers of persons with stroke, recruited from a stroke exercise class in a large urban rehabilitation facility. Caregivers participated in individual, semi-structured interviews that were audiotaped, transcribed verbatim, and analysed using a constant comparative method. An inductive, iterative approach was applied to determine the codes and themes. Results: Four main themes were identified: change in role, change in activity, barriers to activity and health, and change in meaning of activity. Barriers to activity included guilt, time, and energy. Participants revealed that activity became more therapeutic after stroke and that participants preferred purposeful, functional, and partnered activities. Conclusions: These findings emphasize the importance of the husband–wife dyad and of movement toward a family-centred care approach. Education should be provided to caregivers regarding their role, barriers, and health-promoting activities. Future research should focus on determining appropriate physical-activity programmes for caregivers as well as on evaluating implementation of partnered exercise programmes for caregivers and persons with stroke.

Examine the theoretical construct of a gap between people's perceived current and preferred movement abilities and its potential for evaluating rehabilitation outcomes against clients' desired goals.A cross-section of 311 community-dwelling adults completed a 24-item movement ability measure (MAM) and a visual analog movement scale. In a nonrandomized pre-post design, two subsets of that population completed the measures again after 2 weeks: 35 clients undergoing outpatient physical therapy and 34 in a comparison group who were not undergoing physical therapy. Scores on the MAM were analyzed using item response theory methods.The gap between current and preferred ability in the 311 adults represented one level difference on average out of six designated movement levels on both measures. Clients about to undergo physical therapy had gaps approximately twice the size of gaps in the 34-person comparison group on both measures (P0.001). Both the MAM and the movement scale showed a significantly narrower gap after 2 weeks for the group in physical therapy (P0.001) but no change for the comparison group.Assessing gaps between client-perceived current and preferred movement ability following intervention may help in the evaluation of rehabilitation outcomes from the client's perspective.

Background: Timely access to publicly funded health services has emerged as a priority policy issue across the continuum of care from hospitals to the home and community sector. The purpose of this study was to examine wait lists and wait times for publicly funded outpatient and community occupational therapy (OT) and physical therapy (PT) services. Methods: A mailed self-administered questionnaire was sent in December 2005 to all publicly funded sites across Ontario that deliver outpatient or community OT or PT services (N = 374). Descriptive statistics were used to describe the study sample and to examine wait lists and wait times by setting and client condition. Results: Overall response rate was 57.2% (n = 214). More than 10,000 people were reported to be waiting for OT or PT services across Ontario. Of these, 16% (n = 1,664) were waiting for OT and 84% (n = 8,842) for PT. Of those waiting for OT, 59% had chronic conditions and half were waiting for home care rehabilitation services. Of those waiting for PT, 73% had chronic conditions and 81% were waiting at hospital outpatient departments. Conclusions: Individuals with chronic conditions experience excessive wait times for outpatient and community OT and PT services in Ontario, particularly if they are waiting for services in hospital outpatient departments.

Aim. This paper is a report of a narrative literature review conducted to explore how expectations and wants are distinguished in empirical research on hope and illness and the related issues of realistic hope and temporality. Background. Particularized hope has been identified as comprising wants and expectations. The distinction is important in relation to debates around 'realistic' hopes, the temporal dimension of hope and hope-sustaining strategies. Data sources. A systematic search of the literature was undertaken for qualitative research papers published between January 1996 and July 2007 relating to hope and recovery in adults with physical ill health. Seven papers were identified. Review methods. A narrative synthesis approach was adopted and the papers were appraised for quality using the Critical Appraisal Skills Programme method. Textual descriptions and tabulation were used to compare central themes and thematic analysis was used to explore the findings. Results. A lack of conceptual clarity in relation to hope as a want or an expectation was identified. Healthcare professionals' role in encouraging 'realistic' hopes emerged as problematic because of the lack of understanding about the possible benefits of hope and difficulties in identifying 'realistic' hopes. There has been limited research exploring temporality and the impact of hope-sustaining activities. Conclusion. The lack of clarity about particularized hope, its dimensions, properties or different forms limits knowledge about the conditions under which hope is a positive force versus when it can be damaging. Distinguishing conceptually between hope as a want and hope as an expectation has potential value in improving healthcare practice and informing future investigations.

