Assignment: Strategic Plan for Implementation of Evidence-based Practice

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Physiotherapy Canada 2020; 72(4); 366–373; doi:10.3138/ptc-2019-0040

ABSTRACT

Purpose: Currently, there is a paucity of research describing physiotherapy services for individuals with multiple sclerosis (MS) in Canada. Using qualitative methods, we aimed to develop a survey to examine physiotherapy practice patterns for people with MS receiving services in Canada. Method: We began by conducting a review of the current literature and combining participatory action research methods with the expertise of registered physiotherapists and individuals with MS. Semi-structured interviews were conducted with 10 participants to obtain their input into survey development. The interviews were then transcribed verbatim and analyzed thematically. Results: Five key themes emerged from the thematic analysis: (1) provide additional answer options, (2) reformat or clarify questions, (3) ensure that questions or options are appropriate, (4) ensure good readability and flow, and (5) determine the appropriate length of the survey. After a final revision, the survey consisted of 24 items in the following domains: demographics, MS programme and patient population, interdisciplinary care, and programme and service barriers. Conclusions: This survey is the first of its kind in Canada and is the first step toward improving the quality of health of people living with MS and the effectiveness of current physiotherapy practices for them.

Key Words: health services; multiple sclerosis; physical therapy modalities; rehabilitation, surveys and questionnaires.

RÉSUMÉ

Objectif : très peu d’études portent sur les services de physiothérapie pour les personnes atteintes de sclérose en plaques (SP) au Canada. À l’aide de méthodes qualitatives, la présente étude visait à préparer un sondage sur les modes d’exercice de la physiothérapie pour la SP au Canada. Méthodologie : analyse des publications à jour et combinaison de méthodes de recherche-action participatives avec les compétences de physiothérapeutes diplômés et de personnes atteintes de SP. Les chercheurs ont réalisé des entrevues semi-structurées avec dix participants pour obtenir leur avis sur l’élaboration du sondage. Les entrevues ont ensuite été transcrites textuellement, puis analysées par thèmes. Résultats  : cinq thèmes principaux ont émergé de l’analyse thématique : 1) fournir d’autres possibilités de réponses, 2) reformuler ou clarifier les questions, 3) s’assurer que les questions ou les options sont appropriées, 4) s’assurer d’une bonne lisibilité et d’un bon enchaînement et 5) déterminer la bonne longueur du sondage. Après la dernière révision, le sondage se composait de 24 points dans les domaines suivants : démographie, programme pour la SP et population de patients, soins interdisciplinaires et obstacles aux programmes et aux services. Conclusion : le sondage est le premier du genre au Canada et représente la première étape vers l’amélioration de la qualité de vie des personnes ayant la SP ainsi que de l’efficacité des pratiques actuelles de physiothérapie auprès d’elles.

Mots-clés : modalités de physiothérapie; réadaptation; sclérose en plaques; services de santé; sondages et questionnaires

ARTICLE

Use of Participatory Action Research in the Development of a Survey of Physiotherapy Services for People with Multiple Sclerosis in Canada Ayse Kuspinar , PT, PhD ; * Vanina Dal Bello-Haas , PT, PhD ; * Diana Liu , PT ; * Karen Essah , PT ; * Lily Cao , PT ; * Michelle Ploughman , PT, PhD †

From the: *School of Rehabilitation Science, McMaster University, Hamilton, Ont.; †Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Nfld.

Correspondence to: Ayse Kuspinar, School of Rehabilitation Science, McMaster University, 1400 Main St. W., Room 435, IAHS, Hamilton, ON L8S 1C7; [email protected].

Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft.

Competing Interests: None declared. This research was supported in part by the Neuroscience Division – Physiotherapy Foundation of Canada Joint Award for Physiotherapy Research in the Neurosciences.

Acknowledgements: The authors thank Shanna Wilson for her initial contributions to the study.

