PHYSIOTHERAPY CANADA

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 Physiotherapy Canada Advancing health through scientific inquiry and knowledge translation Volume 72 • Number 2 • Spring 2020 Pour l’avancement de la santé par l’enquête scientifique et la transmission du savoir Eighteenth Issue in a Special Series on Education in Physiotherapy Fourth Issue in a Special Series on Paediatric Physiotherapy: A Celebration of the Breadth of Our Practice and Knowledge Highlights Guest Editorial Functional Status as a Central Indicator of Health Status: The Role of Physiotherapy / L’activité fonctionnelle, un indicateur central de l’état de santé : le rôle de la physiothérapie Articles • E volving Trends in Physiotherapy Research Publications between 1995 and 2015 by T.S. Jesus, S. Gianola, G. Castellini, H. Colquhoun, and D. Brooks • R ecovery of Sensorimotor Functional Outcomes at Discharge from In-Patient Rehabilitation in Three Stroke Units in the Province of Quebec by C.L. Richards, A. Durand, F. Malouin, S. Nadeau, J. Fung, L. D’Amours, and C. Perez • D esigning, Implementing, and Evaluating a Practice Tutor Internship Model during an Acute Care Clinical Internship by B. Mori, J. Coleman, K. Knott, K. Newman, and A. O’Connor Official Journal of the Canadian Physiotherapy Association Revue officielle de l’Association canadienne de physiothérapie

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https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 #1 Excellent Program In Canada in Osteopathy for physiotherapists The courses are practice-oriented to assess and deliver quality care to remove the causes of dysfunction and pain by viewing the body as a whole. Educational program for health professionals includes all techniques in each field: • Myofascial, visceral, and cranial techniques • Specific osteoarticular adjustments • Specific program for children, pregnant women and professional athletes • Emphasis on development of palpation skills • Proven clinical methodology • Supervised clinical practice For further details regarding the program, please contact our registrar at [email protected] or 1-800-263-2816, ext 229 Montreal —Toronto —Vancouver —Winnipeg —Quebec —Halifax McMaster University HEALTH SCIENCES Since 1998, more than 400+ Sept 11-12-13, 2020 PROGRAM SCOPE fPrhoymsitohteheprraopgirsatms h, aavcheigervaindguated Introduction to Neurofunctional their training goals. Acupuncture The McMaster University Contemporary ..UUU......NNN........III..TTT........324................ANOOUH......xpeocc....i..attpva....del22..1..S.r.3-..&3..3k..-E.-.e-2..x1F..4l..4tea..4.,.r-.t.ce-..2a2..e1..m0l..5..5..PP2,i..,t..rr02..y2.o.o..0..0bb..P..2.2.llr..ee0..o0..mm..b.....s.sl..e....--m....V....s..i..s..-..c....Ae....r..c..a..u..l..t....Re....e....Pg....a..u..i..l.n.a....t....i..o......n Acupuncture Program has been teaching .U...N....I.T....5........CDL..o.he..wr.c.o.e.4n.r.-.i.c5.E..-x.P6.t.a.r,.ie.2n..m.0.S.2i.yt..0y.n..d.P..rr.o.o..mb...le.e..sm....s...-.............................. Neurofunctional Electroacupuncture to Integrated Management health care professionals for over 20 Registration Deadline: Aug 7, 2020 years. Physiotherapists trained through the program have consistently achieved McMASTER CERTIFICATE their goals. 300 hours Continuing Education in Neurofunctional Acupuncture. The program is Evidence-Based and The scope of the Program is beyond clinically oriented, with over 100 hours of hands-on simple needle insertion; it provides the workshops on functional anatomy palpation, needle practitioner with a unique framework for insertion techniques, anatomy laboratory, condition­ assessment and treatment. specific blueprint treatment design, and over 30 real The Neurofunctional Operating System patient case studies. has been shown to consistently generate clinical results above and beyond traditional treatment models. Visit our website for testimonials at www.mcmasteracupuncture.com STUDENTS RATES AVAILABLE CONTACT US: 905-521-2100 x75175 / [email protected]

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 CALL FOR PAPERS Physiotherapy Canada SPECIAL SERIES Promoting Healthy Behaviour through Exercise and Physical Activity in Individuals Living with Chronic Conditions Guest Editors: Dr. MacKay-Lyons, PhD, PT is a Professor at Dalhousie University and Dr. Richardson, PhD, PT is a Professor at McMaster University. Physical inactivity is common in individuals with chronic disease and is associated with increased risk of mortality, morbidity, and hospitalizations. Adherence to exercise and interventions to increase physical activity and reduce sedentary behaviour could have substantial benefits to individuals and healthcare systems. Physiotherapists are in a unique position to lead interdisciplinary teams and create solutions to enhance active behaviours, as well as maintain health and wellbeing in individuals with one or more chronic conditions. Over the next few years, Physiotherapy Canada will be running a special series of articles exploring research on approaches to promote behavioural change, exercise and physical activity with the goal of sharing innovations and discoveries, and encouraging physiotherapists to continue to be the leaders in this area. The series will include articles that address: Submissions directly or indirectly related to one or more of the above topics Interdisciplinary research: Research from different disciplines (e.g., physical therapy, are requested now and throughout 2020 and 2021, for publication through occupational therapy, nursing, medicine, engineering, computer science) that aims to 2021 and 2022. promote activity in individuals with chronic conditions. All submissions must follow the journal’s author guidelines and must be submitted to our online peer-review system, ScholarOne Manuscripts. You can find the guidelines here or on Behavioural approaches: Behavioural and cognitive approaches integrated into the “For Authors and Reviewers” page at utpjournals.press/ptc. To submit to ScholarOne, interventions to address exercise, changes in physical activity, and preventive approaches please visit mc04.manuscriptcentral.com/ptc. to sedentary behaviour. Target groups: Addressing these issues at population, community, or individual levels. If you have questions about the relevance of a project you are working Methods of approach: Conceptual frameworks, intervention studies, measurement, on or require more detail, please contact the guest editors: systematic reviews, knowledge translation, and qualitative studies will all be considered. Marilyn MacKay-Lyons: [email protected] Julie Richardson: [email protected]

