PHYSIOTHERAPY CANADA

184 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 In the MMI admissions process, the interviewer plays end, presented a more accurate and fair depiction of the a crucial role. In our study, experience with interview- candidates. Participants agreed that CBS has potential as ing influenced the overall admissions experience; it is a method to identify and evaluate unique non–fact-based possible, however, that because this is the first time the characteristics of the PT profession not identified by RBS program has conducted a qualitative examination after and that it would assist in the PT admissions process. Al- admissions, the opinions of new and more experienced though this study only included the MMI for admission participants are now understood better than before. to the MPT program at the University of Saskatchewan, Participants’ level of fatigue, their use of the materials the findings may be generalized to other health-related provided, and overall logistics (e.g., interactions with admissions processes in Canada. candidates, perceptions of time) were influenced by their past experience. It seems worthwhile to further explore KEY MESSAGES this issue. What is already known on this topic Although different cases are usually used for the morn- The Multiple Mini-Interview (MMI) has been shown ing and afternoon cycles, for the purpose of this project the same cases were used all day at the research stations. to be reliable, valid, and suitable for assessing candidates’ Participants expressed concerns about this resulting in skills in non–fact-based knowledge categories such as fatigue and an inability to maintain the same standard communication.1,4,6 throughout the day. Although the candidates were allo- cated randomly to the different MMI cycles, several par- What this study adds ticipants agreed that the stronger candidates were in the Participants considered the criterion-based system to morning’s circuits. Although this would create a problem in an admissions process relying on RBS, CBS solves this be more accurate and fair than the rank-based system problem because candidates are assessed individually for scoring the MMI. Criterion-based scoring also identi- rather than relative to the rest of their assigned circuit— fies desirable characteristics for the physical therapy that is, whether they are in a strong or a weak circuit, profession. The findings of this study suggest that the CBS should produce their true score. use of criterion-based scoring in Master of Physical Therapy admission MMIs should be expanded. Professionalism, communication, and critical think- ing are thought to underpin success in a PT career.22–28 REFERENCES These categories are increasingly considered to be as im- portant as academic credentials in determining profes- 1. Uijtdehaage S, Doyle L, Parker N. Enhancing the reliability of the sional and academic outcomes.22,27,29 Using CBS, partic- Multiple Mini-Interview for selecting prospective health care ipants evaluated candidates according to several criteria leaders. Acad Med. 2011;86(8):1032–9. http://dx.doi.org/10.1097/ in these three categories, which were chosen with the ACM.0b013e3182223ab7. Medline:21694560 goal of finding the right candidates with the highest potential, not just those with the best test scores (i.e., 2. Eva KW, Rosenfeld J, Reiter HI, et al. An admissions OSCE: the grade-point average). It is important to investigate the Multiple Mini-Interview. Med Educ. 2004;38(3):314–26. http:// predictive value of the new scoring system (CBS in the dx.doi.org/10.1046/j.1365-2923.2004.01776.x. Medline:14996341 MMI) in determining the likelihood of a candidate’s completing the program successfully. In addition, the 3. Till H, Myford C, Dowell J. Improving student selection using multi- selection profile should be compared from year to year ple mini-interviews with multifaceted Rasch modeling. Acad Med. to determine what, if any, adjustments may need to be 2013;88(2):216–23. http://dx.doi.org/10.1097/ACM.0- made. b013e31827c0c5d. Medline:23269299 Our study has several limitations. First, some of the 4. Roberts C, Walton M, Rothnie I, et al. Factors affecting the utility study participants assisted in developing one of the of the Multiple Mini-Interview in selecting candidates for graduate- cases, which may have biased their assessment of candi- entry medical school. Med Educ. 2008;42(4):396–404. http:// dates’ responses. Second, our analysis did not consider dx.doi.org/10.1111/j.1365-2923.2008.03018.x. Medline:18338992 participants’ subjectivity or the difficulty of the various stations. 5. Harasym PH, Woloschuk W, Mandin H, et al. Reliability and validity of interviewers’ judgments of medical school candidates. Acad Med. CONCLUSION 1996;71(1 Suppl):S40–2. http://dx.doi.org/10.1097/00001888- To our knowledge, this is the first study to investigate 199601000-00038. Medline:8546779 CBS in the MMI. CBS was well accepted by participants, 6. Lemay JF, Lockyer JM, Collin VT, et al. Assessment of non-cognitive the majority of whom preferred it over the already- traits through the admissions Multiple Mini-Interview. Med Educ. known RBS method. Participants felt that CBS evaluated 2007;41(6):573–9. http://dx.doi.org/10.1111/j.1365- a valid set of non–fact-based characteristics and, in the 2923.2007.02767.x. Medline:17518837 7. Admissions, Undergraduate Medical Program, Michael G. DeGroote School of Medicine. Manual for interviewers [Internet]. Hamilton (ON): McMaster University; 2013 [cited 2013 Jan]. Available from: http://fhs.mcmaster.ca/mdprog/interviews.html. 8. Ornstein AC. Norm-referenced and criterion-based tests: An over- view. NASSP Bull. 1993;77(555):28–39. http://dx.doi.org/10.1177/ 019263659307755505. 9. Montgomery PC, Connolly BH. Norm-referenced and criterion- referenced tests. Use in pediatrics and application to task analysis of motor skill. Phys Ther. 1987;67(12):1873–6. Medline:3685115

van der Spuy et al. Experiences with Two Multiple Mini-Interview Scoring Methods for Master of PT admission 185 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 10. Popham JW. Educational evaluation. Englewood Cliffs (NJ): 22. Vendrely AM. An investigation of the relationships among academic Prentice-Hall; 1975. performance, clinical performance, critical thinking, and success on the physical therapy licensure examination. J Allied Health. 11. Leonard J. How group composition influenced the achievement of 2007;36(2):e108–23. Medline:19759986 sixth-grade mathematics students. Math Think Learn. 2001;3(2– 3):175–200. http://dx.doi.org/10.1080/10986065.2001.9679972. 23. Roberts LC, Whittle CT, Cleland J, et al. Measuring verbal com- munication in initial physical therapy encounters. Phys Ther. 12. Creswell JW. Qualitative inquiry and research design: Choosing 2013;93(4):479–91. http://dx.doi.org/10.2522/ptj.20120089. among five traditions. Thousand Oaks (CA): Sage; 2006. Medline:23197846 13. Fontana A, Frey JH. Interviewing: the art of science. In: Denzin NK, 24. Pinto RZ, Ferreira ML, Oliveira VC, et al. Patient-centred communi- Lincoln YS, editors. Handbook of qualitative research. Thousand cation is associated with positive therapeutic alliance: a systematic Oaks (CA): Sage; 1994. p. 361–75. review. J Physiother. 2012;58(2):77–87. http://dx.doi.org/10.1016/ S1836-9553(12)70087-5. Medline:22613237 14. van Manen M. Researching lived experience: human science for an action sensitive pedagogy. London (ON): Althouse Press; 1997. 25. Black LL, Jensen GM, Mostrom E, et al. The first year of practice: an investigation of the professional learning and development of 15. Bogdan RC, Biklen SK. Qualitative research for education: An intro- promising novice physical therapists. Phys Ther. 2010;90(12):1758– duction to theory and methods. 2nd ed. Boston: Allyn & Bacon; 2003. 73. http://dx.doi.org/10.2522/ptj.20100078. Medline:20930050 16. Wolcott HF. Writing up qualitative research. 2nd ed. Thousand Oaks 26. Øien AM, Steihaug S, Iversen S, et al. Communication as negotiation (CA): Sage; 2001. p. 12–48. processes in long-term physiotherapy: a qualitative study. Scand J Caring Sci. 2011;25(1):53–61. http://dx.doi.org/10.1111/j.1471- 17. Guba EG. Criteria for assessing the trustworthiness of naturalistic 6712.2010.00790.x. Medline:20384974 inquiries. Educ Tech Res. 1981;29(2):75–91. 27. Cahalin LP. The Linda Crane lecture professionalism & core values 18. Meadows LM, Morse JM. Constructing evidence within the qualita- in physical therapy: lessons learned from Linda Crane. Cardiopulm tive project. In: Morse JM, Swanson JM, Kuzel J, editors. The nature Phys Ther J. 2012;23(2):30–9. Medline:22833707 of qualitative evidence. Thousand Oaks (CA): Sage; 2001. p. 187–200. 28. Aguilar A, Stupans I, Scutter S, et al. Exploring the professional 19. Grice KO. Use of multiple mini-interviews for occupational therapy values of Australian physiotherapists. Physiother Res Int. admissions. J Allied Health. 2014;43(1):57–61. Medline:24598901 2013;18(1):27–36. http://dx.doi.org/10.1002/pri.1525. Medline:22585620 20. Cameron AJ, Mackeigan LD. Development and pilot testing of a multiple mini-interview for admission to a pharmacy degree pro- 29. Kelland K, Hoe E, McGuire MJ, et al. Excelling in the role of gram. Am J Pharm Educ. 2012;76(1):10. http://dx.doi.org/10.5688/ advocate: a qualitative study exploring advocacy as an essential ajpe76110. Medline:22412209 physiotherapy competency. Physiother Can. 2014;66(1):74–80. http://dx.doi.org/10.3138/ptc.2013-05. Medline:24719513 21. Oliver T, Hecker K, Hausdorf PA, et al. Validating MMI scores: are we measuring multiple attributes? Adv Health Sci Educ Theory Pract. 2014;19(3):379–92. http://dx.doi.org/10.1007/s10459-013-9480-6. Medline:24449121

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Clinician’s Commentary on van der Spuy et al.1 Admissions to health professional programmes are highly In 2009, the Essential Competency Profile for Physiothera- competitive; thus, programmes seek to ensure that they are ex- pists in Canada was introduced; it describes the essential knowl- tending offers of admission to candidates who best exemplify edge, skills, and attitudes required by entry-to-practice physio- the profile of their profession. Considering applicants involves therapists and by all physiotherapists throughout their careers a multiple-sampling process that includes assessing academic in Canada.12 Although all Canadian entry-to-practice physio- ability, personal statements, interviews, and references. therapy programmes have an individualized approach to their admissions assessments, these processes consistently include The standard for assessing academic and cognitive skills an academic evaluation and a cognitive evaluation. It is the across all health disciplines involves reviewing academic perfor- non-cognitive evaluation in which a variety of strategies may or mance, whereas personal characteristics and non-cognitive may not be used, such as the MMI, written personal profiles, skills are assessed through written personal statements in re- and personal statements. sponse to specific questions, personal and professional refer- ences, and interviews. Over the past decade, there has been an The study by van der Spuy and colleagues1 highlights the ongoing discourse about the merits of the personal or panel process that the University of Saskatchewan undertook to de- interview versus the multiple mini-interview (MMI).2–5 In their scribe participants’ attitudes, beliefs, and experiences using the article ‘‘Interviewers’ Experiences with Two Multiple Mini- rank-based and criterion-based methods of scoring. The results Interview Scoring Methods Used for Admission to a Master of of their investigation revealed that the criterion-based scoring Physical Therapy Programme,’’ van der Spuy and colleagues1 system was viewed more favourably by both interviewees and explored the fairness and objectivity of two methods of scoring interviewers. Participants strongly agreed that criterion-based the MMI. scoring offered a fairer, more objective, and more accurate depiction of the candidates. The traditional interview typically consists of one or more interviewers engaging in an unstructured or semi-structured This is the first published study that provides food for dialogue with a candidate for anywhere from 15 minutes to 1 thought about the strategies used to assess and measure non- hour. However, a growing body of evidence has shown inconsis- cognitive domains in the admissions process for the physio- tent reliability and susceptibility to bias that has raised ques- therapy profession. On the basis of the work of van der tions about using the traditional interview as a key element of Spuy and colleagues,1 one can surmise that physiotherapy pro- the decision-making process for admission to health discipline grammes interested in adopting the MMI as an element of their programmes.2–4 admissions process should consider the criterion-based scoring system to assess critical non-cognitive skills. The MMI, through An alternative to the traditional interview, originating at purposeful development of questions related to the physio- McMaster University, is the MMI, which gives candidates the therapy essential competencies, offers an opportunity to assess opportunity to interact with multiple interviewers.2 On average, the non-cognitive domains essential to the development of the an MMI consists of 10 stations, with one interviewer at each sta- compassionate, comprehensive, and competent physiotherapist tion; each interviewer has 2 minutes to read a question, and the of the 21st century. interviewee’s interaction with the interviewer lasts 8 minutes.2 Evidence to date has suggested that the MMI is an efficient use Sharon Switzer-McIntyre, BPE, BScPT, MEd, PhD of resources, generally reliable, and well received overall by both Assistant Professor, OIEPB Program, Department of Physical interviewees and interviewers.3 Therapy, Faculty of Medicine, University of Toronto Throughout the literature, there have been no reported asso- ciations between pre-entry academic status and performance in REFERENCES the MMI. This may suggest that the MMI is actually testing non- cognitive attributes such as critical thinking, moral and ethical 1. van der Spuy I, Busch A, Bidonde J. Interviewers’ experiences with decision making, empathy, communication skills, professional- two multiple mini-interview scoring methods used for admission to ism, cultural sensitivity, advocacy, and knowledge of the health a master of physical therapy programme. Physiother Can. care system.2–10 The two most common evaluation strategies 2016;68(2):179–85. http://dx.doi.org/10.3138/PTC.2015-24. used to measure performance during an MMI are (1) norm referenced (rank based), which ranks each candidate relative 2. Eva KW, Rosenfeld J, Reiter HI, et al. An admissions OSCE: the to the other candidates, and (2) criterion referenced, which Multiple Mini-Interview. Med Educ. 2004;38(3):314–26. http:// evaluates each candidate against a preset standard for accept- dx.doi.org/10.1046/j.1365-2923.2004.01776.x. Medline:14996341 able achievement.11 3. Pau A, Jeevaratnam K, Chen YS, et al. The Multiple Mini-Interview To meet the needs of the 21st-century health care system, (MMI) for student selection in health professions training—a many health professions are developing core essential compe- systematic review. Med Teach. 2013;35(12):1027–41. http:// tencies, with the expectation that they will provide a clear guide dx.doi.org/10.3109/0142159X.2013.829912. Medline:24050709 to the necessary behaviour, skills, knowledge, and practices that will enable the development, over time, of compassionate, com- 4. Axelson RD, Kreiter CD. Rater and occasion impacts on the reliability prehensive, and competent health professionals.12 The MMI of pre-admission assessments. Med Educ. 2009;43(12):1198–202. facilitates the evaluation of the non-cognitive attributes pre- http://dx.doi.org/10.1111/j.1365-2923.2009.03537.x. valent in the construct of this competency-based approach to Medline:19930511 education and practice.2–4 186

