Variations in demand and provision for publicly funded outpatient musculoskeletal physiotherapy services across Quebec, Canada

Geographic accessibility to physiotherapy care in Aotearoa New Zealand

Disparities in care access for health conditions where physiotherapy can play a major role are abetting health inequities. Spatial analyses can contribute to illuminating inequities in health yet the geographic accessibility to physiotherapy care across New Zealand has not been examined. This population-based study evaluated the accessibility of the New Zealand physiotherapy workforce relative to the population at a local scale. The locations of 5,582 physiotherapists were geocoded and integrated with 2018 Census data to generate 'accessibility scores' for each Statistical Area 2 using the newer 3-step floating catchment area method. For examining the spatial distribution and mapping, accessibility scores were categorized into seven levels, centered around 0.5 SD above and below the mean. New Zealand has an above-average physiotherapy-to-population ratio compared with other OECD countries; however, this workforce is maldistributed. This study identified areas (and locations) where geographic accessibility to physiotherapy care is relatively low.

Unraveling attrition and retention: A qualitative study with rehabilitation professionals

BACKGROUND

Health human resources are scarce worldwide. In occupational therapy (OT), physical therapy (PT), and speech-language pathology (S-LP), attrition and retention issues amplify this situation and contribute to the precarity of health systems.

OBJECTIVE

To investigate the phenomena of attrition and retention with OTs, PTs and S-LPs who stayed in, or left their profession.

METHODS

Cultural-historical activity theory provided the theoretical scaffolding for this interpretive description study. We used purposeful sampling (maximum variation approach) to recruit OTs, PTs, and S-LPs from Quebec, Canada. Individual interviews were conducted with 51 OTs, PTs, and S-LPs from Quebec, Canada, in English or French (2019-2020). Inductive and deductive approaches, and constant comparative techniques were used for data analysis.

RESULTS

Six themes were developed: 1) characteristics of work that made it meaningful; 2) aspects of work that practitioners appreciate; 3) factors of daily work that weigh on a practitioner; 4) factors that contribute to managing work; 5) relationships with different stakeholders that shape daily work; and 6) perceptions of the profession. Meaningfulness was tied to participants' sense that their values were reflected in their work. Factors outside work shaped participants' work experiences. Recurrent negative experiences led some to leave their profession.

CONCLUSION

Findings underscore a critical need to address contributing factors to attrition and retention which are essential to ensuring the availability of OTs, PTs and SLPs for present and future rehabilitation needs.

Transition of care from post-acute services for the older adults in Quebec: a pilot impact evaluation

BACKGROUND

Early discharge of frail older adults from post-acute care service may result in individuals' reduced functional ability to carry out activities of daily living, and social, emotional, and psychological distress. To address these shortcomings, the Montreal West Island Integrated University Health and Social Services Centre in Quebec, Canada piloted a post-acute home physiotherapy program (PAHP) to facilitate the transition of older adults from the hospital to their home. This study aimed to evaluate: (1) the implementation fidelity of the PAHP program; (2) its impact on the functional independence, physical and mental health outcomes and quality of life of older adults who underwent this program (3) its potential adverse events, and (4) to identify the physical, psychological, and mental health care needs of older adults following their discharge at home.

METHODS

A quasi-experimental uncontrolled design with repeated measures was conducted between April 1st, 2021 and December 31st, 2021. Implementation fidelity was assessed using three process indicators: delay between referral to and receipt of the PAHP program, frequency of PAHP interventions per week and program duration in weeks. A battery of functional outcome measures, including the Functional Independence Measure (FIM) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 scale, as well as fall incidence, emergency visits, and hospitalizations were used to assess program impact and adverse events. The Patient's Global Impression of Change (PGICS) was used to determine changes in participants' perceptions of their level of improvement/deterioration. In addition, the Camberwell Assessment of Need for the Elderly (CANE) questionnaire was administered to determine the met and unmet needs of older adults.

RESULTS

Twenty-four individuals (aged 60.8 to 94 years) participated in the PAHP program. Implementation fidelity was low in regards with delay between referral and receipt of the program, intensity of interventions, and total program duration. Repeated measures ANOVA revealed significant improvement in FIM scores between admission and discharge from the PAHP program and between admission and the 3-month follow-up. Participants also reported meaningful improvements in PGICS scores. However, no significant differences were observed on the physical or mental health T-scores of the PROMIS Global-10 scale, in adverse events related to the PAHP program, or in the overall unmet needs.

