Physiotherapy Service Provision Research Articles

Wearable sensor and smartphone assisted vestibular physical therapy for multiple sclerosis: usability and outcomes.

Vertigo, dizziness, gaze instability and disequilibrium are highly prevalent in people with MS (PwMS) and head movement induced dizziness is commonly reported. Vestibular physical therapy (VPT) is a specialised, non-invasive and effective therapy for these problems but usually involves travel for the person to a specialist center with both personal and carbon costs. The use of wearable sensors to track head movement and smartphone applications to deliver and track programs has potential to improve VPT in MS. This study investigated the usability and effects of a commercially available digital VPT system (wearable head sensor, smartphone app and clinician software) to deliver VPT to PwMS. A pre/post treatment design was employed and the primary outcome was the System Usability Scale (SUS). Other patient reported outcomes were the Service User Acceptability Questionnaire (SUTAQ), the Patient Enablement Instrument (PEI) and the Dizziness Handicap Inventory (DHI). Physical outcomes measurements included Mini-BESTest (MB), Modified Dynamic Gait Index (mDGI), Gait Speed (GS), Dynamic Visual Acuity (DVA) and head kinematics and symptoms during exercise. Sixteen PwMS (14 female), mean age 44(±14) years were recruited to the study and twelve completed VPT. Mean adherence to exercise, measured digitally was 60% (±18.4). SUS scores were high at 81 (±14) and SUTAQ scores also demonstrated high levels of satisfaction and acceptability of the system. Statistically significant improvements in MB (mean change 2.25; p = 0.004), mDGI (median change 1.00; p = 0.008), DVA (median change -1.00; p = 0.004) were found. Head frequencies significantly improved with concurrent decreased intensity of dizziness during head movements (mean change across 4 gaze stabilization exercises was 23 beats per minute; p < 0.05). Non-significant improvements were seen in DHI (p = 0.07) and GS (p = 0.15). 64.5% of follow up visits were conducted remotely (video or phone), facilitated by the system. This study had two main outcomes and benefits for PwMS. Firstly, we showed that the system used was both acceptable and could be used by PwMS. Secondly, we demonstrated an improvement in a range of dizziness, balance and gait metrics with remotely delivered care. This system has the potential to positively impact on MS physiotherapy service provision with the potential to deliver effective remote care.

The Perceptions of Telehealth Physiotherapy for People with Bronchiectasis during a Global Pandemic-A Qualitative Study.

Physiotherapy is a core component of management for people with bronchiectasis and has predominantly been delivered in an in-person consultative format. With the global pandemic, a telehealth physiotherapy model of service evolved, but the perceptions and experiences from the consumer perspective of this service have not been evaluated. Participants who had a diagnosis of bronchiectasis and received a minimum of two telehealth physiotherapy sessions during the months of March 2020 to December 2020 at a private hospital were invited to take part in a semistructured interview. Interview transcripts were coded independently, with themes established by consensus from two researchers. In total, nine participants completed interviews (age range 44 to 83 years, 67% male), with four themes identified. Themes were initial mixed opinions and acceptance of telehealth physiotherapy as an alternate model, ease of use and limitations to the telehealth platform, enablers and barriers to physiotherapy service provision, and preferences for future models of telehealth physiotherapy beyond a pandemic. In the event of the continuation of telehealth physiotherapy services for people with bronchiectasis, the perceptions and experiences outlined by consumers could be applied to inform future modification of this model of service.

Integrating a request for assistance model within the East Lothian MSK physiotherapy service

