Person-Centered Rehabilitation Model: Framing the Concept and Practice of Person-Centered Adult Physical Rehabilitation Based on a Scoping Review and Thematic Analysis of the Literature.

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.

Scoping review of the person-centered literature in adult physical rehabilitation.

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.

Important Movement Concepts: Clinical Versus Neuroscience Perspectives.

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.

Integrating Physiotherapists into Primary Health Care Organizations: The Physiotherapists' Perspective.

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.

Objectif : mieux comprendre les points de vue des physiothérapeutes sur les obstacles et les incitatifs perçus à leur intégration aux équipes de première ligne (ÉPL). Méthodologie : les chercheurs ont privilégié une démarche descriptive et qualitative sous forme d'entrevues semi-structurées en personne ou par téléphone. Les entrevues ont été enregistrées, transcrites textuellement, puis vérifiées par les intervieweurs pour en garantir la fiabilité. Les chercheurs ont analysé les données selon les six étapes de l'analyse thématique de Braun et Clarke. Résultats : huit physiothérapeutes ont passé l'entrevue, représentant diverses régions démographiques et géographiques de l'Ontario. Ils ont abordé des thèmes communs : le processus d'orientation, leurs expériences d'intégration du rôle de physiothérapeute à l'organisation, l'élaboration d'un programme par rapport aux soins individuels, les caractéristiques du physiothérapeute et de l'équipe interdisciplinaire et les ressources offertes dans l'organisation. Il en est ressorti des observations fondamentales sur les principaux vecteurs d'intégration : 1) la diversité et la nouveauté de ce rôle du physiothérapeute, 2) la compréhension qu'ont les membres de l'équipe du rôle du physiothérapeute et 3) les mesures et les valeurs des physiothérapeutes envers les ÉPL. Conclusions : Le processus d'intégration est influencé par une variation entre les facteurs individuels et systémiques. L'intégration des physiothérapeutes aux ÉPL s'améliorerait si les physiothérapeutes, les autres professionnels de la santé et les planificateurs des systèmes comprenaient mieux le rôle de la physiothérapie au sein de ces équipes.

Conceptualizing movement by expert Bobath instructors in neurological rehabilitation.

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.

Commonalities and differences in the implementation of models of care for arthritis: key informant interviews from Canada.

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.

Person-centred rehabilitation: what exactly does it mean? Protocol for a scoping review with thematic analysis towards framing the concept and practice of person-centred rehabilitation.

INTRODUCTION: Person-centredness is a philosophy for organising and delivering healthcare based on patients' needs, preferences and experiences. Although widely endorsed, the concept suffers from a lack of detail and clarification, in turn accounting for ambiguous implementation and outcomes. While a conceptual framework based on a systematic review defines person/patient-centred care components (Scholl et al, 2014), it applies across healthcare contexts and may not be sensitive to the nuances of the rehabilitation of adults with physical impairments. Accordingly, this study aims to build a conceptual framework, based on existing literature, of what person-centredness means in the rehabilitation of adults with physical impairments in the clinical encounter and broader health service delivery. METHODS AND ANALYSIS: We will use a scoping review methodology. Searches on relevant databases will be conducted first, combining keywords for 'rehabilitation', 'person-centered' and associated terms (including patient preferences/experiences). Next, snowball searches (citation tracking, references lists) will be performed. Papers will be included if they fall within predefined selection categories (seen as most likely informative on elements pertaining to person-centred rehabilitation) and are written in English, regardless of design (conceptual, qualitative, quantitative). Two reviewers will independently screen titles and abstracts, followed by screening of the full text to determine inclusion. Experts will then be consulted to identify relevant missing papers. This can include elements other than the peer-reviewed literature (eg, book chapters, policy/legal papers). Finally, information that helps to build the concept and practice of person-centred rehabilitation will be abstracted independently by two reviewers and analysed by inductive thematic analysis to build the conceptual framework. DISSEMINATION: The resulting framework will aid clarification regarding person-centred rehabilitation, which in turn is expected to conceptually ground and inform its operationalisation (eg, measurement, implementation, improvement). Findings will be disseminated through local, national and international stakeholders, both at the clinical and service organisation levels.

The paradox of normalization through rehabilitation: growing up and growing older with cerebral palsy.