Clinician’s Commentary on van der Spuy et al. 187 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 5. Thomas A, Young ME, Mazer BL, et al. Candidates’ and interviewers’ 9. El Says F, Ayuob N, Fahmy AR, et al. Experience of establishment of perceptions of multiple-mini interviews for admission to an occu- multiple mini structure interview as part of student admission policy pational therapy professional program. Occup Ther Health Care. at Faculty of Medicine, King Abdulaziz University, 2011-2012. 2015;29(2):186–200. http://dx.doi.org/10.3109/ Med Teach. 2013;35(Suppl 1):S74–7. http://dx.doi.org/10.3109/ 07380577.2015.1012776. Medline:25821884 0142159X.2013.765543. Medline:23581900 6. Cox WC, McLaughlin JE, Singer D, et al. Development and assess- 10. Popham JW. Educational evaluation. Englewood Cliffs (NJ): ment of the Multiple Mini-Interview in a school of pharmacy Prentice-Hall; 1975. admissions model. Am J Pharm Educ. 2015;79(4):Article 53. http:// dx.doi.org/10.5688/ajpe79453. Medline:26089562 11. Frank JR, editor. The CanMEDS 2005 physician competency frame- work: better standards, better physicians, better care. Ottawa: Royal 7. Cameron AJ, Mackeigan LD. Development and pilot testing of a College of Physicians and Surgeons of Canada; 2005. multiple mini-interview for admission to a pharmacy degree pro- gram. Am J Pharm Educ. 2012;76(1):Article 10. http://dx.doi.org/ 12. Accreditation Council for Canadian Physiotherapy Academic 10.5688/ajpe76110. Medline:22412209 Programs, Canadian Alliance of Physiotherapy Regulators, Canadian Physiotherapy Association, Canadian Council of Physiotherapy 8. Vendrely AM. An investigation of the relationships among academic University Programs. The essential competency profile for physio- performance, clinical performance, critical thinking, and success on therapists in Canada. Toronto: Authors; 2009. the physical therapy licensure examination. J Allied Health. 2007;36(2):e108–23. Medline:19759986 DOI:10.3138/ptc.2015-24-CC

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 EDUCATION Standing on the Precipice: Evaluating Final-Year Physiotherapy Students’ Perspectives of Their Curriculum as Preparation for Primary Health Care Practice Sinead McMahon, BSc (hons), DipHSM, MISCP;* Grainne O’Donoghue, PhD, BSc, MSc, MISCP;† Catherine Doody, PhD, MSc, DipTP, MISCP;* Geraldine O’Neill, PhD, PGDPSE, PGDipSTAT, DipCOT;‡ Terry Barrett, BSoc Sc, MEd, PhD, DSUS;‡ Tara Cusack, PhD, MMedSc, Grad Dip Phys, SMISCP* ABSTRACT Purpose: To explore final-year physiotherapy students’ perceptions of primary health care practice to determine (1) aspects of their curriculum that support their learning, (2) deficiencies in their curriculum, and (3) areas that they believe should be changed to adequately equip them to make the transition from student to primary health care professional. Methods: Framework analysis methodology was used to analyze group opinion obtained using structured group feedback sessions. Sixty-eight final-year physiotherapy students from the four higher education institutions in Ireland participated. Results: The students identified several key areas that (1) supported their learning (exposure to evidence-based practice, opportunities to practise with problem-based learning, and interdisciplinary learning experiences); (2) were deficient (primary health care placements, additional active learning sessions, and further education and practice opportunities for communication and health promotion), and (3) required change (practice placements in primary health care, better curriculum organization to accommodate primary health care throughout the programme with the suggestion of a specific primary health care module). Conclusion: This study provides important insights into physiotherapy students’ perceptions of primary health care. It also provides important indicators of the curriculum changes needed to increase graduates’ confidence in their ability to take up employment in primary health care. Key Words: education; physical therapy specialty; primary health care; students. RE´ SUME´ Objectif : Explorer les perceptions qu’ont les e´ tudiants de dernie` re anne´ e en physiothe´ rapie des soins primaires afin de de´ terminer (1) les aspects du curriculum qui favorisent leur apprentissage, (2) les lacunes dans le curriculum et (3) les changements ne´ cessaires pour mieux les pre´ parer a` la profession en soins primaires. Me´ thodes : Les opinions du groupe ont e´ te´ recueillies lors de se´ ances de groupe structure´ es et analyse´ es au moyen d’un cadre me´ thodologique analytique. Soixante-huit e´ tudiants de dernie` re anne´ e en physiothe´ rapie des quatre e´ tablissements d’enseignement supe´ rieur d’Irlande ont pris part a` l’e´ tude. Re´ sultats : Les e´ tudiants ont releve´ des (1) e´ le´ ments favorables a` leur apprentissage (exposition a` la pratique fonde´ e sur les donne´ es probantes, apprentissage par proble` mes, expe´ riences d’apprentissage interdisciplinaire); (2) des lacunes (manque de stages en soins primaires, de se´ ances d’apprentissage actif et de formation en communication et en promotion de la sante´ ); (3) et des changements ne´ cessaires (stages en soins primaires, re´ organisation du curriculum afin d’inte´ grer les soins primaires tout au long du programme, inclusion d’un module spe´ cifique sur les soins primaires). Conclusion : Cette e´ tude apporte un e´ clairage utile sur les perceptions qu’ont les e´ tudiants en physiothe´ rapie des soins primaires. Elle met e´ galement au jour les changements qui s’imposent afin d’ame´ liorer la confiance des diploˆ me´ s en leur capacite´ de pratiquer en soins primaires. Around the world, there is an increasing focus on ing primary health care teams in Ireland2 and com- investing in, and reforming, health care services to meet munity primary health care centres and, more recently, the demands of progressively aging populations with family health teams in Canada,3,4 where employment complex chronic presentations.1 This, it is hoped, will opportunities for physiotherapists will increase as more lead to better provision of primary health care services funding becomes available. in the future. Health care reform strategies are aiming to meet the needs of whole communities in an integrated, Primary health care is defined as an approach to care interdisciplinary, and user-friendly manner by establish- that includes a range of services designed to keep people well, from promotion of health and screening for disease From the: *School of Public Health, Physiotherapy and Population Science, University College Dublin; †School of Health and Human Performance, Dublin City University; ‡Teaching and Learning, University College Dublin, Ireland. Correspondence to: Sinead McMahon, Health Sciences Building, UCD Belfield, Dublin 4, Ireland; [email protected]. Contributors: All authors designed the study; collected, analyzed, and interpreted the data; drafted or critically revised the article; and approved the final draft. Competing interests: None declared. Physiotherapy Canada 2016; 68(2);188–196; doi:10.3138/ptc.2015-11E 188

McMahon et al. Evaluating Final-Year Physiotherapy Students’ Perspectives of Their Curriculum 189 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 to assessment, diagnosis, treatment, and rehabilitation unable to identify transferable skills required by potential as well as personal social services.5 In the Irish context, employers. Transferable skills are defined as those cogni- primary health care refers to the delivery of publicly tive and personal skills (such as information handling funded, interdisciplinary care. Services provide first-level skills; technical and numeracy skills; information technol- contact that is fully accessible by self-referral, and they ogy skills; organizational skills, managing self-learning, have a strong emphasis on working with communities and presentation skills) that are central to occupational and individuals to improve their health and social well- competence in all sectors and at all levels.13 being.5 Currently, physiotherapists in primary health care are not directly accessible to the general public; Kilminster and colleagues14 explored preparedness however, as we will show, this is what is envisaged by for practice among medical students and identified that the Department of Health and Children in the future. preparedness is dependent on the transfer of learning, presuming that doctors are prepared for practice by their To avail themselves of these new employment oppor- learning in medical school and that they will transfer this tunities, physiotherapy graduates will need to be ready learning to the practice setting. However, research has and confident that they can deliver care in an interdisci- suggested that identifying strategies for improving trans- plinary primary health care team. This article presents fer of learning that do not involve deliberate practise for the first time an exploration of final-year physio- is very difficult.15 The need for situated learning was therapists’ perceptions of how well their curriculum supported by Lave and Wenger,16 who identified that prepares them for working in primary health care. Gather- learning is specific and dependent on the context in ing student perceptions provides reflective, experiential which it is achieved. feedback from key stakeholders in the educational pro- cess.6 Of the key stakeholders involved in curriculum Physiotherapy curricula need to be responsive to the evaluation, none have a better perception of the impact of changing needs of the health service, government initia- the curriculum than the students who have completed it.7 tives, and society. In Ireland, however, the transition for students from graduate to practising health care pro- The key question that we aimed to address in this fessional is made all the more difficult by the ongoing study was whether students believe their physiotherapy restructuring of the public health service and the devel- education in Ireland prepares them for employment in opment of primary health care teams and networks.17 primary health care. From a pragmatic perspective, if The challenge for educators is to ensure that the learning students, just before graduation, do not believe that opportunities provided meet the needs of both students they are prepared to work in primary health care, they and patients. A 3-year review of the clinical learning considerably limit their employment opportunities. opportunities available to students in the primary health Physiotherapy programmes must ensure that graduates care setting in Ireland demonstrated that only 5% (171/ are ‘‘fit for purpose,’’ meaning that they require compe- 3,142) of all placements available were in primary health tent diagnostic and clinical skills, an ability to communi- care.18 Therefore, the possibilities for students to gain cate effectively with their colleagues and patients, an experience in the primary health care context during ability to self-manage, and an understanding of the im- their physiotherapy education are limited. A follow-up plications of cultural differences. Physiotherapy educa- Delphi survey of physiotherapists employed in primary tors need to know which elements of their programmes health care revealed that more than 70% did not believe are beneficial in building a perception of preparedness that students were adequately prepared for primary to work in primary health care while also examining health care practice because they lacked an understand- what students perceive to be the deficits in the curricu- ing of the structures involved and the complexity of lum and the elements that they believe require change. cases.19 The main barriers to providing placement oppor- tunities identified by the physiotherapists were a lack of Various studies in the disciplines of nursing, medicine, a tradition of taking students and a lack of physiotherapy and physiotherapy have explored the issue of integrating tutor support for both physiotherapists and students in primary health care into the curriculum.8,9 It has been the primary health care setting.19 Since 2006 in Ireland, suggested that 4th-year medical students who have support for physiotherapy practice placements has mainly spent 8 weeks in a primary health care setting during been provided by specific practice tutor posts, the majority the course of their educational programmes will be of which are based in acute hospital settings.20 It is more successful in making the transition to working in essential for the future of physiotherapy education that that environment.10 This is in accordance with Kolb and there be successful collaboration between academic staff Kolb’s11 theory of experiential learning, which suggests and primary health care practitioners. that providing concrete experience and the opportunity for reflective observation leading to active experimenta- To date, several studies have been conducted to tion is essential for learning. Jones and colleagues12 evaluate the curricular content of physiotherapy pro- found that physiotherapy graduates did not feel pre- grammes. These studies have focused on different areas pared to apply for employment in general and were of practice, ranging from gerontology,21 joint manipula-

190 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 tion,22 and electrophysical agents23 to physical activity cardiorespiratory, and neurological physiotherapy. Ethi- and exercise prescription.24 Methods previously used to cal approval for this study was granted by the relevant conduct these evaluations have included interviews,21 universities’ human research ethics committees. No fund- focus groups,22 surveys,25 and structured group feedback ing was received to conduct this study. sessions (SGFS)24 involving clinical staff, academic staff, and students. SGFS were first described by Gibbs and Data collection colleagues26 as structured discussion that encourages Of the final-year students contacted, 51% (68/134) students to air their views and defend their statements with peers while allowing time for individual thought participated in the study, 10 of whom were male and 12 and reflection on the views of others. of whom had previously completed primary health care experience. Four SGFS were held, one in each institution, However, none of these studies explored curricular and each session included only students from that insti- content to focus on the education required for the tution. Students who had previously completed primary primary health care setting. This study considered several health care experience were included in each group. methodologies to determine how best to gather students’ For the purposes of this study, primary health care perceptions of their curricula. Because it was thought experience was defined as an interdisciplinary approach that surveys and interviews might result in students only to providing health care to patients living in the com- responding to the questions and not actually addressing munity. Each session was moderated by a facilitator, the kernel of their concerns,25,27 it was decided that and an assistant facilitator observed the participants’ focus groups and SGFS would offer an opportunity for behaviour and took notes on the discussion. Each SGFS group discussion and debate.24,28,29 Although focus groups was scheduled to take 90 minutes, and the protocol set are a popular form of group interview because they rely out next was used for all four sessions.31 explicitly on group interaction to generate data,30 SGFS were chosen because they offer a three-stage process Each session was divided into three distinct stages, as in which students develop their own initial thoughts described by Frazer and colleagues32 (see Figure 1). To on a topic before being confronted with other people’s open, the facilitator welcomed the group and presented perceptions. SGFS tend to moderate extreme views while the purpose and context of the session. In Stage 1 (10– allowing a group consensus to emerge. 15 min), students worked alone; they were initially asked to consider their understanding of primary health care Therefore, the aim of this study was to explore, using practice as a potential employment setting for themselves SGFS, final-year physiotherapy students’ perceptions of as new graduates. They were then asked to consider (1) their ability to work on a primary health care team on components of their curriculum that they perceived graduation to determine (1) aspects of their curriculum supported their understanding of primary health care that support their learning, (2) deficiencies in their practice, (2) components of their curriculum that did curriculum, and (3) areas they believe should change. not add to or develop their understanding of primary health care practice, and (3) what they would like to see METHODS changed in their curriculum to improve their under- standing of primary health care practice. Approximately Participants and recruitment 10 minutes was allocated for uninterrupted thought and Physiotherapy education in Ireland is, mainly, a 4-year recording of individual ideas without input from others. In Stage 2 (20–25 min), students worked in small groups, Bachelor of Science physiotherapy degree programme discussing their views from Stage 1. Each group was delivered by universities at Level 8 (Irish National Frame- asked to record its responses. Finally, in Stage 3 (45–50 work of Qualifications).31 Although the programmes are min), students came back together in one large group not exactly the same, substantial similarities exist, and for a plenary discussion. Each point from the small all are accredited by the Irish Society of Physiotherapy. groups was discussed and recorded in writing once We invited by email all final-year students registered in majority support (>50%) was achieved, and all com- undergraduate physiotherapy programmes (n ¼ 134) in ments were noted until no new points emerged. the higher education institutions in Ireland to attend SGFS.32 The students were informed that the main pur- Data analysis pose was to gather feedback on their curriculum and All information from each group was recorded in how it addressed the concept of primary health care practice, the results of which would, in turn, be used to writing, and data were reduced and analyzed using inform future curricula. At the time of recruitment, all framework analysis, a systematic process informed by students had completed the clinical component of their Ritchie and Spencer.33 Framework analysis was chosen programme (more than 1,000 hours) and were within 2 because it can provide outcomes and recommendations months of receiving their professional qualification. in a short time frame. The analysis was undertaken in a Clinical experience is composed of a broad range of coherent, systematic, and visible way, which, although practice areas, which must include musculoskeletal, mainly inductive, allowed for the inclusion of a priori as