Keywords: eHealth; Musculoskeletal; Service development Purpose: East Lothian Health and Social Care Partnership (ELHSCP) aimed to transform physiotherapy service provision by utilising a Request for Assistance (RFA) model in accordance with the Scottish Government's Active and Independent Living Programme. Technological options including telephone triage were explored to provide this. Development of this service was accelerated due to Covid-19. Aims:1.Create a single point of access to physiotherapy, with referral to onward services across East Lothian as appropriate.2.Successfully address people's needs through early intervention and promote self-management.3.Entrench a patient-focused approach with streamlined processes and pathways.4.Reduce waiting times for MSK Physiotherapy and GP Practices, saving cost and improving patient experience. Methods:•The MSK Advice Line opened in June 2020 and was based on a RFA service model.•The service was provided by Advanced Physiotherapy Practitioners (APPs) who used advanced critical thinking and expert clinical and diagnostic reasoning skills to facilitate a patient-centred management plan.•Access to the service was made by self-referral. Patients contacted a central number and were offered a telephone assessment.•Following assessment and diagnosis, management options were discussed and decided upon in partnership with the patient.•Due to Covid-19 remote platforms were utilised, with the option of escalation for face to face assessment or onward referral, in line with Government guidelines, as appropriate.•Regular service development huddles were established to ensure consistent service provision across the team and create learning opportunities.•Meetings were arranged with GP Practices in East Lothian to improve communication and build effective working relationships. Results: Over 6000 patients contacted the RFA phoneline•Patient Outcomes:1.58% of patients were converted to ongoing physiotherapy treatment, either remotely or face to face.2.40% of patient were happy to self-manage and required no further input.3.2% of patients were referred onward to other services or did not answer their phone.•A Patient Satisfaction Questionnaire was undertaken:1.58% reported the service as excellent.2.13% rated it as great.3.29% rated it as good.4.77% of respondents were happy with remote service.•GP Outcomes1.High levels of satisfaction among GP Practices was noted.2.31% reduction in requests for MRIs from GP Practices in East Lothian since launch. Conclusion(s): Implementation of the MSK Advice Line has demonstrated that the RFA model can be successful in creating a single point of access to physiotherapy services, ensuring patients are successfully directed to the most appropriate service to suit their needs. Evidence shows high levels of patient and GP satisfaction. Suggestions for future work include an ‘online chat’ function to support access routes for the younger population and the ability for APP's to request imaging and onward referral to secondary care. Impact:1.Reduce physiotherapy waiting time.2.Improve patient journey.3.Decrease prescribing and imaging requests, in line with new guidelines. Due to the success of the MSK Advice Line, the RFA model will continue to be a core component of the MSK physiotherapy service and will be rolled out across other services within the ELHSCP. Funding acknowledgements: Not funded.

A national survey of oncology physiotherapy services for cancer survivors in Australia.

Cancer is a leading cause of illness globally. Advancements in screening and treatment have led to improved survivorship. Physiotherapy is integral in improving survivorship for people with cancer, with strong evidence supporting the use of various physiotherapy services. However, the scope and extent of these services within clinical practice in Australia is unknown. Identify and describe physiotherapy service provision for cancer survivors in Australia and describe the scope of physiotherapy services provided to cancer survivors. This cross-sectional study recruited physiotherapists and their respective managers involved in cancer service/s provision across Australia. Physiotherapy departments of tertiary hospitals and known oncology rehabilitation programs were contacted through a government directory and snowball sampling. The online survey included questions related to the extent and scope of service provision of physiotherapy for cancer survivors. Quantitative data were descriptively analyzed whereas open-ended responses were analyzed and presented narratively. Seventy-nine physiotherapy services were identified from 159 hospitals and/or health networks. Of the 55 (70%) responses received, 87% were from metropolitan areas, whereas 13% were regionally/rurally based services. Prehabilitation services mostly offered individual programs whereas rehabilitation programs had a mix of individual and group-based programs. The service content between prehabilitation and rehabilitation were similar, comprising primarily exercise-based interventions, followed by education and impairment-based therapies. Few designated physiotherapy services for cancer survivors exist in Australia. There is also disparity between service provision between metropolitan and regional/rural areas highlighting a need for clinicians, managers, and policy makers to invest more resources in establishing oncology physiotherapy services.

A national survey in United Arab Emirates on practice of passive range of motion by physiotherapists in intensive care unit.

Patients admitted to intensive care units (ICU) are at an increased risk of developing immobility related complications. Physiotherapists are challenged to employ preventive and rehabilitative strategies to combat these effects. Passive limb range of motion (PROM) exercises- a part of early mobilization-aid in maintaining joint range of motion and functional muscle strength and forms a part of treatment for patients in ICU. However, there is a lack of evidence on practice of PROM exercises on patients admitted to ICU in the United Arab Emirates (UAE). This study aimed at exploring practices regarding the same in UAE. This survey, conducted from January 2021 to February 2021 in College of Physiotherapy, Sharjah University studied practice of physiotherapists in the intensive care units. Physiotherapists currently working in ICU completed an online questionnaire composed of forty-two questions about physiotherapy service provision, assessment and intervention in the intensive care units. 33 physiotherapists completed the survey. 66.6% of respondents routinely assessed PROM for all the patients in ICU referred for physiotherapy. 84.8% of them assessed all the joints. More than half of the respondents (57.8%) reported that they administered PROM regularly to all the patients. According to 63.6% respondents, maintaining joint range of motion was the main reason for performing PROM. Responses pertaining to sets and repetitions of PROM were variable ranging from 1-6 sets and from 3 to 30 repetitions. Personal experience, resources/financial consideration and research findings were found to have influence on the practice. PROM was found to be one of the frequently used mobilization techniques administered by physiotherapists in the intensive care units and was mostly performed after assessment. Maintaining joint range of motion was the main aim for performing PROM. Variability was found in the sets and repetitions of PROM administered. Various factors influenced the practice of PROM.