PURPOSE: To examine the experience of normalization through rehabilitation for persons growing up & growing older with lifelong physical impairment (cerebral palsy [CP]). METHOD: 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. RESULTS: 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. CONCLUSIONS: 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. IMPLICATIONS FOR REHABILITATION: • 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.

Models of integrating physical therapists into family health teams in ontario, Canada: challenges and opportunities.

PURPOSE: To explore the potential for different models of incorporating physical therapy (PT) services within the emerging network of family health teams (FHTs) in Ontario and to identify challenges and opportunities of each model. METHODS: A two-phase mixed-methods qualitative descriptive approach was used. First, FHTs were mapped in relation to existing community-based PT practices. Second, semi-structured key-informant interviews were conducted with representatives from urban and rural FHTs and from a variety of community-based PT practices. Interviews were digitally recorded, transcribed verbatim, and analyzed using a categorizing/editing approach. RESULTS: Most participants agreed that the ideal model involves embedding physical therapists directly into FHTs; in some situations, however, partnering with an existing external PT provider may be more feasible and sustainable. Access and funding remain the key issues, regardless of the model adopted. CONCLUSION: Although there are differences across the urban/rural divide, there exist opportunities to enhance and optimize existing delivery models so as to improve client access and address emerging demand for community-based PT services.

Inter-professional Education in the Acute-Care Setting: The Clinical Instructor's Point of View.

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.

Dementia care at the intersection of regulation and reflexivity: a critical realist perspective.

OBJECTIVES: To understand point-of-care decisions, and in particular rule breaking, by personal support workers (PSWs) regarding institutionalized elders with dementia within a context of legislative and organizational care mandates. METHODS: Qualitative baseline data including focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) were collected during a 2-year, multi-method trial of a 12-week interprofessional arts-informed educational intervention in two Alzheimer support units and were analyzed using a critical realist approach. RESULTS: PSW care decisions were the outcome of a discordant interrelationship between PSWs' reflective deliberations, and legislative and organizational care mandates. PSWs responded to discordance through rule breaking in order to provide individualized care. Unbeknownst to PSWs, rule breaking was contingent upon supervisors' case-by-case complicity as they strove to balance fears of regulatory citations with private assessment of the soundness of PSW logic. DISCUSSION: Quality care emerges at the intersection of policies governing long-term care, PSW rule breaking, and the supportive but undisclosed role supervisors play in these violations. Understanding this complexity has important implications for initiatives to improve care practices and to challenge legislation and policies that impede dementia care.

The FIM™ as a measure of change in function after discharge from inpatient rehabilitation: a Canadian perspective.

PURPOSE: To examine the FIM™ 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™ scores at admission, discharge, and follow-up; change in FIM™ scores from admission to discharge and from discharge to follow-up; correlation between FIM™ scores at admission, discharge and follow-up, and predictors of the change in FIM™ scores between discharge and follow-up. RESULTS: The majority of the change in FIM™ 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™ scores are highly correlated indicating that collection of the follow-up FIM™ 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.

Rehabilitation services following total joint replacement: a qualitative analysis of key processes and structures to decrease length of stay and increase surgical volumes in Ontario, Canada.

OBJECTIVES: The purpose of this study was: (1) to identify key total joint replacement (TJR) care processes and structures from acute care and rehabilitation hospitals; (2) to determine the perceived implications of practice patterns and processes on wait times, discharge planning, transitions in care, utilization of rehabilitation services, and outcomes; and (3) to understand how acute care hospitals funded for additional cases were addressing current and future rehabilitation needs. METHODS: A qualitative descriptive approach using key informant interviews was used to provide further insights and depth of understanding to current practice patterns, structures and processes of care for TJR patients. RESULTS: Twenty-three key informants from a total of 15 hospitals across Ontario participated in this project. Themes that emerged related to processes of care (e.g. patient education, preoperative services, clinical pathways), and structures that supported these processes of care (e.g. organizational supports, increased funding and resources). The results point to a number of key practices that can facilitate smooth, integrated care for TJR patients, particularly in relation to best practices to decrease length of stay and increase surgical volumes. Increased funding related to strategic priorities placed on TJRs by the provincial government was viewed as an important impetus to implement a number of these key practices. CONCLUSION: From a rehabilitation perspective, there is need for consistent funding to secure more rehabilitation services for both preoperative and post-operative management of care that allows for shorter lengths of stay and to ensure optimal outcomes.

