What matters to program partners when implementing a community-based exercise program for people post-stroke? A theory-based qualitative study and cost analysis.

Background: Community-based exercise programs integrating a healthcare-community partnership (CBEP-HCP) can facilitate lifelong exercise participation for people post-stroke. Understanding the process of implementation from multiple perspectives can inform strategies to promote program sustainability. Purpose: To explore stakeholders' experiences with undertaking first-time implementation of a group, task-oriented CBEP-HCP for people post-stroke and describe associated personnel and travel costs. Methods: We conducted a descriptive qualitative study within a pilot randomized controlled trial. In three cities, trained fitness instructors delivered a 12-week CBEP-HCP targeting balance and mobility limitations to people post-stroke at a recreation centre with support from a healthcare partner. Healthcare and recreation managers and personnel at each site participated in semi-structured interviews or focus groups by telephone post-intervention. Interviews and data analysis were guided by the Consolidated Framework of Implementation Research and Theoretical Domains Framework, for managers and program providers, respectively. We estimated personnel and travel costs associated with implementing the program. Results: Twenty individuals from three sites (4 recreation and 3 healthcare managers, 7 fitness instructors, 3 healthcare partners, and 3 volunteers) participated. We identified two themes related to the decision to partner and implement the program: (1) Program quality and packaging, and cost-benefit comparisons influenced managers' decisions to partner and implement the CBEP-HCP, and (2) Previous experiences and beliefs about program benefits influenced staff decisions to become instructors. We identified two additional themes related to experiences with training and program delivery: (1) Program staff with previous experience and training faced initial role-based challenges that resolved with program delivery, and (2) Organizational capacity to manage program resource requirements influenced managers' decisions to continue the program. Participants identified recommendations related to partnership formation, staff/volunteer selection, training, and delivery of program activities. Costs (in CAD) for first-time program implementation were: healthcare partner ($680); fitness coordinators and instructors ($3,153); and participant transportation (personal vehicle: $283; public transit: $110). Conclusion: During first-time implementation of a CBEP-HCP, healthcare and hospital managers focused on cost, resource requirements, and the added-value of the program, while instructors and healthcare partners focused on their preparedness for the role and their ability to manage individuals with balance and mobility limitations. Trial Registration: ClinicalTrials.gov, NCT03122626. Registered April 17, 2017-Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT03122626.

Publicly funded home care service use in the first 2 years after spinal cord injury in Ontario, Canada.

The objectives of this study were to describe home care utilization and costs in community-dwelling individuals 2 years post-spinal cord injury (SCI) in Ontario, Canada. This retrospective incident cohort study uses administrative health care data to identify individuals with traumatic SCI (tSCI). Time to service delivery and frequency of service delivery and costs were calculated. A total of 798 individuals with tSCI comprised the cohort. In the first 2 years, personal support/homemaking was the most utilized service. Median cumulative home care 2 years post-discharge was $7,200 ($1,240-35,410 25-75% interquartile range). This study highlights the importance of home care to individuals with SCI.

Describing the current state of post-rehabilitation health system surveillance in Ontario - an invited review.

Context: Spinal cord injury (SCI) presents numerous physiological, psychosocial, and environmental complexities resulting in significant healthcare system resource demands. Objective: To describe the current health system surveillance mechanisms in Ontario, Canada and highlight gaps in health surveillance among adults with SCI across their lifespan. Methods: A review of administrative data sources capturing SCI-specific information took place via internet searching and networking among SCI rehabilitation and health services experts with emphasis on functionality, health service utilization, and quality of life data. Results: The review identified a distinct paucity of data elements specific to the health surveillance needs of individuals with SCI living in the community. The gaps identified are: (1) a lack of data usability; (2) inadequate linkage between available datasets; (3) inadequate/infrequent reporting of outcomes; (4) a lack of relevant content/patient-reported outcomes; and, (5) failure to incorporate additional data sources (e.g. Insurance datasets). Conclusion: Currently, SCI-specific health data is disproportionately weighted towards the first 3-6 months post injury with detailed data regarding pre-hospital care, acute management and rehabilitation, but little existing infrastructure supporting community-based health surveillance. Given this reality, the bolstering of meaningful community health surveillance of this population across the lifespan is needed. Addressing the identified gaps in health surveillance must inform the creation of a comprehensive community health dataset incorporating patient-reported outcome measures and enabling linkage with existing administrative and/or clinical databases. A future harmonized data surveillance strategy would, in turn, positively impact function, health services, resource utilization and health-related quality of life surveillance.

