Abstracts of scientific papers and sessions, CPA Congress 2011

Scientific papers, education sessions and special interest papers to be presented at the Canadian Physiotherapy Association national congress (2011).


Results:
The TP group had significantly more pain, more medication usage, treatment days and less functional improvement at treatment conclusion and at 3-month follow-up than the FP and TN groups (p < 0.05). For the FP and TN groups, there were no statistically significant differences in medication use and functional improvement at follow up. The TN Group had the highest return to work rate with a trend towards statistical significance (p < 0.075).

Materials and Methods:
Using the Cochrane protocol, MEDLINE, CINAHL, SPORTDiscus, PEDro, EMBASE, EBM, and COCHRANE databases were searched. Articles were included if (1) participants were adult athletes; (2) RMT was compared to sham/control; (3) they used a single group pre-post or randomized controlled trial (RCT), and reported outcomes of respiratory muscle strength and sport performance; (5) it was published in English. Quality assessment using PEDro and data abstraction was performed by two authors.
Analysis: Meta-analyses using RevMan 5.0.25 were calculated when outcomes and study design were similar.
Results: Of the 6,918 citations reviewed, 31 met the inclusion criteria and 25 were RCTs. Meta-analyses demonstrated an overall positive effect of RMT on sport performance (p = 0.02) and particularly, for rowers (p = 0.04). Ratings of perceived breathlessness (p = 0.004) and perceived exertion also were greater after RMT (p = 0.04). Meta-analyses showed greater improvement after RMT for maximal inspiratory pressures (<0.00001), maximal voluntary ventilation for 15 sec (p = 0.007) and maximum sustained voluntary ventilation for several minutes (p < 0.0001). Subgroup analyses revealed differences according to training device.

Conclusions:
Larger sample sizes and closer matching of the RMT protocol (intensity, contraction velocity, range of motion, etc.) to the ventilatory demands of the athlete's sport may further eluciate whether RMT can improve performance. Relevance to Physiotherapy Practice: Patients with these severe respiratory conditions are often cared for by physical therapists in Canadian intensive care units but questions remain regarding best treatment practices.

Materials and Methods: A literature review was conducted in the spring and summer of 2009.
Analysis: A critical review of relevant articles published in English was completed. Statistical analysis was completed where appropriate and data were available.
Results: Some relevant articles are of low quality or have methodological problems which may lead to erroneous conclusions. Randomized control trials showed that earlier ICU mobilization is safe and is associated with positive outcomes. Systematic reviews comparing prone to supine position reported improved oxygenation, reduced risk of ventilator associated pneumonia and an increased risk of pressure ulcers in the prone position. A subgroup analysis showed a significant reduction in mortality in patients with higher illness severity in prone position. Systematic reviews comparing kinetic therapy to control reported that kinetic therapy decreased the incidence of nosocomial pneumonia but had no effect on mortality, duration of mechanical ventilation, or duration of ICU and hospital stays.

Conclusions:
Stepwise early mobilization of ICU patients is safe and is associated with favourable outcomes in both hospital length of stay and functional ability of the patient. Early intervention with sufficient frequency, duration, and for adequate time periods is the key to success for many physiotherapy interventions for this type of patient.

Purpose/Objectives & Rationale:
The objective of the present case report is to illustrate the influence of psychological factors on the rehabilitation process of patients suffering from pain.
Relevance to Physiotherapy Practice: Traditionally, psychological risk factors for chronic pain are seen as inherent patient characteristics that clinicians are asked to evaluate and modify. The present case report provides evidence that these psychological barriers to rehabilitation can also be involuntarily created and/ or perpetuated by clinicians themselves when too much attention is placed on the presumed source of pain.

Materials and Methods:
We describe the case of VT, a 17-year-old female complaining of neck and back pain following a motor vehicle accident.

Analysis:
We report the evolution of VT based on a series of validated and objective outcome measures: numerical pain scale (pain intensity), McGill Pain Questionnaire (pain quality), Pain Disability Index (perceived impact of pain on disability).

Results:
After seven weeks of unsuccessful treatments, the condition of VT improved drastically when a physiotherapist reassured her about the findings of the physical exam, corrected her misbeliefs about pain, and brought her attention away from the physical "abnormalities" initially identified.

Conclusions:
The present case report highlights the importance of addressing psychological factors when evaluating and treating people suffering from painful conditions, and warns physiotherapists against the potential drawbacks of according too much attention to the physical "abnormalities".

Purpose/Objectives & Rationale:
To standardize care and facilitate best practice in a busy acute care setting by developing and implementing a clinical practice guideline for mobilizing patients with a DVT.
Relevance to Physiotherapy Practice: The evidence base for physiotherapy is building, but this evidence is not consistently being transferred to and implemented by the front-line physiotherapist. To provide best patient care, we need to find ways to translate this evidence into practice in busy, acute settings.

Materials and Methods:
After a CPA teleconference on this topic, a survey was done in our region and found that physiotherapists had 8 different practices for mobilizing patients with a DVT. Many were aware of the latest research but did not know how to apply it in their settings. A group of front-line clinicians developed a practice guideline and followed the Fraser Health Authority's clinical decision tool process which involved identifying stakeholders and a rigorous review of the guideline. The next step was to disseminate the guideline to over 200 physiotherapists and implement it at the individual sites. Six months after implementation, a survey was done to see if there was a practice change.
Analysis: Pre and post implementation surveys were reviewed to show evidence of practice change.
Results: There was less variation in physiotherapist's practice post-implementation and physiotherapists were using the document clinically to guide their practice.

Conclusions:
It is important to engage front-line clinicians to change actual practice. A careful approach with new evidence (such as DVT and mobility) can facilitate practice change.

Purpose/Objectives & Rationale:
Achilles tendinopathy is a chronic, activity-limiting syndrome. Many treatments have been advocated, but few directly address the underlying pathology -tendinosis. The purpose of this study was to review and summarize the evidence base for treating Achilles tendinopathy.
Relevance to Physiotherapy Practice: Many patients are drawn to oral or injection therapies as alternatives or adjunts to physiotherapy. MEDLINE (1950to August 2010 was searched using a string of terms related to Achilles tendinopathy. The Cochrane Collaboration Library was searched for systematic reviews of treatments for Achilles tendinopathy. Abstracts of identified studies were screened against inclusion criteria. Study quality was assessed using the 5 point Oxford Scale.

Analysis:
Due to the small number of trials, a meta-analysis was not conducted.

Results:
The search strategy identified 72 RCTs of which 14 qualified. A total of 777 patients (male:female ratio 0.51) were enrolled of average age 45.6 years, ranging from 18 to late 70s. Symptom duration ranged from 3 months to several years. The most common outcome measures were pain at rest or with activity. There was moderate evidence of clinically meaningful, long term reductions in pain and improved function with eccentric exercise. There was weak evidence of short term pain relief with orthotics. There was moderate to weak evidence of a lack of effect of high energy shockwave therapy, oral therapy including NSAIDs, or injections of corticosteroid or platelet-rich plasma.
Conclusions: Active exercise remains the best supported treatment for Achilles tendinopathy, positioning physiotherapists as leaders in the treatment of this widespread condition. Purpose/Objectives & Rationale: Literature highlights effective exercise programs for reducing falls in older adults. The objective of this study was to undertake a knowledge synthesis of available evidence on what facilitates knowledge translation (KT) of evidence-based programs for falls prevention into the community-setting.

A086 -REALIST REVIEW OF KNOWLEDGE TRANSLATION STRATEGIES FOR GETTING OLDER ADULTS' FALLS PREVENTION EXERCISE PROGRAMS INTO THE COMMUNITY
Results: Seventy-six subjects (80.68 ± 5.97 years) participated in the progressive physiotherapy program. After 12 weeks, the participants improved on the Berg (p = 0.000), the Time Up and Go test (p = 0.003) and the 5-meters walking time (p = 0.015). There were no significant differences between the improvement at 12 and 15 weeks of intervention for each variable.

Conclusions:
The above findings indicate that a 12-week physiotherapy exercise program is sufficient to improve balance and gait control.

S003 -EFFECT OF A COMPREHENSIVE TRIAGE SYSTEM ON ACCESS TO SPINE SURGICAL SERVICES
Schneider G, Thomas K, Salo P, Faris P, Benour M, and the University of Calgary Spine Program; University of Calgary, Faculty of Medicine, Graduate Sciences Education, Medical Sciences, Departments of Surgery and Clinical Neurosciences. Correspondence: Geoff Schneider, 28 Valley Stream Close NW, Calgary, AB T3B 5V7; gmschnei@ucalgary.ca Purpose/Objectives & Rationale: Timely access to surgical consultation for patients with spinal dysfunction in Canada is generally poor. We examined the effect of a triage system on access to spine surgical services.
Relevance to Physiotherapy Practice: Physiotherapist's expertise allows them to be a valued member of a triage team facilitating appropriate referrals for operative and non-operative spine care.

Materials and Methods:
In this retrospective cohort study, the primary outcome was time from physician referral of patients with spinal dysfunction to surgical consultation and surgery. A random sample of patients was selected from the year prior to (n = 68) and following (n = 94) the inception of a triage system. Data was retrieved from patient files and electronic medical records.
Analysis: 'Descriptive analyses' were used to summarize patient referrals. Estimation methods (mean, 95% CI) were used to compare the groups with respect to time (days) to surgical consultation and spine surgery from referral.

Results:
Logarithmic transformation was used, as the data was not normally distributed. The geometric mean (95% CI) days to surgical consultation was 78 (55-112) and 74 (59-94); and to surgery was 206 (166-256) and 205 (177-237) pre and post triage respectively. The triage team assessed 3300 patients of whom 53% were referred for surgical consultation and the remainder referred for timely evidence-based rehabilitation and pain management. Surgeons noted a higher rate of appropriate surgical referrals post triage.
Conclusions: Wait-times for surgical consultation and surgery were unaffected by the initiation of a triage system. Future studies examining cost-effectiveness, acceptability, and functional outcomes are needed. A pilot project was conducted in order to determine: a) The feasibility of delivering a faculty-moderated Case Workshop Series by multi-point video-conference using existing infrastructure (Ontario Telemedicine Network; OTN) during a Master's of Science in Physical Therapy (MScPT) clinical placement, b) The student-perceived value of a moderated Case Workshop held during a physical therapy clinical placement, and c) Differences in perceived value between first and second year MScPT students.

Innovation in Education
Relevance to Physiotherapy Practice: This project demonstrates a successful and innovative use of technology to support clinical education of MScPT students.

Materials and Methods:
Participants: 26 first-and 34 second-year Queen's University MScPT students. Case Workshop Series: students met 4 times via video-conferencing (Groups of 5-10) in order to "workshop" patient cases with each other under the guidance of a faculty moderator. Program Evaluation: Case Workshop Questionnaires and Focus Group Interviews.
Analysis: Questionnaire responses were summarized by frequency counts. Transcribed data from the focus groups underwent a thematic analysis.
Results: 53% of the first year, and 100% of the second year participants reported that their participation enhanced their learning. Focus group interviews revealed the following themes: expectations, structure and content of sessions, the use of topic themes, moderator role, learning, resources available, social networking, technology, logistics and other challenges.

Conclusions:
This project established that a faculty-moderated Case Workshop for small groups of MScPT students using existing video-conference infrastructure (i.e., OTN) was feasible within our context. Lessons from this project will assist a re-development of the model to the unique needs of first year students.

A002 -FACILITATION BY DISTANCE: A NOVEL METHOD FOR FACULTY DEVELOPMENT AND STUDENT LEARNING
Mori B, Yeung E, Davies R. Department of Physical Therapy, University of Toronto. Correspondence: Brenda Mori, 160-500 University Ave.,Toronto, ON M5G 1V7; brenda.mori@utoronto.ca

Purpose/Objectives & Rationale:
The purpose of this study was to explore the use of web conferencing to facilitate small group learning from a distance.
Relevance to Physiotherapy Practice: Small group learning has traditionally relied on face-to-face facilitation and little is known about remote facilitation.

Methods:
A qualitative approach using focus group methodology was used. Final year physiotherapy students enrolled in an orthopaedic course in 2008 or 2009 were invited to participate. Sixteen students participated. Three focus groups were conducted; two consisting of students who experienced remote facilitation and one consisting of students who experienced face-to-face facilitation. Participants were asked about their experiences with small group learning during this course, including group process and the role of their facilitator.

Analysis:
The focus groups were audio taped and transcribed verbatim. Data were coded and analyzed for common ideas using a constant comparison approach.
Results: Regardless of method of facilitation, participants expressed a desire for similar facilitator traits and style of facilitation. Students in the remote facilitation groups identified unique challenges related to the facilitator and web conferencing technology.

Conclusions:
Facilitation by distance is a feasible method for facilitating small group learning. To maximize the remote facilitation experience, attention should be paid to facilitator development that addresses the distinct features of facilitating a small group remotely, small group preparation, quality of technology, and room set up. Future faculty development initiatives should consider the unique role of the remote facilitator and its potential to engage those clinicians (as both teachers and learners) who would otherwise have limited ability to participate due to distance. Purpose/Objectives & Rationale: Academic dishonesty (AD) refers to a number of behaviours that are associated with misconduct or misrepresentation to gain an academic advantage. The purpose of this study was to explore academically dishonest behaviours based on Physical Therapy (PT) students' current practices and educators' prior behaviours as PT students.

A004 -ACADEMIC DISHONESTY AMONG PHYSICAL THERAPY STUDENTS: A PILOT STUDY
Relevance to Physiotherapy Practice: Exploration of both students' and educators' experiences is necessary to provide insight into the potential effect of changes in curriculum over time.

Materials and Methods:
A web-based questionnaire was sent to 174 students and 250 educators from the PT program at the University of Toronto. The questionnaire gathered data on demographics, as well as the prevalence, seriousness and contributing factors regarding AD.
Analysis: Data were analysed with descriptive statistics and non-parametric tests.

Results:
In all, 52.4% of educators and 44.3% of students responded to the questionnaire over a six-week data collection period. Scenarios rated the most serious were the least frequently performed by educators and students. The impact of generation on attitudes and prevalence of AD were not significant. The most commonly reported contributing factors of AD were school-related pressure, disagreement with evaluation methods and the perception that "everyone else does it." Conclusions: This study parallels the findings of similar research conducted on other healthcare programs. It suggests that AD occurs throughout the curriculum with greater incidence in situations associated with helping peers rather than personal gain. The consistency in behaviours across generations may reflect a 'culture of cheating' in the program that is accepted as the social norm and may be a function of the environment. Objectif : Cette étude vise à identifier les moyens mis en oeuvre par les professeurs pour développer les compétences en pratique factuelle chez les étudiants des programmes de maîtrise et du baccalauréat en physiothérapie et en ergothérapie de l'Université d'Ottawa et à évaluer la perception que les étudiants ont de leurs compétences en pratique factuelle.

Purpose/Objectives & Rationale:
The purpose of this study was to explore how physiotherapists working in stroke care understand their role(s) in clinical practice and how their post-licensure experiences with the Bobath Concept are reflected in the ways that they practice.
Relevance to Physiotherapy Practice: The Bobath Concept, although not generally supported in the scientific literature, is identified by physiotherapists internationally as highly influencing their practice. There is a need to better understand how the Bobath Concept influences physiotherapy clinical practice given its popularity as a treatment approach in stroke care.

Materials and Methods:
Registered physiotherapists with post-licensure education in the Bobath Concept as well as other neurological physiotherapy approaches and working in adult neurology for greater than two years participated in two activities. First, they responded in writing and verbally to a stroke clinical case. Second, each physiotherapist participated in an indepth interview regarding their pre and post-licensure educational experiences and their clinical practice.

Analysis:
A hermeneutic phenomenology framework was adopted for this study, which included an adaptation of Carol Gilligan's "The Listening Guide" as a way to analyze the interview transcripts in a principled way." Results: Common themes emerged from the clinical case and interview data analysis regarding the physiotherapists' understanding of the Bobath Concept and its influence on their clinical practice and perception of their role(s).

Conclusions:
The Bobath Concept offers physiotherapists a unique perspective regarding their clinical practice. The results of this study support the need for further research into the Bobath Concept in physiotherapy clinical practice, and makes suggestions for future research study design and ongoing physiotherapy education. IMT has a strong evidence base for decreasing dyspnea and improving exercise tolerance and quality of life, however, it is not prescribed routinely in pulmonary rehabilitation. The purpose of this study is to assess the effectiveness of a behavioural (Beh)-versus an information (Inf)-based intervention for increasing health professionals' prescription of IMT to people with COPD during out-patient pulmonary rehabilitation.

A048 -A BEHAVIOURAL-BASED INTERVENTION INCREASES PRESCRIPTION OF INSPIRATORY MUSCLE TRAINING (IMT) FOR PEOPLE WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Relevance to Physiotherapy Practice: Introduction of an evidenced based exercise such as IMT into daily practice likely requires addressing more issues besides providing evidence-based information.
Materials and Methods: Sixty-one health professionals and 488 COPD out-patients in six hospital-based pulmonary rehabilitation programs participated in the study. Centres were randomly allocated to Beh or Inf implementation interventions. Beh consisted of two interactive 45 min workshops: Session 1 provided hands-on instruction of inspiratory muscle testing and training and Session 2 focused on concerns related to IMT raised by the health professionals. Inf was a 90 min didactic lecture that focussed on evidence for IMT in COPD and prescription details for IMT. Both interventions were supplemented by handouts and an inspiratory muscle force meter. Beh group received a supply of Threshold© trainers.
Analysis: Chi 2 and Mann-Whitney U tests were used to examine differences in health professionals' demographics and knowledge via a multiple choice exam, respectively.