Multiple sclerosis (MS) is a chronic autoimmune dis- order of the central nervous system that causes demye- lination of the motor and sensory neurons; as a result, it is a major contributor to neurological disability, primar- ily in individuals aged 20–50 years. 1 The data from a 2013 worldwide epidemiology study showed that Canada has one of the highest rates of MS in the world, with a preva- lence of approximately 1 in 340 people. 1,2 Individuals with MS experience a wide variety of impairments: fatigue;

bladder dysfunction and sensory disturbances; limita- tions in activity, including impaired mobility and reduced exercise tolerance; and restrictions on their participation in social activities, work, and leisure. 3

Not only does MS affect individuals’ physical daily function, it also affects their economic productivity, espe- cially because it most often strikes during their primary working years. 4 Functional losses result in a significant financial burden on individuals, their family or caregiver,

Kuspinar et al. Use of Participatory Action Research in the Development of a Survey of Physiotherapy Services for People with Multiple Sclerosis in Canada 367

the health care system, and society. A Canadian epide- miology and economic study estimated that the total per capita cost of health care for adults (aged >20 y) with MS was approximately $16,800 in 2011 compared with $2,500 for individuals without a neurological disease. 5 Moreover, especially among people with MS who had greater dis- ability, the use of health care services rose as productivity declined. 4 By 2031, the annual health sector costs associ- ated with MS in Canada are expected to reach $2 billion. 5

Medical treatment for MS is challenging because it has no known cure. 6 However, the introduction of disease- modifying drugs in the mid-1990s has helped miti- gate the effects of MS by decreasing the regularity of relapses and impeding the progression of the disease. 2,6 MS can optimally be managed using a multidisciplinary approach, and physiotherapists play a key role as rehabil- itation experts. 2,3 A recent systematic review of systematic reviews found strong evidence to support the benefits of non-pharmacological interventions such as physiother- apy in improving functional outcomes, reducing fatigue, and enhancing the quality of life of individuals with MS. 3

An environmental scan that explores the structure (e.g., type and dosage of interventions) and organiza- tion (e.g., setting, process of referral, funding source) of physiotherapy services for MS was recently conducted in Europe. 7 An environmental scan is the acquisition and use of data to provide evidence about the directions of a profession, help plan for the future, raise awareness of issues, initiate a project, or all of these. 8 For example, in a study of 17 European rehabilitation centers, 7 patients who experienced improved mobility had received phys- ical rehabilitation that involved aerobic and resistance training rather than passive stretching, suggesting that the focus of the intervention mattered. However, despite the extensive research supporting the benefits of physiother- apy services in managing MS, there are no Canadian data describing the type of services provided, therapy environ- ments (e.g., home, clinic, hospital), intensity or duration of treatment programmes, outcome measures, or degree to which clinicians use evidence-based practices. 3

Cross-sectional surveys have proved useful for map- ping physiotherapy service and practice patterns in Can- ada for other conditions, including diabetes, obesity, chronic obstructive pulmonary disease, and low back pain. 9 – 12 Their results report on the demographics and statistics of patient populations, best practice methods, and the still-existing limitations of the physiotherapy approaches used in treating these conditions. This infor- mation helps to guide the development of new roles and practice patterns. 9,13

Such surveys have the potential to inform future ser- vices and guide the design of new programmes and treat- ment protocols. They identify the barriers that impede the delivery of adequate services, which can also help direct advocacy efforts to promote systemic changes at

all organizational levels to advance the physiotherapy services available for the care of patients with MS. 14 In addition, an awareness of the organizational context of physiotherapy service delivery informs current practice guidelines, allowing researchers to determine the appli- cability and feasibility of the parameters used in clinical trials across various settings and jurisdictions. 7

Although growing evidence supports the effectiveness of rehabilitation in MS, 15 knowledge about the specific physiotherapy services that people with MS receive in daily practice is lacking. 16 Currently, the organizational structures and contexts of physiotherapy services and treatments in the care of individuals with MS in Canada are not known. Moreover, no data are available to confirm the extent to which evidence-based interventions are being implemented in routine practice. This knowledge is foundational for improving the care of people with MS. Hence, the objective of this study was to develop a survey to determine what physiotherapy services and practice patterns are currently available for people receiving MS services in Canada. This survey would identify any gaps in MS service delivery, recommend improvements at the level of individual practising clinicians and at the orga- nizational level, and ultimately improve the care experi- ences of patients with MS.