McMahon et al. Evaluating Final-Year Physiotherapy Students’ Perspectives of Their Curriculum 191 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Figure 1 Format of structured group feedback sessions. well as emergent concepts. In the initial familiarization Aspects of their curriculum that students perceived supported stage, the authors developed a feel for the meaning their transition to primary health care practice of the data, identifying emerging themes and using key codes to develop a thematic framework. Second-level Exposure to evidence-based practice coding was then used to identify more specific themes Student groups frequently voiced the belief that that emerged, and charts were developed using the headings from the thematic framework. To ensure coder ‘‘evidence-based practice is covered very well, so even if reliability, the primary researcher and two experienced I was on my own I would feel able to look up informa- qualitative researchers checked inter-coder and intra- tion’’ (2.1). Students identified the importance of being coder reliability on a random selection of transcripts. able to communicate their findings. The resulting 93% inter-coder reliability and 95% intra- coder reliability suggested excellent agreement.34 Kappa Presentations as part of our assessments were good coefficients for inter- and intra-coder reliability ranged because it is important to be able to present not just to from .75 to .91, suggesting good to excellent agreement.35 patients but to other members of the multidisciplinary (interdisciplinary) teams, and that can be very hard if RESULTS you have not done it before. (1.5) Results are presented in the following three sections: In terms of their ability to tackle areas that they thought (1) aspects of their curriculum that students perceived were not well covered in the academic curriculum, stu- supported their transition to primary health care prac- dents reported confidence in knowing how to search the tice; (2) aspects of their curriculum that students per- literature and databases. ‘‘We discuss cases, look up evi- ceived to be deficient and that, if addressed, would dence, and reflect on this, so I would feel confident I better prepare them for primary health care practice; could this’’ (3.1). and (3) aspects of their curriculum that students per- ceived required change. Figure 2 provides an overview Practise with problem-based learning of these themes. In terms of pedagogical approaches, the students Each theme is presented, augmented by student quo- identified active participation, problem-based learning, tations. (The numbers in parentheses after the quota- role play, and case-based reflection as beneficial for tions represent university and student number.) enhancing the problem-solving and clinical reasoning skills that they believed were necessary for primary health care practice. ‘‘Small-group case scenarios are

192 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Figure 2 Themes identified by final-year physiotherapy students regarding their perceptions of working in a primary health care setting on graduation. good; we get to reflect as we do it without any pressure’’ Additional active learning opportunities in academic curricula (2.2). Students identified active learning opportunities as Interdisciplinary learning being important. ‘‘There is some repetition of lectures— Participation in interdisciplinary learning opportuni- it would be better to have case-based/problem-based learning. We should use the time better—look into using ties was valued highly by all student groups: ‘‘We only webinar and problem-based learning more’’ (3.2). Stu- had one module where we worked with other students, dents advocated the need for diverse learning oppor- but it was good because you got to know what the other tunities, such as ‘‘more role play in college, especially disciplines do’’ (1.1); ‘‘It should be compulsory to have to when learning communication skills’’ (4.2). spend time with others—occupational therapists, speech therapists, dieticians, and nurses to gain greater under- Lack of education on and practise in how to communicate or standing of team—to encourage holistic care; this is vital interact with patients and members of the team in primary care’’ (2.5). Students highlighted their lack of confidence in their Aspects of their curriculum that students perceived to be ability to communicate with patients and other members deficient of an interdisciplinary team. In terms of patients, they noted that ‘‘we are told to ‘educate patients,’ but how Students identified several deficits in relation to how are we supposed to do this? We don’t know how’’ (4.2). they believed their curriculum currently prepared them In relation to written communication, they highlighted for primary health care practice. the need for skills to know ‘‘how to communicate with team and know how to write letters—for example, deal- Lack of contextual experiential learning opportunities in practice ing with people who did not attend; this is not covered All students were in agreement that primary health in college’’ (2.2). They also highlighted their concerns regarding their confidence in talking to team members. care practice placements were essential. ‘‘There are not ‘‘We don’t have the confidence to speak up at meetings, enough primary care placements: they should be core’’ especially if the whole multidisciplinary (interdisciplinary) (1.2). This is crucial because students are well aware team are there; we need more practice in college or on that these placements are where future employment placement’’ (1.1). opportunities lie.

McMahon et al. Evaluating Final-Year Physiotherapy Students’ Perspectives of Their Curriculum 193 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Lack of education relating to health promotion munities of practice has been recognized as being essen- In terms of academic content relating to primary tial for the development of professional skills that are specific to that workplace.36,37 health care, students believed that ‘‘health promotion should be covered earlier in the curriculum and should However, there are issues with providing a sufficient reoccur as a common theme throughout’’ (1.7). number of practice placements in primary health care. In a recent study that investigated the main barriers to Aspects of their curriculum that students perceived required providing practice placement opportunities in primary change health care, a lack of a tradition of providing placements and a lack of tutor support in the primary health care Practice placements in primary health care setting were identified as key barriers.19 Physiotherapy All students thought that they should be offered the tutors, who would support both physiotherapists and students, have been identified as a key resource by chance to complete a primary health care placement as primary health care clinicians who were considering part of their educational experience. One student group providing context-specific primary health care learning said, ‘‘Primary care placements should be mandatory’’ opportunities for students.19,20 Therefore, it will be essen- (4.2). Students who had experienced a primary health tial in the future for academic faculty and primary health care placement believed that the experience was invalu- care clinicians to work together to develop closer collabo- able. ‘‘On the placement in primary care, you really got ration and support a more patient-centred ethos. to see the setup and administration and how to work with others’’ (1.6). Another student group noted, ‘‘We Students identified the need to include or further lack contacts in primary care—there is no networking— develop interdisciplinary educational opportunities where- no point of contact in primary care compared to hospi- by they would learn with and from other members of tal’’ (1.3). an interdisciplinary team to improve collaboration and quality of care.38 Inter-professional educational oppor- Ensure the concepts of primary health care are threaded tunities, such as specific modules, can be included in throughout the curriculum both the academic and the clinical components of the physiotherapy curriculum. Inter-professional education Students highlighted the need for ‘‘an earlier intro- is important for the future because primary health care duction to the structure of the health service and a recap teams will function within a wider primary health care of any changes that have occurred toward the end of our network, an inter-professional work environment that course’’ (2.1). One student commented, ‘‘We currently relies on professionals having excellent specialist skills, have a primary care lecture only in final year—this is a positive attitude toward working together, knowledge too late’’ (3.2) of other health professionals, and the ability and con- fidence to work with each other in a collaborative and Inclusion of a primary health care module respectful manner.39 To work in primary health care, students suggested Previous research has shown that inter-professional that a module on primary health care should be included education can increase students’ confidence in their in the curriculum: ‘‘It would be really good to have a own professional identity, strengthen their value of other module on primary care in college that was inter-profes- roles, and improve their preparation for placements.40–43 sional and had role-play examples of real cases in pri- A systematic review of postgraduate, work-related inter- mary care’’ (1.2). ‘‘We need to know all organizational/ professional education42 identified six trials44–49 that professional issues that might arise—for example, we compared an intervention and a control group, and it need to know all the planning that goes with seeing found that four studies45,47–49 reported positive out- someone in their own home’’ (4.1). comes. Barr50 also commented that work-based inter- professional education was far more likely than college- DISCUSSION based education to improve the quality of service or Students unanimously agreed that they needed spe- bring about direct patient benefit. Interdisciplinary knowl- edge would therefore appear to be essential for successful cific primary health care practice placement opportuni- primary health care team functioning and an important ties during their education, and they identified the lack component for inclusion in the physiotherapy curriculum. of these opportunities as being a major curricular deficit. A variety of learning opportunities is currently provided Students identified three generic skills that they be- across a wide variety of clinical situations during stu- lieved would improve their ability to deliver primary dents’ education, but there is a distinct lack of context- health care: communication skills, an ability to educate specific primary health care practice placements.18 In patients, and motivational skills, particularly with respect line with Lave and Wenger’s16 theory of situated learn- to educating and motivating patients to change their ing, it is essential that these context-specific opportuni- behaviour and enhance their health. This finding is in ties be available; this also concurs with Kolb and Kolb’s11 line with the results of a meta-analysis by McGrane and experiential learning theory. Therefore, students’ con- cerns are valid: Inclusion of primary health care practice placements is important because immersion in com-

194 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 colleagues51 that indicated that motivational interven- modules designed with both academic and clinical com- tions are successful in increasing healthy physical activity. ponents. Alternatively, specific modules relating to pri- These authors further suggested that physiotherapists mary health care could be designed that would encom- are ideally placed to take on this role and that motiva- pass issues relating to health promotion. tional interventions must become part of physiotherapy practice.51 From a curriculum development perspective, However, it is important that modules not be stand- the inclusion, or further development, of these skills alone; they need to be linked vertically throughout would serve to enhance students’ ability to provide phys- the programme to develop students’ understanding of iotherapy services across a wide spectrum of sectors and primary health care while also linking horizontally to specialties, not only in primary health care. How these their ongoing learning.57 Spiral curricula,56 which inte- skills might be incorporated into the curriculum is ex- grate concepts into all years of a programme, are fre- plored in the following paragraphs. quently used in health disciplines to revisit key concepts such as health promotion. At the University of Toronto, Students perceived that building their confidence in for example, work has been undertaken, using a spiral both oral and written communication was important. In curriculum, to integrate community health teaching into the primary health care setting, there is little evidence the undergraduate medical curriculum.58 to date of what constitutes optimal inter-professional communication;52 however, having the confidence and Finally, students identified that introducing education ability to empower patients to change their behaviour relating to primary health care in the final year of study and embrace a healthier lifestyle would appear to be key is too late. They suggested an early introduction to pri- skills for physiotherapists. As educators, we must provide mary health care, which would then be built on as the opportunities for students to practise and develop these programme progresses, with the possibility of a specific communication skills in a safe and supportive environ- primary health care module with direct input from staff ment. working in primary health care. There has been a funda- mental shift in where health care will be delivered in the Students also suggested that educators need to pro- future, and it is crucial that graduates feel empowered to vide more active learning opportunities in both clinical deliver that care. and academic settings. For example, problem-based learn- ing,53 role play,54 and case studies55 all have the benefit CONCLUSION of improving students’ ability to communicate with their This is the first study that has explored physiotherapy colleagues while also enabling them to develop their problem-solving skills. Offering students more oppor- students’ perceptions of how they believe their cur- tunities to communicate with colleagues across the inter- riculum has prepared them for employment in primary disciplinary spectrum, increased attendance at interdisci- health care. This study highlights the need for enhanced plinary team meetings, more opportunities to present integration of primary health care into the undergraduate their work in public, and more formative feedback on physiotherapy curriculum in an explicit, organized, and written components of their work would all serve to systematic manner, using the principles of good curri- increase student learning while increasing their confi- culum design.56,57 The study also emphasizes the lack of dence. However, as with any educational development, practice placements in the primary health care setting; close collaboration and co-operation among academic, the need to increase the focus on health promotion, inter- clinical, and student stakeholders will be vital to ensure disciplinary working, and communication skills through the success of this initiative. active participation; the requirement for more diverse and innovative teaching methods, such as problem-based Another student suggestion was a greater curricular learning and role play; and engaging with staff from a focus on health promotion. This is in keeping with cur- primary health care setting throughout the programme. rent trends in physiotherapy practice, which is moving To increase learning and improve the confidence of toward illness prevention. Providing students with the the next generation of physiotherapy practitioners in skills necessary not simply to manage illness but also to primary health care, there is an urgent need for physio- be proactive agents of change by promoting health and therapy education programmes to explicitly adopt pri- well-being is crucial. In keeping with students’ sugges- mary health care as the conceptual foundation for their tion to improve curricular organization, health promo- curriculum. tion should be tracked through the physiotherapy cur- riculum.7 Authors who have written about curriculum KEY MESSAGES design have suggested that core areas required for practice should be visited and revisited at increasing What is already known on this topic levels of complexity as students progress through their With an increasing focus on investing in, and reform- programme.56,57 Learning opportunities should be estab- lished in the curriculum to enable the development of ing, health care services to meet the demands of progres- this understanding; they could take the form of specific sively aging populations with complex chronic presenta- tions, it is essential that students feel confident to take up employment in primary health care. However, little