CONCLUSION

Findings from an initial sample undergoing a PAHP program suggest that despite a low implementation fidelity of the program, functional independence outcomes and patients' global impression of change have improved. Results will help develop a stakeholder-driven action plan to improve this program. A future study with a larger sample size is currently being planned to evaluate the overall impact of this program.

CLINICAL TRIAL REGISTRATION

Retrospectively registered NCT05915156 (22/06/2023).

Clinician approaches to new spine pain cases in primary care: Balance of opioid prescribing and early linkage to exercise therapy and spinal manipulation

RATIONALE, AIMS AND OBJECTIVES

Spine pain (SP) is common and often disabling. Clinical practice guidelines discourage opioid treatment and outline the value of varied nonpharmacologic therapies (NPTs). This study elucidates the amount of variability in primary-care clinicians' (PCPs') prescribing of opioids and in their cases' receipt of the two most common NPTs (exercise therapy and spinal manipulation).

METHOD

The design was a retrospective cohort study examining variation in the treatment of PCPs' new SP cases, classified by receipt of (a) prescription of an opioid at the initial visit; (b) exercise therapy and/or spinal manipulation within 30 days of initial visit. The study was set in the primary care clinics at military treatment facilities of the US Military Health System in the period between October 2011 and September 2016.

RESULTS

The majority of cases did not receive a study treatment (66.3%); 19.6% of cases received only NPT within 30 days of initial visit; 11.5% were prescribed only an opioid at the initial visit with receipt of both NPT and opioid during early treatment rare (2.6%). Exercise therapy within 30 days exhibited more than a twofold difference in interquartile percentile rates (IQR) (median provision 15.8%, IQR 9.8%-22.1%). The other treatments exhibited even greater variation; specifically, spinal manipulation (median 8.5%, IQR 3.3%-15.8%), and opioid at initial visit (median 10.3%, IQR 4.4%-18.2%). The availability of physical therapists and doctors of chiropractic had significant association with several clinical provision rates.

CONCLUSION

Among providers of spine care for a sample of Army soldiers, there was substantial variation in the early provision of exercise therapy, spinal manipulation, and opioid prescriptions. The magnitude of the case-mix adjusted variation and its association with facility availability of providers suggests that quality of care initiatives may help reduce this variation.

Attrition and Retention of Rehabilitation Professionals: A Scoping Review

INTRODUCTION

Attrition is defined as a permanent departure from one's profession or the workforce. Existing literature on retention strategies, contributing factors to the attrition of rehabilitation professionals and how different environments influence professionals' decision-making to stay in/leave their profession, is limited in scope and specificity. The objective of our review was to map the depth and breadth of the literature on attrition and retention of rehabilitation professionals.

METHODS

We used Arksey and O'Malley's methodological framework. A search was conducted on MEDLINE (Ovid), Embase (Ovid), AMED, CINAHL, Scopus, and ProQuest Dissertations and Theses from 2010 to April 2021 for concepts of attrition and retention in occupational therapy, physical therapy, and speech-language pathology.

RESULTS

Of the 6031 retrieved records, 59 papers were selected for data extraction. Data were organized into three themes: (1) descriptions of attrition and retention, (2) experiences of being a professional, and (3) experiences in institutions where rehabilitation professionals work. Seven factors across three levels (individual, work, and environment) were found to influence attrition.

DISCUSSION

Our review showcases a vast, yet superficial array of literature on attrition and retention of rehabilitation professionals. Differences exist between occupational therapy, physical therapy, and speech-language pathology with respect to the focus of the literature. Push , pull , and stay factors would benefit from further empirical investigation to develop targeted retention strategies. These findings may help to inform health care institutions, professional regulatory bodies, and associations, as well as professional education programs, to develop resources to support retention of rehabilitation professionals.