Qualitative study exploring the factors influencing physical therapy management of early knee osteoarthritis in Canada.

OBJECTIVES: Increasingly, there is emphasis on identifying and initiating treatment of osteoarthritis (OA) in the early phases of the disease. This study aimed to identify the perceived barriers and facilitators to managing clients with early knee OA and the contextual factors affecting implementation of care by physical therapists (PTs). DESIGN: Qualitative study using in-depth semistructured interviews with 33 PTs. The interviews were audio-recorded, transcribed verbatim and analysed inductively using thematic analysis. SETTING: Canada. PARTICIPANTS: A purposive sample of PTs who managed clients with knee symptoms and/or diagnosed knee OA in community/outpatient settings in three provinces in Canada (Ontario, Alberta, British Columbia). RESULTS: Factors that affected physical therapy management of early knee OA were identified at four levels: the community, healthcare system, healthcare provider and client level. Some healthcare provider factors acted primarily as enablers of management, such as PTs' confidence in their ability to manage perceived early knee OA, PTs' beliefs about consequences of OA and the PT scope of practice. However, the study illuminated a range of modifiable factors that can act as barriers to management. These factors included access to services in the community and healthcare system; healthcare provider factors such as time, access to evidence and physician's role in referrals and messaging; and client factors related to client characteristics (eg, general health, socioeconomic status), engagement in management and beliefs about OA. CONCLUSION: These findings provide us with a basis to begin to address specific barriers and to optimise care for early knee OA.

Discharge destination following hip fracture: comparative effectiveness and cost analyses.

This study determines outcomes and costs of similar hip fracture patients that were discharged from hospital to a rehabilitation facility or to the community within 1 year. Community patients had worse outcomes and lower costs compared to rehabilitation facility patients. This study contributes to understanding hip fracture quality of care. PURPOSE: The purpose of this study is to determine the impact on mortality and rehospitalization, as well as health system cost, of similar hip fracture patients being discharged to an inpatient rehabilitation facility or directly to the community within 1 year in Ontario, Canada. METHODS: This was a retrospective study of a propensity-matched cohort completed from the health system perspective. Administrative databases were used to identify and match two groups of older adults (total n = 18,773) discharged alive from acute care for hip fracture repair: patients discharged to inpatient rehabilitation were matched to patients discharged to the community. RESULTS: A higher proportion of patients discharged to the community (27-42%) died or were rehospitalized (SDhighipr = 0.21, SDlowipr = 0.33) and had substantially lower health system costs (SDhighipr = 0.65, SDlowipr = 0.42) up to 1 year post-acute discharge compared to similar patients discharged to inpatient rehabilitation facilities (IPR) (10-11%). CONCLUSIONS: This study demonstrates that similar hip fracture patients are discharged to different post-acute settings (i.e., home-based rehabilitation and inpatient rehabilitation) and have different outcomes, thereby calling into question the appropriateness of post-acute rehabilitation delivery in Ontario, Canada. Future research should focus on determining how trade-offs in resource allocation between settings would impact patient outcomes.

Montreal Accord on Patient-Reported Outcomes (PROs) use series - Paper 3: patient-reported outcomes can facilitate shared decision-making and guide self-management.