Physiotherapy service provision in a specialist adult cystic fibrosis service: A pre-post design study with the inclusion of an allied health assistant.

What is the impact of including an allied health assistant (AHA) role on physiotherapy service delivery in an acute respiratory service? A pragmatic pre-post design study examined physiotherapy services across two 3-month periods: current service delivery [P1] and current service delivery plus AHA [P2]. Clinical and non-clinical activity quantified as number, type and duration (per day) of all staff activity categorised for skill level (AHA, junior, senior). Physiotherapy service delivery increased in P2 compared to P1 (n = 4730 vs n = 3048). Physiotherapists undertook fewer respiratory (p < 0.001) and exercise treatments (p < 0.001) but increased reviews for inpatients (p < 0.001) and at multidisciplinary clinics in P2 (56% vs 76%, p < 0.01). The AHA accounted for 20% of all service provision. AHA activity comprised mainly non-direct clinical care including oversight of respiratory equipment use (e.g. supply, set-up, cleaning, loan audits) and other patient-related administrative tasks associated with delegation handovers, supervision and clinical documentation (72%), delegated supervision of established respiratory (5%) and exercise treatments (10%) and delegated exercise tests (3%). The AHA completed most of the exercise tests (n = 25). AHA non-direct clinical tasks included departmental management activities (11%). No adverse events were reported. AHA inclusion in an acute respiratory care service changed physiotherapy service provision. The AHA completed delegated routine clinical and non-clinical tasks. Physiotherapists increased clinic activity and annual reviews. Including an AHA role offers sustainable options for enhancing physiotherapy service provision in acute respiratory care.

Identifying the physiotherapy and occupational therapy service provision for patients admitted with neurological conditions- are we coordinating care?

Keywords: Multi-disciplinary team, Managing complexity

Identifying Priorities for Physiotherapy Research in the UK: the James Lind Alliance Physiotherapy Priority Setting Partnership

To identify unanswered questions for physiotherapy research and help set and prioritise the top 10 generic research priorities for the UK physiotherapy profession; updating previous clinical condition- specific priorities to include patient and carer perspectives, and reflect changes in physiotherapy practice, service provision and new technologies. The James Lind Alliance (JLA) Priority Setting Partnership (PSP) methodology was adopted, utilising evidence review, survey and consensus methods. Anyone with experience and/or an interest in UK physiotherapy: patients, carers, members of the public, physiotherapists, student physiotherapists, other healthcare professionals, researchers, educators, service providers, commissioners and policy makers. Five hundred and ten respondents (50% patients, carers or members of the public) identified 2152 questions (termed "uncertainties"). Sixty-five indicative questions were developed from the uncertainties using peer reviewed thematic analysis. These were ranked in a second national survey (1,020 responses (62% were complete)). The top 25 questions were reviewed in a final prioritisation workshop using an adapted nominal group technique. The top 10 research priorities focused on optimisation (top priority); access; effectiveness; patient and carer knowledge, experiences, needs and expectations; supporting patient engagement and self-management; diagnosis and prediction. This study is currently the UK's most inclusive consultation exercise to identify patients'and healthcare professionals'priorities for physiotherapy research. The exercise deliberately sought to capture generic issues relevant to all specialisms within physiotherapy. The research priorities identified a range of gaps in existing evidence to inform physiotherapy policy and practice. The results will assist research commissioning bodies and inform funding decisions and strategy.