Using a qualitative research approach, specifically participatory action research (PAR), we engaged physio- therapists and people with MS to construct the survey. The PAR method involves identifying key community participants as stakeholders in a research question, inter- viewing them, and then analyzing their input. 17 It is a cyclical process that combines two concepts: participa- tory research, in which participants are involved in the research process as members of the research team and not as research subjects, and action research, in which the findings are analyzed and used to address community issues and influence social change. 17 We considered this model appropriate for construction of a survey such as ours because it ensured the equal contribution of partic- ipants and researchers, shared learning, and the transfer of expertise among members of the research team. 17

In addition, we used a conceptual framework based on the Donabedian model to ensure that our survey was comprehensive and to guide its overall development. Mosadeghrad, in a review of conceptual models for assessing the quality of health care delivery, 18 described the Donabedian model as having three components: structure, process, and outcome. 19 Structure is used to examine the context within which care is provided, pro- cess describes the interactions between health care pro- viders and patients throughout the delivery of care, and outcomes outline the effects of the health care provided on patients. 19

To place our proposed survey in context, we conducted a literature search and consolidated the findings from

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Recruitment process

Inclusion criteria

Registered physiotherapists were eligible for inclu- sion if they (1) practised in Canada and (2) were currently delivering, or had previous experience delivering, physio- therapy services to individuals with MS. Individuals with MS were eligible for inclusion if they (1) resided in Can- ada and (2) were currently receiving, or had previously received, physiotherapy services delivered by registered physiotherapists.

Participant selection

The participants were selected through purposeful sampling to gather the relevant and informative feedback that would best serve this project’s objective. Sampling continued until data saturation was reached (no new information was elicited). Clinician participants were recruited through the Ontario Physiotherapy Association (OPA), CPA, and word of mouth. An advertisement for the study was placed in the electronic newsletter that CPA and OPA send to all their members. Individuals with MS were recruited through either a faculty member from the McMaster University School of Rehabilitation Sciences or two registered physiotherapists (with experience in neu- rological rehabilitation and community settings).

At the end of this process, seven registered physiother- apists and three individuals with MS were chosen to be involved, following the PAR model, as part of the research team and to act as key stakeholders by participating in survey development.

Semi-structured interviews

We conducted 1-hour semi-structured interviews with the participants by phone, over Skype, or in person to explore their perspectives on the draft survey. Two researchers on the team interviewed each participant. Two separate interview guides were created: one for the interviews with the clinicians and another for the inter- views with the individuals with MS; these are reproduced in online Appendix 2. Using these guides as a reference, we asked the participants for their opinions on the format, structure, content, and readability of each question on the survey as well as their views on the survey as a whole. We also asked them probing questions to encourage them to elaborate on their answers. All participants agreed to be recorded before contributing to the interviews. These recordings were then transcribed verbatim by a third-party transcriptionist, with identifying information removed.

Thematic analysis

Braun and Clarke’s approach to thematic analysis was used to define the key themes that we extracted from the consultation process. 25 Each interview transcript was analyzed by at least two research team members to gen- erate the initial codes. Any disagreements were resolved through discussion with a third independent member

previous environmental scans that explored the practice patterns for other chronic conditions in Canada. 9 – 13 We aimed to create the first survey of how physiotherapy ser- vices for MS are delivered in Canada.