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 Physiotherapy Canada Advancing health through scientific inquiry and knowledge translation Pour l’avancement de la santé par l’enquête scientifique et la transmission du savoir Volume 72 • Number 2 • Spring 2020 • ISSN 0300-0508 • E-ISSN 1708-8313 TABLE OF CONTENTS GUEST EDITORIAL 107 Functional Status as a Central Indicator of Health Status: The Role of ORIGINAL ARTICLES Physiotherapy J. Richardson EDUCATION SERIES 109 L’activité fonctionnelle, un indicateur central de l’état de santé : le rôle de la physiothérapie J. Richardson 112 How to Optimize Measurement Protocols: An Example of Assessing Measurement Reliability Using Generalizability Theory A.A. Gatti, P.W. Stratford, N.M. Brisson, and M.R. Maly 122 Evolving Trends in Physiotherapy Research Publications between 1995 and 2015 T.S. Jesus, S. Gianola, G. Castellini, H. Colquhoun, and D. Brooks 132 Investigating Visual–Spatial Abilities in Students and Expert Physical Therapists F. Radan, N. Johnston, C.H. Nguyen, A. Restrepo, R. Varga, K.K. Patterson, D. Brooks, and J. Vaughan-Graham 137 Using Expert Consensus to Develop a Tool to Assess Physical Therapists’ Knowledge, Skills, and Judgement in Performing Airway Suctioning E. Miller, D. Brooks, and B. Mori 147 Clinician’s Commentary L. Wickerson 149 Reliability and Feasibility of Extended Field of View Ultrasound Imaging Techniques for Measuring the Limb Muscle Cross-Sectional Area L. Kwan, K. Nishihara, A. Cheung, C. D’Amico, A. Hart, N. Keshwani, and S. Mathur 158 Recovery of Sensorimotor Functional Outcomes at Discharge from In-Patient Rehabilitation in Three Stroke Units in the Province of Quebec C.L. Richards, A. Durand, F. Malouin, S. Nadeau, J. Fung, L. D’Amours, and C. Perez 169 Enabling Access to Rehabilitation in Acute Care: Exploring Physiotherapists’ and Occupational Therapists’ Perspectives on Patient Care When Assistants Become the Primary Therapy Providers L. Brice-Leddy, D. Park, W. Bateman, J. Drysdale, L. Ratushny, S. Musse, and S.A. Nixon 177 Designing, Implementing, and Evaluating a Practice Tutor Internship Model during an Acute Care Clinical Internship B. Mori, J. Coleman, K. Knott, K. Newman, and A. O’Connor

192 Clinician’s Commentary A. MacPhail https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 PAEDIATRIC PHYSIOTHERAPY 195 Pilot Evaluation of a School-Based Programme Focused on Activity, Fitness, SERIES and Function among Children with Cerebral Palsy at GMFCS Level IV: Single-Subject Research Design C. Daly, C.L. Moore, S. Johannes, J. Middleton, and L.K. Kenyon 205 Clinician’s Commentary C. Dodds 207 Physical Rehabilitation Practices for Children and Adolescents with Cancer in Canada P.A. Ospina, L. Wiart, D.D. Eisenstat, and M.L. McNeely 217 Clinician’s Commentary C. Chamorro Viña COCHRANE COLLABORATION 219 What Does Cochrane Say about ... Rehabilitation and Cerebral Palsy?

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 Physiotherapy Canada Advancing health through scientific inquiry and knowledge translation Pour l’avancement de la santé par l’enquête scientifique et la transmission du savoir SCIENTIFIC EDITOR EDITORIAL OFFICE Dina Brooks, PhD, MSc, BSc (PT) University of Toronto Press - Journals Division Professor, Vice-Dean & Executive Director 5201 Dufferin St., North York, ON M3H 5T8 Canada Tel.: 416- School of Rehabilitation Science, McMaster University, 667-7777 ext. 7787, Fax: 416-667-7832 or 1-800-221-9985 Hamilton, ON E-mail: [email protected], www.utpjournals.press ASSOCIATE EDITORS INTERNATIONAL ADVISORY BOARD Denise Connelly, PhD, BScPT Rik Gosselink, PhD, PT Associate Professor, School of Physical Therapy, University of Professor, Department of Rehabilitation Sciences, Katholieke Western Ontario, London, ON Universiteit Leuven, Leuven University, Belgium Isabelle Gagnon, pht, PhD Karen Grimmer-Somers, PhD, MMedSci, BPhty, Assistant Professor, School of Physical and Occupational CertHealthEc, LMusA Therapy, McGill University, Montreal, QC Professor, School of Health Sciences Director, Centre for Allied Health Evidence, University of South Australia, Australia S. Jayne Garland, PhD, PT Professor and Department Head, Department of Physical Meg E. Morris, BAppSC(Physio), MAppSc, Grad Dip(Geron), Therapy, University of British Columbia, Vancouver, BC PhD, FACP Professor and Chair, School of Physiotherapy, University of Michael A. Hunt, PhD, PT Melbourne, Australia Associate Professor, Department of Physical Therapy, University of British Columbia, Vancouver, BC Kenneth J. Ottenbacher, OT, PhD Russel Shearn Moody Distinguished Chair in Neurological Marilyn MacKay-Lyons, BSc(PT), MSc(PT), PhD Rehabilitation, Senior Associate Dean for Graduate Research Professor, School of Physiotherapy, Dalhousie University, Education, School of Allied Health Sciences, University of Halifax, NS Texas Medical Branch, USA Stephanie Nixon Carol L. Richards, PhD, PT, FCAHS Associate Professor, Department of Physical Therapy, Professor and Canada Research Chair in Rehabilitation, University of Toronto, Toronto, ON Department of Rehabilitation Medicine, Laval University, Quebec City, QC Kathleen E. Norman, BScPT, PhD Associate Professor and Associate Director (Research and Peter Rosebaum, MD, CM, FRCP(C) Post-Professional Programs), School of Rehabilitation Therapy, Professor, Department of Pediatrics, McMaster University Queen’s University, Kingston, ON Hamilton, ON Brenda O’Neill, BScPT, Fellow HEA, PhD Julius Sim, BA, MSc(Soc), MSc(Stat), PhD Centre for Health and Rehabilitation Technologies (CHART), Primary Care Musculoskeletal Research Centre, Keele Institute Nursing and Health Research, Sch Health Sciences, University, UK Ulster University, Northern Ireland STATISTICAL CONSULTANT Tom Overend, PhD, BSc(PT) Associate Professor, School of Physical Therapy, University of Paul Stratford, PT, MSc Western Ontario, London, ON Professor Emeritus, School of Rehabilitation Science, McMaster University, Hamilton, ON Marco Pang, BScPT, PhD Assistant Professor, Department of Rehabilitation Sciences, The PUBLISHER Hong Kong Polytechnic University, Kowloon, Hong Kong Canadian Physiotherapy Association Alex Scott, PhD 955 Green Valley Crescent, Suite 270, Ottawa, ON Associate Professor, Department of Physical Therapy, Centre K2C 3V4 Canada for Hip Health and Mobility, University of British Columbia, Tel.: 613-564-5454 or 800-387-8679, Fax: 613-564-1577 Vancouver, BC E-mail: [email protected] www.physiotherapy.ca Jenny Setchell, BSc(PT), Grad Cert (Appl PT), PhD Competing Interest Statements for Physiotherapy Canada NHMRC Research Fellow, School of Health and Rehabilitation Editorial Board members are available online at Sciences, The University of Queensland, Brisbane, Australia https://www.utpjournals.press/journals/ptc/editorial-board