BACKGROUND: There is a shift toward making health care patient centered, whereby patients are part of medical decision-making and take responsibility for managing their health. Patient-reported outcomes (PROs) capture the patient voice and can be used to engage patients in medical decision-making. OBJECTIVE: The objective of this paper is to present important factors from patients', clinicians', researchers', and decision-makers' perspectives that influence successful adoption of PROs in clinical practice. Factors recommended in this paper were informed by a patient partner. DISCUSSION: Based on themes arising from the Montreal Accord proceedings, we describe factors that influence the adoption of PROs and how PROs can have a positive effect by enhancing communication and providing opportunities to engage patients, carers, and clinicians in care. Consideration of patient factors (e.g., health literacy), family support and networks (e.g., peer-support networks), technology (e.g., e-health), and health care system factors (e.g., resources to implement PROs) is necessary to ensure PROs are successfully adopted. PRO evaluation plans most likely to succeed over the long term are those incorporating PROs identified by patients as necessary for self-management and that coincide with providers' needs for collaboratively developing treatment plans with patients and families.

Qualitative Study Exploring the Meaning of Knee Symptoms to Adults Ages 35-65 Years.

OBJECTIVE: While osteoarthritis (OA) has mainly been viewed as a disease affecting older people, its prevalence in younger adults is substantial. However, there is limited research on how younger adults understand knee symptoms. This article explores the meaning of knee symptoms to adults ages 35-65 years. METHODS: This qualitative study comprised 6 focus groups and 10 one-on-one interviews with 51 participants (median age 49, 61% female), who self-reported knee OA or reported knee symptoms (i.e., pain, aching, or stiffness) on most days of the past month. Constructivist grounded theory guided the sampling, data collection, and analysis. Data were analyzed using a constant comparative method. RESULTS: Central to participants' understanding of knee symptoms was the perception that symptoms were preventable, meaning that there was the potential to prevent the onset of symptoms and to alter the course of symptoms. This understanding was demonstrated in participants' explanation of symptoms. Participants commented on the cause, prevention, and course of symptoms. Moreover, participants reflected on their experience with symptoms, indicating that symptoms made them feel older than their current age. However, they did not perceive their symptoms as normal or acceptable. CONCLUSION: Participants interpreted knee symptoms as potentially preventable, suggesting that they may be open to primary and secondary prevention strategies.

Impact of vitamin D supplementation on health-care use in a 25-hydroxyvitamin D-tested population in France: a population-based descriptive cohort study.

OBJECTIVE: Chronic vitamin D deficiency has been associated in some patients with diffuse musculoskeletal pain. These unspecific symptoms may partly explain why vitamin D deficiency is often diagnosed late. Our aim was to analyse health-care claims after vitamin D supplementation in patients likely to have vitamin D deficiency. DESIGN: Ambulatory health-care claims were compared before and after a vitamin D supplementation prescribed following a 25-hydroxyvitamin D assay. SETTING: Health Insurance Fund (FHIF) database of the Rhône-Alpes area, France. SUBJECTS: Among patients reimbursed for a 25-hydroxyvitamin D assay between 1 December 2008 and 31 January 2009, those supplemented with vitamin D after the assay were matched on the date of assay to patients who did not receive vitamin D. RESULTS: Among the 3023 patients who had a 25-hydroxyvitamin D assay, 935 were consequently supplemented and matched to 935 patients not supplemented. Their median age was 50·0 and 49·5 years, respectively. Patients supplemented decreased their muscle relaxant consumption whereas no change was observed in the reference group, the difference between the two groups was significant (P=0·03). Second and third Pain Relief Ladder prescriptions decreased in both groups but not significantly differently between groups (P=0·58). There was a decrease in prescriptions of biological examination in both groups with no significant difference. CONCLUSIONS: Besides a decrease in muscle relaxant prescriptions in the supplemented group, it was difficult to assess the impact of vitamin D supplementation in patients likely to have vitamin D deficiency. Prospective cohort studies and randomized trials are needed to assess the efficiency of screening and supplementing vitamin D deficiency.

A qualitative study of the consequences of knee symptoms: 'It's like you're an athlete and you go to a couch potato'.

