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author:("Davis, eileen")
1.  Development and preliminary evaluation of a rehabilitation consult for survivors of head and neck cancer: an intervention mapping protocol 
Evidence suggests that rehabilitation interventions can improve function and quality of life in survivors of head and neck cancer (HNC), but there is a lack of coordinated, integrated services, and those offered are inconsistent. To address these gaps, we will develop and conduct preliminary evaluation of a rehabilitation consult, built on the theoretical foundations of goal setting and self-management, and composed of a brief functional evaluation, a resource compendium, and collaborative goal-setting and action planning processes.
The development of the rehabilitation consult will be guided by intervention mapping, which consists of six steps: 1. Needs assessment; 2. Definition of program objectives; 3. Selection of theory-based intervention methods; 4. Production and pretesting; 5. Adoption, implementation and sustainability planning; 6. Process and effect evaluation. Within the intervention mapping framework, an iterative process of constructing drafts and mini-evaluations with consumers and experts will be used, modifying the rehabilitation consult intervention until a version suitable for formal evaluation is established. The rehabilitation consult will then be evaluated using a prospective, mixed method, single group design with 30 survivors of head and neck cancer. Outcomes will be assessed pre- and post-intervention and at 6-month follow-up.
Survivors of head and neck cancer have among the most complex rehabilitation needs of all cancer patients. The rehabilitation consult is expected to improve knowledge and uptake of rehabilitation resources and strategies in survivors of head and neck cancer and thereby improve long-term function and quality of life. If the rehabilitation consult is effective in cancer patients with such high and diverse needs, this project will produce a toolkit that will be adaptable for other types of cancer in other jurisdictions.
PMCID: PMC4297361  PMID: 25571966
Head and neck cancer; Rehabilitation; Intervention mapping; Protocol; Self-management; Goal setting
2.  A qualitative study of the consequences of knee symptoms: ‘It's like you're an athlete and you go to a couch potato’ 
BMJ Open  2014;4(10):e006006.
To explore the perceived consequences of knee symptoms on the lives of people aged 35–65 years who had diagnosed osteoarthritis (OA) or OA-like symptoms.
A qualitative study with six focus groups and 10 one-on-one interviews. Constructivist grounded theory guided data collection and analysis. Data were analysed using the constant comparative method.
Toronto, Canada.
51 participants (median age 49; 61% female) who self-reported knee OA or reported knee pain, aching or stiffness on most days of the past month participated in the study.
The core finding, disruption and change, illustrates the range of perceived consequences of knee symptoms in peoples’ lives. Participants described the consequences of symptoms on their physical activity (giving up high-level activities or changing how or how much they performed activities), social life (leisure, family and work) and emotional life. Knee symptoms also altered the way participants thought about their bodies and themselves. They reported that they had a new awareness of their knee and that they no longer trusted their knee. They also conveyed that their sense of self was altered.
This study illuminates the significant and varied consequences that mild to moderate knee symptoms have on the lives of adults age 35–65 years. Findings highlight the need for clinicians to tailor advice and support to the individual's needs considering their symptoms, the consequences of symptoms on their lives and their personal context.
PMCID: PMC4202017  PMID: 25324325
3.  The role of pain and functional impairment in the decision to recommend total joint replacement in hip and knee osteoarthritis: an international cross-sectional study of 1909 patients. Report of the OARSI-OMERACT Task Force on total joint replacement 
To assess the pain and functional disability levels corresponding to an indication for total joint replacement (TJR) in hip and knee osteoarthritis (OA).
Design: international cross-sectional study in 10 countries. Patients: consecutive outpatients with definite hip or knee OA attending an orthopaedic outpatient clinic. Gold standard measure for recommendation for TJR: surgeon's decision that TJR is justified. Outcome measures: pain (ICOAP: intermittent and constant osteoarthritis pain, 0-100) and functional impairment (HOOS-PS/KOOS-PS: Hip/Knee injury and Osteoarthritis Outcome Score Physical function Short-form, 0-100). Analyses: Comparison of patients with versus without surgeons' indication for TJR. ROC curve analyses and logistic regression were applied to determine cut-points of pain and disability defining recommendation for TJR.
In all, 1909 patients were included (1130 knee/779 hip OA). Mean age was 66.4 (SD 10.9) years, 58.1% were women; 628/1130 (55.6%) knee OA and 574/779 (73.7%) hip OA patients were recommended for TJR. Although patients recommended for TJR (yes versus no) had worse symptom levels (pain, 55.5 [95% confidence interval 54.2, 56.8] vs. 44.9 [43.2, 46.6], and functional impairment, 59.8 [58.7, 60.9] vs. 50.9 [49.3, 52.4], respectively, both p<0.0001), there was substantial overlap in symptom levels between groups, even when adjusting for radiographic joint status. Thus, it was not possible to determine cut points for pain and function defining ‘requirement for TJR’.
Although symptom levels were higher in patients recommended for TJR, pain and functional disability alone did not discriminate between those who were and were not considered to need TJR by the orthopaedic surgeon.
