Background and Purpose: The purpose of this study was to identify practitioner barriers (education, attitudes and beliefs, interest and perceived role, and self-efficacy) and organizational barriers (perceived support and resources) to physical therapists’ implementation of evidence-based practice (EBP) for people with stroke.
Subjects: The participants were 270 physical therapists providing services to people with stroke in Ontario, Canada.
Methods: A cross-sectional mail survey was conducted.
Results: Only half of respondents had learned the foundations of EBP in their academic preparation or received training in searching or appraising research literature. Although 78% agreed that research findings are useful, 55% agreed that a divide exists between research and practice. Almost all respondents were interested in learning EBP skills; however, 50% indicated that physical therapists should not be responsible for conducting literature reviews. Average self-efficacy ratings were between 50% and 80% for searching and appraising the literature and below 50% for critically appraising psychometric properties and understanding statistical analyses. Despite Internet access at work for 80% of respondents, only 8% were given protected work time to search and appraise the literature.
Discussion and Conclusion: Lack of education, negative perceptions about research and physical therapists’ role in EBP, and low self-efficacy to perform EBP activities represent barriers to implementing EBP for people with stroke that can be addressed through continuing education. Organizational provision of access to Web-based resources is likely insufficient to enhance research use by clinicians.
Evidence-based practice (EBP) has been defined as “integrating individual clinical expertise with the best available external clinical evidence from systematic research”1(p71) and as a culture in which clinicians naturally and consistently consider evidence in every aspect of practice.2 Although clinicians use research evidence for diverse purposes, 3 primary areas of practice that research evidence informs are: (1) the selection of standardized assessment tools (ie, outcome measures3), (2) the interpretation of scores on assessment tools, and (3) the selection of therapeutic, rehabilitative, or preventive interventions.1 A primary assumption underlying EBP is that the integration of high-quality research findings, clinical expertise, and patient preferences improves the effectiveness of health service delivery and, consequently, client outcomes. Evidence supporting this assumption for people with stroke has been reported.4,5 Compliance with a clinical practice guideline in postacute stroke rehabilitation was associated with not only physical recovery4 but also patient satisfaction.5 Optimizing access to and use of research findings to implement EBP on an ongoing basis requires certain attributes and resources commonly classified as characteristics of the individual practitioner and of the organization.6–8
Practitioner characteristics, such as awareness, knowledge, attitudes, skills, and self-efficacy, are viewed as primary influences on the successful implementation of EBP.6–14 Self-efficacy is defined as a judgment of one’s ability to organize and execute activities in a specific domain.15 We have labeled perceived ability to undertake the activities required to implement EBP as “EBP self-efficacy.” The value of this construct lies in its ability to determine behavior. For example, physical therapists with a high level of self-efficacy to perform EBP activities would be expected to engage in these activities more frequently than physical therapists with low EBP self-efficacy.15,16
In addition to practitioner characteristics, organizational resources (eg, the presence of a library, a resource person, Internet access, and managerial and peer support) also may affect the implementation of EBP.7,17,18 For example, access to online databases is an organizational resource that is necessary to enable literature searches.9 Findings of a qualitative study17 indicated that the presence of an organizational mandate facilitated the use of standardized assessment tools among physical therapists.
Physical therapy practitioners appear to value the principles of EBP9,19 but report inconsistent reliance on research evidence in their clinical decision making.20–22 An understanding of practitioner and organizational characteristics that may impede EBP is needed to inform the development of educational interventions aimed at enhancing the integration of research into physical therapist practice.23,24
Studies of practitioner and organizational barriers to EBP have been conducted among physical therapists in the United States9 and in the United Kingdom.19 Differences in entry-level training, health care systems, and professional practice across countries, however, limit the generalizability of this research to the Canadian context. Although level of confidence to perform select EBP activities has been evaluated previously,9,19,25 self-efficacy theory has not been used to understand physical therapists’ perceived ability to undertake the entire EBP process. Previous research4,5 showing improved patient outcomes with the integration of research evidence in stroke rehabilitation supports targeting physical therapists providing services to people with stroke in an evaluation of barriers. Thus, the primary objective of this study was to evaluate practitioner and organizational factors affecting the implementation of EBP by physical therapists providing services to people with stroke. Practitioner factors included education about EBP, attitudes and beliefs, interest and perceived role in EBP, and self-efficacy to perform EBP activities. Organizational factors were support and availability of resources for implementing EBP. A secondary objective was to identify sociodemographic variables and practice and organizational characteristics related to these factors.