METHODS

The Hamilton Integrated Research Ethics Board exempted this project from formal ethics approval because the recruited individuals were not under study; their input was used only to develop the survey questions.

Literature review

An initial literature search was conducted of MED- LINE ( January 2008–April 2018) and CINAHL ( January 2008–April 2018) to determine the current landscape of environmental scans of physiotherapy services for other health conditions in Canada. MEDLINE was selected because it includes more than 23 million citations from more than 5,600 journals. 20 Similarly, CINAHL was selected because it includes more than 6 million citations from more than 5,300 journals. 21 The search strategy was developed in collaboration with a health sciences librar- ian. Detailed search strategies and keywords are outlined in online Appendix 1.

We reviewed Canadian research from the past 10 years that explored similar objectives to analyze recent studies in a common health care system. Studies using the survey or questionnaire approach to examining physiotherapy services were used because they aligned with the objec- tives of this research project. Two reviewers screened the abstracts and then the full-text articles. They examined the structure and content of the questions in those stud- ies to uncover common characteristics, which were later used as the foundation for this survey. A data extraction form was developed and used to obtain the relevant infor- mation from the full-text articles. Each reviewer identi- fied key domains from the literature search, and then the research team decided on the most relevant domains to include in the draft version of the survey.

Draft version of survey

We drafted a 24-item questionnaire containing ques- tions relevant to physiotherapy practices for people with MS, guided by the results of the literature search, in par- ticular the previously described environmental scan of European physiotherapy services for people with MS. 7 The “Description of Physiotherapy” developed by the Canadian Physiotherapy Association (CPA) was used to standardize the terminology in the survey response options, 22 and Statistics Canada terminology was used to define population size. 23 Finally, the clinical practice guidelines for the physiotherapy management of indi- viduals with MS were used to develop a comprehen- sive list of response options related to physiotherapy treatment. 24

Kuspinar et al. Use of Participatory Action Research in the Development of a Survey of Physiotherapy Services for People with Multiple Sclerosis in Canada 369

of the research team. The codes were then examined and used to develop a coding structure and preliminary themes, which were then refined and finalized by all researchers.

Survey revision

After the thematic analysis was complete, the draft sur- vey was revised to integrate the final themes. The survey was then returned by email to the participants to deter- mine whether the revisions accurately represented the topics explored during the interviews. The survey was finalized after considering the participants’ final feedback.

RESULTS

Literature search

The literature search process is shown in Figure 1 . A total of 519 articles were identified in the databases; 67 duplicates were removed, 352 articles were removed during title and abstract screening because they did not meet the inclusion criteria (e.g., were not Canada spe- cific, did not involve physiotherapy, or were irrelevant to

the research question), 71 articles were removed during full-text screening (68 did not meet inclusion criteria, and full text for 3 was not accessible). A total of 29 articles were included in the final summary.

Survey development

The survey domains identified in the literature were either eliminated or included after we had a rigorous dis- cussion of the key elements required to fulfil the purpose of our survey. For instance, the surveys used in the studies asked questions about the demographics of the respon- dents, which we applied to the demographics section of our survey. They also consistently included the facilitators of and barriers to receiving care, which we also incorpo- rated into our survey. A third key domain was the for- mat of the survey questions in the literature (e.g., closed ended, open ended), which we used to inform the format of our questions and response options.

The conditions or procedures described in the arti- cles were cardiovascular disease, stroke, spasticity, hip fracture, obesity, low back pain, hemophilia, chronic pain, cerebral palsy, burns, HIV, diabetes, osteoarthritis,

Figure 1 Flow diagram of literature search.

Records identified through database search

(n = 519)

Duplicates removed (n = 67)

Title and abstracts screened (n = 452)

Records excluded did not meet inclusion criteria

(n = 352)

Articles assessed for eligibility (n = 100)

Articles excluded did not meet inclusion criteria

(n = 68) or not accessible (n = 3)

Full-text articles included (n = 29)

Full-text articles analyzed (n = 29)

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chronic obstructive pulmonary disease, trauma, total joint arthroplasty, post-cardiac surgery, and ventricu- lar drains. In addition, one study involved smokers, and another investigated critically ill children.