What are the perceived needs of people living with chronic pain regarding physiotherapy services? A scoping review protocol

INTRODUCTION

Chronic pain represents a major health issue, affecting the physical and mental health of approximately one in five people worldwide. It is now widely recognized that health professionals should use interventions that meet the needs of people living with chronic pain. Therefore, physiotherapists should attend to patients' perceived needs regarding physiotherapy services, i.e. the needs that are perceived by patients themselves based on their beliefs, values, preferences and expectations. However, previous reviews have mainly focused on health professionals' and experts' evaluations of patients' needs, which may result in inadequate answers to these needs. Therefore, a better understanding of patients' perceived needs could lead to more ethical and higher quality physiotherapy services.

OBJECTIVE

The aim of this scoping review is thus to explore what is known from the existing literature about the perceived needs of people living with chronic pain regarding physiotherapy services.

METHODS

This scoping review will follow Arksey and O'Malley's six-step framework. Medline, Embase, CINHAL, and APA PsycINFO will be used to search the scientific literature. The grey literature will also be searched using Google Scholar, OpenGrey and ProQuest Dissertation & Theses Global (PQDTGlobal). Studies published in English and French will only be considered. Two independent reviewers will perform the selection and extraction processes. Descriptive statistics will be performed to characterize the included studies. Quantitative, qualitative and mixed methods studies will be analyzed and synthetized using convergent qualitative meta-integration. Thereby, we will use the seven steps for convergent qualitative meta-integration proposed by Frantzen and Fetters to transform, analyze and integrate the quantitative and qualitative data.

INCLUSION CRITERIA

Included studies will describe the perceived needs of adults living with chronic pain regarding physiotherapy services. Studies focusing on the perspectives of health professionals and rehabilitation services other than physiotherapy will be excluded.

Signs of Inequitable Access: Users of Private Physiotherapy Services Do Not Reflect the Urban Population in Winnipeg, Manitoba

Purpose: Both private and public funding cover outpatient physiotherapy (PT) in Canada. Knowledge is lacking in who does and does not access PT services, which limits the ability to identify health/access inequities created by current financing structures. This study characterizes the individuals accessing private PT in Winnipeg to better understand whether inequities exist, given the very limited publicly financed PT. Methods: Patients attending PT in 32 private businesses, sampled for geographic variation, completed a survey online or on paper. We compared the sample's demographic characteristics with Winnipeg population data using chi-square goodness-of-fit tests. Results: In total, 665 adults accessing PT participated. Respondents were older and had higher levels of income and education compared to Winnipeg census data (p < 0.001). Our sample included higher proportions of female and White individuals, and lower proportions of Indigenous persons, newcomers, and people from visible minorities (p < 0.001). Conclusions: There are signs that inequities exist in access to PT in Winnipeg; the cohort who access private PT services does not reflect the wider population, which suggests that some segments of the population are not receiving care.

Strategies to Increase Access to Outpatient Physiotherapy Services: A Scoping Review

Purpose: Multiple Canadian jurisdictions have curtailed public funding for outpatient physiotherapy services, impacting access and potentially creating or worsening inequities in access. We sought to identify evaluated organizational strategies that aimed to improve access to physiotherapy services for community-dwelling persons. Method: We used Arksey and O'Malley's scoping review methods, including a systematic search of CINAHL, MEDLINE, and Embase for relevant peer-reviewed texts published in English, French, or German, and we performed a qualitative content analysis of included articles. Results: Fifty-one peer-reviewed articles met inclusion criteria. Most studies of interventions or system changes to improve access took place in the United Kingdom (17), the United States (12), Australia (9), and Canada (8). Twenty-nine studies aimed to improve access for patients with musculoskeletal conditions; only five studies examined interventions to improve equitable access for underserved populations. The most common interventions and system changes studied were expanded physiotherapy roles, direct access, rapid access systems, telerehabilitation, and new community settings. Conclusions: Studies evaluating interventions and health system changes to improve access to physiotherapy services have been limited in focus, and most have neglected to address inequities in access. To improve equitable access to physiotherapy services in Canada, physiotherapy providers in local settings can implement and evaluate transferable patient-centred access strategies, particularly telerehabilitation and primary care integration.

