Convergent validity and responsiveness of The Standing and Walking Assessment Tool (SWAT) among individuals with non-traumatic spinal cord injury.

Aim: This study aimed to (1) describe the use of the Standing and Walking Assessment Tool (SWAT) among individuals with non-traumatic spinal cord injury or disease (NT-SCI/D); (2) evaluate the convergent validity of SWAT for use among inpatients with NT-SCI/D; (3) describe SWAT responsiveness; and (4) explore the relationship between hours of walking therapy and SWAT change. Methods: A quality improvement project was conducted at the University Health Network between 2019 and 2022. Participants' demographics and impairments data, rehabilitation length of stay, and FIM scores were obtained from the National Rehabilitation Reporting System. The walking measure data were collected by therapists as part of routine practice. Hours of part- or whole-gait practice were abstracted from medical records. To determine convergent validity, Spearman's correlation coefficients were calculated between SWAT stages (admission and discharge) and the walking measures. The change in SWAT levels was calculated to determine responsiveness. Spearman's correlation coefficient was calculated between SWAT change and hours of walking therapy. Results: Among adult NT-SCI/D participants with potential walking capacity (SWAT≥1B), the majority were classified as American Spinal Injury Association (ASIA) Impairment Scale D (AIS D) at admission. The SWAT category of 1C (N = 100, 18%) was the most frequent at admission. The most frequent SWAT stage at discharge was 3C among participants with NT-SCI/D, with positive conversions in SWAT stages from admission to discharge (N = 276, 33%). The mean change in SWAT score was 3 for participants with T-SCI and NT-SCI/D. Moderate correlations between SWAT stages and walking measures were observed. The correlation of hours of gait therapy with the SWAT change (admission to discharge) was 0.44 (p < 0001). Conclusion: The SWAT has sufficient convergent validity and responsiveness for describing standing and walking recovery and communicating/monitoring rehabilitation progress among patients with NT-SCI/D.

Validity and responsiveness of the Standing and Walking Assessment Tool for sub-acute traumatic spinal cord injury.

STUDY DESIGN: This is a retrospective longitudinal study. OBJECTIVE: The Standing and Walking Assessment Tool (SWAT) combines stages of standing and walking recovery (SWAT stages) with established measures (Berg Balance Scale (BBS), 10-m walk test (10MWT), 6-min walk test (6MWT), and modified Timed Up-and-Go (mTUG)). We evaluated the SWAT's validity (known-groups and convergent) and responsiveness among inpatients with sub-acute, traumatic spinal cord injury (SCI). SETTING: Ten Canadian rehabilitation hospitals. METHODS: Upon admission, SWAT stage and core measures (BBS, 10MWT, 6MWT, and mTUG), International Standards for Neurological Classification of SCI sensory and motor scores, and Spinal Cord Independence Measure III (SCIM) were collected from 618 adults with SCI. Known-groups validity was evaluated by comparing SWAT stage distributions across American Spinal Injury Association Impairment Scale (AIS) classification. Convergent validity was evaluated by correlating SWAT stages with scores on other measures using Spearman's rho. The SWAT (stage and core measures) was re-administered at discharge. To evaluate responsiveness, SWAT stages at admission and discharge were compared. The standardized response mean (SRM) was used to evaluate the responsiveness of core SWAT measures. RESULTS: The SWAT stage distribution of participants with AIS D injuries differed from those of participants with AIS A-C injuries (p ≤ 0.002). SWAT stages correlated strongly with BBS and motor scores (ρ = 0.778-0.836), and moderately with SCIM, mTUG, 10MWT, 6MWT, and sensory scores (ρ = 0.409-0.692). Discharge SWAT stage was greater than the admission stage (p < 0.0001). The BBS was the most responsive core SWAT measure (SRM = 1.26). CONCLUSIONS: The SWAT is a valid and responsive approach to the measurement of standing and walking ability during sub-acute SCI.

Development of Reaching, Grasping & Manipulation indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project.