The literature search revealed no existing surveys per- taining to physiotherapy services for individuals with MS in Canada. However, studies involving individuals with other conditions highlighted the key concepts involved in developing a survey. For example, a trend across many of the surveys was the use of closed-ended questions, comprehensive answer options, and concise wording. We used two components of the Donabedian model as a framework for analyzing these trends (the outcomes component was not relevant). 19 As a result, we orga- nized our draft survey into two components: structure, which consisted of questions on organizational struc- ture and material and human resources, and process, which included questions about practice patterns and treatment.

Beta version of the survey

The resulting beta version of our Canadian Survey of Physiotherapy Services for MS (CanPTMS) consisted of 24 items divided into five categories: (1) respondents’ demographics and practice setting (4 items), (2) MS pro- gramme or service offered and the patient population served (12 items), (3) use of an interdisciplinary team (3 items), (4) barriers to delivering MS programmes or ser- vices (3 items), and (5) an additional open-ended feed- back section (2 items). When possible, the answer options were formatted as fixed responses to make the survey respondent friendly and for ease of data analysis. Seven items had open-response options to allow respondents to elaborate on their answers.

Participant characteristics

The 10 participants provided feedback on the beta version of the survey. Two people with MS reported that they had been diagnosed with relapsing-remitting MS, and one person had been diagnosed with second- ary progressive MS. All participants with MS were from central Canada, and the length of time since diagnosis ranged from 6 to 40 years. The physiotherapists’ current practice locations included the Prairie Provinces, cen- tral Canada, and the Atlantic Region, with clinical expe- rience ranging from 2.5 to 24 years. Physiotherapists had experience in outpatient rehabilitation, inpatient rehabilitation, outpatient clinic, and community-based home care.

Thematic analysis

Five key themes emerged from our analysis of the interview data: (a) provide additional answer options, (b) reformat or clarify questions, (c) confirm that questions or options are appropriate, (d) ensure good readability and flow, and (e) determine the appropriate length of the survey.

Provide additional answer options

We questioned the comprehensiveness of the answer options and allowed participants to suggest additional options. For 67% (16 of 24) of the survey questions, at least one participant suggested adding an additional answer option, and for 13% (3 of 24) of the questions, the major- ity of the participants ( n > 5) suggested adding an addi- tional answer option. Participants stated that the checklist response options were not comprehensive enough. Within this theme, several sub-themes were identified: (1) expand types of treatment provided to include mental health approaches, (2) include answers relating to transportation and environmental barriers, and (3) consider caregiver edu- cation and support.

I wouldn’t discount any of the other aspects and conse- quences of the disease rather than just the physical – looking more at the cognitive and emotional. (Multiple Sclerosis [MS] 1)

I put down transportation … is always a big challenge … might be one you want to tease out a bit. (Clinician [C] 2)

You could have in there as well the caregiver – caregiver edu- cation, caregiver support. (C3)

Reformat or clarify questions

We reformatted or clarified 67% (16 of 24) of the sur- vey questions on the basis of feedback from at least one participant. The majority of participants ( n > 5) thought that one question required reformatting or clarification. Two questions created the most uncertainty: one asked about managing MS in terms of acute treatment versus chronic management, and the other asked about treating mild, moderate, and severe MS. The participants thought that asking questions that grouped aspects of MS care together was confusing.