OBJECTIVES: To explore the perceived consequences of knee symptoms on the lives of people aged 35-65 years who had diagnosed osteoarthritis (OA) or OA-like symptoms. DESIGN: A qualitative study with six focus groups and 10 one-on-one interviews. Constructivist grounded theory guided data collection and analysis. Data were analysed using the constant comparative method. SETTING: Toronto, Canada. PARTICIPANTS: 51 participants (median age 49; 61% female) who self-reported knee OA or reported knee pain, aching or stiffness on most days of the past month participated in the study. RESULTS: The core finding, disruption and change, illustrates the range of perceived consequences of knee symptoms in peoples' lives. Participants described the consequences of symptoms on their physical activity (giving up high-level activities or changing how or how much they performed activities), social life (leisure, family and work) and emotional life. Knee symptoms also altered the way participants thought about their bodies and themselves. They reported that they had a new awareness of their knee and that they no longer trusted their knee. They also conveyed that their sense of self was altered. CONCLUSIONS: This study illuminates the significant and varied consequences that mild to moderate knee symptoms have on the lives of adults age 35-65 years. Findings highlight the need for clinicians to tailor advice and support to the individual's needs considering their symptoms, the consequences of symptoms on their lives and their personal context.

Development of a Chronic Care Model for Neurological Conditions (CCM-NC).

BACKGROUND: Persons with neurological conditions and their families face a number of challenges with the provision of health and community-based services. The purpose of this study was to understand the existing health and community service needs and gaps in care and to use this information to develop a model to specify factors and processes that may improve the quality of care and health and well-being for persons with neurological conditions. METHODS: We conducted semi-structured interviews with health care professionals, community-based non-health care professionals working with individuals with neurological conditions, and policy makers -from the Ministries of Health, Community and Social Services, Transportation and Education- across Canada. We used a purposive sampling and snowballing approach to obtain maximum variation across professions, sector and geography (provinces and territories, rural and urban). Data analysis was an iterative, constant comparative process involving descriptive and interpretive analyses and was initially guided by the components of the Expanded Chronic Care Model. RESULTS: A total of 180 individuals completed the interviews: 39% (n = 70) health care professionals, 47% (n = 85) community-based non-health care professionals, and 14% (n = 25) policy makers. Based on the data we developed the Chronic Care Model for Neurological Conditions (CCM-NC). The major needs/gaps are represented by the following themes: acceptance and openness to neurological conditions, evidence informed policy, investments and funding, supported transitions, caregiver support, and life enhancing resources (education, employment, housing and transportation), knowledge and awareness of neurological conditions and availability and access to health services. The model maintains that intersectoral collaboration across the health system, community and policy components is needed. It recognizes that attitudes, policies, enhanced community integration and health system changes are needed to develop activated patients and families, proactive service delivery teams, a person-centred health system and healthy public policy for persons with neurological conditions. CONCLUSION: The CCM-NC will generate debate and discussion about the actions needed in each of the model components to enable people with neurological conditions to sustain healthier lives. Next steps include validating the model with persons with neurological conditions, in and outside of the Canadian context and developing and evaluating interventions to test the model.

Systems analysis of community and health services for acquired brain injury in Ontario, Canada.

PRIMARY OBJECTIVE: To conduct a systems analysis on community and health services for individuals with acquired brain injury (ABI) in the province of Ontario, Canada. RESEARCH DESIGN: This study employed a triangulation design. This design is used when there is a need to validate quantitative results with qualitative data, as is the case in the present study. METHODS AND PROCEDURES: Forty-two healthcare professionals and/or healthcare administrators from organizations across the province and across the continuum of care were surveyed. A 1-day focus group was also held to validate the study findings. MAIN OUTCOMES AND RESULTS: The main results of this study revealed: (1) a lack of services for children/adolescents; (2) service gaps for individuals with co-existing mental health conditions; (3) a lack of services related to employment; (4) changes in casemix, in terms of more individuals with co-morbid medical and mental health conditions (with many of the organizations reporting medical instability and severe behavioural disorders as exclusion criteria); and (5) a need for more organizations to track patient outcomes for evaluation and/or accountability purposes. CONCLUSIONS: Findings from this study will lead to improvement of current services but also improved planning of future services for individuals with ABI.

Spanning boundaries into remote communities: an exploration of experiences with telehealth chronic disease self-management programs in rural northern ontario, Canada.