OBJECTIVE: To describe the development of structure, process, and outcome indicators aimed to advance the quality of Reaching, Grasping & Manipulation (RG&M) rehabilitation for Canadians living with spinal cord injury or disease (SCI/D). METHOD: Upper extremity rehabilitation experts developed a framework of indicators for evaluation of RG&M rehabilitation quality. A systematic search of the literature identified potential upper extremity indicators that influence RG&M outcomes. A Driver diagram summarized factors influencing upper extremity outcomes to inform the selection of structure and process indicators. Psychometric properties, clinical utility, and feasibility of potential upper extremity measures were considered when selecting outcome indicators. RESULTS: The selected structure indicator is the number of occupational and physical therapists with specialized certification, education, training and/or work experience in upper extremity therapy related to RG&M at a given SCI/D rehabilitation center. The process indicator is the total hours of upper extremity therapies related to RG&M and the proportion of this time allocated to neurorestorative therapy for each individual with tetraplegia receiving therapy. The outcome indicators are the Graded Redefined Assessment of Strength, Sensation and Prehension (GRASSP) strength and Spinal Cord Independence Measure III (SCIM III) Self-Care subscores implemented at rehabilitation admission and discharge, and SCIM III Self-Care subscore only at 18 months post-admission. CONCLUSION: The selected indicators align with current practice, will direct the timing of routine assessments, and enhance the volume and quality of RG&M therapy delivered, with the aim to ultimately increase the proportion of individuals with tetraplegia achieving improved upper extremity function by 18 months post-rehabilitation.

The standing and walking assessment tool for individuals with spinal cord injury: A qualitative study of validity and clinical use.

Context/Objective: The Spinal Cord Injury (SCI) Standing and Walking Assessment Tool (SWAT) combines stages of walking recovery with measures of balance and walking. It standardizes the timing and content of walking assessment in inpatient rehabilitation. The study aims were: (1) Evaluate the content validity of the SWAT stages of walking recovery, and (2) Understand physical therapists' (PTs) experiences using the SWAT to gauge acceptance, implementation and impact. Design: Qualitative, exploratory study. Setting: Nine Canadian rehabilitation hospitals. Participants: Thirty-four PTs who had used the SWAT ≥10 times. Interventions: Seven focus group meetings were completed. Semi-structured questions queried the content, order and spacing of SWAT stages, and current SWAT use (i.e. processes, challenges, facilitators, impact on practice). Meetings were audio-recorded and transcribed. Themes and categories were derived through a conventional content analysis. Outcome Measure: Not applicable. Results: PTs agreed with the ordering and content of the SWAT stages, but reported unequal spacing between stages. Three themes related to PTs' use of the SWAT were identified: (1) Variable process: SWAT implementation varied across sites, PTs and patients. (2) Implementation challenges: unfamiliarity of the SWAT, lack of time, not required by place of work, and patients who are outliers or have poor gait quality. (3) Potential to influence clinical decision-making: the SWAT did not influence clinical decisions, but PTs recognized the potential of the tool to do so. Conclusions: Content validity of the SWAT stages was supported and implementation challenges identified. Variability in SWAT implementation may reflect the heterogeneity and person-centeredness of SCI rehabilitation.

Development of Walking indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project.

Objective: To describe the development of structure, process and outcome indicators that will advance the quality of walking rehabilitation for Canadians with spinal cord injury or disease (SCI/D) by 2020. Method: A framework for the evaluation of the quality of walking rehabilitation was developed by experts in walking after SCI/D. A systematic literature review identified factors influencing walking outcomes and potential walking indicators. A Driver diagram analysis summarized the factors affecting walking outcomes and subsequently informed the selection of structure and process indicators. Psychometric properties and clinical utility of potential walking indicators were considered during the selection of outcome indicators. Results: The structure indicator is the number of physical therapists using evidence-based walking interventions per number of ambulatory individuals with SCI/D. The process indicator is the number of received hours of walking interventions during inpatient rehabilitation per number of ambulatory individuals with SCI/D. The intermediary outcome indicator, which is collected at discharge from inpatient rehabilitation, is either the modified Timed Up and Go or the 10-Meter Walk Test, the choice of measure is dictated by the stage of walking recovery, as defined by the Standing and Walking Assessment Tool. The final outcome indicator, collected at 18 months post-discharge, is the Spinal Cord Independence Measure III-Mobility subscale. Conclusion: The selected indicators align with current clinical practice in Canada. The indicators will direct the timing and enhance the volume of walking therapy delivered, to ultimately increase the proportion of patients who achieve their walking potential by 18 months post-rehabilitation.

Effects of exercise interventions on cardiovascular health in individuals with chronic, motor complete spinal cord injury: protocol for a randomised controlled trial [Cardiovascular Health/Outcomes: Improvements Created by Exercise and education in SCI (CHOICES) Study].