PMCID: PMC4151518  PMID: 21044689
Knee; hip; osteoarthritis; joint replacement; surgery; symptom
4.  The pathway to orthopaedic surgery: a population study of the role of access to primary care and availability of orthopaedic services in Ontario, Canada 
BMJ Open  2014;4(7):e004472.
To examine the impact of access to primary care physicians (PCPs), geographic availability of orthopaedic surgeons, socioeconomic status (SES), proportion of older population (≥65 years) and proportion of rural population on orthopaedic surgeon office visits and orthopaedic surgery.
Population multilevel study.
Ontario, Canada.
Ontario residents 18 years or older who had visits to orthopaedic surgeons or an orthopaedic surgery for musculoskeletal disorders in 2007/2008.
Primary and secondary outcomes
Office visits to orthopaedic surgeons and orthopaedic surgery.
Access to PCPs and the index of geographic availability of orthopaedic surgeons, but not SES, were significantly associated with orthopaedic surgeon office visits. There was a significant interaction between access to PCPs and orthopaedic surgeon geographic availability for the rate of office visits, with access to PCPs being more important in areas of low geographic availability of orthopaedic surgeons. After controlling for office visits with orthopaedic surgeons, the index of geographic availability of orthopaedic surgeons was no longer significantly associated with orthopaedic surgery.
The findings suggest that, particularly, in areas with low access to PCPs or with fewer available orthopaedic surgeons, residents are less likely to have orthopaedic surgeon office visits and in turn are less likely to receive surgery. Efforts to address adequate access to orthopaedic surgery should also include improving and facilitating access to PCPs for referral, particularly in geographic areas with low orthopaedic surgeon availability.
PMCID: PMC4120425  PMID: 25082417
Primary Care
5.  A Conceptual Framework for Evaluating Impairments in Myasthenia Gravis 
PLoS ONE  2014;9(5):e98089.
Myasthenia gravis is characterized by weakness and fatigability of different muscle groups, including ocular, bulbar and the limbs. Therefore, a measure of disease severity at the impairment level in myasthenia needs to reflect all the relevant impairments, as well as their variations with activity and fatigue. We conducted a qualitative study of patients with myasthenia, to explore their experiences and related impairments, aimed at developing a conceptual framework of disease severity at the impairment level in myasthenia gravis.
Twenty patients representing the spectrum of disease participated in semi-structured interviews. Interviews were recorded and the transcripts were analyzed by content analysis using an inductive approach with line-by-line open coding. Themes were generated from these codes.
Two main themes were identified: the severity of the impairments and fatigability (i.e., triggering or worsening of an impairment with activity). The impairments were further classified within body regions (ocular, bulbar and axial/limbs). Fatigability was described as a phenomenon affecting the whole body but also affecting specific impairments, and was associated with fluctuation of the symptoms. Patients were concerned that clinical examination at a single point in time might not reflect their true clinical state due to fatigability and fluctuations in severity.
This conceptual framework reflects the relevance of both severity and fatigability in understanding impairment-based disease severity in myasthenia. This framework could inform the development of impairment measures in myasthenia gravis.
PMCID: PMC4028305  PMID: 24844418
6.  Where is the patient in models of patient-centred care: a grounded theory study of total joint replacement patients 
Patient-centered care ideally considers patient preferences, values and needs. However, it is unclear if policies such as wait time strategies for hip and knee replacement surgery (TJR) are patient-centred as they focus on an isolated episode of care. This paper describes the accounts of people scheduled to undergo TJR, focusing on their experience of (OA) as a chronic disease that has considerable impact on their everyday lives.
Semi-structured qualitative interviews were conducted with participants scheduled to undergo TJR who were recruited from the practices of two orthopaedic surgeons. We first used maximum variation and then theoretical sampling based on age, sex and joint replaced. 33 participants (age 38-79 years; 17 female) were included in the analysis. 20 were scheduled for hip replacement and 13 for knee replacement. A constructivist approach to grounded theory guided sampling, data collection and analysis.
While a specific hip or knee was the target for surgery, individuals experienced multiple-joint symptoms and comorbidities. Management of their health and daily lives was impacted by these combined experiences. Over time, they struggled to manage symptoms with varying degrees of access to and acceptance of pain medication, which was a source of constant concern. This was a multi-faceted issue with physicians reluctant to prescribe and many patients reluctant to take prescription pain medications due to their side effects.
For patients, TJR surgery is an acute intervention in the experience of chronic disease, OA and other comorbidities. While policy has focused on wait time as patient/surgeon decision for surgery to surgery date, the patient’s experience does not begin or end with surgery as they struggle to manage their pain. Our findings suggest that further work is needed to align the medical treatment of OA with the current policy emphasis on patient-centeredness. Patient-centred care may require a paradigm shift that is not always evident in current policy and strategies.