Evaluating rehabilitation outcomes from the client's perspective by identifying the gap between current and preferred movement ability.

PURPOSE: 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. METHOD: 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. RESULTS: 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 (P < 0.001). Both the MAM and the movement scale showed a significantly narrower gap after 2 weeks for the group in physical therapy (P < 0.001) but no change for the comparison group. CONCLUSIONS: 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.

Exploring wait list prioritization and management strategies for publicly funded ambulatory rehabilitation services in ontario, Canada: further evidence of barriers to access for people with chronic disease.

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. METHODS: Ambulatory rehabilitation services were defined as community occupational therapy (OT) and physiotherapy (PT) services. A mailed self-administered questionnaire was sent to all 374 Ontario publicly funded sites. Descriptive statistics were used to explore management strategies. RESULTS: The response rate was 57.2%. Client acuity was the most common method used to prioritize access across all settings. The most frequently reported methods to manage wait lists included teaching self-management strategies (85.0%), implementing attendance policies (69.5%) and conducting wait list audits (67.3%). CONCLUSION: Ambulatory rehabilitation settings have implemented a number of strategies for wait list management. The results of this study suggest that an increasing number of Ontarians encounter barriers when accessing publicly funded ambulatory rehabilitation services.

Being careful: a grounded theory of emergent chronic knee problems.

OBJECTIVE: To gain insight into the prediagnostic stages of knee osteoarthritis (OA) and identify the process whereby people recognize and address emergent chronic knee problems. METHODS: Twenty-six people (15 women, mean age 53.2 +/- 7.4 years) participated in a grounded theory study. Ten participants had a recent diagnosis of knee OA, and 16 had no diagnosis. The undiagnosed participants self-reported their symptoms, which had lasted at least 6 months and were consistent with knee OA. During semistructured, one-on-one interviews, participants reflected on the development and impact of their chronic knee problems. A constant comparative approach was used for analysis. RESULTS: Participants described uncertainty in understanding the meaning of intermittent knee symptoms for several years before becoming aware of the emergence of chronic knee problems. Once aware, participants engaged in a circular process of interpreting the meaning of knee symptoms and being careful. Being careful referred to the cycle of perceptions, intentions, and behaviors aimed at avoiding knee damage during physical activity. This cycle continued until participants experienced a disruption that challenged their participation in meaningful activities, at which time they decided to access health care. CONCLUSION: As a new construct, being careful unifies the complex set of experiences and behaviors that describe how participants protected their knee during physical activity. Participants interpret the experiences associated with emerging knee problems through interactions with others. These interactions enhance the participants' self-management, despite not having the benefits associated with diagnosis, such as justification for symptoms and formal assistance.

Wait times for publicly funded outpatient and community physiotherapy and occupational therapy services: implications for the increasing number of persons with chronic conditions in ontario, Canada.

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.

Analysis of factors affecting demand for rehabilitation services in Ontario, Canada: a health-policy perspective.

UNLABELLED: Demand for health services tends to outstrip supply in an environment of economic scarcity. PURPOSE: In this research, we first explore factors affecting demand for rehabilitation services in Canada's most populous province of Ontario; we then interpret these findings and discuss their implications for future demand. METHODS: Consistent with health-policy case-study methodology, we triangulated primary and secondary data sources (42 key-informant interviews and review of publicly available documents, respectively). RESULTS: Demand for rehabilitation seems to be rising quickly across Ontario's continuum of care, and informants identified four primary factors: (1) overall population growth along with an increasingly large cohort aged 65 years or older; (2) increasing rates of chronic and complex conditions, along with changes in hospital discharge patterns; (3) increasing public expectations; and (4) advances in treatment and management of diseases and condition. CONCLUSIONS: Although demand may be rising, access to rehabilitation is now based more on eligibility than on demand alone. The presence of increasing demand does not ensure that there is, or will be, sufficient financial or human resources to meet such demand. This study signals the need to reflect on current policies regarding access, and highlights the need to consider the benefits of health-promotion and injury-prevention strategies in mediating demand.