Overview of Study Design
A cross-sectional mail survey of physical therapists providing services to people with stroke in Ontario, Canada, was conducted. A modified Dillman three-step mailing procedure26 was followed to optimize response. A first questionnaire was mailed in May 2005. Three weeks later, a postcard thank-you/reminder card was sent. A second questionnaire was mailed to nonrespondents at the end of June 2005.
Participants and Sampling
Physical therapists were considered eligible for the study if they were: (1) currently practicing and (2) providing physical therapy services to adults with stroke. Potential participants were sampled from the register of the College of Physiotherapists of Ontario, the provincial regulatory body. A request was submitted to the College of Physiotherapists of Ontario for a mailing list of individuals who were currently practicing and who specified neurology as an area of practice at either their primary or secondary workplace. Registrants who indicated pediatrics as a practice area were excluded. Questionnaires were mailed, and recipients were asked to indicate in the first item of the questionnaire whether they provided services to people with stroke. Those recipients who indicated that they did not provide services to people with stroke were considered ineligible and were asked to leave the rest of the questionnaire blank and return it in the envelope provided. Eligible individuals who did not wish to participate also were asked to return the questionnaire with the remaining items unanswered, and these individuals were considered as refusals. Consent was considered implied for physical therapists who returned a completed questionnaire.
Questionnaire items (Appendix) were designed to identify practitioner and organizational factors influencing EBP. Subgroups of items were used to evaluate education about EBP (items 14–16), attitudes and beliefs (items 2, 3, 5, and 7–10), interest (items 4 and 6) and perceived role (items 11–13) to engage in EBP, self-efficacy to perform EBP activities (items 17.1–17.12), perceived organizational and peer support for EBP (items 25 and 26), and organizational resources and support to promote EBP (items 18–24). One item was used to identify the 3 greatest barriers to updating clinical practice with new knowledge (item 27). Items were added to the end of the questionnaire to evaluate respondent demographics, practice characteristics, and work setting (items 28–47). For the majority of items, respondents indicated their level of agreement with a statement on a 5-point Likert scale with the following response options: “strongly disagree,” “disagree,” “neutral,” “agree,” and “strongly agree.” Response options for items relating to the presence of organizational resources were “yes,” “no,” and “do not know.”
The primary source of items was a survey tool used by Jette et al9 to evaluate physical therapists’ beliefs, attitudes, knowledge, and behavior in relation to EBP. Investigations by other researchers17,19 formed the basis for adding items assessing EBP beliefs and the existence of an organizational mandate supporting EBP. We devised 3 new items (items 11–13) to evaluate physical therapists’ perceived role in searching and appraising the research literature and interpreting its applicability to individual clients.
EBP Self-efficacy Scale
Self-efficacy to perform EBP activities was measured using a new, 12-item scale that we developed in adherence to guidelines for developing self-efficacy scales.27 Eight items initially were generated to evaluate self-efficacy to perform each of the following steps of implementing EBP: (1) identify a clinical problem, (2) formulate a question to guide a literature search, (3) effectively search the relevant literature, (4) critically appraise the evidence for reliability and relevance, (5) appropriately apply the evidence to the clinical problem, (6) understand the patient’s needs and preferences, (7) decide on an appropriate course of action in collaboration with the patient, and (8) continually evaluate the effect of practice.1,28–30
Four items then were added to capture specific aspects of critical appraisal related to understanding psychometric properties of outcome measures, strengths and weaknesses of different study designs, and basic and intermediate statistical procedures. This was done to enable specific identification of a problem area that could be targeted through education. To complete the scale, participants were asked to rate their level of confidence in their ability to perform each activity, using an 11-point scale ranging from 0% (“cannot do at all”) to 100% (“certain can do”). Item-level responses were averaged to obtain a summary score ranging from 0% to 100%. Construct validity is inherent in the scale’s construction, given that item development was based on the established process of EBP.31 Internal consistency estimated using data collected in this study (n=261) was .90 (Cronbach alpha), which meets the level required for using the scale at the individual level.32
Three physical therapists working in acute care or rehabilitation hospital settings reviewed the questionnaire and the EBP self-efficacy scale and verified their readability and relevance. The questionnaire was shortened and some questions were reworded to enhance clarity based on the feedback provided.