PMCID: PMC3883472  PMID: 24359110
Osteoarthritis; Hip and knee replacement; Models of care; Qualitative methods; Patient experiences of care; Patient-centered care
7.  Evaluation of patient-centered rehabilitation model targeting older persons with a hip fracture, including those with cognitive impairment 
BMC Geriatrics  2013;13:136.
The purpose of this study was to evaluate outcomes for older persons post-hip fracture repair, including those with cognitive impairment (CI), following implementation of a novel model of care – the Patient-Centered Rehabilitation Model including persons with CI (PCRM-CI). The PCRM-CI is an interdisciplinary rehabilitation program that incorporates education for healthcare professionals (HCPs), including nurses, which is focused on geriatric care including management of dementia and delirium, support for HCPs from an Advanced Practice Nurse, and family support and education. Primary outcome measures were mobility gain from admission to discharge and whether or not patients returned home post-discharge.
The PCRM-CI intervention was evaluated using a quasi-experimental design, following implementation in two community hospital inpatient rehabilitation units. One hundred forty-nine patients aged 65 and older participated as patients in the usual care (76) or PCRM-CI intervention (73) groups. Patient mobility was assessed at admission and discharge by the Functional Independence Measure Motor Subscale (FIMM); the difference in mobility scores was defined as mobility gain. Patient discharge location was also captured to determine whether or not patients returned home from inpatient rehabilitation.
No difference in mobility gain was found between the usual care and PCRM-CI groups as measured by the FIMM. Patients in the intervention group were more likely to return home post-discharge than those in the usual care group (p = 0.02).
Results of the PCRM-CI evaluation suggest that older adults with CI can successfully be rehabilitated post-hip fracture repair using this novel, interdisciplinary rehabilitation program.
Trial registration
This trial has been registered with the US National Institutes of Health (ID: NCT01566136)
PMCID: PMC4028934  PMID: 24330470
Person-centered care; Cognitive impairment; Rehabilitation; Healthcare restructuring; Hip fracture
8.  Surgery or Consultation: A Population-Based Cohort Study of Use of Orthopaedic Surgeon Services 
PLoS ONE  2013;8(6):e65560.
This population-based cohort study has the objective to understand the sociodemographic characteristics and health conditions of patients who do not receive surgery within 18 months following an ambulatory visit to an orthopaedic surgeon.
Administrative healthcare databases in Ontario, Canada were linked to identify all patients making an initial ambulatory visit to orthopaedic surgeons between October 1st, 2004 and September 30th, 2005. Logistic regression was used to examine predictors of not receiving surgery within 18 months.
Of the 477,945 patients in the cohort 49% visited orthopaedic surgeons for injury, and 24% for arthritis. Overall, 79.3% did not receive surgery within 18 months of the initial visit, which varied somewhat by diagnosis at first visit (84.5% for injury and 73.0% for arthritis) with highest proportions in the 0–24 and 25–44 age groups. The distribution by income quintile of patients visiting was skewed towards higher incomes. Regression analysis for each diagnostic group showed that younger patients were significantly more likely to be non-surgical than those aged 65+ years (age 0–24: OR 3.45 95%CI 3.33–3.57; age 25–44: OR 1.30 95%CI 1.27–1.33). The odds of not getting surgery were significantly higher for women than men for injury and other conditions; the opposite was true for arthritis and bone conditions.
A substantial proportion of referrals were for expert diagnosis or advice on management and treatment. The findings also suggest socioeconomic inequalities in access to orthopaedic care. Further research is needed to investigate whether the high caseload of non-surgical cases affects waiting times to see a surgeon. This paper contributes to the development of evidence-based strategies to streamline access to surgery, and to develop models of care for non-surgical patients to optimize the use of scarce orthopaedic surgeon resources and to enhance the management of musculoskeletal disorders across the care continuum.
PMCID: PMC3672140  PMID: 23750266
9.  Improving Primary Health Care in Chronic Musculoskeletal Conditions through Digital Media: The PEOPLE Meeting 
JMIR Research Protocols  2013;2(1):e13.
Musculoskeletal (MSK) conditions are the most common cause of severe chronic pain and disability worldwide. Despite the impact of these conditions, disparity exists in accessing high quality basic care. As a result, effective treatments do not always reach people who need services. The situation is further hampered by the current models of care that target resources to a limited area of health services (eg, joint replacement surgery), rather than the entire continuum of MSK health, which includes services provided by primary care physicians and health professionals. The use of digital media offers promising solutions to improve access to services. However, our knowledge in this field is limited. To advance the use of digital media in improving MSK care, we held a research planning meeting entitled “PEOPLE: Partnership to Enable Optimal Primary Health Care by Leveraging Digital Media in Musculoskeletal Health”. This paper reports the discussion during the meeting.
The objective of this study was to: (1) identify research priorities relevant to using digital media in primary health care for enhancing MSK health, and (2) develop research collaboration among researchers, clinicians, and patient/consumer communities.
The PEOPLE meeting included 26 participants from health research, computer science/digital media, clinical communities, and patient/consumer groups. Based on consultations with each participant prior to the meeting, we chose to focus on 3 topics: (1) gaps and issues in primary health care for MSK health, (2) current application of digital media in health care, and (3) challenges to using digital media to improve MSK health in underserviced populations.