Results:
No COPD patients were prescribed IMT during the 6-month pre-intervention phase and this did not change after Inf. Prescription rates for IMT increased after Beh by 10.2% (95% CI, 5.7-17.1%).

Conclusions:
Beh is more effective than Inf towards increasing health professionals' prescription of IMT for people with COPD. Relevance to Physiotherapy Practice: The PCRT was developed to assist physiotherapists engage in reflection on their clinical practice by providing a structured format of questions to guide their thoughts. The authors were interested in piloting the PCRT to determine whether the tool stimulated reflection and which of the two methods of administration was most valuable.

Materials and Methods:
Five physiotherapists spanning a wide range of practice settings, specialities, years in practice and representing both male and female physiotherapists participated in this qualitative research study. Participants completed the PCRT individually and during a facilitated interview. They were then interviewed by the principal researcher using a semi-structured interview designed to gain understanding of their perspectives and experiences when using the tool.
Analysis: Two researchers independently utilized a thematic approach to analyse the transcripts from the primary, semi-structured interviews. The data was reduced into themes that represented the perspectives of the participants relative to the research question and project purpose as interpreted from within the perspective of the researchers.
Results: Three themes were identified by the participants: (1) participants preferred self-directed reflection; (2) a structured process was valuable; and (3) acknowledgement of the limitations inherent in self-reflection and the need for behavioural drivers to ensure professional accountability for maintaining competent practice.

Conclusions:
The PRCT is an easily administered tool that can provide physiotherapists with a structured means to stimulate reflection on clinical practice.

Purpose/Objectives & Rationale:
To describe the usefulness of reflective diaries as a teaching and evaluative tool in pain education for physiotherapy students. Both successes and challenges will be addressed.
Relevance to Physiotherapy Practice: Pain is the most common symptom treated by physiotherapists. Pain education presents a unique challenge in that pain science is constantly changing. The topic does not lend itself well to traditional didactic lecture and quantitative assessment of knowledge. Reflective diaries represent a novel approach to these challenges.

Materials and Methods:
Data are taken from a senior-year elective course in understanding pain for physical therapists. Students are required to complete a weekly reflective diary based on the previous week's discussion, and to submit the diary as the main evaluative component at the end of the course.
Analysis: Qualitative interpretation of select passages from the reflective diaries of 60 students will be presented using Bloom's taxonomy of learning as a framework. Mean student ratings of the course as a learning experience and the fairness of the evaluation procedure were used to evaluate the student's perspective.

Results
: After 3 years (60 students), the mean student rating for the course as a learning experience is 6.9/7 with the mean rating of fairness of reflective diaries as an evaluation procedure at 6.1/7. The diaries are useful for demonstrating learning across levels of Bloom's taxonomy which would not have been captured using traditional evaluation methods.

Conclusions:
Reflective diaries are a novel and promising approach to achieving and evaluating deeper learning of pain concepts in a classroom setting. Relevance to Physiotherapy Practice: Physiotherapy and physiotherapist assistant students frequently get little or no time to interact and work together prior to graduation and entering the work force. Despite this there is an expectation that they will be able to work as a collaborative intraprofessional team.

Materials and Methods:
A half-day classroom-based intraprofessioanl activity was developed by two educators from the University of Ottawa and La Cité collégiale. The students were divided into mixed teams. The classroom activity included introductions, icebreaker activities and a case competition. The cases were de-idenitified cases that had been solicited from physiotherapists practicing as part of an intraprofessional team in Ottawa. At the conclusion of the activity the students were asked to complete a questionnaire. No idenitifying information was collected and students were asked to include constructive feedback about the event.

Analysis:
The survey responses were analyzed and the responses coded in NVivo 8.

Results:
The activity was viewed by the students as a successful means to learn about the scope of practice, roles and responsibilities of their colleagues on an intraprofessional team. The case permited the physiotherapy and physiotherapist assistant students to apply their knowledege and explain their actions and plans.

Conclusions:
Opportunities, such as a classroom-based activity with a case competition for intraprofessional student teams can encourage the sharing of information about education, scope of practice, professional and ethical perspectives. The students requested that the activity become an annual event. Relevance to Physiotherapy Practice: The community/home care environment is an expanding area of health care provision. However, there are limited clinical placement opportunities for PT students in this, mainly private, health care environment. No research exists to guide future decision-making.

Materials and Methods:
An online survey (multiple choice, Likert scale, short answer questions) was used to collect quantitative / qualitative data from Community Care Access Centre (CCAC) administrators, private home care company managers, and home care physical therapists in three Local Health Integrated Networks in ON.
Analysis: Percentages were calculated for quantitative survey data. Qualitative data was analysed by investigators highlighting common words and themes.
Results: Twenty-two surveys were completed. PT participation was poor and correlated directly with financial reimbursement provided by their company to complete the survey. Seventy two percent of private home care company managers and PTs felt that in a fee-for-service environment, a PT's income decreases while supervising a student during placement. Seventy-six percent of respondents indicated their company had guidelines related to student placements and supervision but no participant was able to provide any written documentation regarding these guidelines.

Conclusions:
Clarity of CCAC and company policy related to student supervision in the community/home care setting is essential. An alternate model of payment for PTs when supervising students in the community / home care setting is required. The majority of Canadian PT students presently graduate with minimum or no exposure to a community / home care environment. Whiplash-associated disorder (WAD) is a common condition representing considerable burden. The purpose of this study was to evaluate the validity of the Self-report version of the Leeds Assessment for Neuropathic Signs and Symptoms (SLANSS) for use in evaluating people with WAD.

A007 -PROPERTIES OF THE SLANSS TOOL FOR ASSESSMENT AND PROGNOSIS IN WHIPLASH
Relevance to Physiotherapy Practice: Physiotherapists often provide rehabilitation services for people with WAD. Assessment of the condition is challenging however. Previous reports indicate the SLANSS tool may be useful for this population. However it has never been formally validated for use in WAD.

Materials and Methods:
Data from two separate databases were combined. All subjects presented for physiotherapy treatment of WAD following motor vehicle accident. The SLANSS was part of a battery of tests performed on initial assessment. Pain threshold (PPT), neck disability index (NDI), pain intensity (NRS), age, sex and duration of symptoms were also extracted from the databases. A subset of patients was followed up 3 months later. Analysis: Exploratory factor analysis was performed to evaluate the factor structure of the the SLANSS. Concurrent validity was evaluated through bivariate correlations with NDI, NRS and PPT. Moderators (age, sex and duration) were explored through tests of association. Linear regression was used to evaluate the predictive validity of the SLANSS on 3-month outcomes.
Results: Factor analysis revealed three factors. Hypotheses for concurrent validity were satisfied. No moderators were identified. SLANSS explained 16% of variance in 3-month outcomes.

Conclusions:
The validity of the SLANSS has been supported for use in WAD.

A008 -THE USEFULNESS OF PRESSURE PAIN THRESHOLD AS AN ASSESSMENT TOOL FOR PEOPLE WITH WHIPLASH
Walton DM, * Levesque L. *The University of Western Ontario, School of Physical Therapy, London ON. Corresponence: David Walton, 114 Richmeadow Cres., London, ON; dave_m_walton@yahoo.ca

Purpose/Objectives & Rationale:
Previous authors have shown that pressure pain threshold (PPT) holds promise as a prognostic tool in acute whiplash. Until now, these studies have been performed using lab-based instruments that are not accessible to clinicians. This presentation will describe the clinimetric properties of a more accessible, lower cost digital algometer in terms of reliability, population norms, and predictive validity.
Relevance to Physiotherapy Practice: Whiplash-associated disorder (WAD) is a common outcome of motor vehicle accident. Judicious assessment requires patient self-report and clinical observation. PPT stands to add potentially useful information to clinical assessment.

Materials and Methods:
Healthy volunteers and people with neck pain were tested by two raters and on two separate days to determine intra-, inter-and test-retest reliability. Data from three databases were combined to determine normative values and identify important moderators. Finally, people with acute WAD were evaluated within 30 days of injury and again 3 months later to determine short-term outcomes.
Analysis: Intra-class correlation coefficients for reliability, means and standard deviations for norms, simple bivariate correlations for moderators, and multiple regression for prognosis.
Results: Reliability coefficients ranged from 0.76 to 0.97. Means and standard deviations were in keeping with previously reported lab-based values. Sex, age and pain intensity were important moderators. Regression showed that PPT accounted for a significant 14.2% of variance in short-term disability, after controlling for sex, age and pain intensity.

Conclusions
: PPT can be reliably tested in a clinical setting using an accessible digital algometer. PPT holds promise for assessment of prognosis in acute WAD.  Relevance to Physiotherapy Practice: Diagnostic FB injections are recommended for individuals with chronic WAD who do not respond to conservative physiotherapy. It is important that physiotherapists recognize those patients who may benefit from FB.

Materials and Methods:
This cross-sectional study involved 30 WAD individuals who responded to cervical FB procedures (WAD_RF); 19 WAD individuals who did not respond (WAD_C) and 21 Healthy Control (HC) individuals. Quantitative Sensory Testing (pressure; thermal pain thresholds, brachial plexus provocation test), nociceptor flexor reflex (NFR) and sLANSS significant reductions in urethral excursion during coughing. Surprisingly, after treatment the resting position of the bladder neck was Purpose/Objectives & Rationale: To assess the effectiveness of physiotherapy for urinary incontinence (UI) compared with a control intervention, for reducing the number of UI episodes and severity of UI, in postmenopausal women aged 55-85 years with osteoporosis or low bone density, and stress, urge or mixed UI.
Relevance to Physiotherapy Practice: A recent study found that near 40% of patients presenting to a specialized osteoporosis service reported having UI at least once per week (1). This is important because UI can significantly limit a woman's ability to be physically active and is an independent risk factor for falls and low trauma fractures in older women.

Materials and Methods:
Participants (n = 48) were randomly allocated to either the physiotherapy group (once/week for 12 weeks) or the control group. All measurements were completed at baseline, 14 weeks and 1 year. Outcome assessors were blind to group allocation.
Analysis: Intention to treat analysis was conducted. Between-group differences were analyzed using the Mann-Whitney U test.
Results: At 14 weeks there was a significant difference between groups in the number of leakage episodes on the 7-day bladder diary (p = 0.04) and total Urogenital Distress Inventory (UDI) score (p = 0.04), in favour of the physiotherapy group. At 1 year (46/48 participants completed study to date) there was a significant difference between groups, in favour of the physiotherapy group, for the number of leakage episodes (p = 0.04), 24 hour pad test (p = 0.01), and UDI (p = 0.03).
Conclusions: Physiotherapy was effective in reducing the amount and severity of UI in postmenopausal women with osteoporosis and UI. Results were maintained 1 year later.

Purpose/Objectives & Rationale:
Providing written information about exercises has been shown to reduce stress levels and increase satisfaction with the treatment received. The purpose of this study was to evaluate parental stress level and satisfaction after receiving a new Torticollis Intervention Booklet (TIB).
Relevance to Physiotherapy Practice: There are few educational tools with comprehensive information about physical therapy exercises for infants with torticollis. This project was meant to generate evidence on how to best complement physiotherapists' intervention.

Materials and Methods:
This is a randomized clinical trial conducted at the Montreal Children's Hospital (MCH). Seventy-Three infants referred to physiotherapy for a positional torticollis were recruited and randomized to the Physiotherapy + TIB group (n = 37) or to the Physiotherapy + Standard Exercise Sheet group (n = 36). Infants received standard physiotherapy treatment and verbal instructions delivered by their own physiotherapists and were assessed 1 and 3 months after their initial visit by a blind evaluator. Outcomes measured were cervical ROM, parental stress level (Parental Stress Index) and parental satisfaction (Measure of Processes of Care).
Analysis: Intention to treat analysis was performed. T-tests on the change between assessment sessions were performed for each variable.
Results: Parents receiving the TIB reported lower stress level (p = 0.01) and greater satisfaction related to provider partnership and information delivered (p < 0.001) than those receiving standard care.

Conclusions:
A thorough and well-illustrated booklet accompanying verbal instructions for home exercises in the treatment of PT leads lower parental stress and greater parental satisfaction and may lead to earlier restitution of ROM. . The objective of this study is to Describe BSITD-III, BSID-II and BSID-I results in 3 cohorts of extremely low birth weight (ELBW, less than 800g) children seen at 18 months corrected age.

A072 -THE BAYLEY SCALES OF INFANT AND TODDLER DEVELOPMENT IN EXTREMELY LOW BIRTH WEIGHT SURVIVORS AT 18 MONTHS CORRECTED AGE
Relevance to Physiotherapy Practice: BSITD-III is used for research and clinical evaluation of infants. This study will enable clincians and researchers to compare current and previous studies of high risk populations.

Materials and Methods: ELBW toddlers free of severe cerebral palsy, visual impairment able to complete test items between 1984
Materials and Methods: Images were acquired for 32 postmenopausal women with osteoporosis (mean (SD) age: 71 (7) y).
should be directed at establishing the limitations of this technology in the management of knee osteoarthritis and other being developed to foster it in children. It is unknown how physical literacy, relates to participation in leisure time physical activity or Analysis: The numbers of students enrolled in and graduating from the Community Therapy Assistant program were observed, as Materials and Methods: Drawing from a pragmatic grounded theory approach, 12 physiotherapists working within community Conclusions: The Tool matches human resource time available to the time requirements of clients based on the complexity of the interventions in order to meet health needs. It provides a systematic, evidence-informed approach for determining manageable and effective caseloads and the efficient allocation of available human resources within a service. The Tool will be globally useful and relevant to the profession when its applications are reported and shared. The Tool is a living document which will evolve according to changing practice, professional and service trends. Clinicians and administrators are strongly encouraged to use the Tool, report their findings and share their experiences to ensure its relevance, appropriateness and continued usefulness to advance the physiotherapy profession and contribute to the informed and effective utilization of these health professionals.

P002 -BACK TO THE GYM AFTER HIP AND KNEE REPLACEMENT
Westby MD, Gill G. Mary Pack Arthritis Centre, Vancouver Coastal Health, Vancouver. Correspondence: Marie Westby, Mary Pack Arthritis Centre, 895 West 10th Ave., Vancouver, BC V5Z 1L7; marie.westby@vch.ca Learning Objectives and Session Content: More than 62,000 Canadians undergo total hip or knee replacement surgery each year to relieve the pain and functional limitations associated with arthritis. A growing body of research shows that many individuals are not reaching their full potential following surgery and continue to have muscular weakness, gait abnormalities and functional difficulties more than two years later. A fitness facility or gym provides an ideal community setting to address long term physical impairments and functional limitations once post-acute rehabilitation is complete. It is important to provide evidence-based and consistent guidance on appropriate use of fitness equipment to ensure patient safety and exercise effectiveness.

Objectives:
By the end of this session, participants will: 1. Be familiar with the evidence on the benefits, risks and biomechanical issues associated with strength training and aerobic exercise equipment found in a typical gym setting. 2. With the use of two case studies, describe the physical impairments and functional limitations commonly seen following these surgeries that can be addressed in a gym setting. 3. Appropriately advise patients, health and fitness professionals on safe and effective use of exercise equipment following hip and knee replacement.
Relevance to Physiotherapy Profession: Many adults undergoing a total hip or knee replacement will choose to continue their rehabilitation process in a fitness or gym facility after discharge from the physiotherapy practice setting. While some will receive health and/or fitness professional guidance or supervision, others will exercise independently with no further professional support. The quality of the supervision will vary based on the professional's clinical and fitness knowledge, experience with hip and knee replacement clients and familiarity with the ever changing array of fitness equipment. This interactive session will give participants the opportunity to integrate their knowledge of biomechanical considerations (joint kinematics and kinetics), clinical experience and the related research evidence and apply these to common strength training and aerobic exercise equipment. Two case studies will allow for clinical problem solving and group discussion.
Target Population: This session will be of interest to health and exercise professionals including clinicians, program designers, educators and researchers interested in total joint replacement rehabilitation and exercise.
Description of Supporting Evidence: Adults undergoing total joint replacement surgery exhibit marked functional impairments and activity limitations in the period leading up to surgery and in some cases, several years after (Meier 2008, Trudelle-Jackson 2002. Cardiovascular deconditioning puts these individuals at risk for coronary artery disease (Philbin 1995) and surgical complications. Prolonged lower extremity weakness is a major risk factor for falls in older adults.
Regular, moderate intensity physical activity is recommended for older adults and has numerous health benefits including weight control, bone health and improving aerobic capacity (http://www.csep.ca). Long-standing strength deficits can be addressed through progressive strength training using appropriate forms of resistance. A growing body of biomechanical data and descriptive and pilot studies suggest that many popular types of exercise equipment are safe and effective for individuals with arthritis and joint replacement surgery (Westby 2001) and thus should be considered an option for individuals in the later phases of joint replacement rehabilitation.
Description: This session will be an interactive, practical format with opportunity for participant discussion and clinical reasoning.