The prevalence of practitioner and organizational factors was estimated using percentages. Logistic regression then was used to examine relationships between sociodemographic and practice characteristics of respondents (ie, independent variables) and each practitioner factor (ie, dependent variable). Independent variables included age, sex, highest degree obtained, number of years practiced, number of hours worked per week, number of patients seen per day, care delivery within a multidisciplinary team (yes/no), supervision of physical therapist students (yes/no), membership in a professional organization (yes/no), and participation in research activities (yes/no). Research participation was derived using the percentage of time that respondents reported spending in research activities (>0%=yes, 0%=no). Dependent variables were items used to determine education about EBP, attitudes and beliefs, interest and perceived role in EBP, and self-efficacy to perform EBP activities.
Logistic regression also was used to identify associations between organizational characteristics (independent variables), including facility location and type, number of physical therapists at the facility, and status as a teaching institution, and each organizational factor (dependent variable), including items measuring perceived peer and organizational support and the existence of resources (eg, access to journals, Internet, personnel) to facilitate EBP.
Prior to examining associations among variables, categories were combined in the following manner to produce binary dependent variables for use in logistic regression.9 For statements with a positive response set rated using a Likert scale, the “strongly agree” and “agree” categories were collapsed to form an “agree” category and the “neutral,” “disagree,” and “strongly disagree” categories were combined to form a “disagree” category. For items with a negative response set, the “strongly disagree” and “disagree” categories were collapsed to form a “disagree” category and the “neutral,” “agree, and “strongly agree” categories were combined to form an “agree” category. For items with response categories of “yes,” “no,” and “do not know,” the latter 2 categories were pooled based on the assumption that the effect of not knowing about the presence of a resource, for example, would have a similar effect as not having the resource. There is no research to guide the selection of a cutoff point for dichotomizing respondents into high and low levels of self-efficacy ratings. Thus, the median self-efficacy rating (≤63 points/>63 points) was used because, at a minimum, it resulted in equally large subgroups that would optimize the reliability of estimated associations.
Categories of demographic variables with low cell counts also were collapsed in order to obtain stable estimates in regression analyses. Logistic regression then was performed to estimate the influence of each independent variable on a dependent variable without adjustment for other variables given the exploratory nature of the analysis. Odds ratios (ORs) and associated 95% confidence intervals (CIs) were reported for statistically significant associations at a type I error level of .05. These analyses were considered descriptive and exploratory and were conducted to provide a basis for hypothesis development. Data were analyzed using SAS software, version 9.1.*
The questionnaire was mailed to 1,155 individuals. Figure 1 illustrates the outcome of sampling. Of the 702 individuals who returned a questionnaire, 334 (48%) were eligible to participate in the study. Among eligible respondents, 64 people (19%) refused to participate and 270 (81%) completed a questionnaire. Analyses were conducted on this sample of 270 physical therapists.
Table 1 presents respondent and practice characteristics. Respondents were between 23 and 68 years of age (mean=40, SD=10), and 88.8% were women. A bachelor’s degree was the most commonly cited highest degree obtained (76.9%), and 45.4% of the respondents reported having more than 15 years of practice experience. Table 2 presents characteristics of the organizations for which the respondents worked. The most frequently cited characteristics were an urban location (60.9%) and employment in an acute care hospital (39.6%) or teaching hospital (67.3%). Table 3 provides the percentages of participants by category of response—disagree, neutral, or agree—to statements concerning education about EBP, attitudes and beliefs, and interest and perceived role in EBP.
Education in EBP
Table 4 shows that age, highest degree obtained, and number of years practiced were associated with academic preparation in EBP and formal training with critical appraisal. Sex also was associated with training in critical appraisal skills; male respondents were 2.9 times more likely than female respondents to report training (95% CI=1.2–7.0). Age, years practiced, hours of work per week, practice in a multidisciplinary team, and participation in research were each associated with formal training with search strategies. For example, compared with respondents who had more than 15 years of practice experience, respondents with less than 5 years of experience were 31.2 times more likely to have learned the foundations of EBP in their academic preparation (95% CI=11.0–88.6), 9.3 times more likely to report having received formal training with search strategies (95% CI=3.8–22.9), and 99.8 times more likely to report having received formal training in critical appraisal skills (95% CI=13.2–754.9).