INTRODUCTION: Recent studies demonstrate that cardiovascular diseases and associated complications are the leading cause of morbidity and mortality in individuals with spinal cord injury (SCI). Abnormal arterial stiffness, defined by a carotid-to-femoral pulse wave velocity (cfPWV) ≥10 m/s, is a recognised risk factor for heart disease in individuals with SCI. There is a paucity of studies assessing the efficacy of conventional training modalities on arterial stiffness and other cardiovascular outcomes in this population. Therefore, this study aims to compare the efficacy of arm cycle ergometry training (ACET) and body weight-supported treadmill training (BWSTT) on reducing arterial stiffness in individuals with chronic motor complete, high-level (above the sixth thoracic segment) SCI. METHODS AND ANALYSIS: This is a multicentre, randomised, controlled, clinical trial. Eligible participants will be randomly assigned (1:1) into either ACET or BWSTT groups. Sixty participants with chronic (>1 year) SCI will be recruited from three sites in Canada (Vancouver, Toronto and Hamilton). Participants in each group will exercise three times per week up to 30 min and 60 min for ACET and BWSTT, respectively, over the period of 6 months. The primary outcome measure will be change in arterial stiffness (cfPWV) from baseline. Secondary outcome measures will include comprehensive assessments of: (1) cardiovascular parameters, (2) autonomic function, (3) body composition, (4) blood haematological and metabolic profiles, (5) cardiorespiratory fitness and (6) quality of life (QOL) and physical activity outcomes. Outcome measures will be assessed at baseline, 3 months, 6 months and 12 months (only QOL and physical activity outcomes). Statistical analyses will apply linear-mixed modelling to determine the training (time), group (ACET vs BWSTT) and interaction (time × group) effects on all outcomes. ETHICS AND DISSEMINATION: Ethical approval was obtained from all three participating sites. Primary and secondary outcome data will be submitted for publication in peer-reviewed journals and widely disseminated. TRIAL REGISTRATION NUMBER: NCT01718977; Pre-results. TRIAL STATUS: Recruitment for this study began on January 2013 and the first participant was randomized on April 2013. Recruitment stopped on October 2018.

Effects of Seated Postural Stability and Trunk and Upper Extremity Strength on Performance during Manual Wheelchair Propulsion Tests in Individuals with Spinal Cord Injury: An Exploratory Study.

Objectives. To quantify the association between performance-based manual wheelchair propulsion tests (20 m propulsion test, slalom test, and 6 min propulsion test), trunk and upper extremity (U/E) strength, and seated reaching capability and to establish which ones of these variables best predict performance at these tests. Methods. 15 individuals with a spinal cord injury (SCI) performed the three wheelchair propulsion tests prior to discharge from inpatient SCI rehabilitation. Trunk and U/E strength and seated reaching capability with unilateral hand support were also measured. Bivariate correlation and multiple linear regression analyses allowed determining the best determinants and predictors, respectively. Results. The performance at the three tests was moderately or strongly correlated with anterior and lateral flexion trunk strength, anterior seated reaching distance, and the shoulder, elbow, and handgrip strength measures. Shoulder adductor strength-weakest side explained 53% of the variance on the 20-meter propulsion test-maximum velocity. Shoulder adductor strength-strongest side and forward seated reaching distance explained 71% of the variance on the slalom test. Handgrip strength explained 52% of the variance on the 6-minute propulsion test. Conclusion. Performance at the manual wheelchair propulsion tests is explained by a combination of factors that should be considered in rehabilitation.

Do Performance-Based Wheelchair Propulsion Tests Detect Changes Among Manual Wheelchair Users With Spinal Cord Injury During Inpatient Rehabilitation in Quebec?

OBJECTIVE: To quantify and compare the responsiveness and concurrent validity of 3 performance-based manual wheelchair propulsion tests among manual wheelchair users with subacute spinal cord injury (SCI) undergoing inpatient rehabilitation. DESIGN: Quasi-experimental repeated-measures design. SETTING: Publicly funded comprehensive inpatient SCI rehabilitation program. PARTICIPANTS: Consenting adult manual wheelchair users with a subacute SCI admitted and discharged from inpatient rehabilitation (N=14). INTERVENTION: Participants performed 20-m propulsion at both self-selected natural and maximal speeds, the slalom, and the 6-minute propulsion tests at rehabilitation admission and discharge. MAIN OUTCOME MEASURES: Time required to complete the performance-based wheelchair propulsion tests. Standardized response means (SRMs) were computed for each performance test and Pearson correlation coefficients (r) were calculated to explore the associations between performance tests. RESULTS: The slalom (SRM=1.24), 20-m propulsion at maximum speed (SRM=.99), and 6-minute propulsion tests (SRM=.84) were the most responsive. The slalom and 20-m propulsion at maximum speed were strongly correlated at both admission (r=.93) and discharge (r=.92). CONCLUSIONS: The slalom and 6-minute propulsion tests best document wheelchair propulsion performance change over the course of inpatient rehabilitation. Adding the 20-m propulsion test performed at maximal speed provides a complementary description of performance change.