The 2-day discussion led to emergence of 1 overarching question and 4 research priorities. A main research priority was to understand the characteristics of those who are not able to access preventive measures and treatment for early MSK diseases. Participants indicated that this information is necessary for tailoring digital media interventions. Other priorities included: (1) studying barriers and ethical issues associated with the use of digital media to optimize MSK health and self-management, (2) improving the design of digital media tools for providing “just-in-time” health information to patients and health professionals, and (3) advancing knowledge on the effectiveness of new and existing digital media interventions.
We anticipate that the results of this meeting will be a catalyst for future research projects and new cross-sector research partnerships. Our next step will be to seek feedback on the research priorities from our collaborators and other potential partners in primary health care.
PMCID: PMC3628154  PMID: 23612113
primary health care; Internet; digital media; health service delivery
10.  Comparing Recruitment and Retention Strategies for Rehabilitation Professionals among Hospital and Home Care Employers 
Physiotherapy Canada  2012;64(1):31-41.
Purpose: The objective of this study was to compare hospital and home care employers' rankings of both the importance and the feasibility of workforce strategies for recruiting and retaining rehabilitation professionals. Methods: An online self-administered questionnaire was distributed to all employers of rehabilitation professionals in Ontario hospitals (n=144) and Community Care Access Centre home care providers (n=34). Importance and feasibility rankings were based on the percentage of high ratings; 95% CIs were used to determine significant differences between hospital and home care rankings of recruitment and retention strategies. Results: The response rate was 50% (72/144) from hospitals and 73.5% (25/34) from home-care settings. The recruitment and retention strategies considered most important and feasible for rehabilitation therapists, regardless of setting, were communication between employer and worker, compensation packages, access to research, and professional development in budget planning. Tangible resources, support personnel, work safety, and marketing rehabilitation careers to high school students were ranked significantly higher by hospitals than by home care providers. Conclusions: Similarities exist between hospital and home care employers in terms of the importance and feasibility of recruitment and retention strategies for rehabilitation professionals. However, when developing a rehabilitation health human resources plan, the strategies identified as different between hospital and home care settings should be taken into account.
PMCID: PMC3280794  PMID: 23277683
health manpower; home care services; rehabilitation; personnel selection; recrutement; rétention; stratégies de ressources humaines; réadaptation; hôpitaux; soins à domicile
11.  A single group follow-up study of non-surgical patients seen by physiotherapists working in expanded roles in orthopaedic departments: recall of recommendations, change in exercise and self-efficacy 
BMC Research Notes  2012;5:669.
Specially trained physiotherapists (advanced practice physiotherapists (APP)) are working in orthopaedic clinics to improve access to orthopaedic services and support chronic disease management. Little attention has been paid to the impact APPs may have on non-surgical patients. In non-surgical patients with hip or knee arthritis consulting an APP in an orthopaedic clinic, the objectives were to: 1) describe patients’ recall of APP recommendations, use of self-management strategies, and barriers to management six weeks following consultation; and, 2) compare exercise behaviour and self-efficacy at baseline and six weeks.
This was a single group pre-and post-intervention study of patients who saw an APP when consulting the orthopaedic departments of two hospitals. At baseline and six weeks participants completed the adapted Stanford Exercise Behaviour Scale (response options: none, < 60 minutes/week, 1–3 hours/week or > 3 hours/week), and the Chronic Disease Self-efficacy Scale (range 1–10; higher scores indicate higher self-efficacy). At follow-up participants completed questions on recall of APP recommendations, use of self-management strategies and barriers to management. Seventy three non-surgical patients with hip or knee arthritis participated, a response rate of 89% at follow-up. Seventy one percent of patients reported that the APP recommended exercise, of whom 83% reported exercising to manage their arthritis since the visit. Almost 50% reported an increase in time spent stretching; over 40% reported an increase in time spent walking or doing strengthening exercises at follow-up. Common barriers to arthritis management were time, cost and other health problems. Mean chronic disease self-efficacy scores significantly improved from 6.3 to 7.2 (p < 0.001). The mean difference was 0.95 (95% CI 0.43, 1.62); the effect size was 0.51.
This pilot study of an APP intervention for non-surgical patients referred for orthopaedic consultation showed promising results, particularly for enhancing use of conservative management strategies such as exercise.
PMCID: PMC3538671  PMID: 23206311
Arthritis; Physiotherapists; Advanced practice; Non-surgical; Self-management behaviours; Orthopaedics
12.  A Clinical Prediction Model for Long-Term Functional Outcome after Traumatic Spinal Cord Injury Based on Acute Clinical and Imaging Factors 
Journal of Neurotrauma  2012;29(13):2263-2271.