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 STATEMENT OF PURPOSE OBJECTIF Physiotherapy Canada is the official, scholarly, refereed journal of the Physiotherapy Canada est la publication scientifique officielle révisée Canadian Physiotherapy Association, giving direction to excellence in en profondeur de l’Association canadienne de physiothérapie. Son clinical science and reasoning, knowledge translation, therapeutic skills objectif est de fournir des orientations à l’excellence en sciences et en and patient-centred care. raisonnement clinique, transmission du savoir, compétences thérapeutiques et soins centrés sur le patient. Recognized as one of the top five evidence-based journals of physiotherapy worldwide, Physiotherapy Canada publishes the results Reconnu comme l’un des cinq grands journaux de physiothérapie of qualitative and quantitative research including systematic reviews, reposant sur des faits scientifiques dans le monde, Physiotherapy meta analyses, meta syntheses, public/health policy research, clinical Canada publie les résultats de recherches qualitatives et quantitatives, practice guidelines, and case reports. Key messages, clinical notamment des revues systématiques, des méta-analyses, des commentaries, case studies, evidence-based practice articles, brief métasyntheses, des recherches en politiques de la santé ou en reports, and book reviews support knowledge translation to clinical politiques publiques, des directives en pratique clinique et des études practice. de cas. Ses messages clés, commentaires cliniques, études de cas, articles fondés sur des faits scientifiques, résumés de discussions et Founded in 1923, Physiotherapy Canada meets the diverse needs of comptes-rendus de livres favorisent la transmission du savoir à la national and international readers and serves as a key repository of pratique clinique. inquiries, evidence and advances in the practice of physiotherapy. Fondée en 1923, Physiotherapy Canada répond aux divers besoins de Physiotherapy Canada (ISSN 0300-0508) is published four times per lecteurs canadiens et étrangers et se positionne comme un véritable year in spring, summer, fall and winter by the University of Toronto recueil sur la recherche, les faits scientifiques et les progrès dans la Press for the Canadian Physiotherapy Association. pratique de la physiothérapie. EDITORIAL SUBMISSIONS PRESENTATIONS D’ARTICLES Physiotherapy Canada welcomes manuscripts reporting results of Physiotherapy Canada accepte les articles qui font état de résultats de qualitative or quantitative research. Systematic reviews, meta analyses recherche qualitative ou quantitative. Les examens systématiques, les (quantitative), meta syntheses (qualitative), public/health policy méta-analyses (quantitatives), les métasynthèses (qualitatives), les research, clinical practice guidelines, case reports (quantitative), case recherches sur les politiques publiques et de santé, les guides de pratique studies (qualitative), evidence-based practice articles and brief reports clinique, les rapports de cas (quantitatifs), les études de cas (qualitatives), are also welcomed. Submissions are now being accepted online via les articles sur la pratique factuelle et les rapports de mémoire sont aussi Physiotherapy Canada’s online peer-review system ScholarOne. To log les bienvenus. Vous pouvez présenter vos articles en ligne grâce au in or see submission guidelines, please go to https://mc04. système électronique d’examen par les pairs ScholarOne de Physiotherapy manuscriptcentral.com/ptc. For technical support information or Canada. Pour ouvrir une session ou pour connaître les lignes directrices questions regarding the editorial process please contact us at sur la présentation d’un article, consultez la page https://mc04. [email protected]. manuscriptcentral.com/ptc. Pour obtenir un soutien technique ou des réponses à vos questions concernant le processus rédactionnel, veuillez Physiotherapy Canada is indexed by Allied and Complementary communiquer avec nous à [email protected]. Medicine Database (AMED), CrossRef, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, National Physiotherapy Canada est indexée par Allied and Complementary Archives Publishing Co., Online Computer Library Center (OCLC), Medicine Database (AMED), CrossRef, l’index cumulatif des PEDro, PubMed Central (PMC), Rehabilitation & Sports Medicine publications sur les soins infirmiers et les soins paramédicaux Source, ScholarsPortal, Scopus, SIPX, and the Web of Science (Science (CINAHL), Google Scholar, National Archives Publishing Co., Online Citation Index Expanded). Computer Library Center (OCLC), PEDro, PubMed Central (PMC), Rehabilitation & Sports Medicine Source, ScholarsPortal, Scopus, SIPX The statements and opinions in this journal are solely those of the et Web of Science (Science Citation Index Expanded). contributors and not those of the publisher or of the Canadian Physiotherapy Association. Les opinions publiées dans cette revue sont celles des contributeurs et ne représentent pas les opinions de l’éditeur ou de l’Association COPYRIGHT canadienne de physiotheérapie. © Canadian Physiotherapy Association, 2020. All rights reserved. No part of this material may be reproduced, stored in a retrieval system, or DROIT D’AUTEUR transcribed in any form or by any means, electronic, mechanical, © Association canadienne de physiothérapie, 2020. Tous droits photocopying, recording, or otherwise, without written permission réservés. Aucune partie de la présente publication ne peut être from the Canadian Physiotherapy Association and its publisher, reproduite, emmagasinée dans un système de recherche documentaire, University of Toronto Press. ou transcrite, d’aucune façon que ce soit ou par quelque moyen électronique ou mécanique que ce soit — photocopie, enregistrement Requests should be made to Permissions Coordinator, Journals ou autre — sans l’autorisation écrite de l’Association canadienne de Division, University of Toronto Press, journal.permissions@utpress. physiothérapie (ACP) et de son éditeur, l’University of Toronto Press. utoronto.ca, fax: 416-667-7832 or 1-800-221-9985. Les demandes doivent être adressées au coordonnateur des SUBSCRIPTIONS autorisations, Division des périodiques de l’University of Toronto Press, Individual and institutional subscriptions are available at [email protected], numéro de télecopieur : www.utpjournals.press/loi/ptc. 416-667-7832 ou 1-800-221-9985. 