Trunk strength and function using the multidirectional reach distance in individuals with non-traumatic spinal cord injury.

CONTEXT: Trunk control is essential to engage in activities of daily living. Measuring trunk strength and function in persons with spinal cord injury (SCI) is difficult. Trunk function has not been studied in non-traumatic SCI (NTSCI). OBJECTIVES: To characterize changes in trunk strength and seated functional reach in individuals with NTSCI during inpatient rehabilitation. To determine if trunk strength and seated reach differ between walkers and wheelchair users. To explore relationships between trunk and hip strength and seated functional reach. DESIGN: Observational study. SETTING: Two SCI rehabilitation facilities. PARTICIPANTS: 32 subacute inpatients (mean age 48.0 ± 15.4 years). OUTCOME MEASURES: Isometric strength of trunk and hip and function (Multidirectional Reach Test: MDRT) were assessed at admission and within 2 weeks of discharge. Analysis of variance was conducted for admission measures (MDRT, hip and trunk strength) between walkers and wheelchair users. Changes in MDRT, hip and trunk strength were evaluated using parametric and non-parametric statistics. The level of association between changes in values of MRDT and strength was also examined. RESULTS: Significant differences between walkers and wheelchair users were found for strength measures (P < 0.05) but not for MDRT. Left- and right-sided reaches increased in wheelchair users only (P < 0.05). Associations between changes in hip strength, trunk strength, and reach distance were found (R = 0.67-0.73). CONCLUSION: In clinical settings, it is feasible and relevant to assess trunk, hip strength, and MRDT. Future studies require strategies to increase the number of participants assessed, in order to inform clinicians about relevant rehabilitation interventions.

Physical Therapists' Perceptions of Leadership across the Health Care Continuum: A Brief Report.

PURPOSE: To describe and compare Canadian physical therapists' perspectives on the importance of characteristics required for leadership in the workplace and in society and to explore the implications for the profession. METHODS: This quantitative, cross-sectional study used a web-based survey of members of the Canadian Physiotherapy Association (CPA) with a registered email address (n=6156). The perceived importance of leadership characteristics at the workplace level versus the societal level was examined using a Mann-Whitney U test, with the significance set at α=0.05. RESULTS: A total of 1,511 respondents completed the questionnaire for a 24.5% response rate; they rated communication, professionalism, and credibility as the most important characteristics. For each of the 15 leadership characteristics, significantly fewer physical therapists chose the rating "extremely important" at the societal level than did so at the workplace level (p<0.001 for all characteristics). CONCLUSIONS: Physical therapists consistently rate leadership characteristics as more important in the workplace than at the societal level. Future research should aim to guide understanding about the reasons for this difference in perceived importance of leadership characteristics across different contexts.

Objectif: Décrire et comparer les points de vue des physiothérapeutes du Canada au sujet de l'importance des caractéristiques requises des chefs de file en milieu de travail et dans la société et explorer les répercussions pour la profession. Méthode: Cette étude canadienne transversale quantitative a été menée au moyen d'un sondage Web des membres de l'Association canadienne de physiothérapie (ACP) qui avaient une adresse électronique inscrite (n=6156). Nous avons analysé l'importance perçue des caractéristiques du leadership au niveau du milieu de travail par rapport à celui de la société au moyen d'un test de Mann-Whitney dont la signification a été fixée à α=0,05. Résultats: Au total, 1 511 répondants ont rempli le questionnaire, ce qui donne un taux de réponse de 24,5%. Pour eux, la communication, le professionnalisme et la crédibilité sont les caractéristiques les plus importantes. Pour chacune des 15 caractéristiques du leadership, moins de physiothérapeutes ont choisi la cote « extrêmement important ¼ au niveau de la société que ceux qui l'ont fait à celui du milieu de travail (p<0,001 pour toutes les caractéristiques). Conclusion: Les physiothérapeutes jugent constamment que les caractéristiques du leadership sont plus importantes en milieu de travail qu'au niveau de la société. Des recherches à venir devraient viser à comprendre les causes de ces différences au niveau de l'importance perçue des caractéristiques du leadership dans différents contextes.

What Do We Know about Knowledge Brokers in Paediatric Rehabilitation? A Systematic Search and Narrative Summary.