McMahon et al. Evaluating Final-Year Physiotherapy Students’ Perspectives of Their Curriculum 195 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 is known about final-year physiotherapy students’ per- 14. Kilminster S, Zukas M, Quinton N, et al. Preparedness is not enough: ceptions of how well their curriculum prepares them. understanding transitions as critically intensive learning periods. Med Educ. 2011;45(10):1006–15. http://dx.doi.org/10.1111/j.1365- What this study adds 2923.2011.04048.x. Medline:21916940 This study identifies the need for enhanced integra- 15. Norman G. RCT ¼ results confounded and trivial: the perils of grand tion of primary health care into undergraduate curricula educational experiments. Med Educ. 2003;37(7):582–4. http:// in an explicit, organized, and systematic manner. This dx.doi.org/10.1046/j.1365-2923.2003.01586.x. Medline:12834412 integration needs to include practice placement opportu- nities, development of communication skills, and health 16. Lave J, Wenger E. Situated learning: legitimate peripheral participa- promotion education. We believe that adopting these tion. Oxford (UK): Cambridge University Press; 1991. http:// recommendations will better equip students to make dx.doi.org/10.1017/CBO9780511815355. the transition to primary health care employment. 17. Department of Health and Children. Department of Health state- REFERENCES ment of strategy 2011–2014 [Internet]. Dublin: The Department; 2012 [cited 2015 Jul 2]. Available from: http://health.gov.ie/blog/ 1. World Health Organization. A summary of the 2008 world health publications/department-of-health-statement-of-strategy-2011- report primary health care now more than ever [Internet]. Geneva: 2014/ The Organization; 2008 [cited 2014 Oct 6]. Available from: http:// www.who.int/whr/2008/en 18. McMahon S, Cusack T, O’Donoghue G. A profile of physiotherapy practice education settings 2009–2012. Physiother Pract Res. 2. Department of Health and Children. Primary care—A new direction 2014;35(2):95–100. [Internet]. Dublin: Stationery Office; 2001 [cited 2015 Jan 15]. Available from: http://www.health.gove.ie/blog/publications/ 19. McMahon S, Cusack T, O’Donoghue G. Barriers and facilitators to primary-care-a-new-direction providing undergraduate physiotherapy clinical education in the primary care setting: a 3-round Delphi study. Physiotherapy. 3. Dufour SP, Lucy SD. Situating primary health care within the 2013;100(1):14–9. http://dx.doi.org/10.1016/j.physio.2013.04.006. International Classification of Functioning, Disability and Health: Medline:23954025 enabling the Canadian Family Health Team Initiative. J Interprof Care. 2010;24(6):666–77. http://dx.doi.org/10.3109/ 20. Health Service Executive. Report on the review of the practice 13561820903550671. Medline:20178420 education system [Internet]. Dublin: The Executive; 2011. Available at: http://www.tcd.ie/slscs/assets/documents/undergraduate/ 4. Cott CA, Mandoda S, Landry MD. Models of integrating physical clinical-speech/Therapy%20Group%20Details/ therapists into family health teams in Ontario, Canada: challenges Report%20on%20the%20Review%20of%20the%20Practice%20 and opportunities. Physiother Can. 2011;63(3):265–75. http:// education%20System%20%202011.pdf dx.doi.org/10.3138/ptc.2010-01. Medline:22654231 21. Wong R, Stayeas C, Eury J, et al. Geriatric content in physical thera- 5. Department of Health and Children. Primary care: a new direction. pist education programs in the United States. J Phys Ther Educ. Quality and fairness—a health system for you health strategy [Inter- 2001;15(2):4–9. net]. Dublin: Stationery Office; 2004 [cited 2015 Jun 29]. Available from: http://health.gov.ie/wp-content/uploads/2014/03/The- 22. Boissonnault W, Bryan JM, Fox KJ. Joint manipulation curricula in National-Primary-Care-Steering-Group-Progress-Report.pdf physical therapist professional degree programs. J Orthop Sports Phys Ther. 2004;34(4):171–8, discussion 179–81. http://dx.doi.org/ 6. Harvey L. Student feedback. Qual High Educ. 2003;9(1):3–20. http:// 10.2519/jospt.2004.34.4.171. Medline:15128186 dx.doi.org/10.1080/13538320308164. 23. Chipchase LS, Williams ST, Robertson ST. A survey of electrophysical 7. O’Donoghue G, Doody C, Cusack T. Using student-centred evalua- agents’ curricula in entry level physiotherapy programs in Australia tion for curriculum enhancement: An examination of undergraduate and New Zealand. NZ J Physiother. 2005;33(2):34–47. physiotherapy education in relation to physical activity and exercise prescription. Stud Educ Eval. 2011;37(2–3):170–6. http://dx.doi.org/ 24. O’Donoghue G, Doody C, Cusack T. Using student-centred evalua- 10.1016/j.stueduc.2011.04.004. tion for curriculum enhancement: an examination of undergraduate physiotherapy education in relation to physical activity and exercise 8. Albutt G, Ali P, Watson R. Preparing nurses to work in primary care: prescription. Stud Educ Eval. 2011;37(2–3):170–6. http://dx.doi.org/ educators’ perspectives. Nurs Stand. 2013;27(36):41–6. http:// 10.1016/j.stueduc.2011.04.004. dx.doi.org/10.7748/ns2013.05.27.36.41.e7085. Medline:23821989 25. Chapple M, Murphy R. The nominal group technique: extending the 9. Tandeter H, Carelli F, Timonen M, et al. A ‘‘minimal core curriculum’’ evaluation of students’ teaching and learning experiences. Assess for family medicine in undergraduate medical education: a European Eval High Educ. 1996;21(2):147–160. http://dx.doi.org/10.1080/ Delphi survey among EURACT representatives. Eur J Gen Pract. 0260293960210204. 2011;17(4):217–20. http://dx.doi.org/10.3109/13814788.2011.585635. Medline:21574859 26. Gibbs G, Habeshaw S, Habeshaw T. 53 interesting ways to appraise your teaching. Bristol (UK): Technical & Educational Service Ltd; 10. Howe A, Ives G. Does community-based experience alter career 1988. preference? New evidence from a prospective longitudinal cohort study of undergraduate medical students. Med Educ. 27. Husbands CT, Fosh P. Students’ evaluation of teaching in higher 2001;35(4):391–7. http://dx.doi.org/10.1046/j.1365- education: experiences from four European countries and some 2923.2001.00866.x. Medline:11319005 implications of the practice. Assess Eval High Educ. 1993;18(2):95– 114. http://dx.doi.org/10.1080/0260293930180202. 11. Kolb A, Kolb D. Learning styles and learning spaces: enhancing experiential learning in higher education. Acad Manag Learn Educ. 28 Scott J. The use of a special tutorial group to help with course direc- 2005;4(2):193–212. http://dx.doi.org/10.5465/AMLE.2005.17268566. tion. Br J Educ Technol. 2003;34(1):89–93. http://dx.doi.org/10.1111/ 1467-8535.00309. 12. Jones M, McIntyre J, Naylor S. Are physiotherapy students ade- quately prepared to successfully gain employment? Physiotherapy. 29. Brennan J, Williams R. Collecting and using student feedback: a 2010;96(2):169–75. http://dx.doi.org/10.1016/j.physio.2009.11.008. guide to good practice. York (UK): Learning and Teaching Support Medline:20420964 Network; 2004. 13. Whittle SR, Eaton DGM. Attitudes towards transferable skills in 30. Kitzinger J. Qualitative research: introducing focus groups. BMJ. medical undergraduates. Med Educ. 2001;35:148–53. http:// 1995;311(7000):299–302. http://dx.doi.org/10.1136/ dx.doi.org/10.1111/j.1365-2923.2001.00773.x bmj.311.7000.299. Medline:7633241 31. Quality and Qualifications Ireland. National framework of qualifica- tions [Internet]. Dublin: Quality and Qualifications Ireland; 2014 [cited 2015 Jun 23]. Available from: http://www.qqi.ie/Pages/ National-Framework-of-Qualifications-(NFQ).aspx

196 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 32. Frazer K, Connolly M, Naughton C, et al. Identifying clinical learning 46. Thompson C, Kinmonth AL, Stevens L, et al. Effects of a clinical- needs using structured group feedback: first year evaluation of pre- practice guideline and practice-based education on detection and registration nursing and midwifery degree programmes. Nurse Educ outcome of depression in primary care: Hampshire Depression Today. 2014;34(7):1104–8. http://dx.doi.org/10.1016/ Project randomised controlled trial. Lancet. 2000;355(9199):185–91. j.nedt.2014.02.003. Medline:24568698 http://dx.doi.org/10.1016/S0140-6736(99)03171-2. Medline:10675118 33. Ritchie J, Spencer L. Analysing qualitative data. In: Bryman A, Burgess R, editors. Qualitative data analysis for applied policy 47. Morey JC, Simon R, Jay GD, et al. Error reduction and performance research. London: Routledge; 1993. p. 173–94. improvement in the emergency department through formal team- work training: evaluation results of the MedTeams project. Health 34. Miles MB, Huberman AM. Qualitative data analysis and expanded Serv Res. 2002;37(6):1553–81. http://dx.doi.org/10.1111/1475- sourcebook. 2nd ed. London: Sage; 1994. 6773.01104. Medline:12546286 35. Daly LE, Bourke GJ. Interpretation and uses of medical statistics. 5th 48. Morey JC, Simon R, Jay GD, et al. Error reduction and performance ed. Oxford (UK): Blackwell Science Ltd; 2000. http://dx.doi.org/ improvement in the emergency department through formal team- 10.1002/9780470696750. work training: evaluation results of the MedTeams project. Health Serv Res. 2002;37(6):1553–81. http://dx.doi.org/10.1111/1475- 36. Lindquist I, Engardt M, Richardson B. Early learning experiences 6773.01104. Medline:12546286 valued by physiotherapy students. Learn Health Soc Care. 2004;3(1):17–25. http://dx.doi.org/10.1111/j.1473-6861.2004.00060.x. 49. Young AS, Chinman M, Forquer SL, et al. Use of a consumer-led intervention to improve provider competencies. Psychiatr Serv. 37. Richardson B. Professional development 2—professional knowledge 2005;56(8):967–75. http://dx.doi.org/10.1176/appi.ps.56.8.967. and situated learning in the workplace. Physiotherapy. Medline:16088014 1999;85(9):467–74. http://dx.doi.org/10.1016/S0031-9406(05)65471-5. 50. Barr H. Working together to learn together: learning together to work 38. Centre for the Advancement of Interprofessional Education. Defin- together. J Interprof Care. 2000;14(2):177–9. http://dx.doi.org/ ing interprofessional education (IPE) [Internet]. Fareham (UK): 10.1080/713678556. The Center; 2002 [cited 2015 Jun 29]. Available from: http:// www.caipe.org.uk/resources/defining-ipe/ 51. McGrane N, Cusack T, O’Donoghue G, et al. Motivational strategies for physiotherapists. Phys Ther Rev. 2014;19(2):136–42. http:// 39. World Health Organization. Adelaide recommendations on healthy dx.doi.org/10.1179/1743288X13Y.0000000117. public policy. Geneva: The Organization; 1998 [cited 2014 Oct 18]. Available from: http://www.who.int/healthpromotion/conferences/ 52. Hayward C, Willcock S. General practitioner and physiotherapist previous/adelaide/en/index2.html communication: how to improve this vital interaction. Prim Health Care Res Dev. 2015;16(3):304–8. http://dx.doi.org/10.1017/ 40. Cusack T, O’Donoghue G. The introduction of an interprofessional S1463423614000103. Medline:24642048 education module: students’ perceptions. Qual Prim Care. 2012;20(3):231–8. Medline:22828679 53. Gunn H, Hunter H, Haas B. Problem based learning in physiotherapy education: a practice perspective. Physiotherapy. 2012;98(4):330–5. 41. Cusack T, O’Donoghue G, Butler ML, et al. A pilot study to evaluate http://dx.doi.org/10.1016/j.physio.2011.05.005. Medline:23122440 the introduction of an interprofessional problem-based learning module. Interdiscipl J Problem-Based Learn. 2012;6(2):5. http:// 54. Lane C, Hood K, Rollnick S. Teaching motivational interviewing: dx.doi.org/10.7771/1541-5015.1350. using role play is as effective as using simulated patients. Med Educ. 2008;42(6):637–44. http://dx.doi.org/10.1111/j.1365- 42. Parsell G, Bligh J. Interprofessional learning. Postgrad Med J. 2923.2007.02990.x. Medline:18452516 1998;74(868):89–95. http://dx.doi.org/10.1136/pgmj.74.868.89. Medline:9616489 55. Nath J. The roles of case studies in the educational field. Int J Case Meth Res Applic. 2005;17(3):396–400. 43. Reeves S. Community-based interprofessional education for medical, nursing and dental students. Health Soc Care Community. 56. Harden RM. What is a spiral curriculum? Med Teach. 2000;8(4):269–76. http://dx.doi.org/10.1046/j.1365- 1999;21(2):141–3. http://dx.doi.org/10.1080/01421599979752. 2524.2000.00251.x. Medline:11560697 Medline:21275727 44. Brown JB, Boles M, Mullooly JP, et al. Effect of clinician communi- 57. Ornstein AC, Hunkins FP. Curriculum foundations, principles and cation skills training on patient satisfaction: a randomized, con- issues. 5th ed. Boston: Allyn & Bacon; 2009. trolled trial. Ann Intern Med. 1999;131(11):822–9. http://dx.doi.org/ 10.7326/0003-4819-131-11-199912070-00004. Medline:10610626 58. Johnson IL, Scott FE, Byrne NP, et al. Integration of community health teaching in the undergraduate medicine curriculum at the 45. Campbell JC, Coben JH, McLoughlin E, et al. An evaluation of a University of Toronto. Am J Prev Med. 2011;41(4 Suppl 3):S176–80. system-change training model to improve emergency department http://dx.doi.org/10.1016/j.amepre.2011.06.003. Medline:21961661 response to battered women. Acad Emerg Med. 2001;8(2):131–8. http://dx.doi.org/10.1111/j.1553-2712.2001.tb01277.x. Medline:11157288

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 GLOBAL HEALTH Ethics and Community-Based Rehabilitation: Eight Ethical Questions from a Review of the Literature Stephen Clarke, BA;* Jessica Barudin, MSc(PT);† Matthew Hunt, PhD, PT ‡§ ABSTRACT Purpose: This article reviews the literature regarding ethics and community-based rehabilitation (CBR) with the goal of identifying and analyzing ethical considerations associated with this approach. Method: We conducted a critical interpretive review of the academic literature related to CBR in low- and middle-income countries and to indigenous communities in high-income countries. Using an inductive analysis of the collected articles, we identified five key topic areas related to ethical considerations. We then critically appraised this literature and developed eight questions that reflect areas of ethical tension, uncertainty, or debate. Results: The five key topic areas are partnerships among stakeholders, respect for culture and local experience, empower- ment, accountability, and fairness in programme design. The eight ethical questions are linked to these topics and associated with how CBR practices reflect commitments to equity, respect, inclusion, participation, and social justice. Conclusion: Continued engagement with ethical considerations asso- ciated with CBR can help to strengthen the foundations of this important and influential approach. It is crucial that all those involved in CBR projects, including physiotherapists, pay careful attention to the development of partnerships that, despite asymmetries among stakeholders, are respectful and effective. Key Words: ethics; global health; health equity; rehabilitation. RE´ SUME´ Objectif : Examiner la litte´ rature portant sur la re´ adaptation a` base communautaire (RBC) et l’e´ thique afin de re´ pertorier et d’analyser les conside´ rations e´ thiques lie´ es a` cette approche. Me´ thode : Nous avons effectue´ un examen critique de la litte´ rature universitaire portant sur la RBC dans les pays a` faible et moyen revenu et dans les communaute´ s autochtones dans les pays a` revenu e´ leve´ . Suivant une analyse inductive des articles collige´ s, nous avons re´ pertorie´ cinq principaux the` mes lie´ s aux conside´ rations e´ thiques. Nous avons ensuite e´ value´ la litte´ rature de fac¸ on critique et formule´ huit questions touchant a` des e´ le´ ments qui font l’objet de tension e´ thique, d’incertitude ou de de´ bat. Re´ sultats : Les cinq the` mes re´ pertorie´ s sont : partenariats entre les intervenants, respect pour la culture et l’expe´ rience locale, autonomie, responsabilisation et e´ quite´ dans la conception de programmes. Les huit questions d’ordre e´ thique se rattachent a` ces the` mes et visent a` de´ terminer la mesure dans laquelle les pratiques de RBC sont le reflet d’un souci d’e´ quite´ , de respect, d’inclusion, de participation et de justice sociale. Conclusion : Un souci continu des conside´ rations e´ thiques lie´ es a` la RBC permettra de consolider les assises de cette approche importante et influente. Il est impe´ ratif que les intervenants en RBC, y compris les physiothe´ rapeutes, prennent soin de former des partenariats qui, malgre´ le rapport asyme´ trique entre les intervenants, sont respectueux et efficaces. People with disabilities (PWD) are more likely than the community-based rehabilitation (CBR) approach.3 others to live in poverty, not participate in their com- Emerging from a World Health Organization (WHO) pro- munities or in the workforce, and be denied access to posal after the 1978 International Conference on Primary basic rights.1–3 In many contexts around the world, Health Care and the Declaration of Alma-Ata, it has since PWD have limited institutional supports and resources become a widespread development practice that aims to available to them as they seek to meet their daily needs support PWD, particularly in settings in which insti- and develop the full range of their capabilities, and tutional rehabilitation programmes are ineffective or recognizing these realities prompted the development of not widely available.4 In 2004, the International Labour From the: *Biomedical Ethics Unit and Department of Philosophy, McGill University; †Cedar and Gold, Montreal; ‡School of Physical and Occupational Therapy and §Centre for Interdisciplinary Research in Rehabilitation Correspondence to: Matthew Hunt, School of Physical and Occupational Therapy, McGill University, 3654 Boul. Sir William Osler, Montreal, QC H3G 1Y5; [email protected]. Contributors: Matthew Hunt and Jessica Barudin designed the study; Jessica Barudin conducted the literature search; Jessica Barudin and Stephen Clarke reviewed the collected articles; all authors participated in analysis and interpretation; all authors contributed to drafting and critically revising the article; and all authors approved the final draft. Competing interests: None declared. Acknowledgements: The authors thank the members of the Global Health, Ethics and Rehabilitation works-in-progress group at McGill University for their helpful comments on an earlier version of this article. Physiotherapy Canada 2016; 68(2);197–205; doi:10.3138/ptc.2015-35GH 197