BACKGROUND: In rural and remote settings, providing education programs for chronic conditions can be challenging because of the limited access and availability of healthcare services. The purpose of this study was to explore the experiences of participants in a chronic disease self-management program via telehealth (tele-CDSMP) and to identify facilitators and barriers to inform future tele-CDSMP delivery models. MATERIALS AND METHODS: Nineteen tele-CDSMP courses were delivered to 13 Northern Ontario (Canada) communities. Two types of group were delivered: (1) single telehealth site (one community formed a self-management group linked to program leaders via telehealth) and (2) multiple telehealth sites (several remote communities were linked to each other and program leaders via telehealth). Following the completion of the courses, participants were invited to partake in a focus group. RESULTS: Overall, 44 people participated in the focus groups. Four main themes were identified by tele-CDSMP participants related to the overall experience of the program: (1) bridging the access gap, (2) importance of group dynamics, (3) importance of strong leaders, and (4) preference for extended session time. Key barriers were related to transportation, lack of session time, and access to Internet-based resources. The main facilitators were having strong program leaders, encouraging the development of group identity, and providing enough time to be comfortable with technology. CONCLUSIONS: Our findings suggest overall the tele-CDSMP was a positive experience for participants and that tele-CDSMPs are an effective option to increasing access to more geographically isolated communities.

Factors influencing participation in cardiac rehabilitation programmes after referral and initial attendance: qualitative systematic review and meta-synthesis.

BACKGROUND: Greater participation in cardiac rehabilitation improves morbidity and mortality in people with coronary heart disease, but little is understood of patients' decisions to participate. METHODS: To develop interventions aimed at increasing completion of programmes, we conducted a qualitative systematic review and meta-synthesis to explore the complex factors and processes influencing participation in cardiac rehabilitation programmes after referral and initial access. To be included in the review, studies had to contain a qualitative research component, population specific data on programme participation in adults >18 years, and be published ≥1995 as full articles or theses. Ten databases were searched (31 October 2011) using 100+ search terms. RESULTS: Of 2264 citations identified, 62 studies were included involving: 1646 patients (57% female; mean age 64.2), 143 caregivers, and 79 professionals. Patients' participation was most strongly influenced by perceptions of the nature, suitability and scheduling of programmes, social comparisons made possible by programmes, and the degree to which programmes, providers, and programme users met expectations. Women's experiences of these factors rendered them less likely to complete. Comparatively, perceptions of programme benefits had little influence on participation. CONCLUSIONS: Factors reducing participation in programmes are varied but amenable to intervention. Participation should be viewed as a 'consumer behaviour' and interventions should mobilize family support, promote 'patient friendly' scheduling, and actively harness the social, identity-related, and experiential aspects of participation.

Increasing access to chronic disease self-management programs in rural and remote communities using telehealth.

OBJECTIVE: This study examined whether a telehealth chronic disease self-management program (CDSMP) would lead to improvements in self-efficacy, health behaviors, and health status for chronically ill adults living in Northern Ontario, Canada. Two telehealth models were used: (1) single site, groups formed by participants at one telehealth site; and (2) multi-site, participants linked from multiple sites to form one telehealth group, as a strategy to increase access to the intervention for individuals living in rural and remote communities. SUBJECTS AND METHODS: Two hundred thirteen participants diagnosed with heart disease, stroke, lung disease, or arthritis attended the CDSMP at a preexisting Ontario Telemedicine Network studio from September 2007 to June 2008. The program includes six weekly, peer-facilitated sessions designed to help participants develop important self-management skills to improve their health and quality of life. Baseline and 4-month follow-up surveys were administered to assess self-efficacy beliefs, health behaviors, and health status information. Results were compared between single- and multi-site delivery models. RESULTS: Statistically significant improvements from baseline to 4-month follow-up were found for self-efficacy (6.6±1.8 to 7.0±1.8; p<0.001), exercise behavior, cognitive symptom management, communication with physicians, role function, psychological well-being, energy, health distress, and self-rated health. There were no statistically significant differences in outcomes between single- and multi-site groups. CONCLUSIONS: Improvements in self-efficacy, health status, and health behaviors were equally effective in single- and multi-site groups. Access to self-management programs could be greatly increased with telehealth using single- and multi-site groups in rural and remote communities.