PURPOSE: To conduct a systematic review of the literature related to the use of knowledge brokers within paediatric rehabilitation, and specifically to determine (1) how knowledge brokers are defined and used in paediatric rehabilitation and (2) whether knowledge brokers in paediatric rehabilitation have demonstrably improved the performance of health care providers or organizations. METHODS: The MEDLINE, CINAHL, EMBASE, and AMED databases were systematically searched to identify studies relating to knowledge brokers or knowledge brokering within paediatric rehabilitation, with no restriction on the study design or primary aim. Following review of titles and abstracts, those studies identified as potentially relevant were assessed based on the inclusion criteria that they: (1) examined some aspect of knowledge brokers/brokering in paediatric rehabilitation; (2) included sufficient descriptive detail on how knowledge brokers/brokering were used; and(3) were peer-reviewed and published in English. RESULTS: Of 1513 articles retrieved, 4 met the inclusion criteria, 3 of which referenced the same knowledge broker initiative. Two papers used mixed methods, one qualitative methodology, and one case presentation. Because of the different methods used in the included studies, the findings are presented in a narrative summary. CONCLUSIONS: This study provides an overview of the limited understanding of knowledge brokers within paediatric rehabilitation. Knowledge broker initiatives introduced within paediatric rehabilitation have been anchored in different theoretical frameworks, and no conclusions can be drawn as to the optimum combination of knowledge brokering activities and methods, nor about optimal duration, for sustained results.

Objectif : Procéder à une critique systématique des publications portant sur l'utilisation des courtiers en connaissances dans le domaine de la réadaptation pédiatrique et déterminer plus précisément (1) comment les courtiers du savoir sont définis et utilisés en réadaptation pédiatrique et (2) s'ils ont amélioré de façon démontrable le rendement de fournisseurs ou d'organisations de soins de santé. Méthodes : On a effectué une recherche systématique dans les bases de données MEDLINE, CINAHL, EMBASE et AMED pour y trouver des études portant sur les courtiers ou le courtage en connaissances en réadaptation pédiatrique, sans restriction quant à la conception ou à l'objectif principal de l'étude. Après une revue des titres et des résumés, les études jugées éventuellement pertinentes ont été évaluées en fonction des critères d'inclusion suivants: (1) elles portaient sur certains aspects des courtiers ou du courtage en connaissances dans le domaine de la réadaptation pédiatrique; (2) elles incluaient des détails suffisamment descriptifs de la façon d'utiliser les courtiers ou le courtage en connaissances; (3) elles ont été critiquées par des pairs et publiées en anglais. Résultats : Sur 1 513 articles extraits, 4 répondaient aux critères d'inclusion, dont 3 mentionnaient la même initiative sur les courtiers en connaissances. Dans deux communications, les auteurs ont utilisé des méthodes mixtes, une méthodologie qualitative et un exposé de cas. Parce qu'on a utilisé des méthodes différentes dans les études incluses, les constatations sont présentées sous forme de résumé narratif. Conclusions : Cette étude présente un survol de la compréhension limitée des courtiers en connaissances dans le domaine de la réadaptation pédiatrique. Les initiatives sur les courtiers en connaissances lancées en réadaptation pédiatrique ont reposé sur différents cadres théoriques et il n'est pas possible de tirer de conclusion quant à la combinaison optimale des activités et des méthodes de courtage en connaissances, ni au sujet de leur durée optimale pour produire des résultats soutenus.

Walking-related outcomes for individuals with traumatic and non-traumatic spinal cord injury inform physical therapy practice.

OBJECTIVES: To describe and compare patient demographics, inpatient lengths of stay (LOS), and walking-related functional outcomes of individuals with spinal cord injuries (SCIs) of traumatic (TSCI) and non-traumatic (NTSCI) etiologies. To contrast these features between individuals who walked from those who did not walk at discharge from inpatient rehabilitation. DESIGN: Prospective observational study; comparisons between TSCI and NTSCI, walkers and non-walkers. Information collected as a pilot project within a provincial SCI informatics strategy. SETTING: Rehabilitation hospital specialized for SCIs. PARTICIPANTS: Adults with NTSCI (n = 31) or TSCI (n = 59) admitted to inpatient rehabilitation, 2007-2009. OUTCOME MEASURES: Lower-extremity motor scores (LEMS), spinal cord independence measure version III (SCIM-III) total and mobility subscores, functional independence measure (FIM), Length of Stay (LOS) at inpatient facilities. RESULTS: Groups (NTSCI vs. TSCI) did not differ in the proportion of individuals that achieved "walker" status (SCIM-III mobility indoors (MI) score ≥ 3 at rehab discharge) (P = 0.41, 48.9% overall). Inpatient LOS at both acute care and rehabilitation facilities did not differ between groups; however, TSCI non-walkers had longer inpatient rehabilitation LOS than TSCI walkers. Among walkers, improvement was shown on all three mobility subscores of the SCIM-III between admission and discharge from rehabilitation; highest significance was shown on the SCIM-III MI. Walking status at discharge (SCIM-III MI) was most strongly correlated with LEMS at rehab admission (r = 0.71, P < 0.001). CONCLUSION: Walking outcomes are comparable among individuals with NTSCI vs. TSCI admitted for specialized SCI rehabilitation. Routine use of SCIM-III mobility items for assessment of walking outcome is recommended for inpatient rehabilitation.