It’s kind of hard to have manag[ing] acute and chronic at the same time, you are doing one or the other … that might need to be separate[d]. (C1)

Because my definition of mild, moderate, severe could be different than someone else’s definition of mild, moder- ate, severe. Are you using a certain scale that’s going to help differentiate that? (C1)

Confirm that questions or options are appropriate

The participants were satisfied with the response options overall. Every participant ( 10) commented that at least one question was appropriate without edits. The majority of the participants ( n > 5) commented that 42% (10 of 24) of the questions were appropriate with- out edits. Many items on the survey draft were deemed appropriate and relevant to the overall survey purpose. For example, as feedback for a question about the types of treatment provided by physiotherapists, several participants believed that the options provided were appropriately exhaustive.

I thought you offered a lot of options there. … I think that’s really good. (C3)

Kuspinar et al. Use of Participatory Action Research in the Development of a Survey of Physiotherapy Services for People with Multiple Sclerosis in Canada 371

Ensure good readability and flow

According to our interview guide, we asked partici- pants open-ended questions about the survey’s readabil- ity and flow, which allowed them to provide both positive and constructive comments. Eighty percent (8 of 10) of the participants were satisfied with the clarity and orga- nization of the survey; therefore, only we made minor changes.

I actually liked how you had your headings, because that made it kind of easier to work your way through because it’s a longer question … so the headings were really help- ful. (C1)

Determine the appropriate length of the survey

Sixty percent (6 of 10) of the participants reported that the length of the survey was appropriate and that the sur- vey gathered all the relevant information concisely.

It wasn’t very long, which is always greatly appreciated. (C2) It’s clear, and it didn’t take too long to answer. (C4) I wouldn’t break it down lengthier to make another ques-

tion. (P3)

Final survey

After holding discussions among the research team members, we finalized the survey to reflect the themes gathered from the interviews. We provided additional answer options for the questions relating to practice set- ting, funding, referrals, treatment, and barriers to receiv- ing physiotherapy care. We reformatted the survey items and answer options relating to referrals, the details of the MS programmes and services provided, and the resources used to inform physiotherapy practice. Other changes were made throughout the survey on the basis of feedback from individual participants that had not developed into themes but that the research team considered relevant.

Member checking was conducted by emailing the final survey to participants, asking whether the survey edits represented the feedback they had provided, and request- ing any additional comments on the final survey. Of the 10 participants, 1 responded with additional feedback; however, after considering that feedback, we made no further changes to the survey. The final survey consisted of 24 questions to collect the following data: demograph- ics, MS programme and patient population, interdisci- plinary care, and programme and service barriers. The final survey is reproduced in online Appendix 3.

DISCUSSION

The evidence to support the effectiveness of MS reha- bilitation interventions is growing; 15 however, knowledge of what specific physiotherapy services people with MS receive is uncertain and has been described as a “black box.” 16 Considering the high rate of MS in Canada, we were surprised to find that no previous environmental scans had been conducted for this population. 1 There

could be several explanations for why so little information on rehabilitation services is available. For example, envi- ronmental scans require extensive resources to recruit enough respondents to generate representative results. In addition, because MS symptomatology is highly hetero- geneous, the treatment parameters and practice patterns likely vary accordingly, making it challenging to collect and compile data. 6,26

Although previous studies have included surveys and environmental scans of services for people with other chronic conditions, our literature search revealed no evi- dence of their survey development processes or evalua- tion. However, in 2019 Wilson and colleagues developed a survey to describe the practice patterns of Canadian phys- iotherapists regarding gait rehabilitation in adults with acquired brain injury. 27 That questionnaire was developed using the available literature and input from physiother- apists and researchers with expertise in acquired brain injury rehabilitation. As in that study, we reported our survey development methodology, which included invit- ing clinicians and people with MS to become research team members and incorporating their perspectives. The final CanPTMS survey will be used to map physiotherapy services for people with MS in Canada.