To improve clinicians' ability to predict outcome after spinal cord injury (SCI) and to help classify patients within clinical trials, we have created a novel prediction model relating acute clinical and imaging information to functional outcome at 1 year. Data were obtained from two large prospective SCI datasets. Functional independence measure (FIM) motor score at 1 year follow-up was the primary outcome, and functional independence (score ≥6 for each FIM motor item) was the secondary outcome. A linear regression model was created with the primary outcome modeled relative to clinical and imaging predictors obtained within 3 days of injury. A logistic model was then created using the dichotomized secondary outcome and the same predictor variables. Model validation was performed using a bootstrap resampling procedure. Of 729 patients, 376 met the inclusion criteria. The mean FIM motor score at 1 year was 62.9 (±28.6). Better functional status was predicted by less severe initial American Spinal Injury Association (ASIA) Impairment Scale grade, and by an ASIA motor score >50 at admission. In contrast, older age and magnetic resonance imaging (MRI) signal characteristics consistent with spinal cord edema or hemorrhage predicted worse functional outcome. The linear model predicting FIM motor score demonstrated an R-square of 0.52 in the original dataset, and 0.52 (95% CI 0.52,0.53) across the 200 bootstraps. Functional independence was achieved by 148 patients (39.4%). For the logistic model, the area under the curve was 0.93 in the original dataset, and 0.92 (95% CI 0.92,0.93) across the bootstraps, indicating excellent predictive discrimination. These models will have important clinical impact to guide decision making and to counsel patients and families.
PMCID: PMC3430477  PMID: 22709268
clinical prediction model; functional outcome; spinal cord injury
13.  OARSI/OMERACT Initiative to Define States of Severity and Indication for Joint Replacement in Hip and Knee Osteoarthritis. An OMERACT 10 Special Interest Group 
The Journal of Rheumatology  2011;38(8):1765-1769.
To define pain and physical function cutpoints that would, coupled with structural severity, define a surrogate measure of “need for joint replacement surgery,” for use as an outcome measure for potential structure-modifying interventions for osteoarthritis (OA).
New scores were developed for pain and physical function in knee and hip OA. A cross-sectional international study in 1909 patients was conducted to define data-driven cutpoints corresponding to the orthopedic surgeons’ indication for joint replacement. A post hoc analysis of 8 randomized clinical trials (1379 patients) evaluated the prevalence and validity of cutpoints, among patients with symptomatic hip/knee OA.
In the international cross-sectional study, there was substantial overlap in symptom levels between patients with and patients without indication for joint replacement; indeed, it was not possible to determine cutpoints for pain and function defining this indication. The post hoc analysis of trial data showed that the prevalence of cases that combined radiological progression, high level of pain, and high degree of function impairment was low (2%–12%). The most discriminatory cutpoint to define an indication for joint replacement was found to be [pain (0–100) + physical function (0–100) > 80].
These results do not support a specific level of pain or function that defines an indication for joint replacement. However, a tentative cutpoint for pain and physical function levels is proposed for further evaluation. Potentially, this symptom level, coupled with radiographic progression, could be used to define “nonresponders” to disease-modifying drugs in OA clinical trials.
PMCID: PMC3260473  PMID: 21807799
14.  Can the Toronto Extremity Salvage Score Produce Reliable Results When Used Online? 
Web-based questionnaires have become popular, however, access to the Internet can be biased regarding age, gender, and education, among other factors. Therefore, it is unknown whether this is a reasonable avenue to administer a questionnaire to patients or whether Web-based can be a reliable alternative to paper-based.
We determined whether the Internet version of the Toronto Extremity Salvage Score is reproducible compared with the paper-based version and the compliance and completion rates.
Patients and Methods
The study population consisted of 81 adults who had had surgery for a musculoskeletal tumor of the lower extremity more than 12 months earlier. The Toronto Extremity Salvage Score was administered by paper at a baseline interview and then readministered via Internet 7 to 14 days later to those with access.
Sixty of the 81 patients (74%) were able to use the Internet. Increasing age and lower education levels were correlated with a lower likelihood of using the Internet. Questionnaires were done online and on paper by 56 patients but 10 were excluded because of self-reported change in circumstances. The mean TESS was 85.7 (range, 41.1–100; SD, 17.26) for the paper-based questionnaire and 85.2 (range, 42.5–100; SD, 17.47) for the Internet-based questionnaire. The intraclass correlation coefficient was 0.97.
The questionnaire can be transferred successfully to the Internet and can be used reliably instead of a paper-based instrument. Recruitment to use an Internet-based questionnaire is limited only by the percentage of patients able to access and use the Internet.
PMCID: PMC3094633  PMID: 21128031
15.  An inpatient rehabilitation model of care targeting patients with cognitive impairment 
BMC Geriatrics  2012;12:21.
The course and outcomes of hip fracture patients are often complicated by the presence of dementia and delirium, referred to as cognitive impairment (CI), which limits access to in-patient rehabilitation. In response to this concern, members of our team developed and piloted an in-patient rehabilitation model of care (Patient-Centred Rehabilitation Model; PCRM) targeting patients with hip fracture and CI (PCRM-CI). We are now conducting a 3-year study comparing an inpatient rehabilitation model of care for community dwelling individuals with hip fracture and CI (PCRM-CI) to usual care to determine whether it results in improved mobility at the time of discharge from inpatient rehabilitation.