Conclusions:
With knowledge of the evidence and biomechanical factors associated with common types of exercise equipment found in fitness or gym settings, physiotherapists will be better equipped to provide safe and effective advice on community-based exercise and thus promote regular physical activity in the joint replacement population. A long-term exercise program beyond the relatively short post-operative therapeutic intervention will help individuals reach their full functional potential and reduce the risk of falls and other health issues after hip and knee replacement. Learning Objectives and Session Content: This presentation will provide an overview of the principles of motor control for movement production and their application to the retraining fast movements that are necessary for balance and community reintegration following stroke. Specifically, this presentation has the following objectives: 1) to provide an overview of the motor control required to produce fast movement; 2) to discuss the importance of, and evidence for, retraining speed of movement following stroke and 3) to provide examples of exercises to retrain speed of movement after stroke.

P003 -TRAINING SPEED OF MOVEMENT POST STROKE
Relevance to Physiotherapy Profession: Balance impairments and mobility restrictions are common after stroke; for example, there are reports that community ambulators post-stroke have fall rates of 73% and falls occur most frequently during walking. Considerable attention has been paid, therapeutically and in research, to some of the motor impairments following stroke including spasticity, muscle weakness and poor coordination of muscle activation. Less is known about impairments in the speed of movement or the ability to produce power. However, speed or power is imperative to the ability to take an effective step to regain balance.
Target Population: This session will be of interest to physiotherapists and researchers interested in mobility and neurological rehabilitation.

Description of Supporting Evidence:
Motor control impairments following stroke result in force production that is slow, weak, and lacking in precision. Remodelling of the hemiparetic muscle leads to slower contractile properties and weakness. Impaired coordination of muscle activity reduces the efficiency of force production in movements and functional tasks. In terms of postural control, these impairments make it difficult to produce force with sufficient speed and magnitude to be effective for postural responses to perturbations. Gait and balance do not require large force contractions but rather require fast bursts of muscle activation. Research has demonstrated that exercise focusing on agility (fast-paced dynamic movements) resulted in faster step reaction times and earlier muscle onset latencies to a force platform translation perturbation than stretching and weight shifting exercises. This suggests that stroke rehabilitation would benefit from the incorporation of fast muscle contractions. Research has been conducted that examined whether exercise geared to improving the speed and pattern of muscle activation was effective in retraining the muscle activation patterns required for standing balance. A single session of exercise retraining with voluntary closed kinetic chain exercise that emphasized speed of movement induced short-term changes in the bursts of muscle activation which transferred to standing balance tasks. Preliminary findings from a 12 session closed kinetic chain protocol on four subjects poststroke revealed that muscle activation and speed of movement improved over the 4 weeks (12 sessions). The central nervous system used a variety of mechanisms to improve muscle activation patterns needed for postural responses following stroke; this variety would be important, given the inherent heterogeneity in stroke impairments across patients. Therefore, there is a growing body of evidence to support the incorporation of the retraining of speed and power into neurorehabilitation.
This session will be an interactive lecture format, with video observation and participant discussion.

Conclusions:
This session aims to advance the rehabilitation of mobility and balance impairments following stroke to decrease the risk of falls and increase community mobility for individuals post-stroke. The session will explore the effects of stroke on the ability to produce fast movements required for mobility and dynamic balance. Research which has been conducted to investigate the impact of retraining fast movements required for balance and mobility following stroke supports the implementation of this additional aspect of rehabilitation. Suggestions for treatment techniques to retrain fast movements will be provided to facilitate application of this current research to the neurorehabiliation setting.

P004 -DEFINING THE EARLY INTERDISCIPLINARY REHABILITATION PROGRAM FOR ADULTS FOLLOWING SEVERE AND MODERATE BRAIN INJURY
Swain EA, * Neiforth M. † *Neuro-Ability Rehabilitation Services; †Vancouver Coastal Health, Vancouver, BC. Correspondence: Elizabeth Swain, 2659 West 6th Ave., Vancouver, BC; V6K 1W6; eswain@interchange.ubc.ca Learning Objectives and Session Content: 1) To discuss the foci of the rehabilitation program provided to adults during the first 3 months following severe or moderate brain injury based on the results of a national interdisciplinary survey; 2) To collaborate regarding evaluation of patient progress pertaining to the nine functional components of this early intervention program; 3) To facilitate interdisciplinary collaboration integral to successful implementation of the early intervention program.
Relevance to Physiotherapy Profession: Standardized practice guidelines do not exist for the rehabilitation of individuals during the first 3 months following severe and moderate brain injury. In addition, standard measurement tools traditionally used to evaluate rehabilitation intervention have a floor effect with this population. Evaluation of client progress, and hence access to services and potential future function, is therefore dependent upon both the identification of the functional components defining foci for assessment and identification of suitable measurement tools. An interdisciplinary national survey identified nine functional components as the foci of the early intervention program. This preliminary step can provide the basis for the identification or development of appropriate measurement tools sensitive to recovery in functional components relevant to this phase of recovery and for the development of national standards of practice.
Target Population: All therapists working with individuals following moderate and severe brain injury throughout the care continuum.

Description of Supporting Evidence:
There is a paucity of research related to rehabilitation intervention of individuals during the first 3 months following severe and moderate brain injury. Research pertaining to treatment of this population is generally focused on medical issues related to mortality and morbidity. Rehabilitation research has explored questions more relevant further along the care continuum. However, during the first 3 months many are unable to participate at a level sensitive to measurement by traditional functional independence measurement tools and issues pertinent to community integration are not yet of prime relevance. This session examines the findings of an interdisciplinary national survey of paired comparisons that establish the foci of the early rehabilitation program.
Description: This session will be presented by a physical therapist and occupational therapist. A lecture component will present the national survey findings and include video clips to provide insight into the family and client perspectives of early rehabilitation. This will be followed by facilitated discussion regarding the findings, their implications, and future action.

Conclusions:
Measuring change for individuals with severe and moderate brain injury is often very difficult especially during the earlier stage of recovery and yet can significantly impact access to appropriate services. A national survey of physical therapists, occupational therapists, and speech-language pathologists determined consensus on nine functional components of the early rehabilitation program during the first 3 months following severe and moderate brain injury. Evaluation of recovery can now be facilitated by identification of measurement tools for these functional components that are sensitive to change by this population. The survey secondarily indicated the importance of the interdisciplinary team to consider all functional components, including those that are not discipline specific.

P005 -SEDENTARY BEHAVIOUR: WHAT IS IT AND HOW DO WE MEASURE IT?
Gorman E, Macri EM, Ashe MC. Centre for Hip Health and Mobility and UBC Department of Family Practice, Vancouver, BC. Correspondence: Erin Gorman, 2647 Willow St., Vancouver, BC V5Z 1M9; erin.gorman@familymed.ubc.ca Learning Objectives and Session Content: This session will provide an overview of the available evidence related to sedentary behaviour in adults and older adults. There will be a demonstration to highlight the use of activity monitors and their potential use in physiotherapy research and practice. The learning objectives for this session are: 1. To define key concepts related to sedentary behaviour; 2. To report the relation between time spent in sedentary behaviour and key health outcomes; and 3. To describe two ways to measure sedentary time and physical activity.

Relevance to Physiotherapy Profession:
Physiotherapists play an important role in health promotion through active living. New evidence highlights that too much sitting can result in detrimental health outcomes, independent of participation in physical activity.
Physiotherapists therefore play a key role in translation of this important knowledge.

Target Population:
This presentation is relevant to physiotherapists working in research and/or clinical practice. In particular, it is relevant for physiotherapists who work in the areas of health promotion, exercise prescription, and chronic disease management.

Description of Supporting Evidence:
Physical activity is an essential part of healthy living, yet many Canadians do not meet guideline recommendations. Further, emerging literature from large cohort studies suggests that independent of physical activity levels, time spent in sitting can have adverse consequences on health outcomes. Owen and colleagues define sedentary behaviours as activities that involve low energy expenditure (<1.5 METs) and which include prolonged sitting in transit, at work or for leisure (Owen, 2009). This is distinct from not meeting physical activity guidelines. Unfortunately, there is often confusion in the literature, with many of the same terms used interchangeably to describe the absence of physical activity and time spent engaging in sedentary behaviours. These behaviours are distinct, as it is possible to be both active (meeting physical activity guidelines) and to still spend a large proportion of time in sedentary behaviours. Research suggests that there may be different physiological mechanisms for how these two distinct behaviours influence cardio metabolic health (Hamilton, 2007).
In research, sedentary time is often operationalized as self-reported sitting time or television time. Although self-report measures of activity still play an important role, advances in technology now permit the objective measurement of patterns of physical activity and sedentary behaviour. Accelerometers are devices worn at the waist to capture movement and to provide very detailed time-stamped activity patterns, resulting in a more comprehensive description than self-report alone. Accelerometry analysis software provides valuable information on the intensity of the activity, the length of time of the activity, how many "bouts" the person spent in light or moderate activity [>10 minutes is considered a bout for accumulation of moderate to vigorous physical activity (MVPA) to meet guideline recommended levels], as well as how long the person remained stationary. Further, using this technology researchers have been able to show that the pattern of sedentary time accrual is important for health, in addition to the total time spent in sedentary behaviours (Healy, 2008). This provides evidence for not only the importance of an overall reduction in sedentary time but also the need for breaking up sedentary time. This new technology therefore provides a better characterization of time spent in different types of activity, and thus allows us to draw associations between activity patterns and health outcomes.

Description:
We will provide an overview of the current evidence and highlight the relevance to physiotherapists; we will provide a practical demonstration of accelerometers and a description of the type of information drawn from these instruments. We will also have smaller breakout sessions to discuss strategies to reduce sedentary time and encourage activity in two age groups: working adults and older adults.
Conclusions: Time spent in sedentary behaviours is quickly emerging as an independent risk factor for adverse health outcomes. As the field emerges, physiotherapists are key to develop strategies to reduce overall sedentary time and provide exercise prescription to optimize health. This session will provide an understanding of the current literature, clarify terminology and discuss objective measurement of activity patterns, to assist in the future development of prevention programs. To provide a brief overview and update on breast cancer related lymphedema and its treatment. 2 To provide an overview of the methods used to develop a standardized assessment and surveillance program for breast cancer related lymphedema among participating rural and urban centres in Alberta. 3. To share the results of the first phase of the program that focused on the development of an evidence-based standardized assessment and surveillance program to be pilot tested (Phase II) in various sites in Alberta.

Relevance to Physiotherapy Profession: Lymphedema is a prevalent and often feared complication of breast cancer treatment.
Lymphedema is a chronic swelling of the upper limb on the surgical side which may present immediately or many years after treatment (Petrek, 2001;Clark, 2005). The estimated incidence of breast cancer related lymphedema is reported between 6% and 30%, with higher incidence rates found in studies with longer follow-up (Sclafani, 2008). Lymphedema is a known consequence of surgical and radiotherapeutic techniques. Moreover, numerous factors such as older age, venapuncture to the limb and obesity have been implicated in lymphedema onset (Heyler, 2010). Recent research has demonstrated effectiveness of active surveillance programs to detect and treat lymphedema in the early stages (Stout-Gergich, 2008). When treated conservatively in the earliest stages, complications of lymphedema may be diminished or reversed (Stout-Gergich, 2008). Physiotherapists, as primary providers in the rehabilitation of breast cancer patients and survivors, are well positioned to serve as leaders in the area by providing evidence-based lymphedema assessment and treatment programs in clinical practice.
Target Population: This session will be of interest to physiotherapists, students, researchers and other health professionals interested in the rehabilitation of patients and survivors with breast cancer and individual suffering from lymphedema.

Description of Supporting Evidence:
In Alberta, the need for a province-wide approach to the assessment and surveillance of breast cancer related lymphedema was identified. The primary purpose of the initiative was to support an evidence-based practice approach across urban and rural centres to improve the quality and effectiveness of care for breast cancer related lymphedema.
Key objectives of the initiative: 1. Develop a standardized and comprehensive assessment and follow-up program for Alberta patients presenting with breast cancer related lymphedema. 2. Improve access to comprehensive assessment services for breast cancer related lymphedema. 3. Develop an integration relationship with treatment providers for early intervention and ongoing management. 4. Disseminate information from the assessment and surveillance program to other healthcare providers who may be involved in the subsequent care of the patient/survivor.
Phase I of the project involved developing a standardized evidence-based approach to the assessment of lymphedema between the participating centres. Components of program that were deemed relevant for the program included: 1. Screening for lymphedema 2. Baseline assessment of lymphedema: methods and outcomes for upper limb size and volume, upper limb range of motion, pain assessment, appropriate outcome measures to assess upper limb function and quality of life 3. Regular follow-up (surveillance program) timelines and outcomes 4. Develop an assessment and surveillance tool for documentation of outcomes The first step in Phase I of the process involved identifying existing centres/community partners and key stakeholders for the project. Key stakeholders interested in participating in the project were identified and these stakeholders included individuals from two urban and three rural centres: Moreover, a number of stakeholders agreed to serve as consultants on the project including surgeons, oncologist and administrators from various sites.
The second step involved performing literature searches on key topics related to the project (e.g., validity and reliability of outcome measures and measurement methods), synthesizing the information, and disseminating the information to participating team members. A meeting was held with the project researchers and representatives from the participating centres to determine the relevant components of the proposed assessment program and how these components could be best captured. Issues and barriers related to the implementation of assessment components as well as the standardized program were identified. The next step in the process involved finalizing components of the program and developing a draft assessment tool in preparation for the Phase II pilot testing of the program at the participating centres.

Description:
The session will be a lecture format. The session will start with an overview of breast cancer related lymphedema and the treatments used in the management of this chronic condition. As well, I will discuss international and national initiatives that are currently underway to improve the care of individuals with lymphedema (20 minutes). Following the overview, I will describe the methods used to develop the standardized assessment and surveillance program among participating rehabilitation medicine departments across Alberta (20 minutes). The session will then focus on the evidence used to inform decisions on the assessment program including the assessment tool, the decision-making process, and the barriers identified, and the strategies put in place to facilitate implementation of the program in the clinical setting (20 minutes).

Conclusions:
In the last couple of years, there has been increased recognition at international (International Lymphedema Framework) and national levels (Canadian Lymphedema Framework), for the need to 'advance comprehensive effective assessment and treatment for lymphedema and related disorders to all persons'. Thus, this project, although specific to the breast cancer population, is line with current international and national efforts to improve the care of individuals with lymphedema. To review evidence related to acupuncture and cancer.

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To review the challenges of utilizing acupuncture for people with cancer in the acute care setting.

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To engage the audience in a discussion on strategies to increase the utilization of acupuncture in the acute care setting.
Relevance to Physiotherapy Profession: As primary care providers, physiotherapist may encounter people diagnosed with cancer in most acute care settings. Since cancer treatments are improving, many patients will survive their cancer treatment and will have to manage the side effects of the primary disease, as well as, those created by cancer treatment. Evidence is available supporting the use of acupuncture to alleviate several side effects associated with cancer and its treatments. However, physiotherapists are not regularly requested to provide this service for people with cancer in the acute care setting. It is imperative that physiotherapists have a basic understanding of the potential benefits of acupuncture for people diagnosed with cancer, so that the most effective treatment can be utilized to assist in the management of observed symptoms. It is also important the physiotherapists are able to demonstrate leadership in managing patient's cancer related side effects.
Target Population: This workshop is appropriate for physiotherapists and other health care providers who interact with people diagnosed with cancer. This information is aimed at care providers primarily in acute care but also to those in the community (both private practice and home care).

Description of Supporting Evidence:
Acupuncture is defined as "a therapeutic and/or preventive medical procedure performed by the insertion of one or more specially manufactured solid metallic needle(s) into specific location(s) on the body." Since its introduction to the Western World from Ancient China, acupuncture has evolved to include various forms, including electroacupuncture. While acupuncture is an invasive modality, adverse effects of acupuncture rarely occur. The risk of a serious adverse reaction is approximately 0.05 per 10,000 treatments. Reported side effects range from local skin irritation to pneumothorax and death, and can include central nervous system injury, infection (most commonly hepatitis B), and extreme drowsiness. Although the overall incidence of these side effects is very small, they can be avoided if proper precautions are taken, such as using appropriate sterile techniques and ensuring adequate acupuncturist training. Recent research has found that acupuncture may aid in reducing side effects of cancer treatment. Specifically, benefits were found in the management of nausea, pain, fatigue, and chemotherapy related hot flashes. Relevant literature will be presented during the pesentation and references will be provided to participants.
Description: This interactive workshop, presented by a physiotherapist, will include podium presentation and open discussion with the audience. Participants will be encouraged to participate throughout the session to help identify strategies to address issues discussed.

Conclusions:
As therapies to manage cancer and its treatment side effects improve, physiotherapists need to have different modalities to assist patients who are having difficulties with complications such as pain, numbness, or other symptoms. Acupuncture is a modality that physiotherapists are able to utilize, however its use with people diagnosed with cancer may be challenging, especially in the acute care hospital setting. Physiotherapists participating in this workshop will have a better understanding of the potential benefits of acupuncture for people diagnosed with cancer. Therapists will also have a stronger understanding of the evidence supporting the use of acupuncture, safety recommendations, and challenges of using this modality in the acute care setting. Participants will contribute to the development of a "tool box" that can be used to educate health care providers, patients, and others on the use of acupuncture by physiotherapists in the acute care setting to manage cancer related side effects.