Group-based exercice training programs for military members presenting musculoskeletal disorders - protocol for a pragmatic randomized controlled trial

BACKGROUND

Musculoskeletal disorders are a leading cause of morbidity and the most prevalent source of disability among soldiers. Their high prevalence in armed forces and limited ressources have led to problems related to access to physical rehabilitation care. To increase access, supervised group-based exercise programs for the most prevalent musculoskeletal disorders (low back pain, patellofemoral pain, rotator cuff-related shoulder pain or lateral ankle sprain) have been developed at a Canadian Armed forces (CAF) base, but their effectiveness has not been evaluated. The primary objective of this randomized controlled trial is to evaluate the mid- and long-term effects of these group-based training programs on pain severity and functional limitations, in comparison with usual individual physiotherapy care. Secondary objectives include comparing both interventions in terms of health-related quality of life, pain-related fear, and patients' satisfaction.

METHODS

One hundred and twenty soldiers with a new medical referral for physiotherapy services for one of the four targeted musculoskeletal disorders will be consecutively recruited. They will be randomly assigned to either group-based training program or usual individual physiotherapy care, and will take part in the assigned 12-week intervention. There will be four evaluation sessions over 26 weeks (baseline, week 6, 12 and 26). At each follow-up, functional limitations, pain severity, health-related quality of life and pain-related fears will be assessed. Patients satisfaction with treatment will also be evaluated at the end of the intervention period. Either two-way repeated measures ANOVA will be used to analyse and compare the effects of the interventions.

DISCUSSION

This RCT will determine the effectiveness of group-based training programs compared to usual individual physiotherapy care. This new intervention model could represent an efficient, and more pro-active approach to manage a higher number of soldiers with musculoskeletal disorders. It could improve access to physical rehabilitation care and improve the health of soldiers.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT05235152 ), February 11th 2022.

Nationwide Environmental Scan of Knowledge Brokers Training

INTRODUCTION

Knowledge brokers (KBs) can promote the uptake of best practice guidelines in rehabilitation. Although many institutions offer training opportunities to health care professionals who wish to undertake KBs roles, the characteristics and content of those educational training opportunities (ETOs) are currently unknown. This study aimed to describe the ETOs available to rehabilitation professionals in Canada and determine whether the ETOs meet the competencies expected of the KBs roles.

METHODS

We conducted a Canada-wide environmental scan to identify ETOs using three strategies: online search, phone calls, and snowball. To be included in the study, ETOs had to be offered to rehabilitation professionals in Canada and be targeting KBs competencies and/or roles. We mapped each of the content to the KBs competencies (knowledge and skills) within the five roles of KBs: information manager, linking agent, capacity builder, facilitator, and evaluator.

RESULTS

A total of 51 ETOs offered in three Canadian provinces, British Columbia, Ontario, and Quebec, were included in the analysis. For KBs competencies, 76% of ETOs equipped attendees with research skills, 55% with knowledge brokering skills, and 53% with knowledge on implementation science. For KBs roles, over 60% of ETOs supported attendees to in performing the capacity builder role and 39% the evaluator role.

DISCUSSION

Findings suggest that ETOs focused primarily on preparing participants with the research and knowledge brokering skills required to perform the capacity builder and evaluator roles. Comprehensive educational training covering all KBs roles and competencies are needed.

Mapping Physiotherapy Use in Canada in Relation to Physiotherapist Distribution

Purpose: In this cross-sectional study, we examined the distribution of physiotherapists at the health region level across Canada in relation to self-reported physiotherapy use across the provinces and territories. Method: We drew on two data sources: the physiotherapy use question from the 2014 Canadian Community Health Survey and physiotherapists' primary employment information, obtained from the Canadian Institute of Health Information's 2015 Physiotherapist Database. We then applied geospatial mapping and Pearson's correlation analysis to the resulting variables. Results: Physiotherapy use is moderately associated with the distribution of physiotherapists (Pearson's r 92 = 0.581, p < 0.001). The use and distribution variables were converted into three categories using SDs of 0.5 from national means as cut-off values. Cross-classification between the variables revealed that 15.2% of health regions have a high use-high distribution ratio; 18.5% have a low use-low distribution ratio; 4.3% have a high use-low distribution ratio; 2.2% have a low use-high distribution ratio; and 60.0% have medium use-medium distribution ratio. Conclusions: The distribution of physiotherapists and self-reported physiotherapy use varies across health regions, indicating a potential inequality in geographical access. Given that most provinces have a regionalized approach to health human resources and health service delivery, these findings may be helpful to managers and policy-makers and may allow them to make a more granular comparison of intra- and inter-provincial differences and potential gaps.