A non-equivalent pre-post design is being used to evaluate the PCRM-CI compared to usual care. All community dwelling (private home or retirement home) patients following a hip fracture are eligible to participate. Recruitment of both cohorts is taking place at two facilities. Target accrual is 70 hip fracture patients in the PCRM-CI cohort and 70 patients in the usual care cohort. We are also recruiting 70 health care providers (HCPs), who are being trained to implement the PCRM-CI, and their unit managers. Patient data are collected at baseline, discharge, and 6 months post-discharge from an inpatient rehabilitation program. Evaluations include mobility, physical function, and living arrangement. Additional outcome variables are being collected from medical records and from the patients via their proxies. Data on the prevalence and severity of dementia and delirium are being collected. Staff data are collected at baseline and one year after implementation of the model to determine change in staff knowledge and attitudes toward patients with hip fracture and CI. Bi-monthly semi-structured interviews with unit managers have been conducted to examine factors and barriers influencing the model implementation. Data collection began in 2009 and is expected to be completed in 2012. The control cohort of 70 patients has been recruited, and 45 patients have been accrued to the intervention group to date.
Evaluation of this model of care is timely given the increasing proportion of persons with cognitive impairment and hip fractures.
Trial registration
The study is registered at, Identifier NCT01566136.
PMCID: PMC3444411  PMID: 22631877
Hip fractures; Dementia; Delirium; Cognitive impairment; Rehabilitation; Models of care; Mobility outcomes; Evaluation; Controlled investigation
16.  Preliminary Development and Validation of a Paediatric Cardiopulmonary Physiotherapy Discharge Tool 
Physiotherapy Canada  2011;63(1):34-44.
Purpose: The purpose of this study was to develop a paediatric cardiopulmonary physiotherapy (CPT) discharge tool. We report on the initial stages of its development and the tool's sensibility (face/content validity, feasibility, and ease of usage).
Methods: Using a modified Delphi technique, a panel of paediatric physiotherapy clinicians and academic leaders in the area of CPT (n=25) was recruited. Four rounds of discussion among the members of the Delphi panel focused on (1) generation of discharge items, (2) reduction of items, (3) discussion of contentious items and refinement of criterion definitions, and (4) determination of scoring options for the test instrument. The sensibility of a draft of the tool was assessed using a sample of convenience (n=15).
Results: Six items (auscultation, discharge planning, mobility, oxygen saturation, secretion clearance, and signs of respiratory distress) were identified for inclusion in the tool. The global mean of all sensibility domains was 6.4 (median=6.6) of a possible 7.0.
Conclusion: Using a modified Delphi process, we developed a six-item paediatric CPT discharge planning tool with good face and content validity. Future work will determine the scoring method for using this tool, interrater reliability, and predictive validity to facilitate optimal timing of hospital discharge for paediatric CPT patients.
PMCID: PMC3024193  PMID: 22210977
cardiorespiratory physiotherapy; Delphi technique; discharge criteria; measurement; tool development; critères de congé; élaboration d'un outil; mesure; physiothérapie cardiorespiratoire; technique Delphi
17.  Patient Disease Perceptions and Coping Strategies for Arthritis in a Developing Nation: A Qualitative Study 
There is little prior research on the burden of arthritis in the developing world. We sought to document how patients with advanced arthritis living in the Dominican Republic are affected by and cope with their disease.
We conducted semi-structured, one-to-one interviews with economically disadvantaged Dominican patients with advanced knee and/or hip arthritis in the Dominican Republic. The interviews, conducted in Spanish, followed a moderator's guide that included topics such as the patients' understanding of disease etiology, their support networks, and their coping mechanisms. The interviews were audiotaped, transcribed verbatim in Spanish, and systematically analyzed using content analysis. We assessed agreement in coding between two investigators.
18 patients were interviewed (mean age 60 years, median age 62 years, 72% women, 100% response rate). Patients invoked religious and environmental theories of disease etiology, stating that their illness had been caused by God's will or through contact with water. While all patients experienced pain and functional limitation, the social effects of arthritis were gender-specific: women noted interference with homemaking and churchgoing activities, while men experienced disruption with occupational roles. The coping strategies used by patients appeared to reflect their beliefs about disease causation and included prayer and avoidance of water.
Patients' explanatory models of arthritis influenced the psychosocial effects of the disease and coping mechanisms used. Given the increasing reach of global health programs, understanding these culturally influenced perceptions of disease will be crucial in successfully treating chronic diseases in the developing world.
PMCID: PMC3208588  PMID: 21985605
18.  Educational Needs of Patients Undergoing Total Joint Arthroplasty 
Physiotherapy Canada  2010;62(3):206-214.
Purpose: To identify the educational needs of adults who undergo total hip and total knee replacement surgery.