Learning Objectives and Session Content:
The RAI-HC is a multi-dimensional assessment used in most Canadian provinces to determine eligibility for home care and service planning for individual patients. Organizations have used aggregated RAI-HC assessments to identify subgroups and inform new models of home care delivery. Home care aggregate provincial RAI-HC data have permitted analyses of the effect of receipt of PT or OT on multiple outcomes using Markov modeling. After adjusting for baseline multiple morbidity, falls, functional status, frailty/instability, age and gender, clients with ADL deficits were more likely to become more independent, less likely to be admitted to hospital or long term care, less likely to die and more likely to be discharged without services. Such analyses provide important evidence for the value of home care PT and can assist in advocating for increased resources. National or provincial RAI databases may provide evidence for other practice related questions. Greater familiarity with the content and potential uses of the assessment will assist PTs in optimizing the existing health information to advance and justify their practice. The learning objectives of this session are: 1. To enhance PTs understanding of the RAI-HC and its potential uses 2. To enhance PTs understanding of population based models of service delivery 3. To enhance PTs use of existing health information and to consider system level outcomes Relevance to Physiotherapy Profession: PTs have strong measurement skills but tend to focus on outcomes of single patients. Little attention has been placed on demonstrating value of PT to the health system. This session aims to stimulate this interest and • Make informed decisions regarding the selection and implemention of an EHR system in their clinic or department • Understand how the use of EHRs in their practice will save them time and money, reduce their environmental footprint, facilitate communication with other health professionals, and improve patient outcomes. Learning Objectives and Session Content: 1) To discuss how learning needs were defined and resources developed to support intraprofessional relationships 2) To describe how these resources are accessible to and utilized by physiotherapists and physiotherapist support personnel 3) To discuss potential ways in which patients will benefit from this effort.

P010 -INTRAPROFESSIONAL RELATIONSHIPS: SUPPORTING QUALITY PRACTICE
Relevance to Physiotherapy Profession: Across Canada, it is recognized that health care dollars continue to stretch requiring facilities and providers to do more with less. At the same time the Canadian population is aging, with expectations that demands on health care will rise. Innovative models of care are sought out to deliver necessary health care services. With regards to physiotherapy, physiotherapist support personnel help to ensure that the public continues to have access to physiotherapy treatment in all practice settings.
As a regulatory organization we are aware of the growing importance of physiotherapist support personnel within the health care team and we recognize and aim to assure that patients receive quality care. This purpose includes minimizing risks and optimizing patient safety. By developing and providing resources for physiotherapists and physiotherapist support personnel, the College endeavours to strengthen and support these working relationships in the interests of the public.
Target Population: This session will be of interest to clinicians, professional practice leaders, facility managers, and physiotherapist support personnel committed to ensuring safe, quality care for the public.

Description of Supporting Evidence:
In 2008 an extensive review of the material available through provincial, national, and international organizations related to the use of physiotherapist support personnel was completed. Following the analysis of this information, a focus group of physiotherapists and physiotherapist support personnel were consulted to find out how their current working relationships were perceived by team members. As a next step a survey was distributed to all physiotherapists within the province with a request that they share this survey with physiotherapist support personnel within their team. The survey yielded responses from over 700 physiotherapists and 400 physiotherapist support personnel. In addition to insights related to working relationships, this survey also helped inform the organization of what type of learning resources would be most valued as learning tools.
Additionally, data collected from various program areas within the organization indicated an increase in the number of questions and concerns related to the utilization of physiotherapist support personnel by physiotherapists. Questions and concerns were raised by patients, physiotherapists, physiotherapist support personnel, other team members, employers, and funders.
Based on this information, a program was developed to target resources to strengthen the working relationships of physiotherapists and physiotherapist support personnel at the point of care. The program is multi-year with an evaluation strategy that will enhance its ongoing development and implementation.
Description: This session will be a lecture format with opportunity for participants to ask questions and share experiences regarding their team dynamics.

Conclusions:
Physiotherapist support personnel are valuable contributors to the team and they are increasingly used to deliver physiotherapy services. As physiotherapists assigning care to physiotherapist support personnel, it is important to ensure quality care and safety while minimizing the risk of harm. The information collected leading into this program emphasized focus on the relationship between the team members.
Through the initial phases of this program, feedback is extremely positive from physiotherapists, physiotherapist support personnel, and team leaders regarding the usefulness of the currently available tools and resources. Ongoing feedback linked to resources will be obtained in addition to collecting data from other College programs and questions raised through these programs. In the future, stakeholders will once again be surveyed.

P011 -PROFESSIONAL PRACTICE PORTFOLIOS: A MUST TO SUPPORT PHYSIOTHERAPISTS AND THEIR PRACTICE NEEDS
Correspondence: Frederic Beauchemin, 6037 Longleaf Dr., Gloucester, ON K1W 1J5; fjbeauchemin@sympatico.ca Learning Objectives and Session Content: Four years ago, The Ottawa Hospital started its journey to remodel its professional practice structure. As a bi-product, these roles were put in place in addition to the Chief role: 5 Professional Practice Coordinators, an Advanced Practice Physiotherapist, 5 Senior Physiotherapists (change in role), Clinical Specialist and Clinical Experts. Once these new leaders were recruited, trained and were competent in their role, it had now become the time to align the new Physiotherapy Leadership team at the Ottawa Hospital to professional practice portfolios. These portfolios required a centralised alignment to ensure that all physiotherapist at the hospital, independent of their location of work (campus, site, unit) or status (full time, part time, casual) could have their professional practice needs met. These portfolios also needed a localised approach so that the delivery and final product would be tailored to meet the individual need relative to the clinical setting and the patient population.
Following an extensive consultation process, 19 core professional practice portfolios were developed: service excellence; role development; partnerships; research strategy; caseload management strategy; performance management and leadership development; best practice/knowledge transfer; standards of care; CQI; orientation; the new staff experience; the support staff; the clinical council; the student experience; education; communication; equipment; casual employee experience; mentorship, link with orthopedics (triage, pre, post surgery).
Participants will be able to successfully navigate these learning objectives: 1. Be familiar with the new professional practice structure at the Ottawa Hospital 2. Understand the steps in determining corporate portfolios and core elements of the portfolios at the Ottawa Hospital 3. Understand the importance of centralised planning to standardise and tailor delivery to better meet the needs of all physiotherapists (all areas) 4. Understand how to set yearly targets/objectives with the portfolios and measurement to meet outcomes (practical application adapted to the participants workplace setting).
Participants will learn from the Ottawa Hospital experience how to develop clear professional practice portfolios to guide professional practice with reachable targets and benchmarks adapted to their workplace setting that raises the support provided to physiotherapists and allows more therapists to move from novice clinicians to proficient and expert clinicians more quickly.

Relevance to Physiotherapy Profession:
The content of this presentation is very relevant to clinicians and organisations. Some therapists who have 15 years of experience for example, have in some case truly only 1 year of experience repeated 15 times. A solid professional practice program using portfolios allows clinicians to look within, identify gaps and develop strategies to improve performance. Smaller organisations or private clinics do not have the structure or the resources to successfully develop from scratch elements of professional practice which includes professional practice portfolios. The Ottawa Hospital has a total of 250 people working within the profession which includes 200 physiotherapists and 40 physiotherapy/rehabilitation assistants. To support these professionals, 7 leaders, most of whom do not carry a clinical load are aligned to the portfolios to support the staff's professional needs. As a result a higher number of our clinicians are able to progress quicker from novice physiotherapists to expert clinicians.
This presentation will benefit clinicians in both hospital and private settings, and this tool can easily be used by smaller organisation so elements can be incorporated within their organisation.

Target Population:
The target populations include: 1) leaders from large academic centers that can use all of the elements discussed to successfully implement all of the portfolios; 2) leaders from smaller organisations or private clinical owners/leaders so they can use the elements of the portfolios that are the most relevant to their practice; 3) individual clinicians so they can be aware of all of the components that allow them to become proficient clinicians quicker; 4) researchers and academics so that further studies can be developed that look at cause and effect relationships between the level of professional practice support (portfolios) and actual clinical performance.

Description of Supporting Evidence:
When we prepared for the re-structure in 2008, an extensive review of the literature was carried out using the internet and Medline search engines using the following keywords: review of program management, centralization, decentralization, Physiotherapy and Occupational Therapy. Through this review, it became evident that very few studies were conducted to compare measurable impact before and after decentralization. Most articles consisted of anecdotal commentary, case studies or the utilization of qualitative structured interviews to assess and publish the impact of decentralization on various Health Professional groups. Still we were able to extract some important common elements from the material reviewed.
The negative points of decentralization identified through the review of articles include a decrease in clinical involvement, fewer opportunities for professional support and leadership, lack of professional career laddering, lack of professional status, lack of professional development activities, sense of loss, limited resources for orientation and mentoring of new staff, less participation in research and publications, less flexibility in resource management, lack of standardized clinical policies and procedures, loss of the operational control of supplies and equipment, less efficiency at maintaining standards of practice, and decreased staff retention.
This is the case in many of our clinical settings today and a strong professional practice structure with clear portfolios allows for physiotherapists and support staff to be well supported independently of the management structure they are currently in.
The evidence is quite clear that within the clinical setting, health care professionals require a solid professional practice program that provides the needed practice support, links with therapists that are expert clinicians, helps further develop the clinical and non clinical skills required to be successful and to have an impact with patients/families, and other care providers.
Description: The first portion of the presentation will be delivered in a podium type fashion to address these various topics: 1) Summary of the new professional practice structure at the Ottawa Hospital; 2) Discussion of the process to engage staff, get feedback, formulate common themes and develop 19 core professional practice portfolios; 3) Give examples of the development of yearly goals with a few portfolios. The second part of the session will be interactive with the audience participating in priority setting in groups, developing key portfolios related to their own workplace and addressing a few goals within each portfolio. It is anticipated that each participant will be able to take back a high level plan to implement professional practice portfolios in their workplace.

Conclusions:
The change in the Physiotherapy Professional Practice Structure at the Ottawa Hospital was presented at Congress 2008, but that was only the first pillar. The first tangible product that has been developed thanks to this new structure has been the professional practice portfolios.
As was true with the new structure itself, the methodology used to communicate, gather data and ideas was key to develop our 5 year strategic plan, develop the key professional practice portfolios and develop a process which consists of setting clear yearly objectives with targets for each of the portfolios. This work and sharing the data will help smaller organizations and clinics to utilize the data and processes developed at the Ottawa Hospital to adapt to their clinical setting. This will lead to greater professional process of providing well delivered feedback to better enable the development of this skill. This workshop will focus on 2 of these models.
Description: This learning session will integrate a variety of didactic and interactive techniques including audience participation, sharing experiences, think-pair share, DVD teaching clip debriefing and role play activities. Participants will leave with teaching tip cards to facilitate applying content from the session to their everyday practice. It will conceptually combine elements of research, education and practice. Participants will draw upon their own practice to identify applications in their settings.
Conclusions: By providing this learning opportunity, we hope to enhance the knowledge, skills, attitude and practice of participants to provide effective feedback within and beyond the physiotherapy profession. This education session will focus on providing participants with an overview of recently published research on pain catastrophizing. An emphasis will be placed on literature that addresses the psychological, neurophysiological and endocrinological mechanisms and clinical implications of elevated levels of pain catastrophizing in people with pain. Research that has linked levels of pain catastrophizing to the following maladaptive responses to pain will be discussed: dysfunctional immune/inflammatory response, amplified neural activation and inaccurate perceptions of ability. The session will link these influences to the development of chronic pain and/or pain-related disability across a variety of pain conditions. Clinical research examining the role, and measurement, of pain castastrophizing as a risk factor for problematic recovery will be highlighted. The evidence-based management of patients with elevated levels of pain catastrophizing will be discussed.

Relevance to Physiotherapy Profession:
Over the past ten years, pain catastrophizing has emerged as one of the most robust predictors of prolonged pain and disability. Pain catastrophizing, defined as a maladaptive orientation to pain, is characterized by pain-related thoughts of helplessness (e.g. "There's nothing I can do to reduce the intensity of the pain"), symptom rumination (e.g. "I keep thinking about how much it hurts"), and threat-value magnification (e.g. "I wonder whether something serious may happen"). Previous research has linked elevated levels of pain catastrophizing to heightened levels of pain intensity, impaired physical function and increased pain behaviour. While pain catastrophizing was originally characterized as a purely psychological construct, emerging research suggests that this factor also plays an important role in the physiological mechanisms of pain. For example, levels of pain catastrophizing have been linked to physiological markers of the inflammatory response, activity in the hypothalamic-pituitaryadrenal axis, and function of higher-order brain functions. Together, this research suggests an intimate link between psychological and biological aspects of pain. This literature can therefore help physiotherapists understand the pathway from high catastrophizing to persistent pain and disability. By integrating knowledge of both the biological and psychological dimensions of pain, physiotherapists stand to improve both their prognostic accuracy and treatment outcomes.
Target Population: This education session is designed for all therapists that treat patients with pain, and researchers that are interested in the subject of pain. An emphasis will be placed on research relating to orthopedic pain conditions. No background knowledge in the field of pain research is required.

Description of Supporting Evidence:
The clinical importance of pain catastrophizing is well supported in the literature. Pain catastrophizing has been linked to levels of pain intensity and pain-related disability across a wide range of patient populations. These relationships have been observed both in cross-sectional and prospective studies, and across different age groups. Clinical measures of pain catastrophizing have been shown to have excellent reliability and validity, and are widely used across healthcare disciplines. Interventions that target pain catastophizing have also been supported by evidence from randomized controlled trials.
Emerging research supports the links between pain catastrophizing and maladaptive neurophysiological responses to pain. Several studies exploring these relationships have been published in high impact, multidisciplinary journals such as Brain, Pain and Psychoneuroendocrinology. The majority of this research is cross-sectional. These findings have been supported with studies using both healthy participants with experimentally induced pain conditions, and people with clinical pain conditions.

Description:
The format for this education session will include a slide show presentation and opportunities for audience participation. Mr. Wideman and Dr. Walton will present research findings from their own work as well as relevant findings from the work of others in an open seminar format aimed at improving the understanding of the importance of pain catastrophizing, and laying the groundwork for ethicial and judicious clinical behaviour change. Formal knowledge exchange approaches will be undertaken, taking both didactic and interactive forms. The hour will be broken into three broad sections: 1. An overview of pain catastrophizing, including a discussion of the usefulness, scoring and interpretation of the Pain Catastrophzing Scale; 2. A discussion of the mechanisms through which catastrophizing can lead to the development of persistent pain or disability, including psychological/perceptual, neural and endocrine processes; 3. A discussion on the state of the evidence in support of clinical intervention strategies that can be employed by physiotherapists. At least 5 minutes will be reserved for questions, and the floor will

Target Population: Orthopaedic physiotherapists
Description of Supporting Evidence: A systematic literature review of all reported cases of pectoralis major rupture was conducted by one of the presenters (a manuscript of findings is currently pending review in the American Journal of Sports Medicine). We compiled an analysis of injury patterns, mechanism of injury, clinical presentations, and treatment options. The anatomic and biomechanical overview is based on evidence resulting from a three-dimensional, digitized anatomic study of the pectorlis major performed in collaboration with anatomy researchers at the University of Toronto. Further evidence is provided by the presenters' own experience in assessing and treating an increasing number of pectoralis major injuries as part of an orthopaedic surgeon's upper extremity practice.
Description: This will be primarily a lecture format that includes graphics and video clips to demonstrate anatomic findings, clinical presentation and assessment techniques, as well as approaches to specific exercises. We will also use audience volunteers to demonstrate appropriate setup, hand placement, movement errors, etc. during descriptions of assessment and treatment techniques.

Conclusions:
Increasing interest in fitness and competitive athletics has resulted in an escalation of reported injuries to the pectoralis major muscle. Almost half of these injuries occur while weightlifting. Given that this has historically been considered a rare injury, physiotherapists may lack familiarity with these clinical presentations and how to properly assess and treat them, either conservatively or post-operatively. We provide an evidence-based overview of the complex musculotendinous anatomy of the pectoralis major, a classification of injury patterns, assessment techniques and surgical management alternatives for treating ruptures to the pectoralis major muscle. This information should provide the foundation for a confident approach to clinical diagnosis and post-operative treatment of pectoralis major injuries.