Using scoping review methods to describe current capacity and prescribe change in Canadian SCI rehabilitation service delivery.

OBJECTIVE: To describe the methodology used to conduct a scoping review of spinal cord injury (SCI) rehabilitation service delivery in Canada, and to explain the reporting process intended to advance future service delivery. EVIDENCE ACQUISITION: A SCI rehabilitation framework derived from the International Classification of Function, Disability and Health was developed to describe the goals and interprofessional processes of rehabilitation. An adapted Arksey and O'Malley (2005) methodological framework was used to conduct a scoping review of SCI rehabilitation services in Canada. Data were obtained from multiple relevant sources via survey (N = 3572 data fields) from 13 of 15 Canadian tertiary SCI rehabilitation sites, systematic reviews, white papers, literature reviews, clinical practice resources, and clinicians. Multidisciplinary teams of content experts (N = 17), assisted with data interpretation and validation by articulating practice trends, gaps, and priorities. EVIDENCE SYNTHESIS: The findings will be presented in an atlas, which includes aggregate national data regarding impairment and demographic characteristics, service utilization, available resources (staff and capital equipment), specialized services, local expertise, and current best practice indicators, outcome measures, and clinical guidelines. Data were collated and synthesized relative to specific rehabilitation goals. The current state of SCI rehabilitation service delivery (specific to each rehabilitation goal) is summarized in a report card within three domains, knowledge generation, clinical application, and policy change, and specifies key 2020 priorities. CONCLUSION: These findings should prompt critical evaluation of current Canadian SCI rehabilitation service delivery while specifying enhancements in knowledge generation, clinical application and policy change domains likely to assist with achievement of best practices by 2020.

Attractiveness of employment sectors for physical therapists in Ontario, Canada (1999-2007): implication for the long term care sector.

BACKGROUND: Recruiting and retaining health professions remains a high priority for health system planners. Different employment sectors may vary in their appeal to providers. We used the concepts of inflow and stickiness to assess the relative attractiveness of sectors for physical therapists (PTs) in Ontario, Canada. Inflow was defined as the percentage of PTs working in a sector who were not there the previous year. Stickiness was defined as the transition probability that a physical therapist will remain in a given employment sector year-to-year. METHODS: A longitudinal dataset of registered PTs in Ontario (1999-2007) was created, and primary employment sector was categorized as 'hospital', 'community', 'long term care' (LTC) or 'other.' Inflow and stickiness values were then calculated for each sector, and trends were analyzed. RESULTS: There were 5003 PTs in 1999, which grew to 6064 by 2007, representing a 21.2% absolute growth. Inflow grew across all sectors, but the LTC sector had the highest inflow of 32.0%. PTs practicing in hospitals had the highest stickiness, with 87.4% of those who worked in this sector remaining year-to-year. The community and other employment sectors had stickiness values of 78.2% and 86.8% respectively, while the LTC sector had the lowest stickiness of 73.4%. CONCLUSION: Among all employment sectors, LTC had highest inflow but lowest stickiness. Given expected increases in demand for services, understanding provider transitional probabilities and employment preferences may provide a useful policy and planning tool in developing a sustainable health human resource base across all employment sectors.

The distribution of physiotherapists in ontario: understanding the market drivers.

PURPOSE: To understand the factors that affect the distribution of physiotherapists in Ontario by examining three potential influences in the multi-payer physiotherapy (PT) market: population need, critical mass (related to academic health science centres [AHSCs]), and market forces. METHODS: Physiotherapist density and distribution were calculated from 2003 and 2005 College of Physiotherapists of Ontario registration data. Physiotherapists' workplaces were classified as not-for-profit (NFP) hospitals, other NFP, or for-profit (FP), and their locations were classified by census division (CD) types (cities and counties). RESULTS: Physiotherapist density varied significantly and distribution was neither uniformly responsive to population need, nor driven primarily by market forces. The largest factor was an AHSC in a CD; physiotherapists locate disproportionately in NFP hospitals in AHSCs rather than in the growing FP sector. CONCLUSIONS: While some patterns can be discerned in the distribution and densities of physiotherapists across Ontario, further work needs to be done to identify why population need and market forces appear to be less influential, and why CDs with AHSCs are so attractive to physiotherapists. With this additional information, it may be possible to identify ways to influence uneven distribution in the future.