Clinical balance assessment: perceptions of commonly-used standardized measures and current practices among physiotherapists in Ontario, Canada.

BACKGROUND: Balance impairment is common in multiple clinical populations, and comprehensive assessment is important for identifying impairments, planning individualized treatment programs, and evaluating change over time. However, little information is available regarding whether clinicians who treat balance are satisfied with existing assessment tools. In 2010 we conducted a cross-sectional survey of balance assessment practices among physiotherapists in Ontario, Canada, and reported on the use of standardized balance measures (Sibley et al. 2011 Physical Therapy; 91: 1583-91). The purpose of this study was to analyse additional survey data and i) evaluate satisfaction with current balance assessment practices and standardized measures among physiotherapists who treat adult or geriatric populations with balance impairment, and ii) identify factors associated with satisfaction. METHODS: The questionnaire was distributed to 1000 practicing physiotherapists. This analysis focuses on questions in which respondents were asked to rate their general perceptions about balance assessment, the perceived utility of individual standardized balance measures, whether they wanted to improve balance assessment practices, and why. Data were summarized with descriptive statistics and utility of individual measures was compared across clinical practice areas (orthopaedic, neurological, geriatric or general rehabilitation). RESULTS: The questionnaire was completed by 369 respondents, of which 43.4% of respondents agreed that existing standardized measures of balance meet their needs. In ratings of individual measures, the Single Leg Stance test and Berg Balance Scale were perceived as useful for clinical decision-making and evaluating change over time by over 70% of respondents, and the Timed Up-and-Go test was perceived as useful for decision-making by 56.9% of respondents and useful for evaluating change over time by 62.9% of respondents, but there were significant differences across practice groups. Seventy-nine percent of respondents wanted to improve their assessments, identifying individual, environmental and measure-specific barriers. The most common barriers were lack of time and knowledge. CONCLUSIONS: This study offers new information on issues affecting the evaluation of balance in clinical settings from a broad sample of physiotherapists. Continued work to address barriers by specific practice area will be critical for the success of any intervention attempting to implement optimal balance assessment practices in the clinical setting.

Secondary health conditions and spinal cord injury: an uphill battle in the journey of care.

PURPOSE: To understand the journey of care in the prevention and management of secondary health conditions (SHCs) following spinal cord injury (SCI). METHOD: This was a case study design with 'Ontario' as the case. The Network Episode Model was used as the conceptual framework. Data sources included in depth interviews with persons with SCI, care providers, and policy and decision makers. Document analysis was also conducted on relevant materials and policies. Key informants were selected by purposeful sampling as well as snowball sampling to provide maximum variation. Data analysis was an iterative process and involved descriptive and interpretive analyses. A coding structure was developed based on the conceptual framework which allowed for free nodes when emerging ideas or themes were identified. RESULTS: Twenty-eight individuals were interviewed (14 persons with SCI and 14 persons representing care providers, community advocacy organization representatives, system service delivery administrators and policy-makers). A major over-arching domain that emerged from the data was the concept of 'fighting'. Eleven themes were identified: at the micro-individual level: (i) social isolation and system abandonment, (ii) funding and equitable care, (iii) bounded freedom and self-management; at the meso care provider level: (iv) gender and caregiving strain, (v) help versus disempowerment, (vi) holistic care-thinking outside the box, (vii) poor communication and coordination of care; and at the macro health system level: (viii) fight for access and availability, (ix) models of care tensions, (x) private versus public tensions and (xi) rigid rules and policies. CONCLUSIONS: Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. If we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level. IMPLICATIONS FOR REHABILITATION: • Secondary health conditions are problematic for individuals with a spinal cord injury (SCI). • This study aimed to understand the journey of care in the prevention and management of secondary health conditions (SHCs) following SCI. • Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. • All stakeholders involved recognized the disparities in access to care and resources that exist within the system. We recommend that if we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level.

Social networks and secondary health conditions: the critical secondary team for individuals with spinal cord injury.