Learning Objectives and Session Content:
Historically the sacroiliac joint is one of the most controversial joints in the body. This session will summarize decades of debate which has centered around three main themes.
Firstly, reported prevalence rates have varied greatly. Some believe that the prevalence is high and the sacroiliac joint is a common source of pain, others argue that it is rarely the primary source of pain. At one end of the spectrum are groups who feel the sacroiliac joint should always be treated. The rationale is that if it is not the primary site of pain in lumbosacral disorders then it causes pain when its mechanics are faulty. This creates strain that produces pain further up the kinetic chain (lumbar ligaments, discs, facet joints). Others do not accept these models and feel the sacroiliac joint is highly over-diagnosed, is rarely the source of pain and thus only infrequently needs intervention.
Secondly, debate continues in some circles regarding the amount of available movement and the functional relevance of that movement in the sacroiliac joint. Advocates support the concept that movement at the joint becomes dysfunctional when it becomes blocked or excessive or when movement is asymmetrical and this can have major implications for pain and function. Opponents to this view argue that there is no meaningful range of motion at these joints and they call into question both the ability to detect minute changes in these motions and the clinical relevance of such changes.
Finally, the literature contains a plethora of possible assessment procedures which have been proposed to help diagnose a sacroiliac joint problem, most based on biomechanical models. Numerous studies are now available that consider whether palpation and osteokinematic testing can detect positional faults and joint movement abnormalities. Alternately, pain provocation tests have been studied both in terms of reliability and validity, but are not designed to give any biomechanical insight. Depending on their training, clinicians tend to follow one or the other of these assessment paradigms.
The last two decades have provided us with a volume of evidence that gives some clarity, though clinician friendly summaries are needed to facilitate translation of this evidence into clinical practice.
The objectives for this session will be to: 1. Outline and critique the literature pertaining to the three main areas of controversy noted above (prevalence rates, ROM, assessment procedures). 2. Present a systematic evidence based assessment algorithm to rule out the lumbar spine and demonstrate which tests will help the clinician make a reliable and validated SIJ diagnosis. 3 Provide suggestions for how clinicians can translate the assessment findings into a patient-centered treatment approach.
Clinicians frequently encounter patients with back pain. Since the area of the SIJ is a common site for referred pain, the clinicians' first challenge is to make a differential diagnosis in an area where symptoms overlap and false positive clinical tests can create diagnostic errors. Subjectively there are only a few historical or subjective clues to help in differential diagnosis. Therefore the clinician must adopt reliable and validated clinical tests. While researchers continue to debate whether or not clinicians can accurately differentiate between lumbar sources of pain (disc, facet, ligaments, muscle), there should no longer be controversy over our ability to distinguish lumbar versus true SIJ pain.

Relevance to Physiotherapy Profession:
Inaccurate diagnoses and the variability in treatment options that result can lead to less than optimal outcomes, wasted healthcare resources, and patient frustration. Physical therapists can increase the accuracy of their evaluation and decrease false positive sacroiliac diagnoses. Outcomes may suffer if the sacroiliac is treated when a lumbar problem is the source of pain, and vice versa. Physical therapists will benefit from learning this evidence-based method of ruling out the lumbar spine and applying reliable tests to confirm the sacroiliac as the problem. The findings from the assessment will help guide individualized treatment options.
Target Population: This session will be relevant to physical therapists and researchers: Physical therapists that regularly assess, treat, and/or direct management of patients with low back pain, sacroiliac joint area pain, and related symptoms.
Researchers who are interested in exploring differential diagnosis in the lumbar spine and looking at the implications of the assessment process on appropriate patient subgrouping Description of Supporting Evidence: Numerous anatomical and biomechanical studies, reliability studies, and validation studies will be summarized in order to differentiate between proven and questionable sacroiliac joint assessment methods. There is substantial evidence to suggest that the facts lie somewhere between these two widely divergent opinions. Adding strength to this body of evidence is that the findings have been validated by several independent research groups. Attendees will be provided an email link for the references summarized.
Description: This session will be a lecture format, followed by presentation of a published case study which will be used to illustrate the clinical application of a structured and evidence-based assessment algorithm and clinical reasoning process for identification of sacroiliac joint pain. The case study will be used to stimulate a question and answer session.

Conclusions:
The breadth of diverse literature on sacroiliac joint diagnosis and screening can now be streamlined into an evidence-based assessment algorithm. As clinicians put this research into practice a greater consistency between clinicians can be achieved as more dependency is placed on reliable and validated clinical tests and less on those tests that have so far failed to achieve credibility in the literature. Old controversies can be put to rest so that research can move forward with randomized controlled treatment trials for sacroiliac joint pain where subject populations are not inadvertently contaminated with lumbar spine patients and the appropriate intervention can be tailored to the appropriate subgroup. This clinician friendly presentation will provide useful tools that can be immediately implemented into clinical practice.

Learning Objectives and Session Content:
In response to requests from participants at this team's presentation at CPA Congress 2010, this session will enhance the exploration of issues related to current practices in use of outcome measurement (OM) in total joint arthroplasty (TJA).
Physiotherapists in Canada are increasingly encouraged to extend their use of standardized outcome assessment beyond that of physical impairment (e.g., range of motion and strength) to capture patient-centred outcomes such as more complex function, activity and participation. Further, therapists are requested to use outcome measures with stronger measurement properties in order to enhance clinical decision-making and permit program evaluation and research application.
At Congress 2010 we introduced three initiatives (a chart audit, focus group and survey), facilitated by the BC Physical Therapy Knowledge Broker, which collectively explored current outcome measurement use and shared creative strategies to enhance its use along the TJA continuum (pre-operative phases through post-operative rehabilitation). Concurrently, but not presented at Congress 2010, one of the members of the team undertook an extensive Delphi survey with two Canadian-American expert panels to reach consensus on clinically important measures in the post-acute arthroplasty population. The collective results of these four initiatives are providing greater clarity as to what steps need to be undertaken to support physical therapists in their regular and sustained utilization of OM. This session will provide participants with a tangible framework for understanding the current utilization of OM and lay the foundation for the subsequent session "Outcome Measurement. Part 2: Similar to Exercise, Incorporating Simple Strategies into Your Current Way of Practice Can Lead to Sustained Use and Rewarding Benefits." Objectives: 1. To highlight the findings of four complementary research initiatives aimed at better understanding current use of outcome measures in the total joint arthroplasty patient population. 2. To illustrate the importance of the successful partnerships, facilitated by a Knowledge Broker, incorporating multiple stakeholders' views and data gathering methods in developing a full/comprehensive picture of outcome measure use and contextual factors that may influence future use and successful knowledge transfer strategies. 3. To engage participants in a discussion on the clinical implications of the use of standardized outcome measures along the TJA continuum.
Relevance to Physiotherapy Profession: Total joint arthroplasty is an increasingly common surgery for advanced osteoarthritis of the hip or knee. In 2006/07, more than 62,000 procedures were performed, with more than 11,000 in BC alone. Most of these clients receive physiotherapy services in one or more clinical settings as part of their routine rehabilitation with the aim of restoring strength, mobility, physical function and quality of life. Physiotherapy interventions after these surgeries vary tremendously across Canada and world wide, as does the use of outcome measurement in this patient population (Westby 2010). Similar to other health professional organizations, the Canadian Physiotherapy Association promotes the use of standardized outcome measures in the clinical setting. This session, together with the content of a complementary session (Part 2) will provide physiotherapy leaders and frontline clinicians with the knowledge and tools to use OM to enhance clinical decision-making and program evaluation ultimately improving patient-centered care.
Target Population: This session will be of interest to clinicians, educators, knowledge brokers, researchers and decision makers interested in outcome measurement in, but not restricted to, the total joint arthroplasty population. Indeed, the concepts and principles will be relevant across the spectrum of practice areas.

Description of Supporting Evidence:
Use of outcome measurement in joint arthroplasty rehabilitation research is inconsistent making clinical interpretation of treatment effects problematic (Riddle 2008). This is even more evident in joint arthroplasty clinical practice (Westby 2010) and in physiotherapy practice in general (Jette 2009). Barriers to routine use of outcome measures are multi-faceted and include personal (practitioner) and environmental factors such as access to resources, organizational policies and the practice context (Rivard 2010). The Physical Therapy Knowledge Broker position is ideally suited to promote the use of outcome measurement through their sensitivity to the practice context and organizational factors (Rivard 2010).
Description: This session will consist of presentations followed by participant discussion regarding their experiences with and insight into the use of outcome measures in the clinical setting.

Conclusions:
Understanding current practices and other contextual factors affecting use of outcome measurement provides a baseline against which the success of knowledge brokering, behavioural change and knowledge transfer strategies can be evaluated. The total joint arthroplasty population provides a relevant and important area of practice to explore these issues. This patient population has been targeted by a number of health care organizations as a key area for standardized use of outcome measurement. Multiple data collection approaches across different health care settings and with varied stakeholder input increases the likelihood of a valid and realistic understanding of "current practice" as well as an appreciation of the contextual issues and eventual success of a change in professional behaviour. The physical therapy knowledge broker is well positioned to facilitate the steps required to elicit this change.

To illustrate the importance and benefits of interpreting standardized outcome measures' scores and integrating the information into the clinical decision-making process to develop realistic goals, guide treatment and better address patients' needs. (1) How confident am I in a measured value? (2) What does the measured value mean? (3) How much
change is required to be reasonably certain a patient has changed? (4) What is the ideal reassessment interval to assess the change? (5) What is the patient's expected terminal goal value? (6) When is the patient expected to reach his expected goal value?
CPA's Outcome Measurement initiative will also be highlighted as it includes the development of an online tool to improve accessibility and interpretation of outcome measures for Canadian physiotherapists.
Relevance to Physiotherapy Profession: An ongoing priority of the Canadian Physiotherapy Association is the successful use of standardized outcome measures to enhance clinical decision-making. Often the impetus for using outcome measures has been external (e.g., payers and administrators); this session will focus on the positive personal benefits to patients and physiotherapists gained by interpreting the scores of outcome measures.
Target Population: By offering key principles and strategies, the session will be relevant to all physiotherapists who assess the outcomes of patients across the spectrum of practice areas.

Description of Supporting Evidence:
Despite the importance and rationale for outcome measurement, studies have shown that a significant number of physiotherapists still do not regularly use standardized outcome measures. In a recent survey examining the use of standardized outcome measures in physical therapy practice, only 48% of participants used them. Reasons for not using standardized outcome measures included: time for patients to complete; time for clinicians to analyze/calculate/score and difficulty for patients to complete independently. A number of other studies have cited a variety of organizational and practitioner barriers including the difficulty to critically appraise the measures and interpret their results. Understanding clinician practice traits may provide some assistance in developing implementation strategies.
Description: This interactive session will consist of a mix of presentations from different stakeholders (Academic, Clinical, and Professional Association) and will involve presentations and participant feedback. It will build on information shared in Outcome Measurement. Part 1: Where are we now?

Conclusions:
Assessing patients and applying the information gained to guide clinical decisions forms the cornerstone of physiotherapy practice. Confidence in clinical decisions is directly related to the confidence in measured values on which the clinical decisions are based. The hallmark of standardized outcome measures is their detailed description for administration and scoring, as well as information concerning the interpretation of score values, and the extent to which the measures have been validated in a clearly described context. It is our belief that the primary reason for the less than optimal utilization of standardized outcome measures is the lack of understanding of the benefits to the patients and physiotherapists. The information provided in this session will be useful in conveying the benefits to patients and physiotherapists, and in providing strategies for selecting the most appropriate measure given the constraints unique to each physiotherapist's practice.

Learning Objectives and Session Content:
Excessive exercise can be viewed as the alpha and omega of the eating disorder (ED). It is both a common trigger in ED development and the last symptom to resolve, occurring in persons with anorexic and bulimic-type disorders, with prevalence between 30-80% (Meyer, Taranis and Touyz, 2008). For people with an ED, excessive exercise behavior leads to longer bouts of hospitalization, predicts shorter relapse time post-discharge and points to a poorer longer term outcome generally. The Readiness and Motivation Interview (RMI) can measure where a person is in regard to their stage of change with this behavior. Despite all the evidence, there are currently no specific guidelines regarding the targeting of exercise or excessive activity within therapeutic interventions for eating disorders (Meyer 2008).
Physiotherapists are the experts in exercise metabolism, training adaption, sports biomechanics and exercise prescription, as well as assessment and intervention of orthopedic and athletic injuries. This session will explore how physiotherapy knowledge and skill is essential in an interdisciplinary approach to the treatment of people with eating disorders.
Learning Objectives: 1. To understand the clinical difference between excessive exercise and overtraining in physically active women. 2. To learn the physical complications of an Eating Disorder and how they apply to exercise prescription and treatment options for physiotherapists. 3. To use two case studies to explore how using an innovative motivational, multi disciplinary approach can effectively address excessive exercise.

Relevance to Physiotherapy Profession:
In Austria, Switzerland, Sweden and Australia, physiotherapy is already an integral part of the treatment of people with EDs. A role for Canadian Physiotherapists is now emerging, but progress is slow. While multidisciplinary programs exist across Canada to help clients manage eating disorders, the HOPE (Healthy Opportunities for People with Eating Disorders) program in St. John's, Newfoundland is the only Public Health Program in the country to employ a physiotherapist solely to work with people with a diagnosis of an ED.
Eating disorders are a mental illness with significant physical complications. A variety of physical impairments are under-recognized in this population, including musculoskeletal complications such as low bone density, proximal muscle weakness, muscle and tendon shortening, tendonitis, stress fractures, poor posture and spinal alignment. (Michelle & Crow,2006: Katzman, 2005.
Physiotherapists have the expertise to treat these complications, but there is a danger inherent in treating clients with these issues without understanding the underlying pathology.
Over training and excessive exercise lead to an energy imbalance which can be life threatening: arrhythmias or cardiac failure due to dehydration, hypophosphatemia, hypokalemia and hypomagnesium. In treating these serious physical symptoms it is easy to loose sight of the fact that excessive exercise has its roots in mental health disorders, eating disorders in particular. Anorexia has the highest mortality rate of all the mental health disorders. People diagnosed with AN have a 57% increased likelihood to die from suicide than people without (Keel PK, Dorter, Eddy, Franco, Charlatan & Herzog. 2003). Physiotherapists can aid in the detecting the early signs of an eating disorder. Early detection and intervention can decrease the likelihood of such tragedies.
Mental illness can lead to physical distress, but the current health care model is one that continues to separate mental and physical health to the detriment of the client. As physiotherapists become more involved with the treatment of EDs recognition of potential mental illness is crucial. We need to be aware of the red flags in order to know when the expertise of other professionals is required. This is critical to ensure that comprehensive care is provided.
Target Population: This presentation is relevant for physiotherapists working with persons with eating disorders or those at risk for eating disorders (competitive athletes, physically active woman, women in the Military and children and adolescents). Issues raised will also be important for therapists working with clients in other areas of mental health, with altered bone metabolism and in other areas using a motivational approach.

Description of Supporting Evidence:
Currently, there are no specific guidelines regarding the targeting of exercise or excessive activity within therapeutic interventions for eating disorders (Meyer 2008). This is primarily due to the common belief that exercise hinders weight gain (Calegero & Pedretty, 2005) and the lack of formal exercise protocols. It is recognized that any exercise program with this population needs to be supervised by a trained professional (Thein et al, 2000). Calegero and Pedrotty (2004) report the use of an exercise program that targets excessive exercise in women with eating disorders results in positive change without interfering with weight gain. In less than 4 weeks, women in the exercise program reported reduced disorder of thought, feeling and behaviors about exercise. Ron Manely and Kit Stanish (2003) report that as the result of an in-patient supervised exercise group, 33% their clients reported their obsession with exercise had decreased. An equal amount reported improved body image; 63% indicated the group increased their interest in pursuing exercise for fun and 90% said that an exercise group should be offered as part of their treatment.
A motivational approach incorporates empathy and reflective listening to promote an open discussion about change (Miller & Rollnick, 2002).It is a useful assessment and intervention strategy in the management of a wide range of issues including eating disorders, alcohol abuse, drug addiction, obesity and physical inactivity. Using the motivational approach, Jossie Geller et al (2008) devised a Readiness and Motivation Interview (RMI) to assess the readiness for change in people with eating disorders. The RMI is a symptom specific measure of readiness for change. Unlike global measures of readiness, which conceptualize the disorder as a single entity, the RMI provides readiness and internality (the extent to which change is occurring for self versus others) scores for each symptom domain of an eating disorder. As a result, a clinical team can know where a client is with regard to their readiness to change (pre contemplation, contemplation, preparation, action and maintenance) behaviors such as restricting, binge/purge and exercise. Knowing a client's stage of change with regard to exercise is valuable information and can assist a physiotherapist in designing effective therapeutic exercise and treatment for this population.

Description: A didactic presentation supported by clinical examples.
Conclusions: Research indicates that an ED reduces life expectancy by as much as 25 years and a third of people who develop an ED never recover (Guesella & Casey, 2002).
Physiotherapists need to be able to tell the difference between healthy physical activity and excessive exercise rooted in mental illness. We also need to be able to work together with our fellow health care professionals to effectively provide intervention when we see that line has been crossed.
The knowledge gap on how to address exercise and the physical complications of an eating disorder is as large as the divide between physical and mental healthcare models. This presentation is the initial step toward exploring best-practice to closing these gaps. Only then can we achieve our ultimate goal of putting our clients on the path to true wellness. To present a framework of translating innovative programs into business practice methodology and promote discussion around same.

Relevance to Physiotherapy Profession:
Physiotherapists are the ideal professional to assist people to golf after injury or disease. Therapeutic Golf Rehabilitation involves the use of golf as a tool to improve balance and return to sport. By integrating golf training principals with physiotherapy and practice, performance is enhanced both on and off the course. Sport specific programs are a valuable addition to the rehabilitation process, are easy to implement and create satisfied patients.