Objectif : Comprendre les facteurs qui affectent la répartition des physiothérapeutes en Ontario en analysant trois influences potentielles dans le marché de la physiothérapie à payeurs multiples, soit les besoins de la population, la masse critique (liée aux centres universitaires de sciences de la santé) et les forces du marché. Méthode : La répartition et la densité de physiothérapeutes ont été calculées pour les années 2003 et 2005 à partir des données d'inscription à l'Ordre des physiothérapeutes de l'Ontario. Les milieux de travail des physiothérapeutes ont été classés par catégories : hôpitaux à but non lucratif (HBNL) ou autres milieux à but non lucratif (BNL) ou à but lucratif (BL). Leurs emplacements ont ensuite été classés par types de division du recensement (villes ou comtés). Résultats : La densité de physiothérapeutes varie considérablement et leur répartition n'était ni unilatéralement définie en fonction des besoins de la population, ni motivée principalement par les forces du marché. Le plus important facteur était un centre universitaire de sciences de la santé dans une division du recensement; les physiothérapeutes sont présents de manière disproportionnée dans les hôpitaux à but non lucratif de tels centres universitaires au lieu d'être dans le secteur en croissance des cliniques à but lucratif. Conclusions : Bien que certains modèles peuvent être dégagés dans la répartition et la densité des physiothérapeutes en Ontario, d'autres recherches devront être entreprises afin de préciser pourquoi les besoins de la population et les forces du marché semblent avoir moins d'influence et pourquoi les divisions du recensement avec centres universitaires de sciences de la santé sont si attrayantes pour les physiothérapeutes. Avec ces renseignements supplémentaires, il pourrait être possible d'identifier des moyens d'influer éventuellement sur la répartition inégale de ces professionnels.

Exploring the concept of leadership from the perspective of physical therapists in Canada.

PURPOSE: To explore the concept of leadership from the perspective of physical therapists in Canada. METHODS: A quantitative, cross-sectional nationwide study was performed using a Web-based survey distributed to all members of the Canadian Physiotherapy Association (CPA) with a registered e-mail address (n=6,156). Frequency distributions and percentages were obtained for all leadership characteristics, and chi-square tests were performed, with significance set at p<0.05. RESULTS: A total of 1,875 members responded, for a 30% response rate. Communication, professionalism, and credibility were rated as extremely important leadership characteristics by the majority of respondents across all three settings (workplace, health care system, and society); practising in the private sector contributed significantly to the perceived importance of business acumen (p<0.001). Overall, 79.6% of respondents self-declared as leaders; male gender, primary work facility in private practice or educational institution, and supervision of students were factors associated with self-declaration as a leader. CONCLUSIONS: The top three characteristics that physical therapists perceive as important differ from those reported among other health care professions. Further research is required to understand whether the presence of multiple health care professionals in an acute-care setting facilitates leadership opportunities or whether physical therapists feel overshadowed. Future studies should also investigate whether individuals practising outside the private sector recognize the business aspects of their workplace.

Objectif : Explorer le concept de leadership du point de vue des physiothérapeutes au Canada. Méthode : Une étude quantitative transversale nationale a été réalisée à l'aide d'un sondage par Internet distribué à tous les membres de l'Association canadienne de physiothérapie (ACP) qui possèdent une adresse de courriel inscrite à l'Association (n=6156). La répartition de la fréquence et les pourcentages ont été obtenus pour toutes les caractéristiques de leadership de l'étude, et des tests du Khi-carré ont été réalisés avec un seuil de signification fixé à <0,5. Résultats : Au total, 1875 membres ont répondu, soit un taux de réponse de 30 %. La communication, le professionnalisme et la crédibilité ont été classés comme des caractéristiques de leadership extrêmement importantes dans tous les milieux (lieu de travail, système de santé et société en général); la pratique dans le secteur privé a grandement contribué à l'importance perçue du concept de « sens des affaires ¼ (p<0,001). Dans l'ensemble, 79,6 % des répondants ont dit se considérer comme des dirigeants (leaders). Les facteurs suivants ont été associés à cette déclaration : le fait d'être de sexe masculin, de travailler principalement en pratique privée ou dans un établissement d'enseignement et d'exercer un travail de supervision auprès d'étudiants. Conclusions : Les trois premières caractéristiques perçues par les physiothérapeutes comme étant importantes diffèrent de celles dont on fait état dans d'autres professions du milieu de la santé. D'autres recherches seront nécessaires pour comprendre si la présence de plusieurs professionnels de la santé dans des établissements de soins de courte durée facilite les possibilités de leadership ou si les physiothérapeutes sentent que les autres professionnels leur portent ombrage. D'autres études devraient aussi tenter de déterminer si les physiothérapeutes qui pratiquent ailleurs que dans le secteur privé sont conscients du côté plus entrepreneurial de leur milieu de travail.