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GUEST EDITORIAL / ÉDITORIALISTE INVITÉE https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 Functional Status as a Central Indicator of Health Status: The Role of Physiotherapy Julie Richardson, PhD Rehabilitation has been posited to be a central health properties of health-related measures of quality of life.9 The strategy in the 21st century,1–3 and this opportunity has International Classification of Functioning, Disability and arisen in Canada as a result of two demographic trends. Health has been proposed and developed as a framework First, Canada’s population is aging, and by 2030 the num­ for conceptualizing and documenting individual, opera­ ber of persons aged 65 years or older is expected to be tional systems, and policy issues related to functioning.10,11 more than 9.5 million, or 23% of Canadians.4 Second, the The framework proposed by Glass, which captures func­ global epidemiological transition from communicable to tional capacity, self-reported performance, and enacted non-communicable disease as causes of illness and death function (actual performance in daily life), can expand our has led to an increase in life expectancy and hence to an concept of function for clinical use.12 increase in multi-morbidity and is prompting the need for long-term management of chronic conditions. The second theme we need to put into practice to view and value function as an essential part of the health In 2017, the World Health Organization (WHO) assessment is to develop strategies that increase our launched “Rehabilitation 2030: A Call for Action,” in impact in primary care and in the community and popu­ which representatives and experts put forth the argu­ lation health sectors. As part of the primary care transition ment that rehabilitation services and strategies should be informed by the expanded chronic care model,13 rehabil­ globally ubiquitous to make them uniformly accessible.5,6 itation has been integrated into primary care. Integrating They have suggested that the WHO adopt functioning as physiotherapy into community health centres and family a third health indicator along with morbidity and mor­ health teams (FHTs) in Ontario, for example, has provided tality.7 Many implementation strategies have been pro­ students the opportunity to learn in these environments, posed to achieve this goal,7 but unless function is viewed and it has prompted a growth in research examining and valued as an essential part of the health assessment the effectiveness of interventions and programming.13–18 affecting both clinical and population health outcomes, However, many Ontario FHTs have only one physiother­ these multi-pronged strategies will be futile. apist for approximately 22,000 patients, and although the focus on group-based programming has increased, many Two main themes need to be put into practice for physiotherapists are still delivering care using a predom­ functional health to be a major health indicator. First, inantly clinical model. Hence, there is a large population functional health needs to be central to all health so that, of patients with unknown functional status and an unmet irrespective of the condition or conditions a person has, or unknown need for rehabilitation that is detrimental to how these conditions affect function as a health outcome their overall health status. Self-monitoring of functioning is considered. Functional health needs to be the new and advice through the personal health record of the elec­ metric for assessing individual and population health tronic health record by the patient and physiotherapist and reflecting how systems are evaluated and funded. maybe a solution to this problem.19 Physiotherapy inter­ Measurement is at the core of this approach. We need to ventions have considerable advantage in contributing to contribute to and advance the measurement of function, the management of chronic conditions; although they the definition of which often lacks conceptual clarity and are associated with small to medium effect sizes, they are consistency. We also need to know more about the mea­ most importantly associated with negligible risk. sures we use and to be able to clearly communicate the meaning attached to the different levels of functioning. Our professional scope is often restricted by limited Finally, we need to better understand how these measure­ resources, so we have an opportunity to develop and eval­ ments of function contribute to overall health status.8 uate alternative approaches within and outside primary care using a population-based perspective. Magnusson The physiotherapy profession has made advances in and colleagues have called for physiotherapists to adopt integrating, standardizing, and evaluating the psychometric From the Institute of Applied Health Sciences, School of Rehabilitation and Department of Health Evidence and Impact, McMaster University, Hamilton, Ont. Correspondence to: Julie Richardson, Institute of Applied Health Sciences, School of Rehabilitation and Department of Health Evidence and Impact, McMaster University, Rm. 443, 1400 Main St. W., Hamilton, ON L8S 1C7; [email protected]. Physiotherapy Canada 2020; 72(2); 107–109; doi:10.3138/ptc-72-2-gee 107