Target Population: This session will be of interest to physiotherapy clinicians, entrepreneurs, managers, researchers and golfers.
Description of Supporting Evidence: Participation in sport and leisure activities promotes health through the lifespan and is recommended for all persons regardless of ability. According to statistics from The Heart and Stroke Foundation and Canadian Stroke Network (2009), about 300,000 Canadians are living with the effects of stroke. Based on participation, Statistics Canada (2008) reports golf as the number one recreational activity in Canada with an estimated 6 million golfers and an expected growth rate of 14 percent between 2009 and 2011. People living with stroke can use golf as a means to promote health. According to the literature, there is evidence that golf increases flexibility, improves core and extremity strength, balance, postural control and coordination, speed and functional fitness in a healthy population. Older golfers score higher on balance tests than non-golfers.
Therapeutic Golf Rehabilitation was first described in the literature in 2001. It is based on sound principals of rehabilitation including neuroplasticity, motor learning, practice and performance. Participation has been shown to improve balance and quality of life in stroke survivors. Three single case study designs demonstrate the philosophy, treatment techniques and outcomes of Therapeutic Golf Rehabilitation. A business model based on five years of operations projects early return on investment and satisfied customers.
Description: This session will be interactive lecture format, with opportunity for discussion regarding clinical experiences and entrepreneurial ideas. Power point, a laptop, a projector, a screen, and podium microphone will be required.

Conclusions:
Using sport during rehabilitation is valuable to the physiotherapy process. Therapeutic Golf Rehabilitation is one example of a successful sport specific physiotherapy model that is easy to implement, enhances outcomes and brings joy to patients. Relevance to Physiotherapy Profession: Physical Therapists are 'drug-free-practitioners' developing and directing therapeutic exercise, and advocating health programs to treat, reverse and / or prevent pain and dysfunction for our clients. Since the pharmaceutical revolution of the 1940's, many conditions that could be treated by physical therapists have been eclipsed by drug intervention (Field, 1998).

P022 -EUCAPNIC BREATH RE-TRAINING AS A PAIN MANAGEMENT TOOL
'Mindfulness breathing' has been shown to beneficially modify response to pain stimuli (Zautra et al 2010), and eucapnic breathing techniques have been shown to have substantial benefit in other hyperventilation related conditions such as asthma, with up to 96% reduction in medication usage (Cowie et al, 2008;McHugh et al, 2003).
While this workshop specifically addresses eucapnic breathing as a pain management tool there is also significant research demonstrating its value for management of asthma and other hyperventilation related disorders, and as a tool for improving fitness and sport performance.

Description of Supporting Evidence:
There is a subgroup of often difficult to manage patients suffering from various conditions clinically linked to chronic hyperventilation such as: hyperalgesia, persistent neural sensitization, sweaty or tingling hands and feet, migraines, headaches, dizziness, non-specific abdominal pain, and anxiety. And unrecognized hypocapnia is common in fibromyalgia, Chronic Fatigue Syndrome, and nonspecific dizziness (Naschitz JE, et al 2006). Hyperventilation in its various forms is known to effect neural sensitization and provoke 'strange' and seemingly unrelated symptoms (Gardner 1996, McLaughlin 2009). Claims have been made that more than 60% of ambulance calls in the USA are related to hyperventilation dysfunction whether chronic, sub-acute or acute (Litchfield 2003).
Estimates of disordered breathing problems in the general population vary from 10% to 90%. A 2004 pilot study by Perri and Halford determined a figure of 75% leading them to suggest that of any four new patients presenting on any given day, the condition of three of them will be affected by breathing issues.
Description: Exercise instruction will be integrated with lecture material incorporating a review of the theory, research, and physiology informing this approach to pain management. A self-monitoring process will be repeated throughout the session so that participants can monitor their own changes in capnic status during the workshop. The basic capnic modification exercise, with variations, will be taught and contextualized. There will be a question period and discussion at the end.

Conclusions:
Aside from the cost of pain syndromes in human suffering, the economic burden of chronic pain in Canada, including medical expenses, lost income, and lost productivity, is estimated to exceed $12.5 billion annually (Warriner B et al 2007) and medications often carry with them unintended adverse effects.
The CPA advocates for the health, mobility and independence of all Canadians. The position statements on the determinants of health and population health suggest that the profession has a role in advocating for healthy public policies (CPA, 2010).
Physiotherapists are able to address the determinants of health in their daily professional practice and are competent in identifying risk factors for disease and disability in individuals and their environment. Therefore, physiotherapists can, and should integrate a population health approach in their practice by collaborating to develop interventions that address population health needs (CPA, 2010).
However, there is little information available to guide the specifics of how physiotherapists can become involved in advocacy efforts on any level regarding Aboriginal health in Canada. A review of research exploring the health needs of Aboriginal populations in Canada did not include papers that were rehabilitation-specific (Young, 2003). Further education and input in the form of practical, grass-roots initiatives will assist physiotherapists to play a greater role in health promotion and prevention and advocate for improving health equity.
Description: This will be a structured panel discussion in which three experts will each present their experience and insights related to the content areas. A moderator will facilitate a discussion with the audience to explore the advocacy role of physiotherapists.

Conclusions:
The International Health Division aims to promote advocacy in global health and human rights issues in Canada and abroad. Health equity for Aboriginal peoples in Canada is a substantial social issue that can be addressed by physiotherapists working in rural and urban settings across Canada. This session will provide physiotherapists with the tools to advocate for and address typical 'international health' issues within their practice in Canada. The session will provide opportunities for participants to learn from the panelists and from each other by providing a forum for discussion and networking.

P024 -LOW BACK PAIN: WHAT'S THE NEXT PRIORITY AFTER RULING OUT RED FLAGS? A MOVE TOWARDS STANDARDIZING AN ASSESSMENT AND TREATMENT PATHWAY
Long A, * Rosedale R, † Davies C. ‡ *Bonavista Physical Therapy, Calgary, AB; †London Health Sciences Centre, London, ON; ‡Westminster Physiotherapy Clinic, New Westminster, BC. Correspondence: Audrey Long, 739 Lake Bonavista Dr., Calgary, BC T2J 0N2; longma@telusplanet.com

Learning Objectives and Session Content:
In low back pain research there has been repeated calls for the identification of specific subgroups that can be matched to specific interventions. This has contributed to an increased focus on a growing number of classification systems that have developed in order to address this need. The systems derive from a number of physiotherapeutic approaches and have significant variability in the assessment procedures used and in the subgroups identified. However, there is a degree of overlap between a number of these systems. This overlap involves the relatively large subgroup of patients found to have Directional Preference and/or the Centralization Phenomenon described by Robin McKenzie and originally used exclusively within the context of the McKenzie System of Mechanical Diagnosis and Therapy.
The objectives for this session will be to: 1. Explain how using a reliable assessment to identify a large subgroup improves the efficiency of the overall patient care pathway. 2. Provide a summary of over 90 clinical publications documenting directional preference and the centralization phenomenon. 3. Summarize and critique prevalence rates and discuss how this important body of literature can be used to promote the role of physiotherapy in the primary care of low back pain, with or without sciatica.
The initial patient contact is crucial and there is a strong consensus in the literature and guidelines that screening for red flags is the first priority. After this step, there is very little consensus on what type of screening or form of assessment should follow. The result of this lack of consensus is that the patient's experience can be extremely divergent. It will vary greatly depending on the practitioner's choice of treatment philosophy, style of practice and form of training.
A large body of evidence will be used to make a case for the assessment for directional preference and centralization as the next important step after the exclusion of red flags. Assessment methods employed to rule in or rule out these phenomena create a clear path to identifying the subgroup of patients that respond to a simple exercise based intervention with subsequent rapid resolution of pain and restoration of range of movement. If the potential for a simple solution is missed at this early stage, more burdensome, complex, invasive and costly interventions may needlessly be pursued. The implications are that patient satisfaction, outcomes, and potential health care costs will all be adversely impacted.
The exponential growth in the evidence-base supporting mechanical assessment and classification of LBP is challenging for working clinicians to track. Cook (2008) has proposed that synopses of literature will become one method of providing clinicians with up-todate evidence summarizing large volumes of literature which the average clinician does not have time to search, read, and interpret. The content of this session will be focused on putting into context over ninety clinical articles related to DP and CP. Trends emerging from the body of evidence will be outlined, strengths and limitations will be discussed, and future directions will be proposed. The assessment method needed to identify this important subgroup is used worldwide, and in some countries it is the predominant form of spinal assessment. It is not however so commonly practiced in Canada and this summary of the literature may be the first step that informs and inspires clinicians to translate this evidence into clinical practice.
Relevance to Physiotherapy Profession: Physical therapists have the skills to transform the primary care of low back pain and sciatica. Adopting assessment methods that reliably classify low back pain patients into treatment and prognostic subgroups can reduce waste of healthcare funds and help direct resources where they are most needed. An understanding of this specific screening procedure and of the implications of the research could lead to its inclusion as an important component in promoting the profession's potential role in musculoskeletal care.
Emerging trends in continuing education have resulted in clinicians acquiring a large repertoire of tools for their treatment tool box. More than ever clinicians need to reflect on their choice of an assessment tool box in which to organize these many treatment options. Assessing the options in a way that reflects the strength of supporting literature will enhance the clinician's ability to prioritize and focus on the components of the assessment which reliably direct treatment. This will facilitate the early identification of a subgroup of patients with a good prognosis and predictable response to simple interventions.
Target Population: This session will be relevant to physical therapists that regularly assess, treat, and/or direct management of patients with LBP with or without sciatica. The content is applicable to acute or chronic patients, and pre-surgical decision making.
Description of Supporting Evidence: Over 90 clinical publications will be grouped and the resulting trends summarized. These references include 17 reliability studies, 50 clinical studies including a variety of observational, case series, prognostic studies, and diagnostic validation studies, and 29 randomized controlled trials pertaining to directional preference and centralization. Participants will be given an email link for the references summarized. Strengths and limitations will be discussed.
Description: This session will be a lecture format, followed by a general question and answer session and brainstorming regarding barriers to translation of this body of evidence into clinical practice.
Conclusions: Centralization and Direction Preference are well documented in the literature and represent the largest and most validated subgroup. This summary of this fast growing body of evidence will help clinicians gain insight into method that can improve traditional care pathways for low back pain and/or sciatica, and promote our profession as primary care providers During this experiential 'sleep-shop' exercises will be interspersed with lectures regarding the theory, research and physiology of sleep, sleep disturbance and client pain experience.

P025 -SOUNDER SLEEP TO UNRAVEL THE INSOMNIA-PAIN CYCLE
Relevance to Physiotherapy Profession: Physical Therapists are 'drug-free-practitioners developing and directing therapeutic exercise, and advocating health programs to treat, reverse and / or prevent pain and dysfunction for our clients. Since the pharmaceutical revolution of the 1940's, many conditions that might have been treated by physical therapists have been eclipsed by drug intervention (Field, 1998). Research clearly indicates the negative effect of disturbed sleep in decreasing pain threshold (Calli-Schmidt 2003;Edmounds, 2009;Hakki Onnen 2001;Older 1998). In addition to pain, many of our patients are dealing with traumarelated stress following motor vehicle accidents. Moreover, other research demonstrates linkages between sleep, healing and other health issues such as obesity, diabetes, memory loss, and psychological disturbances (Barclay L 2010;Mednick S 2006). This workshop specifically addresses improving sleep quality as a stress-reducer and a pain management tool.
Target Population: PT's working with chronic pain populations.

Description of Supporting Evidence:
The benefits of sleep go far beyond pain control. Sleep is sufficiently vital to health that in the natural world some animals actually fly or swim with one half of their brain awake while sleeping with the other half (Rattenborg NC et al 2000) and sleep deprivation is a common form of torture (West LJ et al 2006).
Various sources indicate a prevalence of sleep disturbances in the general population of 25-30 % regularly to up to 70% occasionally. There is evidence that pain and sleep disturbances have a 'bidirectional relationship' with up to 88% of patients with chronic pain also demonstrating sleep disturbances. Decreased sleep has a hyperalgesic effect and significantly decreases pain thresholds (Webster LR et al 2008). Furthermore problems with sleep are a significant predictor of low back pain in industrial workers. (Miranda H et al 2008) Selye's work on the General Adaptation (Stress) Syndrome tells us that stress, the body's response to stressors, is cumulative if not somehow relieved. Research on 'whiplash victims' shows stress, pain and insomnia to be correlated factors in maintaining disability (Selye 1974;Scaer 2001). The exercises as instructed in this workshop are intended to interrupt this stress accumulation model.

Description:
There are two inter-locking parts to this session. First, it is intended to be significantly experiential providing stressreduction benefit to the participants. Secondly, the experience / instructions in the neurosomatic focusing exercises are intended to help overcome the 'cognitive popcorn' that keeps us awake. Therefore, exercises will be integrated with lecture material to incorporate a review of sleep theory, sleep research, and physiology. This approach to pain management allows participants to use these techniques with their own clients. There will be a question period and discussion at the end.

Conclusions:
Aside from the cost of pain syndromes in human suffering, the economic burden of chronic pain in Canada, including medical expenses, lost income, and lost productivity, is estimated to exceed $12.5 billion annually (Warriner B et al 2007). Moreover, sleep and pain medications often carry with them unintended adverse effects.
The value of offering clients improved self-control of pain while possibly also effecting concurrent reduction in potentially dangerous drug side-effects seems self-evident, as is the potential reduction in treatment costs to the individual and to society.

Summary of Supporting Evidence:
It is becoming clear that whiplash is a heterogeneous condition with sub-groups of patients able to be identified based on varying physical and psychological presentations (Sterling and Kenardy, 2008). Whilst the presence of motor dysfunction occurs almost universally in all those with neck pain (Jull et al., 2004;Sterling et al., 2003b), sensory disturbances and psychological factors differentiate those with higher levels of pain and disability (Sterling et al., 2010;Sterling et al., 2003a). These whiplash injured people have a more complex presentation involving widespread sensory mechanical and thermal hyperalgesia, occurring both local and remote to the site of injury, and symptoms of posttraumatic stress. Both these factors are strong predictors of poor functional recovery following whiplash injury (Sterling et al., 2006;Sterling et al., 2005). Sensory hypersensitivity has been shown to occur independently of psychological distress and likely reflects biological phenomena involving augmented central pain processing (Sterling et al., 2008). Further investigation of these phenomena has shown that chronic WAD participants with sensory hypersensitivity also demonstrate hypoaesthesia to vibration, thermal and electrical stimuli suggesting a minor peripheral nerve injury as a possible contributor to whiplash pain (Chien et al., 2010). Furthermore the presence of some of these factors (particularly mechanical and cold allodynia) in patients with a chronic whiplash condition mitigated the successful effects of multimodal physical treatment shown in patients without these features (Jull et al., 2007). Musculoskeletal clinicians play an important role in the early assessment and management of the whiplash injured. As such the early assessment and identification of features associated with both poor and good recovery is necessary for both targeted intervention strategies and/or appropriate referral. Most of these factors have been identified in a laboratory centre and it is essential that the findings are translated into clinical practice. Research has commenced on the development of time-efficient tools for use in clinical practice and these will be discussed and demonstrated. The quest for prevention of the transition to chronicity remains with improved early diagnosis and classification. Background: This evidence-based symposium will be delivered by Dr. Carolyn Emery and Dr. Karim Khan. This lecture will provide an interdisciplinary approach to injury prevention in sport which should be a key consideration for all physiotherapists in clinical practice who work with children or adults who are sport participants or elite athletes. This presentation will provide original data and evidence from the literature related to risk factor identification and prevention strategies for acute and chronic sport injury across the lifespan.

Description of Session
Injury prevention in sport is a key element in the delivery of care by physiotherapists working with sport participants or athletes across the lifespan in the community. Physiotherapists are becoming more active in maximizing the prevention of injuries in sport through primary, secondary and tertiary prevention approaches. Evidence related to the identification of high risk participants in sport and prevention strategies to reduce the risk of injuries will be presented.
Target Audience: This session will not require prior exposure to evidence related to injury prevention in sport. The presenters will address the topic of injury prevention in sport with interdisciplinary evidence across basic science, clinical and population health perspectives.

Summary of Supporting Evidence:
The cost of injury care to the health care system and society is enormous. For example, it is estimated that unintentional injuries cost Canadians approximately 8.7 billion dollars per year with injuries to children accounting for approximately half that total. Further, unintentional injuries result in more potential life years lost before age 70 than any other single health problem in Canada. In fact, sport and recreation is the leading cause of injury in youth. Cross-sectional survey data in Alberta estimates the rate of adolescent sport injury requiring medical attention to be 38 injuries/ 100 adolescents/ year. These injuries significantly lower the quality of life of Canadians. While physical activity prevents all-cause morbidity and mortality associated with a sedentary lifestyle, injuries can become a barrier to active living. Reduction of sport and recreation-related injury would improve quality of life through the maintenance and promotion of active living and the prevention of osteoarthritis. This is a critical issue in health care and in the promotion of health and wellness in our communities. There is a rapidly growing societal need to address sport & recreation injury and its future health impact in young age groups during the time they are most active (and when the benefit of injury prevention strategies may be the greatest). Evidence from systematic reviews, cohort studies and RCTs will be provided to support this session.
Description of Session Format: Lecture/ dialogue between two presenters.
Session Objectives: Upon completion of this session, participants will understand a recursive model which allows the physiotherapist to appropriately consider target risk factors and injury prevention approaches to minimize the risk of injury in sport and recreation; be able to provide evidence-based examples of risk factors and injury prevention approaches appropriate for recreational sport participants and elite athletes; be exposed to evidence supporting prevention strategies for both acute onset and chronic injury and be motivated to incorporate primary and secondary prevention approaches into their clinical practices in order to maximize participation in sport and recreation at all levels.