Measuring Balance and Mobility after Traumatic Brain Injury: Validation of the Community Balance and Mobility Scale (CB&M).

PURPOSE: To further investigate the construct validity of the Community Balance and Mobility Scale (CB&M), developed for ambulatory individuals with traumatic brain injury (TBI). METHODS: A convenience sample of 35 patients with TBI (13 in-patients, 22 outpatients) was recruited. Analyses included a comparison of CB&M and Berg Balance Scale (BBS) admission and change scores and associations between the CB&M and measures of postural sway, gait, and dynamic stability; the Community Integration Questionnaire (CIQ); and the Activities-specific Balance Confidence (ABC) Scale. RESULTS: Mean admission scores on the BBS and the CB&M were 53.6/56 (SD=4.3) and 57.8/96 (SD=23.3) respectively. Significant correlations were demonstrated between the CB&M and spatiotemporal measures of gait, including walking velocity, step length, step width, and step time; measures of dynamic stability, including variability in step length and step time; and the ABC (p<0.05). Significant correlations between the CB&M and CIQ were revealed with a larger data set (n=47 outpatients) combined from previous phases of research. CONCLUSIONS: In patients with TBI, the CB&M is less susceptible to a ceiling effect than the BBS. The construct validity of the CB&M was supported, demonstrating associations with laboratory measures of dynamic stability, measures of community integration, and balance confidence.

Physical therapy health human resource ratios: a comparative analysis of the United States and Canada.

BACKGROUND AND PURPOSE: Health human resource (HHR) ratios are a measure of workforce supply and are expressed as a ratio of the number of health care practitioners to a subset of the population. Health human resource ratios for physical therapists have been described for Canada but have not been fully described for the United States. In this study, HHR ratios for physical therapists across the United States were estimated in order to conduct a comparative analysis of the United States and Canada. METHODS: National US Census Bureau data were linked to jurisdictional estimates of registered physical therapists to create HHR ratios at 3 time points: 1995, 1999, and 2005. These results then were compared with the results of a similar study conducted by the same authors in Canada. RESULTS: The national HHR ratio across the United States in 1995 was 3.8 per 10,000 people; the ratio increased to 4.3 in 1999 and then to 6.2 in 2005. The aggregated results indicated that HHR ratios across the United States increased by 61.3% between 1995 and 2005. In contrast, the rate of evolution of HHR ratios in Canada was lower, with an estimated growth of 11.6% between 1991 and 2005. Although there were wide variations across jurisdictions, the data indicated that HHR ratios across the United States increased more rapidly than overall population growth in 49 of 51 jurisdictions (96.1%). In contrast, in Canada, the increase in HHR ratios surpassed population growth in only 7 of 10 jurisdictions (70.0%). DISCUSSION AND CONCLUSION: Despite their close proximity, there are differences between the United States and Canada in overall population and HHR ratio growth rates. Possible reasons for these differences and the policy implications of the findings of this study are explored in the context of forecasted growth in demand for health care and rehabilitation services.

Strategic responses to fiscal constraints: a health policy analysis of hospital-based ambulatory physical therapy services in the Greater Toronto Area (GTA).

PURPOSE: Ambulatory physical therapy (PT) services in Canada are required to be insured under the Canada Health Act, but only if delivered within hospitals. The present study analyzed strategic responses used by hospitals in the Greater Toronto Area (GTA) to deliver PT services in an environment of fiscal constraint. METHODS: Key informant interviews (n = 47) were conducted with participants from all hospitals located within the GTA. RESULTS: Two primary strategic responses were identified: (1) "load shedding" through the elimination or reduction of services, and (2) "privatization" through contracting out or creating internal for-profit subsidiary clinics. All hospitals reported reductions in service delivery between 1996 and 2003, and 15.0% (7/47 hospitals) fully eliminated ambulatory services. Although only one of 47 hospitals contracted out services, another 15.0% (7/47) reported that for-profit subsidiary clinics were created within the hospital in order to access other more profitable forms of quasi-public and private funding. CONCLUSIONS: Strategic restructuring of services, aimed primarily at cost containment, may have yielded short-term financial savings but has also created a ripple effect across the continuum of care. Moreover, the rise of for-profit subsidiary clinics operating within not-for-profit hospitals has emerged without much public debate and with little research to evaluate its impact.