Methods: A qualitative research design using a semi-standardized interviewing method was employed. A purposive sampling technique was used to recruit participants, who were eligible if they were scheduled to undergo total hip or total knee replacement or had undergone total hip or total knee replacement in the previous 3 to 6 months. A comparative contrast method of analysis was used.
Results: Of 22 potential participants who were approached, 15 participated. Five were booked for upcoming total hip or total knee replacement and 10 had undergone at least one total hip or total knee replacement in the previous 3 to 6 months. Several themes related to specific educational needs and factors affecting educational needs, including access, preoperative phase, surgery and medical recovery, rehabilitation process and functional recovery, fears, and expectations counterbalanced with responsibility, emerged from the interviews.
Conclusions: Educational needs of adults who undergo total hip and knee replacement surgery encompass a broad range of topics, confirming the importance of offering an all-inclusive information package regarding total hip and total knee replacement.
PMCID: PMC2909857  PMID: 21629598
educational needs; patient education; qualitative research; total hip arthroplasty; total knee arthroplasty; arthroplastie totale de la hanche; arthroplastie totale du genou; besoins éducatifs; éducation des patients; recherche qualitative
19.  Disability and satisfaction after Rotator Cuff decompression or repair: a sex and gender analysis 
Rotator-cuff pathology is the most common cause of pain and disability in the shoulder. Examining the combined effect of biological and societal factors on disability would potentially identify existing differences between men and women with rotator cuff pathology which would help to provide suggestions for better models of care. Purpose of this study was to determine the overall differences in disability between men and women and to examine the relationship between factors that represent sex (biological factors) and gender (non-biological factors) with disability and satisfaction with surgical outcome 6 months after rotator cuff surgery.
Patients with impingement syndrome and/or rotator cuff tear who underwent rotator cuff surgery completed the Western Ontario Rotator Cuff (WORC) index, the American Shoulder & Elbow Surgeons (ASES) assessment form, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome measures prior to surgery and 6 months post-operatively. They also rated their satisfaction with surgery at their follow-up appointment.
Results and Discussion
One hundred and seventy patients entered into the study (85 men and 85 women). One hundred and sixty patients (94%) completed the 6-month assessment. Women reported more disability both prior to and after surgery. Disability at 6 months was associated with pain-limited range of motion, participation limitation, age and strength. Satisfaction with surgery was associated with level of reported disability, expectations for improved pain, pain-limited range of motion and strength.
The results of this study indicate that women with rotator cuff pathology suffer from higher levels of pre- and post-operative disability and sex and gender qualities contribute to these differences. Gender-sensitive approach will help to identify existing differences between men and women which will help to promote more effective and tailored care by health professionals.
PMCID: PMC3083386  PMID: 21457534
20.  Comparing Patient Outcomes After THA and TKA: Is There a Difference? 
Both primary total hip (THA) and knee (TKA) arthroplasty relieve pain, restore function, and increase mobility. Despite these successes, there is controversy as to whether THA or TKA provides greater or similar improvement. We therefore compared primary THA and TKA patient results in terms of (1) willingness to have surgery again; (2) WOMAC change score; (3) whether expectations were met; and (4) satisfaction. Patients undergoing primary THA were more willing to undergo their surgery again (THA 96%, TKA 89%), demonstrated greater WOMAC change scores, more frequently reported their expectations were met (THA 78%, TKA 70%), and expressed greater overall satisfaction (THA 89%, TKA 81%). In addition, patients undergoing THA expressed higher satisfaction with pain reduction while performing activities (ie, walking, stairs, and sitting/lying) and their ability to perform daily activities (ie, stairs, transportation, getting up, lying in bed, and light domestic duties) when compared with patients undergoing TKA. Our data suggest primary THA offers superior short-term outcomes when compared with primary TKA.
Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2806999  PMID: 19760472
21.  Patient Satisfaction after Total Knee Arthroplasty: Who is Satisfied and Who is Not? 
Despite substantial advances in primary TKA, numerous studies using historic TKA implants suggest only 82% to 89% of primary TKA patients are satisfied. We reexamined this issue to determine if contemporary TKA implants might be associated with improved patient satisfaction. We performed a cross-sectional study of patient satisfaction after 1703 primary TKAs performed in the province of Ontario. Our data confirmed that approximately one in five (19%) primary TKA patients were not satisfied with the outcome. Satisfaction with pain relief varied from 72–86% and with function from 70–84% for specific activities of daily living. The strongest predictors of patient dissatisfaction after primary TKA were expectations not met (10.7× greater risk), a low 1-year WOMAC (2.5× greater risk), preoperative pain at rest (2.4× greater risk) and a postoperative complication requiring hospital readmission (1.9× greater risk).
Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2795819  PMID: 19844772
22.  Factors influencing inpatient rehabilitation length of stay following revision hip replacements: a retrospective study 
The annual incidence of revision hip replacements has increased in both Canada and United States, particularly in younger adults. Patients following revision hip replacements often require longer hospital length of stay (LOS) but little is known about predictors of inpatient rehabilitation LOS in this group of patients. The purpose of this study was to evaluate the socio-demographic, pre-surgery, surgery and post-surgery related factors that might influence rehabilitation LOS of inpatients following revision hip replacements.