D004 -FIT TO PLAY -CONNECTING YOUR CORE: SMART TRAINING FOR SWINGING SPORTS
Petersen C. City Sports and Physiotherapy Clinics, Vancouver. Correspondence: Suzanne Gorman,1411A Carling Ave., Suite #416, Ottawa, ON K1Z 1A7; info@sportphysio.ca Background: This session will provide a general functional definition of core stability, describe the relevant anatomy and discuss current practices in multi-core (upper and lower) stability training and it's role in the kinetic chain in swinging sports. It will review the research surrounding the functional core and it's importance in maintaining proper alignment and control of the lumbo-pelvic and scapulothoracic regions during swinging sports. Many commonly prescribed exercises by physiotherapists are machine based and involve or isolate a single joint and only allow movement in one plane of motion without full kinetic chain involvement. Participants will be educated on connecting the core with both multidirectional upper and lower core stability training thus providing smart strategies that can be taught to clients involved in swinging sports.
Relevance to Physiotherapy Practice: Clinicians in sports and orthopaedic settings will very likely encounter patients who participate in swinging sports. Injuries to the lumbo-pelvic (lower core) and scapula-thoracic (upper core) are common in sports like golf, racquet sports and field sports.
The changing nature and demands of sports as well as participation by ever younger athletes may also be changing the nature of these injuries. Functional data suggests that elite adolescents possess poor proprioception, strength and agility in key spine stabilizers, including multifidus, iliopsoas and transversus abdominus (Alyas et al, 2007). Non-elite clients engaging in similar swinging activities may also have the same concerns. Recent research has demonstrated that lower extremity position influences scapular muscle recruitment and muscle balance ratios in closed kinetic chain exercises (Maenhout et al, 2009) As well, trunk and lower extremity position and movement influence scapular muscle recruitment and muscle balance ratios in open kinetic chain exercises (De Mey et al, 2010).
The challenge for busy clinicians, and thus the goal of this session, is how to effectively prescribe exercises that ensure optimal recruitment, balance, timing, deceleration control and mimic performance demands of swinging sports.
Target Audience: Physiotherapists who treat patients that participate in swinging and throwing sports or are themselves sport participants.

Summary of Supporting Evidence:
The anatomical and functional core has been studied at length and has been described in literature. Physiotherapists, physicians, coaches and fitness trainers are all well aware of the importance of upper and lower core stability training to a player's overall development, performance and injury prevention (Petersen, 2009). Very few competitive players in swinging sports make it through an entire season without experiencing some form of lumbar, hip, knee, thoracic or shoulder pain associated with kinetic chain weakness and/or malalignment issues (Petersen & Nittinger, 2010). Movements in swinging sports include quick acceleration and deceleration, planting and cutting, lateral movements, twisting and sliding. These quick movements pass through many planes of motion and create rotational and torsional forces on numerous joints and muscles at the same time. If core stability is inadequate this can lead to malaligment concerns and alterations in length tension relationships of muscles. This malalignment can be exacerbated by the unilateral (one sided) nature of tennis strokes since in the modern game seventy five percent of the strokes are forehand or service motion placing abnormal rotational and deceleration stresses on the dominant side (Petersen & Nittinger, 2010).
Abnormal alignment and associated biomechanical changes can contribute to injury in players due to imbalances of muscle length and strength. The subsequent increased tissue tension can cause overuse and tissue breakdown. This malalignment puts athletes at increased risk of injury, and once injured they are likely to take longer to recover, or may even fail to do so (Schamberger, 2002). Weaknesses and imbalances of the core have been related to low back pain (Akuthoto & Nadler, 2004) and lower extremity injuries (Ireland et al, 2003).
The core muscles attach in groups forming functional slings from the hips through the lumbo-pelvic (lower core) to the scapulathoracic (upper core) regions. Four slings of muscle systems have been described in the literature. (Vleeming et al, 1995a) (Snijders et al, 1993 These are the posterior oblique sling, the anterior oblique sling, the longitudinal sling and the lateral sling. These slings of muscles help transfer energy from the legs through the core (trunk) to the upper body and arms. This is especially important in swinging sports that involve rotation and deceleration.
The core musculature includes muscles of the trunk and pelvis that are responsible for the maintenance of stability of the spine and pelvis and help in generation and transfer of energy from the large to small body parts during many sports activities (Baechle et al, 2000) (Putnam, 2003. In tennis players, the abdominal musculature plays a significant role in trunk and core stability providing a mechanical link between the lower and upper limbs (Maquirrian et al, 2007).
It is estimated that fifty percent of the force generated in a tennis service motion starts at the ground and must be transmitted through the lower to upper core and funneled through the scapula to provide power and speed (Kibler et al, 2006). Similar demands can be hypothesized for other swinging sports. This makes it important to develop a good set of connecting your core exercises to ensure these forces are transmitted efficiently.

Description of Session Format:
This session will combine lecture and practical/demonstrations. It will highlight a series of innovative functional multi-core stability exercises that connect your core in a sequence of exercises using a variety of equipment commonly found in the clinical environment. This is a comprehensive lecture and demonstration session that provides therapists, coaches and trainers with exercise tools they can use immediately in the clinical or training venue.
Session Objectives: Upon completion of this session, participants will have an increased understanding of the importance of multicore stability in working with clients involved in swinging sports. They will be better able to prescribe exercise progressions that work the muscle slings in variety of different bridging positions. As well they will be able to confidently prescribe a variety of different functional squatting, split squat, lunge and step up combinations that can connect the upper and lower core and can be carried out in a clinical setting. Participants will leave with a better understanding of multi-core stability and a repertoire of exercises appropriate for multiple sports that can be used by athletes of all ages and can be implemented immediately.

D005 -CAUSE AND PREVENTION OF FALLS AND FALL-RELATED INJURIES ACROSS THE LIFESPAN
Robinovitch SN. Department of Biomedical Physiology and Kinesiology, and School of Engineering Science Simon Fraser University. Correspondence: Susan Muir, 161 Thornton Ave., London,ON N5Y 2Y7;susanw.muir@sjhc.london.on.ca Background: This talk will focus on the epidemiology and biomechanics of falls and fall-related injuries across the lifespan. Comparisons will be made between the causes and consequences of falls in children, young adults, and older adults. This will lead to a discussion of approaches for assessing risk and strategies for preventing falls and their related injuries in these different populations. A review will be provided of "balance recovery" for preventing falls in the event of imbalance, and "safe landing responses" for avoiding injury in the event of a fall, and how these change with age. An emphasis on the changes for older adults will be made and how these changes influence the severity and type of injuries that lead to profound morbidity and mortality in this population. Adults 65 years of age and older are the fastest growing segment of the Canadian population and falls in older adults are a significant public health issue. It is important that the unique health care needs of older adults are met to optimize health, physical function, quality of life and independent living. The speaker will draw upon examples from laboratory experiments and an ongoing project involving video capture of real-life falls for older adults in long-term care.
Relevance to Physiotherapy Practice: Falls are the number one cause of unintentional injury, and have especially devastating consequences for older adults. Approximately 90% of hip fractures, 60% of head injuries, and 40% of vertebral fractures in this population are due to falls. This talk will focus on new and established approaches for assessing risk for falls, and preventing injuries in the event of a fall. Specific distinction will be drawn between the ability to maintain balance, the ability to recover balance (e.g., by stepping or grasping), and the ability to safely arrest a fall (e.g., with the upper extremity). Many key risk factors for falling; strength, balance, and gait are within the clinical domain of physiotherapy. There are effective treatments available to prevent falls or aid an older adult's return to their optimal function after a fall. Physical therapists can help with both of these approaches. Working with a physical therapist will allow older adults to stay active and remain living independently in the community. The risk of falling in older adults can be reduced when specific exercises, activities and interventions are prescribed by a physical therapist. Up to date information on fall prevention and the understanding of underlying mechanisms of falls in older adults will have direct benefit on clinical care that physiotherapists provide to clients.
Target Audience: This talk should be appropriate to care providers and clinician scientists having a wide range of background knowledge and experience. Some familiarity with biomechanical concepts, and the literature of falls and fractures, will be useful but is not essential.

Summary of Supporting Evidence:
Peer-reviewed published results will be reviewed from (a) prospective studies examining risk factors for falls and fall-related injuries (e.g, Study of Osteoporotic Fractures); (b) laboratory studies on age-related changes in balance maintenance and recovery, and safe landing responses; and (c) field studies involving video capture of real-life falls.

Description of Session Format:
This session will involve a lecture of approximately 40 minutes duration, followed by a 20 minute interactive question and answer period with the audience.

Session Objectives:
1. improved understanding of the cause and circumstances of falls in older adults residing in long-term care; 2. improved understanding of the role of sensorimotor, musculoskeletal, and cognitive variables in the cause of falls and fallrelated injuries; 3. improved understanding of the strategies that humans rely upon to avoid injury in the event of a fall, and how these are affected by age. Background: This talk will focus on the assessment and prevention of hip fractures among older adults. The frequency of fallrelated injury is nine times higher among older adults than amongst any other age group. Over half of all older adults who fall will experience an injury, of which 5-10% will sustain a major injury such as a fracture. Research evidence on the magnitude and scope of the morbidity and mortality sequelae of a fall in this group is sobering and clearly shows the public health importance of the problem. Falls have important public health implications as they are a major cause of disability and death in older adults. Hip fractures are the second leading cause of hospitalization in people over the age of 65 years and ninety percent of hip fractures are due to falls. This talk will address three topic areas i) epidemiology, risk factors and rehabilitation strategies to prevent fall-related injuries, ii) hip protectors and flooring materials to prevent injuries and iii) implementation and treatment compliance of rehabilitation interventions.

D006 -ASSESSMENT AND PREVENTION OF HIP FRACTURES IN OLDER ADULTS: A ROUND-
Relevance to Physiotherapy Practice: Falls are the number one cause of unintentional injury, and have especially devastating consequences for older adults. This talk will focus on new and established approaches for assessing risk for falls, and preventing injuries in the event of a fall. Many key risk factors for falling; strength, balance, and gait are within the clinical domain of physiotherapy. There are effective treatments available to prevent falls or aid an older adult's return to their optimal function after a fall. Physical therapists can help with both of these approaches. Working with a physical therapist will allow older adults to stay active and remain living independently in the community. The risk of falling in older adults can be reduced when specific exercises, activities and interventions are prescribed by a physical therapist. Up to date information on fall prevention, the understanding of risk factors for falls and the successful implementation of rehabilitation treatment in older adults will have direct benefit on clinical care that physiotherapists provide to clients.
Target Audience: This talk should be appropriate to care providers and clinician scientists having a wide range of background knowledge and experience. Some familiarity with the literature and clinical treatment of falls and fractures in older adults will be useful but is not essential.
Peer-reviewed published results will be reviewed from (a) prospective studies examining risk factors for falls and fall-related injuries (e.g, Study of Osteoporotic Fractures); (b) laboratory studies on the use of protective equipment and materials to prevent fall-related injuries (hip protectors and flooring materials); and (c) evidence-based review of intervention strategies to prevent falls and improve compliance among clients.

Description of Session Format:
This session will be a round table discussion involving three speakers who will each give a 10-15 minute presentation. This will be followed by a 15 minute interactive question and answer period with the audience.

Session Objectives:
1. Improved understanding of the cause and circumstances of hip fractures in older adults; 2. Improved understanding of the role of hip protectors and flooring to prevent injuries; 3. Improved understanding of the strategies that physiotherapists can use to improve compliance with treatment interventions. Controversy surrounds the hypothesis of CCSVI as a causative factor in MS, the prevalence of CCSVI in MS, and the benefits of endovascular procedures used to treat CCSVI. There is currently limited information about the short and long term safety of the procedures being used. There is also limited evidence, and none from randomized controlled trials, of effectiveness of these procedures. The evidence currently available suggests better outcomes in those who have been recently diagnosed, those with relapsing/remitting MS, and those with mild or moderate disease presentation.

D007 -PHYSICAL THERAPY FOLLOWING ENDOVASCULAR INTERVENTIONS FOR MULTIPLE SCLEROSIS
Despite safety concerns and limited evidence of effectiveness, endovascular procedures for CCSVI are being offered in a number of centers throughout the world and are being accessed by hundreds, possibly thousands, of Canadians with MS. Following intervention, some form of anti-coagulant therapy is prescribed. In addition, intensive physical therapy intervention is suggested, but written exercise guidelines and precautions are not provided.
In this session, evidence supporting the benefits of exercise interventions in MS, as well as currently recommended exercise guidelines and precautions will be reviewed. The applicability of these guidelines to individuals who have undergone endovascular procedures will be discussed within the neurorehabilitation contexts of restoration, maintenance and prevention. Additional precautions that may be needed for this particular population, as well as methods of monitoring for potential adverse events following endovascular procedures will be suggested. Selected outcome measures considered useful in evaluating the effects of endovascular procedures and the physical therapy interventions that follow will be discussed. The value of collecting qualitative data to augment quantitative data will be illustrated.
Relevance to Physiotherapy Practice: Physical therapists possess knowledge and skills that will be of particular value to individuals with MS who have undergone endovascular procedures. Some who seek our services may be doing so for the first time. This will allow us the opportunity to promote regular exercise as one effective tool in the ongoing management of this chronic neurological condition. The development of optimal physical therapy assessment and treatment methods to be used in conjunction with endovascular procedures will take time to determine. This education session presents suggestions for the both assessment and treatment based upon recent clinical experience and currently available evidence.
Although the Expanded Disability Status Scale (EDSS) is commonly used to rate clinical status and disease progression in MS, it is inadequate for evaluating the effects of either endovascular procedures or the physical therapy interventions that follow. The usefulness of four balance measures and two gait measures will be contrasted in the case studies presented. Critical appraisal of possible outcome measures will be useful to physical therapists involved in both clinical practice and future research.
In this session, it will be proposed that interventions following endovascular procedures should initially be impairment and task oriented, focusing upon optimizing any gains in neurological function (e.g., muscle strength) and using these gains in the practice of balance and mobility tasks. A fitness orientation, in the form of aerobic exercise training should be added once compliance with the initial program is established.
Target Audience: A basic understanding of the clinical presentation of MS, as would be taught in a Masters PT program, is needed for participants to benefit optimally from the session. Basic knowledge of exercise prescription is also needed.

Summary of Supporting Evidence:
The current body of evidence supporting exercise interventions for MS used in this presentation will include a meta analysis, a Cochrane review, randomized controlled trials, as well as non randomized and non controlled trials. It should be noted that the available evidence is almost exclusively derived from the study of individuals with mild to moderate disease severity.
The effects of aerobic exercise training have been studied more extensively than the effects of resistance (i.e., strength) training. The reported benefits of low to moderate intensity aerobic training include: a small but clinically significant improvement in quality of life (meta analysis), improvements in peak and maximal oxygen consumption, and improvements in mood. The reported effects of aerobic exercise training upon both lower extremity muscle strength and activity limitations suggest limited or no benefit.
The methodological quality of most studies investigating the benefits of resistance training is low. Benefits reported include consistent findings of improvements in muscle strength, mixed findings of improvements in activity limitations, and findings from single studies of improvements in fatigue and psychological well being.
As physical therapy management following endovascular surgery is an emerging area of practice, the body of evidence briefly summarized above combined with recent clinical experience (case studies) will be used as foundations to propose methods for physical therapy management before and following endovascular procedures.

Description of Session Format:
The session will include approximately 45 minutes of lecture and 15 minutes of discussion. It is hoped that attendees will share their experiences and their ideas for managing this emerging area of practice.
Session Objectives: Upon completion of this session, participants will be able to: • Identify 'red flags' for adverse events that may occur as a result of endovascular procedures performed on individuals with MS.

•
Critically appraise outcome measures as to usefulness in evaluating the effects of endovascular procedures and the physical therapy interventions that follow.

•
Include qualitative data collection methods in the evaluation of effects of endovascular procedures and the physical therapy interventions that follow.

•
Modify current MS exercise prescription guidelines and precautions for use with individuals who have undergone endovascular procedures.