Purpose: To determine the degree to which ambulatory physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) services are available in hospitals with designated rehabilitation beds (DRBs) in Ontario, and to explore the structure of delivery and funding among services that exist. Methods: Questions regarding ambulatory services were included in the System Integration and Change (SIC) survey sent to all hospitals participating in the Hospital Report 2005: Rehabilitation initiative. Results: The response rate was 75.9% (41 of 54 hospitals). All hospitals surveyed provide some degree of ambulatory rehabilitation services, but the nature of these services varies according to rehabilitation client groups (RCGs). The majority of hospitals continue to deliver services through their employees rather than by contracting out or by creating for-profit subsidiary clinics, but an increasing proportion is accessing private sources to finance ambulatory services. Conclusions: Most hospitals with DRBs provide some degree of ambulatory rehabilitation services. Privatization of delivery is not widespread in these facilities.

Publicly funded community-based physical therapy (PT) services in Canada's most populous province of Ontario were partially delisted, or deinsured, in April 2005. Two previous studies examined the short-term effects from the client and provider perspectives; and in this study, we follow up with participants from these preceding studies to assess long-term consequences of this policy. Sixteen of 18 providers (89%) and 64 of 98 clients (65%) agreed to participate in a follow-up telephone interview. Our results indicate that 12 months following delisting, and despite government assurances that access would be preserved, clients rendered ineligible for publicly funded services report ongoing access barriers across Ontario. Clients in this study also express concern about their overall health and report an increased use of other insured health professionals (e.g., physicians) and services (e.g., hospitals). On the other hand, providers within the network of publicly funded clinics report an important decrease in demand for PT services, whereas those from other settings report little change. We conclude that delisting policies may have long-term consequences on uninsured or underinsured clients and that evidence-based policy planning is warranted to ensure that the goals of reform are aligned with the desired outcomes at the client, provider, and system levels.

The purpose of this chapter is to present a review of qualitative research on the issues that individuals with lifelong and early-onset physical impairments encounter as they grow older. Distinguishing aging with disability from aging and disability will be described in order to highlight how our current health-care and rehabilitation policies and practices disadvantage individuals aging with a disability. The findings from this chapter are based on the analysis of 20 qualitative studies and consumers’ accounts derived from a comprehensive review of ten databases in the health sciences spanning 1995–2014. Growing older with a childhood- or early-onset physical impairment is multifaceted and changes over time. During childhood, or the acute phase of recovery, individuals with physical impairment receive comprehensive rehabilitation that provides them with the support and resources they need to achieve functional independence with the ability to return to school or work and participate in activities they value. However, there are many individuals who have encountered declines in function 20–30 years following rehabilitation or upon transition to adulthood (childhood disability) without having access to appropriate health-care or rehabilitation services and programs to respond to their needs.

Total joint replacements (TJR) have emerged as a critical health policy issue. In particular, Canadian demand for these surgeries is forecast to grow annually by 8.7% in the next decade. Although the medical and surgical aspects of TJR have received considerable attention, very little research has explored the impact of increased TJR on the demand for rehabilitation services. In this study, we conducted seven focus group discussions across the province of Ontario (Canada) with multiple stakeholders (n=50) ranging from clinicians and administrators, to policy makers and researchers. Our results indicate that demand for rehabilitation following TJR is rising sharply and that there are three primary factors affecting such demand: (i) increase in the absolute number of TJR surgeries is increasing demand across the continuum of care; (ii) changing profile of clients whereby 'younger and active' groups are more willing to undergo surgery, and 'older and complex' groups are presenting with increased rates of medical complications and comorbidities; and (iii) widespread use of clinical pathways has increased requirements within the rehabilitation sector, but often without corresponding adjustments in levels of human resources. To align increasing demand with supply in the long term, participants offered strong support for health promotion and prevention programs, but they also highlighted the short-term benefits of implementing 'prehabilitation' programs for clients waiting for surgery. Overall, our results indicate that the demand for rehabilitation services after TJR is increasing and that innovative approaches to care delivery are required to align increasing demand with supply.