Attitudes and Beliefs
As shown in Table 5, characteristics associated with attitudes and beliefs included age, sex, highest degree held, hours of work per week, work in a multidisciplinary team, supervision of physical therapist students, and participation in research. For instance, compared with respondents who had a bachelor’s degree, respondents holding a certificate or diploma were less likely to agree or strongly agree that EBP improves quality of care (OR=0.4, 95% CI=0.1–0.8) and more likely to be neutral or agree that EBP places unreasonable demands on physical therapists (OR=2.6, 95% CI=1.1–5.7).
Interest and Perceived Role in EBP
Table 6 presents characteristics associated with interest and perceived role in EBP. Compared with respondents who had a bachelor’s degree, those with a master’s degree were less likely to report interest in learning EBP skills (OR=0.3, 95% CI=0.1–0.8). The number of patients seen per day, number of years practiced, and practice in a multidisciplinary team were associated with perceptions of physical therapists’ role in implementing EBP. For example, physical therapists with less than 5 years of practice experience were 9.7 times (95% CI=1.3–74.4) more likely than those with more than 15 years of practice experience to indicate that physical therapists are responsible for applying research findings to clients, and respondents working in a multidisciplinary team were 2.7 times more likely than those not working in such a team to agree with this statement. None of the characteristics evaluated was associated with agreement with the need to increase the use of evidence in practice.
Self-efficacy ratings for 12 different activities or skills necessary to implement EBP are shown in Table 7. Average item-level scores were greater than 80% for identifying a clinical problem following a patient assessment, understanding patient needs and treatment preferences, deciding on an appropriate course of action in collaboration with the patient, and continually evaluating the effect of practice. Average ratings were between 50% and 80% for formulating a clinical question to guide a literature search, conducting a literature search, critically appraising the literature, critically appraising different study designs, and appropriately applying evidence from the literature to the individual patient. Average ratings below 50% were observed for critically evaluating the psychometric properties of outcome measures and interpreting the results of basic or intermediate statistical procedures.
Table 8 shows that age, sex, highest degree held, and number of years practiced were associated with EBP self-efficacy. Compared with respondents aged 30 to 39 years, those over 50 years of age were less likely to rate their EBP self-efficacy above the median (ie, 63%, OR=0.2, 95% CI=0.1–0.3). Men were 3.0 times more likely than women to rate their self-efficacy at greater than 63%. Respondents with a master’s degree or less than 5 years of practice experience were more likely than those with a bachelor’s degree or more than 15 years of practice experience, respectively, to rate their self-efficacy above 63%.
Peer and Organizational Support
Characteristics associated with perceived support and organizational resources are shown in Table 9. Location and type of facility, the number of full-time physical therapists on staff, and status as a teaching institution were associated with perceived organizational resources to support EBP. Compared with urban settings, organizations in rural settings were less likely to provide journals in paper format (OR=0.4, 95% CI=0.2–0.7), Internet access (OR=0.4, 95% CI=0.2–0.8), or a resource person to assist with EBP (OR=0.2, 95% CI=0.1–0.4). Similar findings were seen for community-based organizations. Organizations with more than 20 full-time physical therapists on staff were 3.7 times (95% CI=1.4–10.1) more likely to mandate the use of research in practice compared with facilities with fewer than 5 full-time staff physical therapists. None of the organizational characteristics evaluated was associated with the provision of protected time. Therapists working in a teaching institution were 6.3 times more likely than respondents working in a non–teaching institution to report receiving financial support (95% CI=3.5–11.4).
Self-reported Barriers to EBP
Figure 2 presents perceived barriers to updating clinical practice with new information noted by more than 10% of the respondents. The 4 most frequently cited barriers were insufficient time provided by management (74.4%), lack of generalizability of research findings to the patient population (33.7%), lack of research skills (30.7%), and lack of understanding of statistical analyses (30.4%). Barriers cited by fewer than 10% of the respondents were lack of support among colleagues (3.7%) and lack of interest (3.3%).
The study findings highlight potential practitioner and organizational barriers to the implementation of evidence-based physical therapy for people with stroke and provide new and comprehensive information on physical therapists’ level of self-efficacy to undertake EBP activities.