An Exploration of Physiotherapy Service Provision to Patients' with Intensive Care Unit (ICU) Acquired Weakness: An Observational Study

An Exploration of Physiotherapy Service Provision to Patients' with Intensive Care Unit (ICU) Acquired Weakness: An Observational Study

An early warning system for safe and effective physiotherapy service provision in an acute hospital setting

Purpose: Much has been discussed since the Francis reports regarding safe staffing levels in the National Health Service. In 2014 The National Institute for Clinical Excellence produced guidance for nursing levels in acute hospitals; while Jones and Jenkins (2014) produced guidance aimed at Allied Health Professionals. Consequently the importance of ‘safe and effective’ levels of staffing within physiotherapy has been a common theme in the Chartered Society of Physiotherapy's publications over recent years.

The views and experiences of physiotherapists on physiotherapy service provision for people with neurological conditions in primary care in Ireland: A qualitative study

The views and experiences of physiotherapists on physiotherapy service provision for people with neurological conditions in primary care in Ireland: A qualitative study

Towards understanding the availability of physiotherapy services in rural Australia

A recent exploration of factors affecting rural physiotherapy service provision revealed considerable variation in services available between communities of the study. Multiple factors combined to influence local service provision, including macro level policy and funding decisions, service priorities and fiscal constraints of regional health services and capacity and capabilities at the physiotherapy service level. The aim of this article is to describe the variation in local service provision, the factors influencing service provision and the impact on availability of physiotherapy services. A priority-sequence mixed methods design structured the collection and integration of qualitative and quantitative data. The investigation area, a large part of one Australian state, was selected for the number of physiotherapy services and feasibility of conducting site visits. Stratified purposive sampling permitted exploration of rural physiotherapy with subgroups of interest, including physiotherapists, their colleagues, managers, and other key decision makers. Participant recruitment commenced with public sector physiotherapists and progressed to include private practitioners, team colleagues and managers. Surveys were mailed to key physiotherapy contacts in each public sector service in the area for distribution to physiotherapists, their colleagues and managers within their facility. Private physiotherapist principals working in the same communities were invited by the researcher to complete the physiotherapy survey. The survey collected demographic data, rural experience, work setting and number of colleagues, services provided, perspectives on factors influencing service provision and decisions about service provision. Semi-structured interviews were conducted with consenting physiotherapists and other key decision makers identified by local physiotherapists. Quantitative survey data were recorded in spreadsheets and analysed using descriptive statistics. Interviews were recorded and transcribed verbatim, with transcripts provided to participants for review. Open-ended survey questions and interview transcripts were analysed thematically. Surveys were received from 11/25 (44%) of facilities in the investigation area, with a response rate of 29.4% (16/54) from public sector physiotherapists. A further 18 surveys were received: five from principals of private physiotherapy practices and 13 from colleagues and managers. Nineteen interviews were conducted: with 14 physiotherapists (nine public, five private), four other decision makers and one colleague. Three decision makers declined an interview. The variation in physiotherapy service availability between the 11 communities of this study prompted the researchers to consider how such variation could be reflected. The influential factors that emerged from participant comments included rurality and population, size and funding model of public hospitals, the number of public sector physiotherapists and private practices, and the availability of specialised paediatric and rehabilitation services. The factors described by participants were used to develop a conceptual framework or index of rural physiotherapy availability. It is important to make explicit the link between workforce maldistribution, the resultant rural workforce shortages and the implications for local service availability. This study sought to do so by investigating physiotherapy service provision within the rural communities of the investigation area. In doing so, varying levels of availability emerged within local communities. A conceptual framework combining key influencing factors is offered as a way to reflect the availability of physiotherapy services.

Physiotherapy management of joint hypermobility syndrome—patient and therapist perspectives