PAR provides a framework by which members of the target community become active members of a research team. 28 The PAR process we used was unique because it incorporated physiotherapists and people with MS as intimate knowledge providers, researchers, and research participants. It prevented a detached method of research by encouraging reflexivity and active learning from all team members (persons affected by MS, clinicians, and academic researchers), probing at a deeper level the meaning of what it is like to live with MS, the barriers that impede the delivery of adequate services, and the services available. Team members living with MS raised points that other members of the team had not considered, such as treatment for cognition and emotional well-being, as well as the common difficulties faced by individuals with MS with respect to accessible transportation and facili- ties. We are not aware of any previous research that has used PAR methods in developing a survey, and our results provide important foundational data for future research undertaking such a participatory approach.

A large volume of research has examined physiother- apy practices for individuals with other health conditions, so one would think that modifying previous surveys to map the existing services for MS would be straightfor- ward. 9 – 12 In fact, although there was some overlap with the questions used in other surveys, our results show that some services and physiotherapy practice patterns are unique to individuals living with MS. 7 By examining our survey questions using the structure and process ele- ments of the Donabedian model, which was developed specifically for examining health care services, we were

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able to uncover four key areas that require attention to improve clarity and comprehensiveness for clinicians and individuals with MS: (1) the uniqueness of clinicians pro- viding services (e.g., level of expertise, practice setting), (2) who receives physiotherapy services and how these services are provided (e.g., patient population, referral processes), (3) interdisciplinary care, and (4) perceived barriers and needs.

This study had several limitations. The first relates to using the Donabedian model as a framework for devel- oping our survey. Despite its many strengths, this model also has certain disadvantages. Its components progress in a linear fashion from structure to process to outcomes, and this progression limits researchers’ ability to recog- nize the interplay among these components and their influence on each other. 19 Nevertheless, implementing an established conceptual framework provided a structure for our survey. 18

Second, our sample may provide a limited represen- tation of people with MS, which may affect the survey’s generalizability. Only MS patients who responded to recruitment postings were contacted for the interview, and all the people with MS whom we consulted had received MS-related physiotherapy services at some point. This means that there was no representation from people with MS who had no access to or experience with the appropriate services. We chose this approach because of the time restraints and resources available to us; it had the added advantage of being simple and cost efficient.

A third limitation relates to using the PAR approach. Participants are crucial to the PAR process; however, it was difficult to recruit a wide enough sample of individu- als and clinicians who were interested in participating in the project. This is likely a result of the extensive level of participation and time commitment required. However, despite the small number of participants we recruited, we approached a saturation of themes because participant feedback included consistent repetition.

Finally, we did not include administrative members of physiotherapy clinics or hospitals in survey development. One or more physiotherapists with an administrative role will be recruited during the pilot testing phase of the sur- vey. Moreover, clinicians and patients were not involved in the literature review or development of the initial draft of the survey. This was due to the difficulties of includ- ing participants in the literature review process and data extraction.

CONCLUSION

We developed a survey to examine the current phys- iotherapy practice patterns of physiotherapists treating individuals with MS in Canada. As part of the future direc- tions of this research, we will continue to test the survey, then distribute it to physiotherapists across Canada to conduct an environmental scan that will address the

current gap in our knowledge of the physiotherapy ser- vices available for individuals with MS in Canada.

Considering that physiotherapists play a crucial role in the management of MS, our survey asks questions that capture the scope of how physiotherapy service is delivered to individuals with MS. This study presents the first Canadian survey to explore the current practice patterns of physiotherapists and the delivery of MS ser- vices nationwide using the Donabedian model and a PAR approach in its development.

KEY MESSAGES

What is already known on this topic

Currently, there is a paucity of research describing the physiotherapy services available to individuals with mul- tiple sclerosis (MS) in Canada and the practice patterns of the physiotherapists who treat them.

What this study adds

This study presents the first Canadian survey to explore the current practice patterns of physiotherapists nation- wide and how they deliver MS services. It is also unique in that it used participatory action research methodol- ogy and followed the Donabedian model. The informa- tion gathered through the survey will be the first step in improving the quality of health of people with MS and the effectiveness of current physiotherapy practices for them.

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