198 Physiotherapy Canada, Volume 68, Number 2 Box 1 Key Topic Areas and Associated Ethical Questions Key topic area Associated ethical questions https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Partnerships among stakeholders 1. What factors limit the development of effective and respectful partnerships? Respect for culture and local experience 2. How can CBR implementers who come from outside a local community avoid imposing their own values in Empowerment a harmful way? Accountability 3. Do targeted empowerment efforts result in disempowerment of others? Fairness in program design 4. Can empowerment efforts deflect attention from socio-political barriers? 5. How can a more comprehensive and inclusive approach to accountability be promoted in CBR programmes? 6. Are CBR programmes sufficiently inclusive? 7. How can limited CBR resources be used most fairly? 8. When could reliance on volunteers become exploitative? CBR ¼ community-based rehabilitation. Organization; the United Nations Educational, Scientific, we drew on the notion of moral experience and defined and Cultural Organization; and WHO endorsed an up- ethical considerations to include experiences or situa- dated definition of CBR as ‘‘a strategy within general tions in which values that individuals deem to be impor- community development for the rehabilitation, equaliza- tant are being thwarted or realized in everyday life and tion of opportunities and social inclusion of all people that are interpreted as falling on the spectrums of right– with disabilities.’’3(p.2) Diverse commentators have pro- wrong, good–bad, or just–unjust.15 posed conceptions of CBR that emphasize elements such as the promotion of human rights,5,6 the balancing We began our review by searching the CINAHL, of fundamental power inequalities,7,8 and the fulfillment Medline, Scopus, and Source databases up to 2014. We of basic needs.9 combined the key word community-based rehabilitation, or CBR, with the following key words related to ethical Alongside evolving definitions of CBR, there has been considerations: ethics, ethical, moral, morality, principles, a lively discussion of the purpose, principles, and com- values, power, empowerment, privacy, confidentiality, mitments that underlay CBR programmes and practices. decision making, human rights, harm, and benefit. We Several authors have identified a range of ethical con- reviewed the titles and abstracts of the texts identified in siderations as being important for the CBR model and this search to assess whether ethical considerations in for the implementation of CBR projects. A key contribu- CBR were or were likely to be addressed in the text and tion to the analysis of ethical issues in CBR was a 2002 whether they were related to CBR in low- and middle- article by Turmusani and colleagues,1 which canvassed income countries or among indigenous communities in ethical issues for CBR in low- and middle-income coun- high-income countries. When the review of an abstract tries. Ethical considerations have also been raised by was inconclusive, a team member read the complete other authors writing about the practice, policy, and text. politics of CBR, as well as its evidence base.10–13 In light of the continued evolution of the CBR movement and Next, we searched the reference lists of all retained ongoing discussions of CBR ethics, we reviewed the aca- articles to identify additional texts that were relevant demic literature related to CBR to investigate how it to our review but had not been identified in the initial addresses ethical considerations. database searches. Finally, we conducted targeted web searches for additional articles by authors who were METHODS identified as having written on topics related to ethics We conducted a critical interpretive review of the CBR and CBR, but few texts were added to the review using this strategy. Following these steps, we retained 60 texts literature.14 Developed to guide literature reviews in the for further analysis. field of bioethics, this approach consists of two elements. A critical interpretive review seeks to ‘‘capture the key Two team members then reviewed all collected texts ideas’’14(p.525) in a body of literature to answer a specific while considering the following questions: What implicit research question; it also aims to critically appraise and or explicit ethical considerations related to CBR are analyze the collected literature to put forward an argu- present in this text? How are these ethical considerations ment that advances knowledge of the area of inquiry. discussed by the authors? Using this analysis, we identi- Our critical interpretive review was guided by the follow- fied 51 texts that offered insight into ethical considera- ing question: How are ethical considerations reflected tions associated with CBR, and we considered these texts in the CBR literature? For the purposes of our review, to be primary sources for our analysis.

Clarke et al. Ethics and Community-Based Rehabilitation: Eight Ethical Questions from a Review of the Literature 199 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Following the critical interpretive review approach, projects follow a ‘‘victim-service’’ model,18(p.97) especially we mapped important ideas related to our research in regard to how success is evaluated. Even if project question and identified key topic areas related to ethi- coordinators seek out community expertise and engage cal considerations and CBR. Through this process, these stakeholders to establish goals, a project may still we associated texts with partnerships among stake- be judged on its ability to compensate for losses result- holders,3,5,6,16–29 respect for culture and local experi- ing from physical disability. This criterion can function ence,7,9,18,25,26,28,30–38 empowerment,5,7–9,17–19,23,25,28,30,37,39– as a predetermined and overarching project goal that 43 accountability,2,5,8,9,17,20,21,23,24,27,30,34,36,40,42,44–47 and fair- may not reflect local realities or priorities—or even align ness in programme design.10,11,17,18,20,27,28,30,40,48–58 During well with CBR philosophy.18 Turmusani and colleagues1 our analysis we also considered each topic area in rela- reported that people who did not have disabilities and tion to all of the collected texts. After critically appraising individuals identified as experts often retained control the collected literature, we then formulated eight ques- of CBR, and PWD had little to no role in meaningful tions that reflect sources of ethical tension, uncertainty, decision making. Pollard and Sakellariou30 surveyed or debate related to CBR. The key topic areas and asso- occupational therapists involved in CBR and found that ciated ethical questions are presented in Box 1. PWD were included in making decisions about im- plementing only 7 of 66 programmes; this suggests that RESULTS there is an important gap between the CBR vision and how it is often practised, and it highlights the extent to Partnerships among stakeholders which effective and respectful partnerships among stake- CBR is a complex strategy that requires the engage- holders in many CBR projects may be limited. ment of diverse stakeholders, and asymmetrical relations Respect for culture and local experience are a common feature of CBR projects.5,6,22,27 Stakeholders Demonstrating respect for culture and local knowledge have different degrees of influence, control of resources, power, autonomy, and dependence. has been described as a key element of the CBR approach; it is crucial in enabling programmes to contribute to Stakeholders in CBR extend across community, dis- vocational and other opportunities for PWD and for trict, provincial, and national levels.5 Groups may also supporting local socio-economic development.1,31 The be active stakeholders in CBR processes, notably disabled success of CBR projects is associated with the degree of people’s organizations and other non-governmental integration and grounding in local cultural contexts, and organizations (NGOs).7 This diversity leads to challenges it is linked to how well initiatives serve the needs of a in sharing information44 because it may not reach all population by supporting, and not undermining, local stakeholders,5 a situation that has implications for equity culture and approaches.1,32 and mutuality in these relationships. Failure to promote strong community partnerships and share information A concern that has been raised with several constructs among all stakeholders also impedes community partici- closely tied to CBR is that they reflect commitments and pation and empowerment and can hinder a project’s assumptions associated with Western biomedicine. For sustainability.26,30 Finkenflu¨ gel argued that ‘‘collecting, example, some commentators have questioned whether aggregating, and dispersing information should be an individual empowerment programmes, which tend to on-going and translucent part of empowering the stake- value independence and individual autonomy, are as rele- holders involved in CBR,’’5(p.164) thus promoting more vant in cultural contexts that have a different understand- equality and greater transparency in CBR partnerships. ing and conception of self, dependence, and commu- nity.40,41 This critique is not limited to empowerment, Question 1: What factors limit the development of effective and however. Chung and colleagues described traditional respectful partnerships? Chinese peasant culture as valuing stability and harmony, and they noted that CBR staff from outside a community A variety of factors may limit CBR professionals from often struggled to incorporate these values when they developing or embracing more effective partnerships in were put in charge of implementing a programme.7 CBR.5 These barriers may include a reluctance by those responsible for initiating CBR projects to cede influence A range of gaps in local applicability and attention to over programmes that they have helped build,17 per- local needs and traditions have been identified in the ceived time constraints associated with partnership CBR literature amid concerns about not considering models,8 and simple inattention.17 Given these realities, local contexts when applying approaches that have creating and maintaining partnerships in CBR can be a worked well elsewhere—for example, applying an urban source of ethical tension, especially when communica- approach to a rural setting.31,33 However, a more signifi- tion is difficult, roles and interests are not clarified, and cant challenge exists for CBR projects as they seek to asymmetries of power are entrenched. engage with communities and pay attention to local con- texts throughout the planning process and across the life Pande and Dalal described management and decision- cycle of projects. Chung and colleagues emphasized the making models in CBR as bearing the lingering imprint of institutional approaches to rehabilitation in which

200 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 importance of carefully attending to the cultural features Empowerment in CBR is understood to encompass a of communities because cultural frameworks and values wide range of elements. Some authors have related em- were of critical importance in shaping the ways in which powerment to improving the legal status of PWD and people perceived health, disability, autonomy, family, their access to government services.5 Others have pri- and relationships.7 marily associated empowerment with increasing partici- pation in local communities.18,41 Still others have sug- Particularly challenging questions may arise in rela- gested that empowerment involves efforts to decrease tion to gender and respect for local cultural values and inequality.7 Particular initiatives to promote empower- traditions. Gender influences inclusion and participation ment, however, may raise ethical concerns because they in communities, and women with disabilities face unique have the potential for negative consequences or fallout. disadvantages in contexts in which male-dominated services are provided.17 Thomas and Thomas40 described Question 3: Do targeted empowerment efforts result in societies in which disabled women might be integrated disempowerment of others? into communities of women but had to remain segre- gated from men. These features may give rise to tensions A key ethical consideration associated with empower- between promoting rights and equity on the one hand ment efforts is the possibility of unanticipated negative and demonstrating respect for local approaches and consequences. In some instances, CBR implementers culture on the other. may design empowerment interventions based on pre- determined, externally defined goals that are not well Failure to take note of local values and traditions aligned with community needs or preoccupations.18 As concerning the notion of disability, rehabilitation, and a result, empowerment may be a source of social strain societal responses to those with impairments can perpet- or rupture, or it may be less effective. Empowerment uate negative attitudes and practices toward PWD.1,18,30,48 efforts may also be disruptive, even when their goals are fully achieved. This reflects the observation of Kendall Question 2: How can CBR implementers who come from and colleagues that ‘‘conceptually, the very word ‘em- outside a local community avoid imposing their own values in powerment’ is a paradox.’’19(p.437) In many instances, a harmful way? power is associated with unequal influence or depen- dence in relationships. These authors suggested that in Pollard and Sakellariou30 warned of unduly imposing some contexts, to ‘‘empower’’ one person or group re- one’s own values on the design and implementation of sults in another person or group being disempowered programmes. This risk is particularly elevated when (e.g., to empower PWD can sometimes result in care- those leading a CBR project come from outside a com- givers being disempowered.)19 munity and have insufficient knowledge of the socio- cultural context.7,31,39 Furthermore, gaps in knowledge CBR programmes may introduce significant changes about a project’s history and prior decisions are more into the decision-making process for families and care- likely to occur with the high turnover of staff members givers.34 Individual empowerment, with its focus on in many international projects.30,39 These situations autonomy and independence, may also disrupt impor- hamper individual workers from gaining a nuanced tant modes of interdependence and community.19 Pande understanding of the social and cultural context in which and Dalal18 stressed, however, that the empowerment of a programme is located. It also suggests the limitations the least powerful can benefit all of a community. They of relying on external CBR workers.30 Those who are noted that there was an implicit connection between involved in a CBR project but who come from outside personal empowerment and community empowerment the community need to recognize the importance of and that better integrating PWD into a community had adaptation because the fit of the CBR model varies benefits for both individuals and communities as a among cultural contexts.1 NGOs and their international whole.18 staff must be attentive to local cultural norms, and they must have sufficient humility to recognize the limits of Question 4: Can empowerment efforts deflect attention from their understanding of local values to avoid problemati- socio-political barriers? cally imposing their own priorities, values, or modes of working.1,17,30 Although CBR is a holistic practice that Many empowerment efforts seek to address exclusion appeals to a set of universal values (e.g., ensuring respect by enhancing the capabilities and resourcefulness of for and promoting the rights of PWD across diverse PWD. Personal empowerment projects focus on recogniz- cultures), CBR professionals need to consider how to act ing and promoting PWD’s own capacities for develop- on these commitments while demonstrating respect for ment.9,18 Such efforts often involve encouraging parti- local cultures. cipants to move past the internalized restraints that diminish their feelings of autonomy and capability. Con- Empowerment cerns have been raised when such individually oriented Empowerment is a key objective associated with CBR empowerment programmes deflect attention from socio- political factors, which often place much greater limita- projects; it includes efforts to ensure that PWD are recog- tions on the inclusion of PWD in a community.9,18,28,35 nized as full and valued members of their communities.39

Clarke et al. Ethics and Community-Based Rehabilitation: Eight Ethical Questions from a Review of the Literature 201 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 If individual empowerment efforts take precedence over In addition to a tendency to focus accountability pri- other initiatives, especially social engagement and advo- marily on donors, other features of CBR projects may cacy to address socio-political barriers to inclusion, constrain accountability efforts. An important character- inclusion will likely remain elusive. istic is the funding patterns that are prevalent in CBR. Project funding cycles are often short, leading to limited Accountability consideration of the longer term impact of projects and a Accountability is an important concern in CBR pro- lack of emphasis on sustainability.20 Including a more comprehensive understanding of accountability in CBR grammes. It can serve to promote the legitimacy of CBR programmes, one that also considers their impact on initiatives and even advance the objective of community local communities and the experiences of community empowerment.47 Some authors have argued that there is partners, is consistent with the broader community en- a need for clearer objectives and targets, as well as care- gagement approach underlying the CBR model.46 fully selected indicators, to judge the effectiveness across CBR settings.44,46 Velema and colleagues reported, how- Fairness in programme design ever, that few CBR programmes develop outcome indica- CBR was originally developed as a strategy to address tors to demonstrate what impact their interventions have had on improving the lives of PWD; this situation raises the lack of well-adapted and relevant programmes to concerns about whether programmes are effectively meet the needs of PWD in low-resource settings.37 Now meeting the needs of the individuals and communities that CBR is well established in many contexts, other they serve.45 According to Pande and Dalal,18 limiting equity concerns have come into focus, including ques- evaluations to more easily quantifiable measures may tions related to resource use, reliance on volunteers, and not advance the greater strategic objectives of a pro- the degree of inclusivity of CBR programmes. Because gramme; if a CBR programme retains a focus on fulfilling CBR programmes often operate under severe time and quotas, it will likely ignore other ways to achieve inde- resource constraints, it is all the more important to pendence for PWD and promote greater social inclusion. attend to concerns of fairness. In CBR programmes, accountability is often construed Question 6: Are CBR programmes sufficiently inclusive? as an obligation to donors and is focused on quantifiable The scope of CBR projects may raise questions of measures over a shorter time frame.42,47,48 In contrast, programmes devote less attention to other directions fairness. Despite the objective to include all PWD, Thomas and forms of accountability, including accountability to and Thomas40 observed that many CBR projects do not participants or partner organizations, and to considering integrate people with more severe disabilities. They asso- the longer term impacts of CBR projects in relation to ciated this disconnect with time pressures and resource their missions and objectives. limitations in individual projects that encouraged the inclusion of people with milder disabilities.40 Lang also Question 5: How can a more comprehensive and inclusive suggested that many CBR projects have not emphasized approach to accountability be promoted in CBR programmes? the inclusion of all PWD, leading to a situation in which increased participation was considered a long-term goal Accountability to donors often appears to crowd out rather than an immediate priority.39 other forms of accountability and limit the reach of who is included in these processes. This situation raises Question 7: How can limited CBR resources be used most fairly? questions about the participation and inclusion of the Deciding when and where to implement a CBR pro- perceptions and experiences of PWD and other stake- holders. Deepak and Sharma48 suggested that CBR pro- gramme also raises concerns about fairness, along with grammes are often overly focused on arbitrary targets to questions about how best to use limited resources. There represent success, distorting the conceptions of project is ongoing debate about what conditions are required success and sustainability. They noted that important for a project to be established in a particular setting, concepts related to accountability, including community including what amount of community participation is ownership, participatory development, and attention to needed.17,50 Within projects, questions arise about how sustainability and self-reliance, emerged primarily from to allocate limited resources fairly. Decisions need to be grassroots organizations in developing countries.48 How- made about how to allocate project resources and how ever, these concepts are not always incorporated into to prioritize different types of programming.13,17 current accountability measures. Commentators have argued that accountability in CBR should be a more Fairness also arises in ensuring project sustainability inclusive and participatory process.27,46,48,50 Enhancing because if a programme ends abruptly, and before the participation of PWD in evaluation and accountability achieving its objectives, it may leave PWD isolated and will lead to a more inclusive approach to accountability, in worse conditions than before.30,39 Deepak and Sharma and it has been described as a potentially emancipatory described how, in many countries, ‘‘programmes of CBR experience.1,23 Such a widened scope of accountability were started with support of international non-govern- reflects commitments to equity, solidarity, and inclusion. mental organizations . . . but these programmes disap- peared, when the support from the [international NGOs] stopped.’’48(p.4) This reality raises questions about the