A notable practitioner-level barrier to the implementation of EBP was the lack of formal education in the principles of EBP and in skills related to searching and critically appraising the research literature among half of the respondents. Jette et al9 obtained similar results in a 2002 survey of 488 members of the American Physical Therapy Association, with the exception that a higher proportion of American physical therapists reported training in critical appraisal skills (67%) compared with our respondents (56%). This difference may be due to the higher prevalence of graduate degree training among the American physical therapists compared with individuals in the current study (56% versus 12% held a master’s degree, 4% versus 0% held a doctoral degree). As with their American counterparts,9 the physical therapists in the present study who were youngest or who had practiced less than 5 years were more likely than the reference group to have learned about EBP principles and critical appraisal in their academic program and to have received formal training to search the research literature. These findings suggest that current Canadian university training programs for physical therapists are emphasizing the foundations of and skills to implement EBP, as indicated in their Web-based descriptions.33,34
Although we may assume that newly graduated physical therapists are being trained to implement EBP, 45% of the current sample and 38% of physical therapists investigated by Jette et al9 graduated more than 15 years ago. Thus, a substantial proportion of practicing physical therapists may be inadequately prepared to access, interpret, and integrate findings from well-conducted research into their clinical practice. Our study findings support this interpretation, as respondents with more than 15 years of practice experience were significantly less likely than those with less than 5 years of experience to rate their perceived ability (self-efficacy) to undertake EBP activities above 63%.
Self-efficacy ratings were lowest for effectively searching and appraising the research literature, particularly with respect to understanding statistical procedures and appropriately applying research evidence to the individual patient. Respondents indicated that they also lacked skills in these areas and perceived these deficiencies as important barriers to advancing practice. Low self-efficacy levels have been noted previously among physical therapists,9,18,19 occupational therapists,18 nurses,11,35 and physicians.36 In Jette and colleagues’ survey,9 more than a third of American physical therapists were either neutral or disagreed that they felt confident in their search (35%) or critical appraisal (45%) skills. As in the current study, agreement was linked with age, years of practice experience, and degree held. The concern, according to self-efficacy theory,37 is that physical therapists with low self-efficacy for searching and appraising the research literature and integrating the findings into clinical practice are less likely to perform these activities than people who perceive their level of skill to be higher. This has been demonstrated in the medical literature, wherein physicians’ self-efficacy has been linked with their prescribing38,39 and counseling39 behavior. In the current study, men may have reported higher levels of self-efficacy to implement EBP compared with women because they also were more likely to have been trained in critical appraisal skills. Higher levels of self-efficacy among men than among women have consistently been observed in previous research.40–47 Authors have proposed that the combined influence of higher education, income, and occupational status48 or the greater availability of certain roles and opportunities in society for men compared with women49 may explain this discrepancy.
Interestingly, the average self-efficacy rating to critically appraise the psychometric properties of outcome measures in the current study (43%) is lower than that observed by Kay et al25 in a survey of staff physical therapists (59%) and professional practice leaders (64%) working in a large Canadian city. However, physical therapists in the study by Kay et al worked in urban, university-affiliated institutions providing inpatient and outpatient services, with potentially greater opportunity for continuing education on psychometric evaluation than participants in the current study. The lack of perceived ability to interpret results of psychometric testing is surprising, however, given extensive efforts in the last decade to promote the use of outcome measures. Nevertheless, this finding may help to explain the lower-than-expected rates of outcome measures use observed among Canadian physical therapists.17,22,25,50
As in previous studies of physical therapists,9,19,51 the respondents in our study held positive attitudes and beliefs about EBP. This was observed despite differences in the predominant practice setting, which ranged across studies from private outpatient clinics,9 to the rehabilitation setting,18 to the acute care hospital setting50 (as in the current study). It was interesting to note that modifiable characteristics, such as working in a multidisciplinary team, supervising students, and participating in research, related to perceptions that EBP improves the quality of care and other positive attitudes regarding EBP. Attitudes are considered an important factor influencing the implementation of EBP,9,12,51,52 and previous investigations involving nurses have linked attitudes with the use of research findings in clinical decision making.13,14
As with American physical therapists,9 almost all respondents in our study desired to increase the use of evidence in their daily practice and were interested in learning or improving their skill levels to do so. These findings indicate that physical therapists would be receptive to continuing education aimed at increasing the implementation of EBP. The educational goals, however, are less clear. Although physical therapists perceived their ability to search and critically evaluate the research literature to be low and identified the lack of these skills as a barrier to implementing EBP, a notable proportion of respondents did not believe that these tasks were their professional responsibility. Most respondents in the current study agreed that it is the physical therapists’ professional role to determine the relevance of research findings to the individual client. Recently graduated physical therapists were almost 10 times more likely than those with greater than 15 years of practice experience to agree with this sentiment, which suggests that current physical therapy training programs may be effectively developing stronger beliefs concerning the physical therapists’ role in implementing EBP.