Background: Joint hypermobility syndrome (JHS) is a complex multi systemic condition characterised by joint laxity in the presence of pain. It is increasingly being recognised as a cause of otherwise unexplained musculoskeletal problems. Physiotherapy is usually the preferred treatment option but there is little evidence for its effectiveness. Exploring patients’ and therapists’ experiences of physiotherapy for JHS may give important insights into ways of more effectively managing the condition. Purpose:Toqualitatively explore patients’ and therapists’ views on the physiotherapy management of JHS in order to more fully understand its potential benefits, disadvantages and challenges. Methods: Seven focus groups in four locations in the United Kingdom were convened, involving people with a prior diagnosis of JHS and therapists with experience of managing people with JHS. The focus groups were audio recorded, fully transcribed and analysed using the constant comparative method to inductively derive a thematic account of the data. Results: In total four focus groupswere conductedwith 25 patients (3 men, 22 women; aged 19-60 years) and a further three focus groups with 16 health professionals (3 men, 13 women; 14 physiotherapists, 2 podiatrists; 0-30 years post qualification). Three themes, developed from the analysis, related to: ‘JHS as a difficult to diagnose, chronic condition’, ‘Physiotherapy to treat JHS’, and ‘Optimising physiotherapy as an intervention for JHS’. Conclusion(s): Patients and therapists both recognised the chronic heterogeneous nature of JHS and noted a lack of awareness of the condition amongst health professionals, patients and more widely in society. Diagnosis and subsequent referral to physiotherapy services for JHS (rather than for acute injury)was often perceived to be difficult and convoluted.Both therapists and patients felt that if left undiagnosed, JHS can become very difficult to treat. On the other hand, if JHS was recognised and treated, many patients were then satisfied with the physiotherapy received. There was considerable agreement between the views of therapists and patients regarding an ‘ideal’ physiotherapy service as one which recognised the chronic nature of JHS and concentrated on injury prevention and symptom amelioration rather than cure. An overarching requirement for education for patients and health care professionals was emphasised in order to optimise physiotherapy provision for JHS. Implications: Education and training is required for health professionals to better recognise, diagnose andmanage JHS. Physiotherapy service provision for JHS needs to follow a long-term condition, rather than acute condition model. A ‘whole-body’ approach needs to be taken, rather than treating individual painful joints in isolation. More research is required to understand the specific therapeutic action of physiotherapy as an intervention to manage JHS.

Service Level Decision-making in Rural Physiotherapy: Development of Conceptual Models.

Understanding decision-making about health service provision is increasingly important in an environment of increasing demand and constrained resources. Multiple factors are likely to influence decisions about which services will be provided, yet workforce is the most noted factor in the rural physiotherapy literature. This paper draws together results obtained from exploration of service level decision-making (SLDM) to propose 'conceptual' models of rural physiotherapy SLDM. A prioritized qualitative approach enabled exploration of participant perspectives about rural physiotherapy decision-making. Stakeholder perspectives were obtained through surveys and in-depth interviews. Interviews were transcribed verbatim and reviewed by participants. Participant confidentiality was maintained by coding both participants and sites. A system theory-case study heuristic provided a framework for exploration across sites within the investigation area: a large area of one Australian state with a mix of regional, rural and remote communities. Thirty-nine surveys were received from participants in 11 communities. Nineteen in-depth interviews were conducted with physiotherapists and key decision-makers. Results reveal the complexity of factors influencing rural physiotherapy service provision and the value of a systems approach when exploring decision-making about rural physiotherapy service provision. Six key features were identified that formed the rural physiotherapy SLDM system: capacity and capability; contextual influences; layered decision-making; access issues; value and beliefs; and tensions and conflict. Rural physiotherapy SLDM is not a one-dimensional process but results from the complex interaction of clusters of systems issues. Decision-making about physiotherapy service provision is influenced by both internal and external factors. Similarities in influencing factors and the iterative nature of decision-making emerged, which enabled linking physiotherapy SLDM with clinical decision-making and placing both within the broader healthcare context. The conceptual models provide a way of thinking about decisions informing rural physiotherapy service provision. Copyright © 2015 John Wiley & Sons, Ltd.

Rationing is a reality in rural physiotherapy: a qualitative exploration of service level decision-making

BackgroundDeciding what health services are provided is a key consideration in delivering appropriate and accessible health care for rural and remote populations. Despite residents of rural communities experiencing poorer health outcomes and exhibiting higher health need, workforce shortages and maldistribution mean that rural communities do not have access to the range of services available in metropolitan centres. Where demand exceeds available resources, decisions about resource allocation are required.MethodsA qualitative approach enabled the researchers to explore participant perspectives about decisions informing rural physiotherapy service provision. Stakeholder perspectives were obtained through surveys and in-depth interviews. A system theory-case study heuristic provided a framework for exploration across sites within the investigation area: a large area of one Australian state with a mix of rural, regional and remote communities.ResultsThirty-nine surveys were received from participants in eleven communities. Nineteen in-depth interviews were conducted with physiotherapist and key decision-makers. Increasing demand, organisational priorities, fiscal austerity measures and workforce challenges were identified as factors influencing both decision-making and service provision. Rationing of physiotherapy services was common to all sites of this study. Rationing of services, more commonly expressed as service prioritisation, was more evident in responses of public sector physiotherapy participants compared to private physiotherapists. However, private physiotherapists in rural areas reported capacity limits, including expertise, space and affordability that constrained service provision.ConclusionsThe imbalance between increasing service demands and limited physiotherapy capacity meant making choices was inevitable. Decreased community access to local physiotherapy services and increased workforce stress, a key determinant of retention, are two results of such choices or decisions. Decreased access was particularly evident for adults and children requiring neurological rehabilitation and for people requiring post-acute physiotherapy. It should not be presumed that rural private physiotherapy providers will cover service gaps that may emerge from changes to public sector service provision. Clinician preference combines with capacity limits and the imperative of financial viability to negate such assumptions. This study provides insight into rural physiotherapy service provision not usually evident and can be used to inform health service planning and decision-making and education of current and future rural physiotherapists.