202 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 sustained involvement of NGOs in particular locales as cially given the focus that global health ethics places on well as the project models used. promoting ‘‘the idea of human development beyond that conceived within the narrow, individualistic model of Question 8: When could reliance on volunteers become human flourishing’’62(p.130) and focusing on solidarity exploitative? with those who are marginalized or who suffer.63 In ac- cordance with these values, several authors have pushed Volunteers are a key component of CBR programmes, for CBR actors to take a more active stance in advocating and commentators have suggested that having a large for disability issues and the rights of PWD, draw atten- number of volunteers is an indicator of programme suc- tion to oppressive social structures, and promote the cess.48 On the one hand, having a large number of volun- sustainability of projects by adopting more collaborative teers reflects effective community engagement, and CBR and inclusive approaches.3,20,28–30 proposals may promise numerous volunteers to increase their chances of securing financial support.48 On the A primary consideration for CBR ethics is promoting other hand, a large number of volunteers allows re- and sustaining effective and respectful partnerships among source-challenged programmes to sustain their projects stakeholders. As has been discussed for community-based for little to no cost.45,48,51 Several authors have raised and action research, several factors support the develop- questions about whether using volunteers in CBR projects ment of effective partnerships even when partners have risks becoming exploitative. In some settings, unpaid divergent backgrounds and roles: mutual trust, attention CBR personnel may work under the impression that to the privilege and position of each partner, humility, they will eventually receive a salary.48 Brinkmann also acknowledgement of different viewpoints, and a commit- questioned this practice, stating that the ‘‘strenuous ment to solidarity.64–66 These considerations are equally work of CBR workers is compensated in a dubious relevant in the CBR context, including the development manner, and in most cases they do not even receive a of what Iris Marion Young has termed asymmetrical reci- salary. This happens because of the assumption that procity, which entails recognizing the situated realities of CBR can not be implemented without ‘volunteers.’’’49(p.91) partners, including the asymmetries of life experience, worldview, and opportunity while embodying the commit- The difficult economic situations in many of the ment to mutual respect, trust, and consideration.67(p.49) locales in which CBR takes place suggest that exploita- Enhanced attention to one’s presuppositions, power, tion may be more of a risk,49 especially when family and privilege can help support effective partnerships in members of PWD are expected to act as volun- CBR. teers.20 Community participation is crucial for CBR success,17,18,49,50 but, to address concerns of exploitation This moral posture may be especially important for and commit to fairness, programmes need to consider professionals, including physiotherapists, who come from the distribution of burdens and benefits associated with another cultural setting to participate in a CBR project volunteer efforts. as experts. Rule22 reported how improved relationships resulted when mid-level CBR professionals were given DISCUSSION training in how they approached their work with PWD. CBR was developed to address an important ethical CBR professionals noted that framing their role as work- ing with PWD, rather than as working for PWD, was a concern related to social justice and equity: the lack of crucial step in beginning to address previously ignored support and services to promote the well-being, and issues of social justice and empowerment. As new partner- address the needs, of PWD in many contexts. The CBR ships are developed, CBR stakeholders may take inspira- approach is also closely aligned with a commitment to tion from resources such as the Partnership Assessment promote participation and inclusion for PWD. Many of Tool, which was developed by the Canadian Coalition the ethical considerations identified in our review relate for Global Health Research and which encourages a to these values and are reflected in questions about deliberate and transparent approach to discussing the who is included in programmes, how partnerships are goals, expectations, and responsibilities of all partners.68 enacted, the possibility of exploitation, fairness in project Careful attention to establishing and nurturing effective design, and missed opportunities to address social and respectful partnerships is an important ethical goal barriers or enhance inclusion. Thus, it is not surprising in CBR. that the ethical considerations identified in our review of the CBR literature largely depart from the issues that Organizations and teams engaged in CBR will also are commonly linked to the ethics of rehabilitation in benefit from creating and maintaining ‘‘moral spaces’’ institutional settings in high-resource countries59 and in their routines and schedules to ensure that ethical that they have more in common with those arising in reflection takes place, including debriefing and learning domains such as community-based and action re- from challenging experiences.69 Two elements may be search.60,61 particularly valuable for CBR organizations. The first is to maintain a collective memory of these discussions, The ethics of CBR programmes can also be situated in especially when there is a high turnover of personnel. the expanding literature on global health ethics, espe- PWD and other community stakeholders may, in fact,

Clarke et al. Ethics and Community-Based Rehabilitation: Eight Ethical Questions from a Review of the Literature 203 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 prove to be the people best placed to provide this con- with, and investigation of, ethical considerations asso- tinuity. The second element is ensuring that learning ciated with CBR by increasing our knowledge about about the ethical challenges of CBR and responding to practices such as the inclusion of all PWD, the roles of these challenges in specific projects are shared beyond stakeholders throughout the life cycle of CBR projects, that milieu. Organizations or networks will benefit from and the impact of different models of empowerment creating channels for sharing experiences related to and advocacy. ethical issues across projects and learning from each other’s experiences. In turn, leaders of CBR programmes Conducting empirical and conceptual research to can use these experiences to inform policy development address the eight questions identified in this review would and train new staff. Creating spaces to discuss and re- make a valuable contribution to advancing CBR ethics. spond to ethical issues can allow stakeholders to address Our observations suggest that there is an important role considerations that were identified in this review, such for rehabilitation researchers, including physiotherapy as equity in partnerships, respect for local culture and researchers, in conducting research to advance the knowl- practices, allocating project resources prudently, and edge of best practices in CBR and developing evidence ensuring fairness in the distribution of both the benefits to guide the implementation of CBR programmes that and the burdens of a project. uphold commitments to social justice and equity. Mirroring discussions in the field of international CONCLUSION development more broadly,70 attention has also been We have identified ethical considerations that have directed to issues around CBR accountability and the participation of PWD in planning and evaluating CBR been raised in the CBR literature and proposed various programmes. Relying on models of upward accountability strategies for addressing them. Continued engagement to donors has led to critical reflection on these practices with the ethics of CBR—by CBR researchers, practitioners, in CBR or, as Miles has somewhat caustically phrased it, and policymakers, as well as PWD and members of dis- showing ‘‘what a great job we did.’’9(p.94) This critique abled people’s organizations—will be needed to ensure connects with concerns that have been expressed about that the ethical foundations of CBR continue to be re- the development of an ‘‘audit culture’’ that is reinforced fined and strengthened. We have also formulated eight by a focus on quantification and that could undermine key questions that warrant further exploration and devel- inclusion and attention to project goals that are less opment. In addressing these questions, insight and sup- quantifiable.71 port can also be drawn from a range of sources, includ- ing ethical analysis in fields such as global health, Discussing accountability in development organiza- community-based and action research, critical disability tions, Cavill and Sohail72 distinguished between practical studies, and international development. and strategic accountability. Practical accountability focuses on the effectiveness of operations and how well KEY MESSAGES services are delivered, thus privileging quantifiable data based on mechanisms such as audits and quality assurance What is already known on this topic tools. Strategic accountability requires that the overall Community-based rehabilitation (CBR) is an influen- mission of a programme and the long-term effects of its implementation be taken into account.72 Placing more tial development strategy that promotes rehabilitation, emphasis on strategic accountability in CBR projects social inclusion, and poverty reduction for people with can counterbalance the attention given to practical ac- disabilities. The CBR approach is associated with values countability.44,47 Doing so will allow for a more engaged that include participation, respect, equity, social justice, and meaningful approach to accountability, one that is and solidarity. consistent with certain core values of CBR—equity, com- munity participation, and inclusion1—especially when What this study adds all stakeholders are included in decision-making, evalua- We identified ethical considerations in the CBR litera- tion, and accountability practices. ture that were centered around five topics: partnership Uncertainty remains about which best practices in between stakeholders, respect for local culture and ex- CBR projects will ensure that benefits are optimized for perience, empowerment, accountability, and fairness in PWD and that risks and burdens are minimized.2,71 In- programme design. In analyzing these key topic areas, deed, the scientific evidence base for CBR remains quite we developed eight questions that reflect areas of ethical limited, fails to incorporate researchers from low- and tension, debate, or uncertainty that should be further middle-income countries, and is mostly descriptive.13,21 discussed and analyzed with regard to how CBR practices Expanding the CBR evidence base would help answer and programmes reflect CBR’s underlying ethical com- questions about how to design and implement pro- mitments. We recommend several approaches to sup- grammes that are more effective, responsive, and sus- port reflection and discussion of ethics in CBR, including tainable and that address the needs of a wide range of recognition of asymmetrical reciprocity among CBR PWD. Such research could also deepen the engagement partners and the creation of moral spaces within organi- zations and teams.

204 Physiotherapy Canada, Volume 68, Number 2 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 REFERENCES 21. Kuipers P, Wirz S, Hartley S. Systematic synthesis of community- based rehabilitation (CBR) project evaluation reports for evidence- 1. Turmusani M, Vreede A, Wirz SL. Some ethical issues in community- based policy: a proof-of-concept study. BMC Int Health Hum Rights. based rehabilitation initiatives in developing countries. Disabil 2008;8(1):3. http://dx.doi.org/10.1186/1472-698X-8-3. Rehabil. 2002;24(10):558–64. http://dx.doi.org/10.1080/ Medline:18325121 09638280110113449. Medline:12171646 22. Rule S. Training CBR personnel in South Africa to contribute to the 2. Finkenflu¨ gel H, Wolffers I, Huijsman R. The evidence base for empowerment of persons with disabilities. Disabil CBR Incl Dev. community-based rehabilitation: a literature review. Int J Rehabil 2013;24(2):6–21. http://dx.doi.org/10.5463/dcid.v24i2.180. Res. 2005;28(3):187–201. http://dx.doi.org/10.1097/00004356- 200509000-00001. Medline:16046912 23. Deepak S. Promoting empowerment: emancipatory research in community-based rehabilitation programme: a guide for CBR 3. International Labour Office, United Nations Educational, Scientific, programme managers. Bangalore: AIFO; 2012. and Cultural Organization, World Health Organization. CBR: a strategy for rehabilitation, equalization of opportunities, poverty 24. Mannan H, MacLachlan M, McAuliffe E. The human resources reduction, and social inclusion of people with disabilities. Joint challenge to community based rehabilitation: the need for a scien- Position Paper 2004. Geneva: World Health Organization; 2004. tific, systematic and coordinated global response. Disabil CBR Incl Dev. 2013;23(4):6–16. http://dx.doi.org/10.5463/dcid.v23i4.157. 4. World Health Organization. Community based rehabilitation: CBR guidelines. Geneva: World Health Organization; 2010. 25. Lang R. Community-based rehabilitation and health professional practice: developmental opportunities and challenges in the global 5. Finkenflu¨ gel H. Empowered to differ: stakeholders’ influences in North and South. Disabil Rehabil. 2011;33(2):165–73. http:// community-based rehabilitation. Rotterdam: Vrije Universiteit; 2004. dx.doi.org/10.3109/09638288.2010.487923. Medline:20500051 6. Khasnabis C, Motsch KH. The participatory development of interna- 26. Flower J, Wirz S. Rhetoric or reality? The participation of disabled tional guidelines for CBR. Lepr Rev. 2008;79(1):17–29. people in NGO planning. Health Policy Plan. 2000;15(2):177–85. Medline:18540234 http://dx.doi.org/10.1093/heapol/15.2.177. Medline:10837041 7. Chung EY, Packer T, Yau M. When East meets West: community- 27. Boyce W, Lysack C. Community participation: uncovering its mean- based rehabilitation in Chinese communities. Disabil Rehabil. ings in CBR. In: Thomas M, Thomas MJ, editors. Selected readings 2011;33(8):697–705. http://dx.doi.org/10.3109/ in community based rehabilitation, Series 1: CBR in transition. 09638288.2010.506240. Medline:20690860 Bangalore: APDRJ Group;2000. p. 39–54. 8. Boyce W. Evaluating participation in community programs: an 28. Miles S. Engaging with the disability rights movement: the experi- empowerment paradigm. Can J Program Eval. 1993;8(1):89–102. ence of community-based rehabilitation in southern Africa. Disabil Soc. 1996;11(4):501–18. http://dx.doi.org/10.1080/09687599627561. 9. Miles M. CBR works best the way local people see it and build it. Asia Pac Disabil Rehabil J. 2003;14(1):86–98. 29. AlHeresh R, Bryant W, Holm M. Community-based rehabilitation in Jordan: challenges to achieving occupational justice. Disabil Rehabil. 10. Aultman JM, Campos EC. Ethical and social dilemmas surrounding 2013;35(21):1848–52. http://dx.doi.org/10.3109/ community based rehabilitation in Costa Rica. Int J Psychosoc 09638288.2012.756944. Medline:23343361 Rehabil. 2004;8:Article 8. 30. Pollard N, Sakellariou D. Operationalizing community participation 11. Koros M, Boyce W, Hodgson J. Community based rehabilitation: a in community-based rehabilitation: exploring the factors. Disabil strategy for peace-building. BMC Int Health Hum Rights. 2002;2:6. Rehabil. 2008;30(1):62–70. http://dx.doi.org/10.1080/ http://dx.doi.org/10.1186/1472-698X-2-6. 09638280701192980. Medline:17852288 12. Clapton J, Kendall E. Autonomy and participation in rehabilitation: 31. Kuipers P, Allen O. Preliminary guidelines for the implementation of time for a new paradigm? Disabil Rehabil. 2002;24(18):987–91. community based rehabilitation (CBR) approaches in rural, remote http://dx.doi.org/10.1080/09638280210152058. and indigenous communities in Australia. Rural Remote Health. 2004;4(3):291. Medline:15885015 13. Cleaver S, Nixon S. A scoping review of 10 years of published literature on community-based rehabilitation. Disabil Rehabil. 32. Gauld S, Smith S, Kendall MB. Using participatory action research 2014;36(17):1385–94. http://dx.doi.org/10.3109/ in community-based rehabilitation for people with acquired brain 09638288.2013.845257. Medline:24151820 injury: from service provision to partnership with Aboriginal com- munities. Disabil Rehabil. 2011;33(19-20):1901–11. http://dx.doi.org/ 14. McDougall R. Reviewing literature in bioethics research: increasing 10.3109/09638288.2010.550382. Medline:21261554 rigour in non-systematic reviews. Bioethics. 2015;29(7):523–8. http://dx.doi.org/10.1111/bioe.12149. Medline:25655982 33. Kuipers P, Kendall E, Hancock T. Developing a rural community- based disability service: (I) service framework and implementation 15. Hunt MR, Carnevale FA. Moral experience: a framework for bioethics strategy. Aust J Rural Health. 2001;9(1):22–8. http://dx.doi.org/ research. J Med Ethics. 2011;37(11):658–62. http://dx.doi.org/ 10.1046/j.1440-1584.2001.00333.x. Medline:11703263 10.1136/jme.2010.039008. Medline:21515876 34. Twible R, Henley E. A curriculum model for a community develop- 16. Hartley S, Okune J. CBR policy development and implementation. ment approach to community-based rehabilitation. Disabil Handicap Norwich (UK): University of East Anglia; 2008. Soc. 1993;8(1):43–57. http://dx.doi.org/10.1080/02674649366780031. 17. Thomas M, Thomas MJ. A discussion on some controversies in 35. Miles M. Community, individual or information development? community based rehabilitation. Asia Pac Disabil Rehabil J. Dilemmas of concept and culture in South Asian disability planning. 2002;13(1):2–10. Disabil Soc. 1996;11(4):485–500. http://dx.doi.org/10.1080/ 09687599627552. 18. Pande N, Dalal AK. In reflection: making sense of achievements and failures of a CBR initiative. Asia Pac Disabil Rehabil J. 2004;15(2):95– 36. Kuipers P, Cornielje H. Alternative responses to the human resource 105. challenge for CBR. Disabil CBR Incl Dev. 2012;23(4):17–23. 19. Kendall E, Buys N, Larner J. Community-based service delivery in 37. Gregory RJ. Community based service delivery: power and pathology: rehabilitation: the promise and the paradox. Disabil Rehabil. or, social rehabilitation is still a ‘‘commie plot.’’ Disabil Rehabil. 2000;22(10):435–45. http://dx.doi.org/10.1080/09638280050045901. 2001;23(1):22–5. http://dx.doi.org/10.1080/09638280150211257. Medline:10950496 Medline:11213319 20. Kuyini AB, Alhassan AR, Mahama FK. The Ghana community-based 38. Thomas M, Thomas MJ. A discussion on the shifts and changes in rehabilitation program for people with disabilities: what happened community based rehabilitation in the last decade. Neurorehabil at the end of donor support? J Soc Work Disabil Rehabil. Neural Repair. 1999;13(3):185–9. http://dx.doi.org/10.1177/ 2011;10(4):247–67. http://dx.doi.org/10.1080/1536710X.2011.622981. 154596839901300308. Medline:22126142