108 Physiotherapy Canada, Volume 72, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 population health frameworks to contribute to the health ensure that function becomes a central measure of health agenda,20 and Satariano and colleagues outlined a pub­ status. lic health agenda to address all forms of mobility restric­ tions.21 This direction is supported by research on and Finally, we need to be innovative in testing new meth­ knowledge translation of effective interventions, along ods of delivering care, effective in communicating the with ways to optimize the transformation of the health value we bring to health care, and influential in shaping care system to prioritize physical functional health as a the future health of Canadians. central focus of personal and population health. REFERENCES Functional status as a central component of health sta­ tus can be enhanced by increasing its awareness among 1. World Health Organization. Rehabilitation 2030 [Internet]. Geneva: the general population: having individuals engage in The Organization; 2020 [cited 2019 Sept 16]. Available from: https:// self-monitoring, self-management, and functional lit­ www.who.int/disabilities/care/rehab-2030/en/. eracy, all of which are key strategies for achieving this outcome. Functional literacy involves developing indi­ 2. World Health Organization (WHO). Rehabilitation: key for health in viduals’ knowledge, behavior, and skills so that they opti­ the 21st century. Geneva: WHO; 2017. mize their physical activity throughout their lives, in the presence of aging, cumulative injury, or comorbid health 3. Stucki G, Bickenbach J, Gutenbrunner C, et al. Rehabilitation: the problems.22 As a result, they will develop a greater under­ health strategy of the 21st century. J Rehabil Med. 2018;50(4):309–16. standing of their own functioning, what changes in func­ https://doi.org/10.2340/16501977-2200. Medline:28140419 tion mean, and how to approach and self-manage these changes, much as they have done in becoming more 4. Canada. Action for seniors report. Ottawa: Government of Canada; aware of nutritional issues. 2014. Functional literacy also requires individuals to develop a 5. Stucki G, Bickenback J. Functioning: the third health indicator in better awareness of and skill level aimed at self-monitoring the health system and the key indicator for rehabilitation. Eur J Phys their physical changes, including subtle changes (preclini­ Rehabil Med. 2017;53(1):134–8. cal disability), and optimizing their physical function. This approach has the potential to maximize functional health 6. Gutenbrunner C, Bickenbach J, Borg K, et al. Scaling up expectancy and functional life expectancy by compressing rehabilitation: towards an international policy agenda. J Rehabil the survival curves (morbidity and the onset of disability)23 Med. 2018;50(4):307–8. https://doi.org/10.2340/16501977-2317. and increasing individuals’ control over their own health. Medline:29644377 Targeting population health will require us to con­ 7. Stucki G, Bickenbach J, Melvin J. Strengthening rehabilitation in ceive of functional health from a life course perspective health systems worldwide by integrating information on functioning in physical and social environments.24–26 Contextualizing in national health information systems. Am J Phys Med Rehabil. functional health within a natural history perspective will 2017;96(9):677–81. https://doi.org/10.1097/phm.0000000000000688. enable us to identify pathways of functioning associated Medline:27984221 with ageing and multi-morbidity, and targeting the critical points along these pathways will increase the efficiency of 8. Min L, Shekelle P. Wanted: a FRAME for staging functional decline interventions. We can contribute to population health by in older adults. J Am Geriatr Soc. 2012;60(11):2167–8. https://doi. linking it to public health, whose mandate is to “monitor org/10.1111/j.1532-5415.2012.04215.x. Medline:23148420 health status” and “inform, educate, and empower people about health issues.”27 9. Tulsky D, Carlozzi N, Cella D. Advances in outcomes measurement in rehabilitation medicine: current initiatives from the National Moving forward, we need to develop and strengthen Institutes of Health and the National Institute on Disability and partnerships and collaboration with agencies that deliver Rehabilitation Research. Arch Phys Med Rehabil. 2011;92(10 community and population-based care. One example is Supplement):S1–6. https://doi.org/10.1016/j.apmr.2011.07.202. LiveWell, a partnership among Hamilton Health Sciences Medline:21958917 (a network of hospitals and a cancer centre), the YMCA, and McMaster University;28 it intends to expand these 10. World Health Organization (WHO). International classification of opportunities by sharing space with prevention clinics functioning, disability and health. Geneva: WHO; 2001. and developing a new YMCA in a downtown site. Other examples in our profession show that we are already 11. Stucki G, Bickenbach J. Functioning information in the learning engaged in community-based approaches, such as ther­ health system. Eur J Phys Rehabil Med. 2017;53(1):139–43. apy interventions in schools and partnerships with local public health units to “walk with a physio.” Providing 12. Glass TA. Conjugating the “tenses” of function: discordance among leadership, coalescing prevention and health promo­ the hypothetical, experimental, and enacted function in older tion initiatives,29 and incorporating these concepts into adults. Gerontologist. 1998;38(1):101–12. https://doi.org/10.1093/ physiotherapy programme curricula are all necessary to geront/38.1.101. Medline:9499658 13. Barr VJ, Robinson S, Marin-Link B, et al. The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model. Hosp Q. 2003;7(1): 73–82. https://doi.org/10.12927/hcq.2003.16763. Medline:14674182 14. Dufour S, Brown J, Lucy D. Integrating physiotherapists within primary health care teams: perspectives of family physicians and nurse practitioners. J Interprof Care. 2014;28(5):460–5. https://doi.org /10.3109/13561820.2014.915210. Medline:24797363 15. Dufour S, Lucy S, Brown J. Understanding physiotherapists’ roles in Ontario primary health care teams. Physiother Can. 2014;66(3): 234–42. https://doi.org/10.3138/ptc.2013-22. Medline:25125776 16. Ontario Physiotherapy Association. Physiotherapy in primary health care [Internet]. Toronto: The Association; 2017 [cited 2017 Oct 31]. Available from: https://opa.on.ca/wp-content/uploads/ Physiotherapists-Primary-Health-Care.pdf. 17. Ministry of Health and Long-Term Care. Ontario boosting access to primary care for people across the province [Internet]. Toronto: The Ministry; 2017 [cited 2017 Oct 31]. Available from: https://news.









































