Decision Making About Rural Physiotherapy Service Provision Varies With Sector, Size and Rurality

Introduction: Decisions about physiotherapy service provision occur within the context of organisations, locations, and settings. The uniqueness of rural communities means it is important to consider contextual factors when making decisions about rural health services. As literature describing decision making about rural physiotherapy services is limited, this study sought perspectives on service level decision making (SLDM) from a range of stakeholders. The research approach needed to support consideration of both location and the broader health system. Method: A sequential mixed methods approach within a systems theory-case study heuristic provided the framework to explore rural physiotherapy SLDM. The investigation site, a large area of one Australian state, contained a mix of regional, rural, and remote communities. Perspectives on SLDM were obtained through surveys of physiotherapists, colleagues, and managers, with follow up interviews of a purposeful sample of participants. Results: Responses from physiotherapists, colleagues, manager surveys (n=34), and in-depth interviews (n=19) revealed commonalities and differences between sites and sectors. Available skill and expertise were common considerations across sites. Decisions about prioritisation of services occurred in both public and private settings; however, organisational priorities were a greater influence in the public sector and financial viability in the private sector. Service size influenced the perceived degree of autonomy of physiotherapists in SLDM, with physiotherapists in smaller sites having more independence. Directions from health facility management and the increasing need to prioritise services were reflected in physiotherapy responses from larger facilities. National health reforms and state level priorities were noted as influencing factors, as were connection to community, rurality, and the distance from decision makers. Conclusion: This study provides insight into decisions informing rural physiotherapy service provision. Understanding context and diversity is important to understanding local health service decisions. System level influences from macro and meso level decision makers provide the framework within which micro level physiotherapy SLDM occurs. Service sector, size and rurality then further qualify local service options and influence SLDM. Decisions about service provision need to take into consideration the current availability of services, the context of each location and skill mix required.

Utilising a collective case study system theory mixed methods approach: a rural health example.

BackgroundInsight into local health service provision in rural communities is limited in the literature. The dominant workforce focus in the rural health literature, while revealing issues of shortage of maldistribution, does not describe service provision in rural towns. Similarly aggregation of data tends to render local health service provision virtually invisible. This paper describes a methodology to explore specific aspects of rural health service provision with an initial focus on understanding rurality as it pertains to rural physiotherapy service provision.MethodA system theory-case study heuristic combined with a sequential mixed methods approach to provide a framework for both quantitative and qualitative exploration across sites. Stakeholder perspectives were obtained through surveys and in depth interviews. The investigation site was a large area of one Australian state with a mix of rural, regional and remote communities.Results39 surveys were received from 11 locations within the investigation site and 19 in depth interviews were conducted. Stakeholder perspectives of rurality and workforce numbers informed the development of six case types relevant to the exploration of rural physiotherapy service provision. Participant perspective of rurality often differed with the geographical classification of their location. The numbers of onsite colleagues and local access to health services contributed to participant perceptions of rurality.ConclusionsThe complexity of understanding the concept of rurality was revealed by interview participants when providing their perspectives about rural physiotherapy service provision. Dual measures, such as rurality and workforce numbers, provide more relevant differentiation of sites to explore specific services, such rural physiotherapy service provision, than single measure of rurality as defined by geographic classification. The system theory-case study heuristic supports both qualitative and quantitative exploration in rural health services research.