Clarke et al. Ethics and Community-Based Rehabilitation: Eight Ethical Questions from a Review of the Literature 205 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 39. Lang R. Empowerment and CBR? Issues raised by the South Indian 2002;25(3):163–71. http://dx.doi.org/10.1097/00004356-200209000- experience. In: Stone E, editor. Disability and development: learning 00001. Medline:12352169 from action and research on disability in the majority world. Leeds 57. Rifkin SB, Kangere M. What is participation. In: Hartley S, editor. (UK): Disability Press; 1999. p. 130–48. CBR a participatory strategy in Africa. London: Institute for Interna- tional Child Health. 40. Thomas M, Thomas MJ. Manual for CBR planners. Bangalore: 58. Deepak S, dos Santos LR, Griffo G, et al. Organisations of persons APDRJ Group; 2003. p. 6. with disabilities and community-based rehabilitation. Disabil CBR Incl Dev. 2013;24(3):5–20. http://dx.doi.org/10.5463/dcid.v24i3.269. 41. Kuipers P. Empowerment in community-based rehabilitation and 59. Blackmer J. Ethical issues in rehabilitation medicine. Scand J Rehabil disability-inclusive development. Disabil CBR Incl Dev. Med. 2000;32(2):51–5. http://dx.doi.org/10.1080/ 2014;24(4):24–42. http://dx.doi.org/10.5463/dcid.v24i4.274. 003655000750045541. Medline:10853717 60. Wallwork E. Ethical analysis of research partnerships with com- 42. Finkenflu¨ gel H. Prospects for community-based rehabilitation in the munities. Kennedy Inst Ethics J. 2008;18(1):57–85. http://dx.doi.org/ new millennium. In: Møller V, Huschka D, editors. Quality of life and 10.1353/ken.0.0000. Medline:18561578 the millennium challenge: advances in quality-of-life studies, theory 61. Bastida EM, Tseng T-S, McKeever C, et al. Ethics and community- and research. Dordrecht: Springer; 2008. based participatory research: perspectives from the field. Health Promot Pract. 2010;11(1):16–20. http://dx.doi.org/10.1177/ 43. Mitchell R. The research base of community-based rehabilitation. 1524839909352841. Medline:20038649 Disabil Rehabil. 1999;21(10-11):459–68. http://dx.doi.org/10.1080/ 62. Pinto AD, Upshur REG, editors. Introduction to global health ethics. 096382899297251. Medline:10579666 Abingdon (UK): Routledge; 2013. 63. Benatar SR, Daar AS, Singer PA. Global health challenges: the need 44. Cornielje H, Velema JP, Finkenflu¨ gel H. Community based rehabili- for an expanded discourse on bioethics. PLoS Med. 2005;2(7):e143. tation programmes: monitoring and evaluation in order to measure http://dx.doi.org/10.1371/journal.pmed.0020143. Medline:16033302 results. Lepr Rev. 2008;79(1):36–49. Medline:18540236 64. Hunt MR, Gogognon P, Ridde V. Ethical considerations related to participation and partnership: an investigation of stakeholders’ 45. Velema JP, Finkenflu¨ gel HJ, Cornielje H. Gains and losses of struc- perceptions of an action-research project on user fee removal for the tured information collection in the evaluation of ‘‘rehabilitation in poorest in Burkina Faso. BMC Med Ethics. 2014;15(1):13. http:// the community’’ programmes: ten lessons learnt during actual dx.doi.org/10.1186/1472-6939-15-13. Medline:24555854 evaluations. Disabil Rehabil. 2008;30(5):396–404. http://dx.doi.org/ 65. Brydon-Miller M. Ethics and action research: Deepening our 10.1080/09638280701256272. Medline:17852313 commitment to principles of social justice and redefining systems of democratic practice. In: Reason P, Bradbury H, editors. The SAGE 46. Grandisson M, He´bert M, Thibeault R. A systematic review on how handbook of action research: Participative inquiry and practice. 2nd to conduct evaluations in community-based rehabilitation. Disabil ed. Thousand Oaks (CA): Sage; 2008. p. 199–210. Rehabil. 2014;36(4):265–75. http://dx.doi.org/10.3109/ 66. Israel BA, Schulz AJ, Parker EA, et al. Review of community-based 09638288.2013.785602. Medline:23614357 research: assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19(1):173–202. http:// 47. Boyce W, Ballantyne S. Developing CBR through evaluation. In: dx.doi.org/10.1146/annurev.publhealth.19.1.173. Medline:9611617 Thomas M, Thomas MJ, editors. Selected readings in community 67. Young IM. Intersecting voices: dilemmas of gender, political based rehabilitation, Series 1: CBR in transition. Bangalore: APDRJ philosophy, and policy. Princeton (NJ): Princeton University Press; Group;2000. p. 73–87. 1997. 68. Canadian Coalition for Global Health Research. Partnership Assess- 48. Deepak S, Sharma M. Volunteers and community based rehabilita- ment Tool [Internet]. Wakefield (QC): The Coalition; 2009 [cited 2015 tion. Asia Pac Disabil Rehabil J. 2001;12(2):141–8. Oct 1]. Available from: http://www.ccghr.ca/resources/partnerships- and-networking/partnership-assessment-tool/ 49. Brinkmann G. Unpaid CBR work force: between incentives and 69. Walker MU. Keeping moral space open. New images of ethics exploitation. Asia Pac Disabil Rehabil J. 2004;15(1):90–4. consulting. Hastings Cent Rep. 1993;23(2):33–40. http://dx.doi.org/ 10.2307/3562818. Medline:8463088 50. Mijnarends D, Pham D, Swaans K, Van BWH, Wright P. Sustainability 70. Groves L, Hinton R, editors. Inclusive aid: changing power and criteria for CBR programmes—two case studies of provincial relationships in international development. Abingdon (UK): programmes in Vietnam. Disabil CBR Incl Dev. 2011; 22(2):3. Routledge; 2013. 71. Townsend JG, Porter G, Mawdsley E. The role of the transnational 51. Lysack C, Krefting L. Community-based rehabilitation cadres: their community of non-government organizations: governance or motivation for volunteerism. Int J Rehabil Res. 1993;16(2):133–41. poverty reduction? J Int Dev. 2002;14(6):829–39. http://dx.doi.org/ http://dx.doi.org/10.1097/00004356-199306000-00005. 10.1002/jid.928. Medline:8349400 72. Cavill S, Sohail M. Increasing strategic accountability: a framework for international NGOs. Dev Pract. 2007;17(2):231–48. http:// 52. O’Toole B. Community-based rehabilitation (CBR): problems and dx.doi.org/10.1080/09614520701196004. possibilities. Eur J Spec Needs Educ. 1987;2(3):177–90. http:// dx.doi.org/10.1080/0885625870020303. 53. Deepak S, Biggeri M, Mauro V, et al. Impact of community-based rehabilitation on persons with different disabilities. Disabil CBR Incl Dev. 2014;24(4):5–23. http://dx.doi.org/10.5463/dcid.v24i4.286. 54. Deepak S, Kumar J, Ortali F, et al. CBR matrix and perceived training needs of CBR workers: a multi-country study. Disabil CBR Incl Dev. 2011;22(1):85–98. http://dx.doi.org/10.5463/dcid.v22i1.16. 55. Mirembe J, Hartley S. Future participation and sustainability of CBR: the way forward. In: Hartley S, editor. Community-based rehabilita- tion (CBR) as a participatory strategy in Africa. London: Institute for International Child Health. 56. Wirz S, Thomas M. Evaluation of community-based rehabilitation programmes: a search for appropriate indicators. Int J Rehabil Res.

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Clinician’s Commentary on Clarke et al.1 In the past few decades, interest and opportunities to partic- Second, in their discussion, the authors offer physiothera- ipate in initiatives positioned at the intersection of global health, pists various practical responses to address these ethical tensions, rehabilitation, and disability—including community-based re- including approaching partnerships in a transparent and con- habilitation—have grown exponentially. Although the implemen- scious way (using tools such as the Partnership Assessment tation of community-based rehabilitation (CBR) varies widely, it Tool); focusing on outcomes inherently tied to the ultimate is generally described as a multi-sectoral strategy in community goals of CBR (considering strategic accountability); and docu- development that focuses on people with disabilities and their menting and sharing information about the ethical discussions families, aiming to equalize educational and employment oppor- that take place in organizations. However, measuring and tunities and increase the social inclusion of participants, as addressing these questions in particular CBR settings often re- outlined in the 2006 Convention on the Rights of Persons with quires specific training that goes beyond typical clinical phy- Disabilities.2 A stronger grasp of the ethical implications of our siotherapy skills. Physiotherapists must also further cultivate es- individual and collective actions becomes critical as physio- sential competencies as strong collaborators and advocates therapists increasingly engage in CBR in Canada and other to forge connections among organizations, government, and countries. Accordingly, Clarke and colleagues1 seek to under- people with disabilities to facilitate sustainable outcomes.4 Of stand how ethical considerations are reflected in the CBR litera- the expanded essential competencies for physiotherapists in ture. Their findings are valuable because they encourage more global health,5 the competency of critical thinker, which in- formal consideration of the ethical issues confronting every volves reflective analysis of one’s own motivations, position, physiotherapist who considers or engages in CBR projects. and actions as well as those of the various CBR stakeholders, is especially relevant for effective CBR practice. Using a critical interpretative approach, Clarke and colleagues reviewed the literature for key ideas about their primary re- In addition, although physiotherapist education includes a search question: How are ethical considerations reflected in strong foundation in clinical ethics, primarily based on prin- the CBR literature? They defined an ethical consideration as a ciples at the individual level (e.g., autonomy of the patient, situation in which values deemed to be important are either in beneficence, non-maleficence, and justice), physiotherapists accordance or in conflict with actual practice, policy, or im- must appreciate that our professional role in CBR also includes plementation aspects of CBR. Drawing on 51 relevant articles, a broader understanding of the social and environmental factors they structure their findings on the research question into five that influence health and practice. As our profession moves key topic areas: partnerships among stakeholders, respect for toward the more society-related principles of equity, people- culture and local experience, empowerment, accountability, and centredness, community participation, and self-determination,6 fairness in programme design. They then formulate eight ques- ethical questions in the context of CBR can help deepen our tions that reflect the main underlying ethical tensions.1 understanding of the determinants of health and empowerment of the populations we work with. Their insights make a useful contribution to the growing evi- dence base for CBR. To apply these results to practice, we asked Third, this study illuminates key topic areas and associated three questions: first, Who would benefit from knowing these ethical questions that reflect the indexed academic literature. results? Second, How can these results be integrated into CBR As with the evidence base of CBR in general,7 we must assess practice? And, third, What do physiotherapists need to con- how well these sources represent the perspectives of people sider about the study limitations so that we can advance CBR who implement CBR and the comprehensive range of ethical practice? tensions that exist in CBR around the world. Given the variation in socio-cultural, economic, and political contexts in which CBR First, Clarke and colleagues’ findings are relevant to CBR stake- is applied, CBR stakeholders themselves are best positioned to holders (including physiotherapists, policy makers, managers, develop and define additional ethical considerations, priority and people with disabilities) as well as to any physiotherapist values, and novel solutions. As well, low-resource settings may interested in promoting social justice and equity in health. not have the capacity and infrastructure to carry out detailed Experienced global health practitioners will find that at least analyses of these ethical questions. Part of physiotherapists’ some of Clarke and colleagues’ discussion of the eight concluding role must be to develop their own capacity and that of all CBR questions will resonate with their own experiences and may participants to engage with local and external ethical experts help both to situate those experiences and to prepare for future and researchers to define, and respond pragmatically to, ethical work. For physiotherapists considering work in a low-resource issues. setting, this landscape of ethical considerations will make them aware of some of the key issues encountered in global health. The ethical questions about CBR in Clarke and colleagues’ This may be especially true for physiotherapy students, who article will hopefully elicit critical reflections about the challenges increasingly seek global health experiences during their pro- in community-based health programmes, both in local com- fessional education.3 Indeed, Clarke and colleagues’ findings are munities and around the world. Their findings are relevant for also relevant for physiotherapists in high-income countries, professionals at all levels of engagement in global health and where the approach of respectful ‘‘asymmetrical reciprocity’’ in provide a foundation from which physiotherapists can begin to partnerships among professionals and clients, their families, understand the variety of ethical questions associated with CBR and other health care providers can help integrate diverse and programmes. The next challenge will be to use these results often competing interests. to inform future practice and empirical research, so that pro- grammes can better reflect the core values of CBR. 206