138 Physiotherapy Canada, Volume 72, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 The inability to effectively clear pulmonary secretions physical therapists in the Canadian health care context can impair ventilation and adequate oxygenation. Suc­ has not been formally evaluated. tioning is one technique that health care professionals use to help individuals manage secretion retention and Rather than further exploring the utility of an existing maintain the integrity of their airways. For the purpose of tool for use with Canadian physical therapists, we chose this study, the term suctioning is used to describe multi­ to create a new tool. There were three reasons for this. ple approaches to removing secretions from the trachea First, most existing tools focus on endotracheal suction­ using a suction catheter, including open and closed sys­ ing and suctioning performed in intensive care units or tem suctioning via an endotracheal or tracheostomy other critical care environments.10 Their broad applica­ tube, as well as orotracheal and nasotracheal suctioning. bility to current practice is therefore limited because they Because suctioning has the potential to cause serious do not reflect the range of suctioning approaches that are adverse effects,1 restrictions are in place to limit who can used and the variety of environments in which suctioning perform it.2 Physical therapists are among those health is performed. Second, more than a third of the articles care professionals authorized to perform suctioning.3 and resources provided insufficient detail to discern how the assessment tools were developed, which detracted In Ontario, physical therapists who perform suction­ from the credibility of these tools as valid assessment ing are required to roster (i.e., register) with the College measures.11 Finally, many of the existing tools predate of Physiotherapists of Ontario (the provincial regulatory the release of more recent peer-reviewed clinical practice body for the profession), indicating that they have guidelines for suctioning and therefore do not consider sufficient training and experience to perform this tech­ more recent evidence and recommended practices1,12 nique in a safe manner.4 This training must include an (e.g., newer evidence about indications for suctioning, evaluative component assessing the physical therapist’s open versus closed system suctioning, and infection con­ knowledge, practical skills, and judgement to perform trol procedures).12 suctioning competently.5 Although professional compe­ tence assessments are an important process because The objective of this study was to develop a compre­ they help to protect the public, they also provide individ­ hensive, up-to-date tool to assess physical therapists’ ual feedback and help institutions identify health care knowledge, skills, and judgement in performing airway professionals in need of further training.6 Despite their suctioning with both intubated and non-intubated adults importance, professional competence assessments have that would be relevant to the Canadian practice context. been reported to be limited beyond initial licensure for We intended this tool to apply across different health many health care professionals.7 care settings and with the suctioning approaches used by physical therapists working with adults. Particular importance has been placed on assessing competence for both high-risk and low-volume health In assessing competence, we selected knowledge, care activities.8 On a survey conducted by Brooks and skills, and judgement as the primary components under colleagues,9 all the participants reported that nurses, consideration given the College of Physiotherapists of respiratory therapists, and physical therapists performed Ontario’s requirement to evaluate these three factors in suctioning in their health care settings; however, nurses relation to the performance of controlled acts.5 We de­ were identified as the health care professional group who fined knowledge as the theoretical or practical under­ performed suctioning most often, and respiratory thera­ standing of a concept, skills as the ability to perform a pists were identified as the health care professional group discrete or observable act, and judgement as the ability to consulted most often when expertise related to suction­ form valuable opinions and make good decisions.13–15 ing was required. Assessing competence for suctioning may therefore be of additional importance for physical METHODS therapists, who may have fewer opportunities to perform We used a modified Delphi method to reach consen­ suctioning in clinical practice than other health care pro­ fessionals. sus about which elements to include in the tool and guide its development. The Delphi method is frequently A number of tools have been developed to assess com­ used to achieve agreement among a group of experts in a petence in performing suctioning. A recent scoping given area using a structured multi-round survey pro­ review identified 36 articles and resources that described cess.16,17 Participants are not given the opportunity to or implemented tools for assessing the competence of physically meet because this reduces the potential for health care professionals who perform suctioning with one participant to exert dominance over others in the adults.10 The majority of these tools were designed to be opinion-building process.18 We followed the six stages of used with nurses and nursing-related professions, such the Delphi method reported by Humphrey-Murto and as nurse technicians, and all but two were developed out­ colleagues,19 modified to include a structured first-round side the Canadian health care context.10 To our knowl­ questionnaire and a final-round sensibility question­ edge, the appropriateness of these tools for use with naire.16,20