D008 -VESTIBULODYNIA: UP-DATE ON ETIOLOGY, ASSESSMENT AND TREATMENT
Gentilcore-Saulnier E. Queen's University, School of Rehabiliation Therapy, Kingston, ON. Correspondence: Evelyne Gentilcore-Saulnier,5-1425 Onésime-Voyer, Cap-Rouge, QC G1Y 3M1; evelyne.g.saulnier@gmail.com Background: Vestibulodynia is a common subtype of vulvodynia (i.e., chronic vulvar pain). The pain of PVD is described as a sharp, burning pain at the entrance of the vagina in response to pressure to the vaginal entrance (Bergeron et al, 2001a). Vestibulodynia affects 12% of pre-menopausal women in the general population (Harlow, Wise, & Stewart, 2001) and has significant negative impacts on sexual functioning, relationship adjustment, psychological well-being, and overall quality of life (Arnold et al, 2006). Currently, PVD is conceptualized from a multidimensional viewpoint in which biological, psychological, and social factors are seen as fundamental to understanding the causes, effects, and treatment (Weijmar et al, 2006), and management should be based on the most recent international guidelines (vanLankveld et al, 2010).
Gentilcore-Saulnier et al's study (2010), using electromyography, demonstrated that although women with PVD exhibited significantly more superficial PFM hypertonicity and over-reactivity to pain than non-affected women, there were less consistent findings at deeper layers -there was a lack of generalized pelvic floor over-reactivity and hypertonicity. The authors posit that the tension begins as a protective guarding response to the pain and over time this response results in the resting tone observed. In addition, Goldfinger et al (2009) showed that these heightened responses were no longer observed after women had undergone a standardized physiotherapy protocol. The authors also evaluated predictors of treatment success as well as the impact of physiotherapy on psychosexual variables in women with vestibulodynia. Similarly recent research by Thibault-Gagnon & McLean (2010), using ultrasound imaging, found shortened pelvic floor muscles in women with vestibulodynia.
Typical physiotherapy interventions include education about the role of the pelvic floor muscles, biofeedback, electrical stimulation, manual techniques, and insertion techniques (e.g., use of vaginal dilators). To date, there has been one prospective or controlled studies conducted on the effectiveness of a comprehensive physiotherapy intervention on women with vestibulodynia in treating the physiological, psychological, and sexual problems (Goldfinger et al, 2009). Their evaluation of improvement of myriad outcome variables (i.e., physical, psychophysical, psychosocial) gives support to the conceptualization of vestibulodynia from a multidimentional viewpoint and highlights the interplay between physical and mental health and led to recommendations of best practice in the field of physiotherapy.
on patient adherence to treatment. The role of the patient experience in adherence cannot be underestimated. Effective providerpatient communication and accessible environments have been shown to improve the patient experience, increase patient satisfaction and adherence (Potter et al, 2003). Due to the multifactorial nature of non-adherence, successful physiotherapists need to be comfortable and confident in discussing any issues that patients may raise. Additional training in communication skills, behavior modification, and the identification of organizational factors which act as barriers to adherence has been identified by physiotherapists as essential in developing better strategies to overcome non-adherence (Potter et al, 2003).
Relevance to Physiotherapy Practice: The cost of non-adherence to treatment of persons with chronic disease is astounding. Funding models continue to be powerful determinants of the frequency and duration of physiotherapy care and are highly influenced by achievement of outcome. With the risk of physiotherapy being deemed ineffective as a consequence of non-adherence, physiotherapists need to develop strategies to improve adherence as a component of effective physiotherapy.
Target Audience: This session will be of interest to a broad range of physiotherapy professionals including clinic owners, managers, professional leaders, clinicians, educators and students who are interested in improving patient adherence.

Summary of Supporting Evidence:
The importance of physiotherapists adopting patient-centered approaches and developing effective communication skills to optimize the physiotherapist interaction is well supported in the literature. Patient most often attribute good experiences to effective communication ability, followed by high quality service provided by the physiotherapists (Liddle, Baxter & Gracey, 2007;Potter et al, 2003). Important communication attributes of a physiotherapist from the patients' perspective relate to the physiotherapists' interpersonal skills, manner and teaching ability (Potter et al, 2003). In addition, physiotherapists are also expected to be organized and demonstrate appropriate professional behavior while providing services in a welcoming and easily accessible environment (Potter et al, 2003).
Interventions that combine cognitive behavioral approaches with the management of practical and organizational patient barriers have been suggested in the literature (Burton, Bradley and Littlewood, 2010;Jack et al, 2009) however have yet to be studied. Moderate evidence exists supporting motivational cognitive behavioral programs are effective in improving short-term adherence to treatment and attendance to clinical sessions (Burton, Bradley and Littlewood, 2010). Treatment goal setting is the most commonly used cognitive-behavioral technique in rehabilitation and has been reported to be positively associated with adherence (Scherzer et al, 2001). However, goal setting, particularly where patients' views are elicited and incorporated, involves significantly evolved communication skills (Parry, 2008) Communication has been described as the most important aspect of practice that health professionals have to master and an essential requirement underpinning any successful encounter. Communication training interventions aimed at improving clinical communication performance have been well studied in medicine and in nursing but not in physiotherapy. Positive effects include changes in attitude, behaviors, quality of care and patient satisfaction (Schultz, Wellard & Swerissen, 2008). However, evidence indicates that for training to be effective, learners need to be ready and motivated for change and training (Schultz, Wellard & Swerissen, 2008, 2008.

Description of Session Format:
This session will be delivered in lecture format with time set aside for participants to practice various strategies to improve patient adherence through role play. During the discussion period, the speakers will encourage participants to share their challenges and successes in improving patient adherence to treatment.
Session Objectives: 1) To discuss how clinical outcomes are related to patient adherence to the recommended treatment plan.
2) To provide communication strategies, systems, and processes for clinicians and support staff to be able to influence patient adherence. 3) To discuss training platforms for staff that can be implemented by management to create consistency in the patient experience regarding these strategies.

D012 -SOCIAL MEDIA GONE WRONG
Correspondence: Donna Larocque, 101B 17 Athabasca Ave., Devon, AB T9G 1G5; devonpt@telus.net Background: Social network sites are a web-based service that allow individuals to 1) construct a public or semi-public profile within a bounded system; 2) articulate a list of other users within whom they share a connection, and 3) view and traverse their list of connections and those made by others within the system (Boyd & Ellison, 2008). They are a widely used networking tool and are fast becoming an indispensable business commodity. However, the rules and boundaries around social, personal and business information shared on these sites are not well defined or understood. The lack of understanding of the personal responsibility surrounding the utilization of these sites and the negative consequences that can result from inappropriate network content have raised significant concerns in many health care groups about the appropriate use of such tools by professionals.

Relevance to Physiotherapy Practice:
The healthcare sector is not immune to the societal trends and fads that impact other fields; they also influence healthcare and subsequently physiotherapy. As physiotherapists in both the public and private sectors learn to utilize social media to promote their business, provide patient education and promote healthy living activities, a need also exists to increase the awareness of the risks associated with utilizing social media and network sites.
Target Audience: Public and private physiotherapy business managers, employees/contractors, physiotherapist, physiotherapists' assistants and students who use social network sites.

Summary of Supporting Evidence:
The use of Internet social networking sites has exploded in popularity as a means for individuals to post information about themselves and communicate with others. By late 2009, the most popular network site, Facebook, reported 200 million active users world-wide (Nelson, Simek & Foltin, 2009). Its popularity has been fuelled by the perception that it is somewhat of a private forum with access limited only to those enrolled. Users of the site have therefore felt relatively free to post personal information about themselves and their social network. Evidence suggests that social network users are, by in large, quite oblivious and unconcerned about their personal privacy with the scope of network users exposing themselves to various physical, cyber and security risks, and make it extremely easy for third parties to create digital dossiers of their behaviours (Gross & Acquisti, 2005). Studies have reported that 20% of users indicate that they had content on their social networking page that they would not want current or prospective employers to see suggesting that users of social network sites are somewhat naive about the potential negative consequences concerning the access and use of the information on these websites (Peluchette & Karl, 2007). Seventy -five percent of employers are reportedly becoming increasingly aware of these sites and are taking advantage of the massive amount of newly available information to assist them in their hiring and dismissal decisions (Byrnside, 2008). In addition to utilizing these sites for background checks, many businesses have also embraced the use of social networking as a way of doing business, creating new avenues to exchange information, recruit, market goods and services and collaborate. Many sites require the creation of a personal profile and the upload of business data. Information posted on these sites can lead to organizational security risks such as exposure of corporate data to the public or workplace exposure of individuals' private information (Williams et al, 2007). Finally, cyberbullying, initially reported in children and adolescent social networking, is quickly proliferating to the workplace. In a recent survey, 11% of respondents reported cyberbullying in the workplace (Priviter and Campbell, 2009).
Although the appropriateness of information on social networks and its use by various parties has been questioned, it poses unique challenges and it is not clear how legislation applies. The development of social media use workplace policies are therefore essential in setting workplace expectations with regards to use of social networks both on and off the job.

Description of Session Format:
Lecture with role playing scenarios and audience participation.
Session Objectives: This workshop will explore the significant risk factors for employer and employee/contractors using social media both from the business and personal perspective.
On completion of the session all participants will 1. Recognize their professional responsibility when engaging with social media websites 2. Understand what needs to be considered when utilizing this business tool 3. Consider some of the potential legal, legislative and cultural implications of social media. All participants will be more aware of the impact that social networking can have on the workplace relationships and be more prepared to develop appropriate workplace policies about social media and its use. Background: Patients presenting with whiplash-associated disorders are a common entity in musculoskeletal clinical practice. Such presentations can be very complex in nature and require accurate diagnosis and a comprehensive bio-psycho-social approach to management. In recent years the evidence for the physical and psychological manifestations of WAD has significantly increased. These include sensory disturbances indicative of augmented central nociceptive processing, motor and sensori-motor changes. In the psychological domain, posttraumatic stress symptoms play an important role. It is important that physiotherapists can assess, interpret assessment findings and integrate these to the most optimal management approaches for WAD.

D013 -WHIPLASH: 'MINOR' INJURY BUT COMPLEX CONDITION
It is clear that current treatment strategies are not successful in reducing the transition to chronicity following injury. Why is this case? The aim of this presentation is to equip physiotherapists with a new understanding of the whiplash condition that includes all aspects of this condition. Participants will learn how to integrate this knowledge into more targeted treatment approaches that go beyond the standard motor control approaches to this condition.
Relevance to Physiotherapy Practice: Whiplash is a recalcitrant condition to standard physiotherapy approaches to treatment. It is important that physiotherapists can recognize those patients at risk of poor recovery and/or at risk of non-responsiveness to treatment. The research evidence also suggests that some patients, especially those with poor outcomes demonstrate a complex clinical picture that will likely require an integrated approach to management from several providers. The physiotherapist, by virtue of our assessment skills, will play a unique and important role in the integration of patient care.
This presentation will provide physiotherapists with an introduction to the skills required to assess the patient with whiplash, taking into account all aspects of the condition both physical and psychological. This lays the foundation for enhanced management and improved patient outcomes.
Target Audience: This presentation is aimed at graduate physiotherapists who are involved in the management of patients with WAD.

Summary of Supporting Evidence:
It is becoming clear that whiplash is a heterogeneous condition with sub-groups of patients able to be identified based on varying physical and psychological presentations (Sterling and Kenardy, 2008). Whilst the presence of motor dysfunction occurs almost universally in all those with neck pain (Jull et al., 2004;Sterling et al., 2003b), sensory disturbances and psychological factors differentiate those with higher levels of pain and disability (Sterling et al., 2010;Sterling et al., 2003a). These whiplash injured people have a more complex presentation involving widespread sensory mechanical and thermal hyperalgesia, occurring both local and remote to the site of injury, and symptoms of posttraumatic stress. Both these factors are strong predictors of poor functional recovery following whiplash injury (Sterling et al., 2006;Sterling et al., 2005). Sensory hypersensitivity has been shown to occur independently of psychological distress and likely reflects biological phenomena involving augmented central pain processing (Sterling et al., 2008). Further investigation of these phenomena has shown that chronic WAD participants with sensory hypersensitivity also demonstrate hypoaesthesia to vibration, thermal and electrical stimuli suggesting a minor peripheral nerve injury as a possible contributor to whiplash pain (Chien et al., 2010). Furthermore the presence of some of Physiotherapists are also required to provide appropriate differential diagnosis in patients with complex conditions. Patients with persistent headache can present with such a multifaceted scenario. Differential diagnosis and identification of headaches that are amenable to physiotherapy management versus those that may require further medical evaluation are essential steps in the effective management of this condition.
Physiotherapists are also expected to maintain an effective treatment role. Exercise prescription is a mainstay of a physiotherapists practice for many musculoskeletal problems. The evidence is overwhelming in support of exercise as part of a multimodal management physiotherapeutic intervention. Physiotherapists are especially trained in exercise prescription and utilize this as a significant part of their patient-centered intervention.
Relevance to Physiotherapy Practice: As primary care providers, physiotherapists are at the forefront in managing patients with various musculoskeletal problems including spinal disorders and headaches. In many circumstances, one of the key factors related to positive treatment outcomes is an accurate diagnosis. Complex and functionally disabling clinical problems such as headaches and back pain require a diagnosis based on scientific evidence and international guidelines. Management of such disorders may require physiotherapy intervention and/or they may require medical treatment, rendering accurate diagnosis essential. Advanced physiotherapy practitioners are often faced with clinical scenarios where the patient may require conservative care or surgical management. Sound decisions are necessary for optimal management of such patients. Arguably, both relative simple and complex clinical problems will benefit from interventions related to exercise where physiotherapists are at the forefront of providing patientspecific, evidence-based exercise prescription.
Target Audience: This workshop will be of interest to a broad range of physiotherapists including students, clinicians, managers, professional leaders, educators, and researchers interested in maximizing patient outcomes in rehabilitation settings.

Summary of Supporting Evidence:
There have been numerous studies published in the past decade supporting the appropriateness, effectiveness, and patient satisfaction related to primary care initiatives involving physiotherapists. Importantly, patient safety has been maintained. As part of the primary care initiatives, the appropriateness and use of diagnostic imaging in physiotherapists practice has been described.
The effective management of cervicogenic headache has been reported in randomized clinical trials and includes manual therapy and exercise intervention. International guidelines have been published outlining the clinical criteria for the diagnosis of various types of headache. Based on the type of intervention required, accurate classification of the type of headache is necessary.
There have been many systematic reviews and randomized clinical trials published evaluating the effectiveness of exercise intervention for various musculoskeletal disorders. Transparent research methodology enables clinicians to transcribe the parameters related to the exercise intervention directly into their clinical practice. Application of exercise principles can be provided by clinicians of all levels of expertise making this type of intervention attractive for use in clinical practice.

Description of Session Format:
Setting the stage -Description of symposium Background: The neurophysiological basis for placebo effects has been established in many different physiotherapy treatment interventions. A growing body of evidence related to the role of patients' expectations and anticipation in enhancing or reducing the pain experience has led experts in the field to reconsider the effect of the placebo response including the influence of the different aspects of human experience on the magnitude of placebo analgesic response. Exploitation of the placebo mechanism for the benefit of the patient has been a topic of much controversy. As evidence-based practitioners, physiotherapists need to understand this placebo mechanism, its role in their treatment interventions and how it is elicited during various therapeutic interactions. A lack of understanding in the relationship between acupuncture and placebo has been identified as a barrier to advancing research in this field. The purpose of the session is to provide a review of the current literature on placebo effects with an emphasis on the literature surrounding acupuncture achieved analgesia.
Relevance to Physiotherapy Practice: As physiotherapists, we should understand the placebo effects linked to our interventions and take advantage of this response in achieving analgesia for our patients. In addition, this knowledge is also key in carefully avoiding adverse reactions, such as a nocebo response, the placebo mechanism's evil twin (Reid 2002).
Target Audience: Physiotherapists and students who treat patients with pain in their practice will find this session relevant. An entry-level to practice background knowledge of pain theory would be useful, however, current physiological theories in pain modulation will be reviewed. No prior knowledge of acupuncture is required.

Summary of Supporting Evidence:
It is clear that expectation is a potent factor in the relief of pain. Evidence continues to emerge shifting the idea that placebo effects are the result of inert agents given to patients, to the idea that placebo effects result from the expectations, beliefs and desires of patients and vary in magnitude as a function of these variables (Price et al, 1999;Price & Barrell, 2000;Price et al 2007). The recent introduction of brain imaging tools has provided scientists in a variety of areas with the capacity to document brain activity and the effects of placebo analgesia (Kong et al, 2005). This has given way to an increasing body of evidence in the field of psychology, pharmacology and neuroimaging supporting placebo analgesia (Price 1999b, Price and Bushnell 2004, Tracey 2010).
Results from psychological studies have shown that the perception of the placebo agent is central to the magnitude of the placebo analgesic effect (Price 1999b, Vase, Riley, & Price, 2002, Price and Bushnell 2004, Tracey 2010 thus highlighting the importance of participants' knowledge and understanding of the therapeutic intervention in maximizing its effect (Vase, Riley & Price, 2002). Pharmacological evidence has suggested that the perception and expectation of the placebo agent trigger the descending opioid inhibitory pathways which can modulate the processing of pain, resulting in not only reducing pain intensity but also in reducing the pathophysiological consequences of pain. These pathways have also been shown to be activated during physical interventions commonly used by physiotherapists such as acupuncture, transcutaneous electrical nerve stimulation (TENS) and exercise. Neuroimaging research has also highlighted the activation of these similar pathways during both the placebo and nocebo conditions (Sackett 2009;Schweinhardt and Bushnell, 2010;Tracey 2010) and have identified different brain activation patterns during different circumstance and with different modalities (Kong et al, 2005).
It is clear that the placebo analgesic effect is multimodal and the identification and understanding of the factors that contribute to it are vital in optimizing the general effectiveness of pain treatments and maximizing the analgesic effect of physical interventions.

Description of Session Format:
The session is a combination of standard presentation with interactive audience contribution. Case studies will be used to assist in knowledge integration.

Session Objectives:
1. To introduce the current literature exploring the placebo and treatment 2. To explore the link between expectation and the relief of pain in terms of placebo analgesia 3. To learn how to exploit the effects of placebo in their treatment and not create a negative effect or nocebo.