OBJECTIVES: To describe the structure of informal networks for individuals with spinal cord injury (SCI) living in the community, to understand the quality of relationship of informal networks, and to understand the role of informal networks in the prevention and management of secondary health conditions (SHCs). DESIGN: Mixed-method descriptive study. SETTING: Ontario, Canada Participants: Community-dwelling adults with an SCI living in Ontario Interventions/methods: The Arizona Social Support Interview Survey was used to measure social networks. Participants were asked the following open-ended questions: (1) What have been your experiences with your health care in the community? (2) What have been your experiences with care related to prevention and/or management of SHCs?, (3)What has been the role of your informal social networks (friends/family) related to SHCs? RESULTS: Fourteen key informant interviews were conducted (6 men, 8 women). The overall median for available informal networks was 11.0 persons (range 3-19). The informal network engaged in the following roles: (1) advice/validating concerns; (2) knowledge brokers; (3) advocacy; (4) preventing SHCs; (5) assisting with finances; and (6) managing SHCs. Participants described their informal networks as a "secondary team"; a critical and essential force in dealing with SHCs. CONCLUSIONS: While networks are smaller for persons with SCI compared with the general population, these ties seems to be strong, which is essential when the roles involve a level of trust, certainty, tacit knowledge, and flexibility. These informal networks serve as essential key players in filling the gaps that exist within the formal health care system.

Application of the Andersen's health care utilization framework to secondary complications of spinal cord injury: a scoping review.

PURPOSE: The purpose of this scoping review was to identify research priority areas related to secondary complications and associated health care use for individuals with spinal cord injury (SCI). DATA SOURCES: Peer-reviewed journals were identified using CINAHL, MEDLINE, PubMed, Embase, Social Sciences Abstracts, Social Works Abstract and PsycInfo search engines. Key references were hand searched. STUDY SELECTION: A total of 289 abstracts were identified from the initial search strategy. We removed studies that did not measure health care and those that did not involve analytical investigation. DATA EXTRACTION: The selected 31 studies were reviewed in detail using a coding template based on the domains and sub-components of the Andersen model (i.e. environmental, population characteristics, health behavior and outcome). RESULTS: Most studies measured predisposing characteristics (e.g., age, gender) and need characteristics (e.g., level of injury). There was a notable absence of environmental characteristics (e.g., health system, neighborhood variables), enabling characteristics and health behaviors (beyond diet and nutrition). CONCLUSIONS: We identified a gap in the SCI literature. Future research should focus on longitudinal study designs with more representation of non-traumatic spinal cord injury, as well as utilizing more advanced statistical analyses (i.e., multivariate level) to adjust for confounding variables.

Balance assessment practices and use of standardized balance measures among Ontario physical therapists.

BACKGROUND: Balance impairment is a significant problem for older adults, as it can influence daily functioning. Treating balance impairment in this population is a major focus of physical therapist practice. OBJECTIVE: The purpose of this study was to document current practices in clinical balance assessment and compare components of balance assessed and measures used across practice areas among physical therapists. DESIGN: This was a cross-sectional study. METHODS: A survey questionnaire was mailed to 1,000 practicing physical therapists in Ontario, Canada. RESULTS: Three hundred sixty-nine individuals completed the survey questionnaire. More than 80% of respondents reported that they regularly (more than 60% of the time) assessed postural alignment, static and dynamic stability, functional balance, and underlying motor systems. Underlying sensory systems, cognitive contributions to balance, and reactive control were regularly assessed by 59.6%, 55.0%, and 41.2% of the respondents, respectively. The standardized measures regularly used by the most respondents were the single-leg stance test (79.1%), the Berg Balance Scale (45.0%), and the Timed "Up & Go" Test (27.6%). There was considerable variation in the components of balance assessed and measures used by respondents treating individuals in the orthopedic, neurologic, geriatric, and general rehabilitation populations. LIMITATIONS: The survey provides quantitative data about what is done to assess balance, but does not explain the factors influencing current practice. CONCLUSIONS: Many important components of balance and standardized measures are regularly used by physical therapists to assess balance. Further research, however, is needed to understand the factors contributing to the relatively lower rates of assessing reactive control, the component of balance most directly responsible for avoiding a fall.

Rehabilitation services after total joint replacement in Ontario, Canada: can 'prehabilitation' programs mediate an increasing demand?

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.