Miller et al. Using Expert Consensus to Develop a Tool to Assess Physical Therapists’ Knowledge, Skills, and Judgement in Performing Airway Suctioning 139 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 Developing the questionnaire a relatively homogeneous participant group, 10–15 experts To establish an initial set of items to include in the first- has been suggested.29 Given that this study aimed to rep­ resent a national perspective and included two related yet round questionnaire, we conducted a literature search. distinct expert types, a larger group of 20–25 study partici­ We searched four scientific electronic databases: MED­ pants was targeted. A recruitment email for the study was LINE, EMBASE, the CINAHL, and the Cochrane Library sent out through the Canadian Physiotherapy Association from inception to March 9, 2018, using both database- Cardiorespiratory Division to its members. We also sent specific search headings – for example, suction/ and (lung/ out a recruitment email to faculty members in physical or trachea/) and (practice guidelines/ or clinical compe­ therapy programmes at Canadian universities. Finally, tence/ or professional standard/) – and key word searching snowball sampling was used, whereby individuals who re­ – such as suction* and (endotrachea* or nasopharyngea* or ceived the recruitment email were asked to forward the oropharyngea*) and (competenc* or knowledge or educat*). study information to other physical therapists who might We considered evidence and recommendations identified be interested. in relevant systematic reviews, a meta-analysis, and clinical practice guidelines, as well as items commonly occurring To administer the questionnaires, we used the online in existing tools that assess competence for suctioning for survey platform SurveyMonkey (SurveyMonkey, San health care professionals working with adults.1,12,21–26 Mateo, CA). Anonymized data were exported to Microsoft Excel 2016 (Microsoft Corporation, Redmond, WA) for We then generated a list of items relevant to the analysis. Descriptive statistics included the response knowledge, skills, and judgement required to perform rate and the frequency of distribution for each item. Eth­ suctioning with adults that was based on our literature ics approval was obtained from the Health Sciences search findings. This list of items was included in the Research Ethics Board at the University of Toronto, and first-round questionnaire, with the items grouped ac­ informed consent was obtained from all participants. cording to domains and supporting competencies. Do­ mains were defined as distinct components of the overall Questionnaire rounds act of suctioning, and supporting competencies were de­ We selected a target of three rounds in an attempt to fined as the essential subcomponents of a domain.27 The initial questionnaire was piloted with two experienced avoid the potential for the false consensus phenomenon, physical therapists and, on the basis of their feedback, we whereby fatigued participants agree in an effort to end made minor wording changes to improve clarity. their participation in a study.30 Participants and the recruitment process Round 1 Recruitment for this study was purposeful, targeting This round focused on refining the list of items to experienced cardiorespiratory physical therapists from include in the tool. Participants were asked to rate their across Canada. This included a mix of practising physical level of agreement about including each item (domains therapists and physical therapists employed in academic and supporting competencies) using a 5-point Likert­ positions related to cardiorespiratory practice. To ensure type scale (1 = strongly disagree, 2 = disagree, 3 = neutral, that respondents had adequate knowledge, practising 4 = agree, and 5 = strongly agree). Text boxes on the ques­ physical therapists were eligible to participate if they had tionnaire enabled the participants to explain their rat­ current independent practice registration with a provin­ ings. Consensus was defined a priori as having at least cial or territorial physical therapy regulator, had 2 or 70% of respondents agree or strongly agree or having at more years of physical therapy practice experience in a least 70% of respondents disagree or strongly disagree setting in which individuals with cardiorespiratory condi­ with an item. This definition was selected because it is a tions made up at least 25% of their caseload, and had fairly typical definition of agreement and disagreement in performed suctioning at least once in the previous 6 consensus studies.30 months. A decision made in advance was to include items in Physical therapists employed in academic positions the draft tool about which we had reached consensus of were eligible to participate if they held a current aca­ agreement and to exclude items about which we had demic position at a Canadian university and identified reached consensus of disagreement, with the exception of cardiorespiratory physical therapy as one of their primary items that achieved only borderline consensus (70%–79% teaching areas. They were not required to have per­ agree or strongly agree or 70%–79% disagree or strongly formed suctioning at least once in the previous 6 months. disagree, with written comments suggesting the need for Individuals not registered to practise physical therapy in further consideration). These items were included in the Canada and individuals under provisional or supervised next round, as were items about which consensus was not practice were excluded. reached. Participants were also given the opportunity to suggest additional items that may have been missed in A lack of agreement exists about the optimal sample the literature review. size when using the Delphi method in health care.28 With