This study included inpatients discharged from a musculoskeletal ward between 2002 and 2006 following rehabilitation revision hip replacement. Data sources included the National Reporting System, a standardized, provincial administrative database and augmented by chart abstraction. The collected elements included the outcome LOS and the following independent variables: age, sex, support at home, environmental barriers, language barrier, number of revision surgeries on the affected hip, comorbidity, previous orthopaedic surgeries in the lower extremities (L/ES), the hip component(s) revised, weight-bearing status, hemoglobin level, complications, days lapsed from surgery to rehabilitation admission and admission scores on the Functional Independence Measure (FIM). Simple linear regression was used to take forward any predictors significant at p < .10 level. Variables that satisfied the significance level were grouped in blocks and entered for regression analyses.
The 275 patients in this sample had a mean age of 69 years; 62% were female and the mean LOS was 29.6 days. Statistically significant predictors of longer LOS were low admission FIM score, female sex, revision of only the femoral component, 2 or more prior surgeries in the L/Es and 2 or more hip revisions (redo revision). The final model explained 28% of variance in inpatient LOS.
A score of 9-14 points lower in admission FIM, female sex, revision of only the femoral component, prior surgeries in the L/Es and redo hip revision are all independent factors associated with 4-6 days longer LOS. These results may facilitate an understanding of bed flow. Additionally, patients with one or a combination of the above characteristics may benefit from enhanced care plans that facilitate achievement of rehabilitation goals for discharge home.
PMCID: PMC2987976  PMID: 20979662
23.  In-hospital mortality following hip fracture care in southern Ontario 
Canadian Journal of Surgery  2010;53(5):294-298.
The incidence of hip fractures is increasing within the aging population. We investigated the overall rate of in-hospital mortality following hip fracture and how this mortality rate compares across academic and community hospitals.
We reviewed prospectively collected data from 17 hospitals in southern Ontario as part of a project to evaluate a new streamlined clinical care pathway developed for acute care of elderly patients with hip fractures. We collected demographic data, prefracture living status, acute care mortality and time to surgery, and we compared these data between community and academic hospitals.
Between March 2007 and February 2008, 2178 consecutive patients were admitted with a hip fracture to 13 community and 4 academic hospitals. The mean age was 79 years and 72% were women. The overall in-hospital mortality rate was 5.0%, with no difference between patients treated in academic versus community hospitals (p = 0.56). We found a greater rate of acute care in-hospital mortality for patients admitted from dependent-living facilities compared with those who were living independently (risk ratio 0.63, 95% confidence interval 0.42–0.96).
Acute care in-hospital mortality following hip fractures remains high and is consistent across academic and community hospitals. With the rising incidence of hip fractures, we need to improve the models of care for these patients to reduce mortality and to maximize functional outcomes while maintaining efficient use of limited health care resources.
PMCID: PMC2947119  PMID: 20858372
24.  Clinicians' Commentary 
Physiotherapy Canada  2009;61(4):231-233.
PMCID: PMC2793697
25.  How do existing HIV-specific instruments measure up? Evaluating the ability of instruments to describe disability experienced by adults living with HIV 
Despite the multitude of health challenges faced by adults living with HIV, we know of no HIV-specific instrument developed for the purpose of describing the health-related consequences of HIV, a concept known as disability. In a previous phase of research, adults living with HIV conceptualized disability as symptoms/impairments, difficulties carrying out day-to-day activities, challenges to social inclusion, and uncertainty that may fluctuate on a daily basis and over the course of living with HIV. In this paper, we describe the extent to which existing HIV-specific health-status instruments capture the experience of disability for adults living with HIV.
We searched databases from 1980 to 2006 for English language, HIV-specific, self-reported questionnaires consisting of at least two items that were tested for reliability and validity. We then conducted a content analysis to assess how well existing questionnaires describe disability as defined by the Episodic Disability Framework, a framework that conceptualizes this experience from the perspective of adults living with HIV. We matched items of the instruments with categories of the framework to evaluate the extent to which the instruments capture major dimensions of disability in the framework.
We reviewed 4274 abstracts, of which 30 instruments met the inclusion criteria and were retrieved. Of the four major dimensions of disability, symptoms/impairments were included in all 30 instruments, difficulties with day-to-day activities in 16, challenges to social inclusion in 16, and uncertainty in 9. Seven instruments contained at least 1 item from all 4 dimensions of disability (breadth) however, the comprehensiveness with which the dimensions were represented (depth) varied among the instruments.
In general, symptoms/impairments and difficulties carrying out day-to-day activities were the disability dimensions characterized in greatest depth while uncertainty and challenges to social inclusion were less well represented. Although none of the instruments described the full breadth and depth of disability as conceptualized by the Episodic Disability Framework, they provide a foundation from which to build a measure of disability for adults living with HIV.
PMCID: PMC2936441  PMID: 20723244

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