Rehabilitation therapies for older clients of the Ontario home care system: regional variation and client-level predictors of service provision

Purpose: To examine regional variation in service provision and identify the client characteristics associated with occupational therapy (OT) and physiotherapy (PT) services for older adults in the Ontario Home Care System. Methods: Secondary analyses of a provincial database containing comprehensive assessments (RAI-HC) linked with service utilization data from every older long-stay home care client in the system between 2005 and 2010 (n = 299 262). Hierarchical logistic regression models were used to model the dependent variables of OT and PT service use within 90 d of the initial assessment. Results: Regional differences accounted for 9% of the variation in PT service provision and 20% of OT service provision. After controlling for the differences across regions, the most powerful predictors of service provision were identified for both OT and PT. The most highly associated client characteristics related to PT service provision were hip fracture, impairments in activities of daily living/instrumental activities of daily living, cerebrovascular accidents, and cognitive impairment. For OT, hazards in the home environment was the most powerful predictor of future service provision. Conclusions: Where a client lived was an important determinant of service provision in Ontario, raising the possibility of inequities in access to rehabilitation services. Health care planners and policy makers should review current practices and make adjustments to meet the increasing and changing needs for rehabilitation therapies of the aging population.Implications for RehabilitationFor older adults in home care, the goal of rehabilitation therapy services is to allow individuals to maintain or improve physical functioning, quality of life and overall independence while living within their community.Previous research has demonstrated that a large proportion of home care clients specifically identified as having rehabilitation potential do not receive it.This article used clinical assessment data to identify the predictors of and barriers to rehabilitation services for older adults in the Ontario Home Care System. Barriers of PT included dementia diagnosis and French as a first language. Barriers to OT included dementia diagnosis.Policies and practices related to service provision for older adults should be reconsidered if we are going to meet the demands of aging populations and increasing rates of functional and cognitive impairments.

Is physiotherapy effective in the management of child and adolescent conversion disorder? A systematic review.

Child and adolescent conversion disorder has the potential to impart significant burden on health-care services and affect quality of life. Clinically, physiotherapists are involved in conversion disorder management; however, no systematic reviews have examined physiotherapy effectiveness in its management. The aim of this review is to identify the efficacy of physiotherapy management of child and adolescent conversion disorder. A search of multiple databases (Medline, CINAHL, Embase, PsychINFO, PEDro and the Cochrane Library) was completed along with manual searching of relevant reference lists to identify articles including children 0-18 years with a diagnosis of conversion disorder who received physical management. Two independent reviewers screened titles and abstracts using criteria. Data were extracted regarding study characteristics, functional outcome measures, length of stay, physiotherapy service duration and resolution of conversion symptoms. Methodological quality was assessed using a tool designed for observational studies. Twelve observational studies were included. No functional outcome measures were used to assess the effectiveness of the treatment protocols in the case studies. Resolution of symptoms occurred in all but two cases, with conversion symptoms still present at 11 months and at 2 years. Length of stay varied from 3 days to 16 weeks, with similar variation evident in length of physiotherapy service provision (2.5 weeks to 16 weeks). There was limited and poor quality evidence to establish the efficacy of physiotherapy management of child and adolescent conversion disorders. More rigorous study designs with consistent use of reliable, valid and sensitive functional outcome measures are needed in this area.

What factors influence physiotherapy service provision in rural communities? A pilot study.

To obtain stakeholder perspectives on factors influencing rural physiotherapy service provision and insights into decision making about service provision. Purposive sampling, open-ended survey questions and semi-structured interviews were used in this exploratory, qualitative study. A rural centre and its regional referral centre formed the pilot sites. Nine participant perspectives were obtained on rural physiotherapy services. Stakeholder perspectives on factors influencing rural physiotherapy service provision and service level decision making. Workforce capacity and capability, decision maker's knowledge of the role and scope of physiotherapy, consideration of physiotherapy within resource allocation decisions and proof of practice emerged as key issues. The latter three were particularly reflected in public sector participant comments. Business models and market size were identified factors in influencing private practice. Influencing factors described by participants both align and extend our understanding of issues described in the rural physiotherapy literature. Participant insights add depth and meaning to quantitative data by revealing impacts on local service provision. Available funding and facility priorities were key determinants of public sector physiotherapy service provision, with market size and business model appearing more influential in private practice. The level of self direction or choice about which services to provide, emerged as a point of difference between public and private providers. Decisions by public sector physiotherapists about service provision appear constrained by existing capacity and workload. Further research into service level decision making might provide valuable insights into rural health service delivery.