140 Physiotherapy Canada, Volume 72, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 Participants were also asked to express their opinion anonymized comments to help them make their deci­ about five rating scales that could potentially be used in sions.18 The participants rated the new items proposed in the tool (e.g., not observed, partially observed, observed; Round 1 and expressed their opinions on a series of re­ poor, fair, good, very good, excellent). For each rating commendations about any items requiring further con­ scale, participants selected one of three choices: 1 = this sideration. Round 2 used the same Likert-type scale as would not be a suitable scale, 2 = neutral, 3 = this would Round 1, and text boxes were again provided for re­ be a suitable scale. Finally, demographic information was sponses. The participants were also asked to rate or re- collected about the participants to provide insight into rate the rating scales moved forward from Round 1; these the breadth of their relevant experience and representa­ included the two rating scales that had received the high­ tion across geographical areas. If participants did not est mean scores in Round 1 and one new scale proposed respond to the questionnaire within 1 week, we sent out by a study participant. Additional questions posed about a reminder email; we followed this same reminder pro­ the rating scale for the tool are included in Figure 1; the cess in all rounds. complete Round 1 and 2 questionnaires are available on request from the authors. Round 2 The focus of this round was to finalize the items to Round 3 This round focused on evaluating the preliminary ver­ include in the tool and select a final rating scale for the tool. Only individuals who had participated in Round 1 sion of the tool that we created on the basis of the re­ were invited to participate. We gave them the results sponses in Rounds 1 and 2. We shared the preliminary from Round 1 in aggregate form along with a summary of tool with an Expert Advisory Committee (EAC) made up Figure 1 Additional Rating Scale Questions 1. Out of the two options provided, which do you prefer? ◯ A tool where the rater rates the physical therapist’s performance on each of the individual supporting competencies that are included (see Example A). ◯ A tool where the rater rates the physical therapist’s performance only on each of the domains that are included, with supporting competencies used to provide examples of desired performance within each domain (see Example B). Example A Rating scale ◯ ◯ Baseline assessment ◯ ◯ Performs a baseline assessment to assess the need for suctioning ◯◯◯ ◯ ◯ ◯ ◯ Determines an appropriate clinical indication for suctioning ◯◯◯ ◯ ◯ Considers potential contraindications for performing suctioning on the individual ◯◯◯ Considers potential complications for performing suctioning on the individual ◯◯◯ patient Example B Baseline assessment Rating scale Supporting competencies: ◯◯◯ Performs a baseline assessment to assess the need for suctioning Determines an appropriate clinical indication for suctioning Considers potential contraindications for performing suctioning on the individual Considers potential complications for performing suctioning on the individual patient 2. Should the tool include an overall opinion on the individual’s performance (that would be rated using the selected rating scale)? ◯ Yes ◯ No Note: Examples provided under each supporting competency have been omitted.

Miller et al. Using Expert Consensus to Develop a Tool to Assess Physical Therapists’ Knowledge, Skills, and Judgement in Performing Airway Suctioning 141 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 8:36:50 PM - IP Address:43.246.243.82 of four regulated health care professionals (two physical the previous rounds and included text boxes to allow par- therapists, one respiratory therapist, and one registered ticipants to explain their ratings and provide additional nurse) with expertise in suctioning or developing health- feedback about the tool. As determined a priori, individ- care-related assessment measures. We then participated ual items in the sensibility questionnaire were considered in a round-table discussion with the EAC, followed by an sensible if they achieved a mean score of at least 4 out of anonymous majority-rules vote to reach consensus on 5, and we used a combined mean score of at least 4 out items still under consideration after Round 2. The EAC of 5 to determine the tool’s global sensibility. also provided feedback on the preliminary tool before we shared it with the participants. Modified Delphi rounds concluded after Round 3. We used the responses from the Round 3 questionnaire to Only those individuals who had participated in Round revise the preliminary tool and then emailed the revised 2 were invited to participate in Round 3. They evaluated tool to all the final-round participants. the preliminary tool by completing a sensibility question- naire adapted from Duong and colleagues, who had RESULTS based their work on a questionnaire originally developed A total of 34 individuals participated in Round 1, 30 by Rowe and Oxman, using the dimensions of sensibility outlined by Feinstein.20,31,32 In this context, sensibility re- of 34 participated in Round 2, and 25 of 30 participated fers to the tool’s level of common sense, which is tied to in Round 3. The participants’ characteristics are pre- its face and content validity.31 The questionnaire was an- sented in Table 1. Round 1 remained open for 3 weeks: an swered using the same five-point Likert-type scale as in initial 2-week period followed by a 1-week extension; the round was re-opened after a number of new participants Table 1 Delphi Participants’ Characteristics Round, no. (%)* Characteristic 1 (n = 34) 2 (n = 30) 3 (n = 25) Employment status 22 (64.7) 19 (63.3) 15 (60.0) Practising physical therapist 4 (11.8) 4 (13.3) 4 (16.0) Teaching position in physical therapy 8 (23.5) 7 (23.3) 6 (24.0) Both 2 (5.9) 1 (3.3) 1 (4.0) Province or territory of employment 4 (11.8) 3 (10.0) 2 (8.0) British Columbia 4 (11.8) 3 (10.0) 3 (12.0) Alberta 20 (58.8) 19 (63.3) 17 (68.0) Saskatchewan 3 (8.8) 3 (10.0) 1 (4.0) Ontario 1 (2.9) 1 (3.3) 1 (4.0) Quebec Nova Scotia 4–41 4–41 4–41 13 18 19 Physical therapy related practice, y Range, min–max 28 (82.4) 25 (83.3) 20 (80.0) Median 5 (14.7) 5 (16.7) 5 (20.0) 1 (2.9) 0 (0) 0 (0) Primary practice setting Acute care (including intensive and critical care) 5 (14.7) 4 (13.3) 4 (16.0) Educational or academic setting 4 (11.8) 4 (13.3) 3 (12.0) Outpatient setting 3 (8.8) 3 (10.0) 3 (12.0) 3 (8.8) 2 (6.7) 1 (4.0) Suctioning procedures, past 6 mo 8 (23.5) 6 (20.0) 5 (20.0) None{ 11 (32.4) 11 (36.7) 9 (36.0) < 1×/mo  1×/mo  1×/wk 1×/d > 1×/d Note: Percentages may not total 100 because of rounding. * Unless otherwise indicated. { Physical therapists employed in academic positions were eligible to participate in the study even if they had not performed suctioning at least once in the previous 6 months.