The lack of protected time to search and appraise the research literature was by far the largest organizational barrier, as indicated by 82% of our respondents compared with only 67% of American physical therapists surveyed.9 Without protected time or the skill to conduct literature searches, physical therapists cannot take advantage of Internet access to online databases, which were widely available to 80% of the survey respondents.
A consistent observation was that physical therapists working in small, community-based, rural, or non–teaching institutions are particularly disadvantaged to implement EBP due to a lack of educational and human resources. Physical therapists working in these practice settings may have the greatest need for interventions designed to enable EBP. We also attempted to assess social networks and organizational culture, which are considered important influences on the implementation of best practices.7 Interestingly, a lack of peer support represented a potential organizational barrier to EBP, as approximately one third of the respondents were neutral or agreed that colleagues were skeptical of new practices. Peer support is considered to have an important effect on EBP behavior given that physical therapists rely heavily on peers when seeking information.18 Although three quarters of the respondents perceived their organization to be supportive of using current research in practice, this support was not in the form of a mandate promoting research use. Physical therapists working in Ontario, Canada, have previously indicated that having an organizational directive facilitated the routine use and reporting of outcome measures.17 The lack of a directive supporting EBP, however, did not appear to represent a barrier in the current study. Given that few respondents reported having such a mandate, perhaps therapists were inexperienced with the potential benefits of having one. Overall, there is a need to develop a supportive organizational infrastructure in addition to enhancing skills of the evidence-based practitioner to increase research integration in physical therapist practice for people after a stroke.53
This study was not without limitations. Difficulty with determining the number of eligible physical therapists available for study makes it challenging to interpret the external validity of our findings. In a recent Canada-wide telephone survey, a coauthor (NKB) confirmed that approximately 138 physical therapists were providing services to people with stroke out of 600 physical therapists (23%) in neurology practice in acute care, rehabilitation, or community settings in Ontario (unpublished results). Given that a large proportion of physical therapists work in these settings, it is probable that our sample was representative.
Respondents were likely individuals with some interest in EBP, which may have led to an overestimation of the percentage of physical therapists with positive attitudes toward and beliefs and interest in EBP. Another limitation was that the study was conducted in only one Canadian province, and it is unclear whether the results would generalize to physical therapists working in other provinces. Provincial-level strategies to coordinate and optimize the care for people with stroke are being implemented across Canada, suggesting that resources and perceptions of physical therapists in Ontario may be similar to those in other provinces. Certainly, the availability of university-based physical therapist programs across the country and the wide distribution of age, professional training, practice experience, and work settings among respondents support the internal and external validity of the study findings. The closed-ended nature of the questionnaire items limits our insight into some of the survey results, such as the exact nature of the respondents’ participation in research activities. This limits the specificity of recommendations that can be made. Finally, we considered the cutoff thresholds used for reporting self-efficacy scale ratings as meaningful, but formal evaluation is needed to verify their clinical validity.
There is a need for continuing education to enhance skills and self-efficacy to search and critically evaluate the research literature and to solicit patient preferences among Canadian physical therapists. Educational initiatives may enhance the quality of physical therapy care and, ultimately, recovery after stroke. Health care organizations can support the individual practitioner by providing resources to enable EBP and opportunities for interactions among health care professionals, students, and researchers that may foster positive attitudes toward this process.
Dr Salbach, Dr Jaglal, and Dr Rappolt provided concept/idea/research design. All authors provided writing. Dr Salbach provided data collection and analysis and project management. Dr Salbach, Dr Jaglal, and Dr Davis provided fund procurement. Dr Salbach provided subjects. Dr Korner-Bitensky and Dr Davis provided consultation (including review of manuscript before submission).
The Research Ethics Board at the University of Toronto approved the study protocol.
An abstract of part of this work was presented at the 15th International Congress of the World Confederation for Physical Therapy; June 3, 2007; Vancouver, British Columbia, Canada.
Dr Salbach was supported by an Ontario March of Dimes–Canadian Institutes of Health Research postdoctoral fellowship to conduct this study. Dr Jaglal is the Toronto Rehabilitation Institute Chair at the University of Toronto.
↵* SAS Institute Inc, PO Box 8000, Cary, NC 27513.
- Received January 31, 2007.
- Accepted May 29, 2007.
- Physical Therapy