Clinician’s Commentary on Clarke et al. 207 https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Sudha R. Raman, BScPT, PhD 2014;94(4):523–33. http://dx.doi.org/10.2522/ptj.20130246. Duke Clinical Research Institute, Duke University, Medline:24336476 4. National Physiotherapy Advisory Group. Essential competency Durham, NC profile for physiotherapists in Canada [Internet]. 2009 [cited 2015 Nov 27]. Available from: http://www.physiotherapy.ca/getmedia/ Graziella Van den Bergh, BScPT, MPhil, PhD fe802921-67a2-4e25-a135-158d2a9c0014/Essential-Competency- Department of Occupational Therapy, Physiotherapy and Profile-2009_EN.pdf.aspx Radiography, Bergen University College, Bergen, Norway 5. Cassady C, Meru R, Chan NM, et al. Physiotherapy beyond our borders: investigating ideal competencies for Canadian physiothera- REFERENCES pists working in resource-poor countries. Physiother Can. 2014;66(1):15–23. http://dx.doi.org/10.3138/ptc.2012-54. 1. Clarke S, Barudin J, Hunt M. Ethics and community-based rehabili- Medline:24719503 tation: eight ethical questions from a review of the literature. 6. Edwards I, Delany CM, Townsend AF, et al. New perspectives on the Physiother Can. 2016;68(2):197–205. http://dx.doi.org/10.3138/ theory of justice: implications for physical therapy ethics and clinical ptc.2015-35. practice. Phys Ther. 2011;91(11):1642–52. http://dx.doi.org/10.2522/ ptj.20100351.10. Medline:21885447 2. United Nations. Convention on the rights of persons with disabilities 7. Cleaver S, Nixon S. A scoping review of 10 years of published [Internet]. UN Doc No A/61/611. 2006 [cited 2016 Jan 7]. Available literature on community-based rehabilitation. Disabil Rehabil. from: http://www.un.org/disabilities/convention/convention- 2014;36(17):1385–94. http://dx.doi.org/10.3109/ full.shtml 09638288.2013.845257. Medline:24151820 3. Pechak CM, Black JD. Proposed guidelines for international clinical DOI:10.3138/ptc.2015-35-CC education in US-based physical therapist education programs: results of a focus group and Delphi Study. Phys Ther.

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 COCHRANE COLLABORATION What Does the Cochrane Collaboration Say about Rehabilitation Interventions for Shoulder Dysfunction? Ada L, Foongchomcheay A, Canning C. Supportive devices for adhesive capsulitis (frozen shoulder). Cochrane Database Syst preventing and treating subluxation of the shoulder after stroke. Rev. 2014;(10):CD011324. http://dx.doi.org/10.1002/ Cochrane Database Syst Rev. 2005;(1):CD003863. http:// 14651858.CD011324. Medline:25271097 dx.doi.org/10.1002/14651858.CD003863.pub2. Medline:15674917 Page MJ, Green S, Kramer S, et al. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Carvalho APV, Vital FMR, Soares BGO. Exercise interventions Syst Rev. 2014;(8):CD011275. http://dx.doi.org/10.1002/ for shoulder dysfunction in patients treated for head and neck 14651858.CD011275. Medline:25157702 cancer. Cochrane Database Syst Rev. 2012;(4):CD008693. http:// dx.doi.org/10.1002/14651858.CD008693.pub2. Stuiver MM, ten Tusscher MR, Agasi-Idenburg CS, et al. Medline:22513964 Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder developing lymphoedema after breast cancer therapy. Cochrane pain. Cochrane Database Syst Rev. 2005;(2):CD005319. http:// Database Syst Rev. 2015;(2):CD009765. http://dx.doi.org/ dx.doi.org/10.1002/14651858.CD005319. Medline:15846753 10.1002/14651858.CD009765.pub2. Medline:25677413 Hoe VCW, Urquhart DM, Kelsall HL, et al. Ergonomic design Verhagen AP, Bierma-Zeinstra SMA, Burdorf A, et al. Conserva- and training for preventing work-related musculoskeletal dis- tive interventions for treating work-related complaints of the orders of the upper limb and neck in adults. Cochrane Database arm, neck or shoulder in adults. Cochrane Database Syst Rev. Syst Rev. 2012;(8):CD008570. http://dx.doi.org/10.1002/ 2013;(12):CD008742. http://dx.doi.org/10.1002/ 14651858.CD008570. Medline:22895977 14651858.CD008742.pub2. Medline:24338903 McNeely ML, Campbell K, Ospina M, et al. Exercise interven- The Cochrane Collaboration is an international not-for-profit tions for upper-limb dysfunction due to breast cancer treat- and independent organization dedicated to making up-to-date, ment. Cochrane Database Syst Rev. 2010;(6):CD005211. http:// accurate information about the effects of health care readily dx.doi.org/10.1002/14651858.CD005211.pub2. available worldwide. It produces and disseminates systematic Medline:20556760 reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of inter- Mehrholz J, Pohl M, Platz T, et al. Electromechanical and robot- ventions. For more information, visit http://www.cochrane.org. assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Data- DOI:10.3138/ptc.68.2.cochrane base Syst Rev. 2015;(11):CD006876. http://dx.doi.org/10.1002/ 14651858.CD006876.pub4. Medline:26559225 Page MJ, Green S, Kramer S, et al. Electrotherapy modalities for 208

BOOK REVIEWS https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Practical Management of Pain, 5th ed. for all professions. Particularly valuable is Turk’s chapter on psychological interventions, which reviews current evidence Honorio Benzon, James P. Rathmell, and describes psychological models as well as the family systems Christopher L. Wu, Dennis C. Turk, perspective. Psychological assessment and management tech- Charles E. Argoff, Robert W. Hurley niques are well described at the level of teaching to a non- psychologist and are helpful for all professions. Part 6, ‘‘Nerve Philadelphia: Mosby (Elsevier); 2014 Block Techniques,’’ consists of 8 chapters; Part 7, ‘‘Interven- ISBN 978-0-323-08340-9 tional Techniques,’’ contains 13 chapters, including one on 1,104 pages, plus online trigger-point injections. US$245.00 The chapter titled ‘‘Physical Medicine Techniques’’ is authored This is the fifth edition of a comprehensive textbook edited by three non-physiotherapists. Although the importance of by five leading pain scientists and clinician-scientists (four exercise and the contribution of modalities are made clear, the anaesthetists and one psychologist, Dr. Dennis Turk). Contribu- role of physiotherapists is described only at the level of im- tors to the volume represent an impressive list of established pairment and activity and is listed in illustrative tables in quite authors from many professions and disciplines, including general terms related to technical skills (e.g., ‘‘Restore bio- anaesthesiology, psychology, neurology, pharmacology, and phys- mechanical dysfunction. . . . Improve strength . . . posture . . . gait ical medicine. Practical Management of Pain is written primarily symmetry . . . [and] general aerobic conditioning. . . .Improve as a comprehensive text (83 chapters, 1,104 pages) for physicians efficiency of activities of daily living. . . . Decrease edema. . . . In- or physician-led teams specializing in pain medicine in the United struct patients to monitor pain response and to pace activity. . . . States. As we know, new understandings of pain science, the Use back or joint conservation techniques’’; p. 639). Although nature of the pain experience, and best practices for assessment this is useful information for an inter-professional audience, and management are continually growing, outstripping the pre- it does not acknowledge the entirety of the physiotherapist’s vious fourth edition of this text, published (as Raj’s Practical current, pain neuroscience–based role in the comprehensive Management of Pain) in 2008. In this new edition, the editors management of pain, particularly chronic pain and disability. I have tried to include the most recent evidence as well as therefore applaud the editors for adding Harriet Wittnick and new chapters on disability assessment, central post-stroke pain, Jeanine Verbunt’s chapter, ‘‘Physical Rehabilitation for Patients and widespread pain and an updated section on intervention with Chronic Pain,’’ which concisely describes a person-centred, techniques. goal-oriented rehabilitation approach to chronic pain manage- ment. This chapter was refreshing to read and important to The book is divided into nine parts. Part 1, ‘‘General Con- share with all professions, including our own. siderations,’’ consists of seven chapters reviewing the history and the current direction of pain care as well as US health care Parts 8 and 9, ‘‘Pain Management in Special Situations and policy related to pain care. Part 2, ‘‘Basic Considerations,’’ reviews Special Topics’’ and ‘‘Research, Ethics, and Reimbursement in the neuroscience of pain, including a chapter on pharmaco- Pain,’’ cover a mix of special topics related to current and future genetics, a field in which information is growing quickly, and pain care, ethics, and accessibility. The chapters on pain in an excellent chapter on the bio-psychosocial aspects of chronic sickle cell disease, pain management in the critically ill patient, pain. Part 3, ‘‘Evaluation and Assessment,’’ is quite comprehen- and pain management in the home are topical and relevant to sive, covering multiple dimensions of clinical assessment from all professions. general musculoskeletal and neurological scanning assessments to psychological, behavioural, and disability measures. It is Overall, the fifth edition of Practical Management of Pain is a interesting that it does not include a chapter on quantitative fundamental textbook for anaesthesiology residents and anaes- sensory testing, although there is a section on this topic in thetists who practise pain management. As a physiotherapist, I a later chapter on complex regional pain syndrome. Part 4, see this as a useful reference text that I would borrow from the ‘‘Clinical Conditions,’’ presents the current evidence for the library or from a colleague. It is well written and up to date and pharmacological and interventional management of common contains some excellent chapters that will be useful and infor- pain conditions; each of its 18 chapters is devoted to a common mative for anyone who works with people for whom pain limits acute or chronic condition ranging from postoperative pain, quality of life. headache, and low back pain to cancer pain and specific neuro- pathic conditions. Some chapters acknowledge the importance Judith P. Hunter, BSc(PT), MSc, PhD of a bio-psychosocial approach, but the concept of a patient- Assistant Professor, Department of Physical Therapy, centred approach is not mentioned. University of Toronto; Department of Rehabilitation Medicine, University of Alberta; Curriculum Director, Parts 5–7 focus on specific pain treatments or interventions. Certificate in Pain Management, University of Alberta; Part 5, ‘‘Pharmacologic, Psychological, and Physical Medicine Treatments,’’ consists of 16 chapters, including useful chapters [email protected]. DOI:10.3138/ptc.68.2.rev 209

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Physiotherapy CANADA CALL FOR PAPERS Physiotherapy Canada Special Series Physiotherapy in Primary Care Guest Editor: Julie Richardson PhD, PT Julie Richardson is a Professor in the School of Rehabilitation Science at McMaster University. The global rise in non-communicable chronic diseases will result in an associated rise in the prevalence of disability. Musculoskeletal conditions are the second most prevalent cause of disability worldwide. A serious uptake of alternative approaches to primary care which includes using a population based perspective needs supporting research and knowledge translation about effective interventions. Optimizing system transformation to prioritize physical functional health as a central focus of personal and population health will be an important contribution of our profession within primary care to address some of these challenges. Physiotherapists are essential within primary care to mitigate the health challenges of the next century as they have expertise in musculoskeletal health and disability prevention, particularly in the presence of comorbid health conditions that compromise the neurological and cardiovascular systems. Capacity shifting and rethinking of what constitutes “vital” signs are needed to align focus with the population needs of an aging society. Over the next two years Physiotherapy Canada is running a special series of articles considering the role and contribution of physiotherapy to Primary Care. Topics of interest include but are not limited to: • innovative approaches including the use of • the management of acute and chronic conditions technology to delivering care • chronic disease management • self‐management strategies and interventions • the contribution of physiotherapy to community • case management and population health • health promotion and prevention across the lifespan • community and population based interventions • complex and multi-component physiotherapy • assessment and management approaches to multi- interventions in primary care morbidity • approaches to serving unmet needs of different • the contribution of physiotherapy within sectors of our communities multidisciplinary teams and to the social determinants of health within primary care Physiotherapy Canada is currently seeking submissions in English and in French related to these or other pertinent topics for global health, disability, and rehabilitation. We accept qualitative or quantitative studies, including systematic reviews. We also accept case reports, evidence-based practice articles, and brief reports. Please see the Physiotherapy Canada Author Guidelines for word count and other requirements. High-quality submissions from authors in LMIC or from authors with disabilities are encouraged. Articles will be published over time as part of a special series. Final deadline for submissions is December 31, 2016, but submissions will be considered as soon as they are received. All submissions must be submitted to our online peer-review system, PRESTO. You can find the guidelines here or on the “Instructions for Authors” page at http://bit.ly/ptc_online. To submit to PRESTO, please click here or visit http://bit.ly/PTCpresto. If you have questions, please contact Julie Richardson [email protected] or 905 525 9140 extn 27811 Physiotherapy Canada 5201 Dufferin Street, Toronto, Ontario M3H 5T8 Canada T: (416) 416-667-7777 F: (416) 667-7881 [email protected] www.utpjournals.com/ptc

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 Johnson.ca/deservemore HERE’S SG_jiCPA_YDM_HA_contest_Aug2015.indd 1 SOMETHING JUST FOR 2015-09-14 5:03 PM

https://www.utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 11:13:27 PM - IP Address:43.246.243.82 two procedures, one bottle, zero waste. Polysonic® Ultrasound Lotion Polysonic® Ultrasound Lotion with Aloe Vera Now you can perform two distinct procedures with one very versatile lotion. You’ll save the time associated with clean-up and the expense of a second, separate application. Polysonic is a multi-purpose ultrasound lotion that provides superior coupling efficiency in a pleasing cosmetic quality base. It can be used for all ultrasound procedures, especially when followed by soft tissue mobilization, or any time a lotion is preferred. • acoustically correct for a broad range of frequencies • comfortable to patients • rich, moisturizing formula • hypoallergenic and bacteriostatic • won’t damage equipment or stain clothing © 2015 Parker Laboratories, Inc. ISO 13485:2003 AD-21-4 REV 0