CONFERENCEPOSTER ABSTRACTS 1–46

Abstract ID: 1

IT'S NOT JUST ABOUT NEUROLOGY: IMPAIRMENT, MEDICAL COMPLEXITY, AND FUNCTIONAL ABILITY PREDICT REHABILITATION LENGTH OF STAY IN CANADA

B. Catharine Craven¹, Karen Ethans², Dany H. Gagnon³, Angelo Gary Linassi⁴, Deborah Tsui⁵, Andrea Townson⁶, Carly Rivers⁷, Jason Chen⁷, Vanessa Noonan⁷

¹Toronto Rehabilitation Institute – UHN, ²University of Manitoba, ³University of Montreal, ⁴University of Saskatchewan, ⁵Hamilton Health Sciences, ⁶UBC Division of Physical Medicine and Rehabilitation, GF Strong Rehab Centre, ⁷Rick Hansen Institute

Background/objective: Predicting clinical and economic variables that impact upon inpatient rehabilitation length of stay (LOS) is controversial, yet significantly influences resource allocation required for optimal outcomes. Our aim was to identify patient-related factors evident at admission to a spinal cord injury (SCI) rehabilitation unit likely to extend LOS. We sought to describe the impact of relevant demographic, impairment, and medical complexity variables at rehabilitation admission on rehabilitation LOS among adult Canadians with traumatic SCI admitted for inpatient rehabilitation.

Methods/Overview: Data were obtained via chart abstraction from Rick Hansen SCI Registry sites. Variables included subject's rehabilitation onset days, LOS, age at injury, sex, International Standards for Neurological Classification for Spinal Cord Injury (ISNCSCI) impairment (Neurological Level of Injury (NLI), ASIA Impairment Scale (AIS)), and medical complexity including prior ventilation (VENT), PEG tube (PEG) or indwelling bladder catheter (IBC) at acute discharge, Pain Interference Scale Score (PISS) > 15 and functional ability using ISNCSCI lower extremity motor scores (LEMS) ≤20/50 at rehabilitation admission. For univariate analyses, the dependent variable was LOS, with VENT, PEG, IBC, LEMS, and PISS as independent variables. Multivariate linear regression analyses used log LOS as the dependent variable with AIS, VENT, IBC, and LEMS as independent variables.

Results: Adult men and women (n = 827, 82% male), mean (SD) age of 45 (18) years, with traumatic SCI AIS A–D; 255 (32%) high cervical C1–C4; 243(31%) low cervical C5–T1; 158 (20%) thoracic T2–T10; and 138 (17%) thoracolumbar T11–S5 were included. Median (lower quartile–upper quartile) rehabilitation onset days were 31 (18–54) days and median rehabilitation LOS 83 (53–122) days. Univariate analyses revealed increased rehabilitation LOS (days) for prior VENT (133 vs. 79), PEG (131 vs. 96), IBC (159 vs. 89), LEMS (111 vs. 62), and PISS (108 vs. 95). Multivariate analyses accounted for 22% of the variation in rehabilitation LOS (r = −0.2255, f 24.38, P < 0.001). Based on this multivariate model, the presence of all four variables (comparator level) AIS C–D, prior VENT, IBC, and LEMS ≤20 predicts a 180-day rehabilitation LOS versus, 40.3 days for absence of these variables.

Conclusions: Impairment grades, specifically NLI and AIS alone, are insufficient predictors of rehabilitation LOS for patients with SCI. Use of direct rather than surrogate assessments of LOS predictors will likely result in improved accuracy of LOS predictions. LOS calculators must account for the patient's medical complexity and functional abilities.

Acknowledgements: Funding Source: Rick Hansen Institute

Abstract ID: 2

CREATION OF AN INTEGRATED PROCESS FOR GOAL SETTING, PATIENT EDUCATION, AND TRANSITION PLANNING IN SPINAL CORD REHABILITATION

Heather Flett, Sandra Mills, Jennifer Holmes, Carol Scovil, Tess Devji, Kristina Guy

Toronto Rehabilitation Institute – UHN

Background/objective: To develop a new interprofessional rehabilitation process which integrates goal setting, patient education and transition planning and focuses on patients as partners. The specific goals of this initiative were to better engage patients in their care, enhance team communication and collaboration, and place patient and family securely within team processes.

Methods/Overview: Toronto Rehablitation Institute's Clinical Best Practice Process was used to systematically guide implementation. Patient's need was identified through patient satisfaction results, retrospective chart audits, and staff and stakeholder feedback. A review of present practice critically examined current goal setting, patient education, and transition planning processes. Best practices were then determined through literature review, benchmarking, and environmental scan. A gap analysis compared present and best practices to identify key opportunities for improvement. During preparation for implementation, LEAN methodology was used during 2-week-long rapid improvement events to develop standard work processes and new clinical tools. Staff education materials and stakeholder engagement were also completed prior to implementation. A phased implementation approach was used whereby pilot testing of new forms and team processes was conducted followed by subsequent evaluation and staff feedback. Implementation involved a hospital wide roll-out of new processes.

Results: Phase one implementation has been completed which involves a new process for care planning in which patients' learning priorities across all domains of spinal cord injury (SCI) rehabilitation inform teaching and learning required during their rehab. New SCI domain-based team rounds forms which drive the “patient as partner” philosophy have also been implemented. Other deliverables include “It's Teamwork” poster which describes interprofessional team roles in different domains of SCI and SCI domains patient orientation form. Seventy clinical staff have been trained to date. Pre-implementation surveys were completed by 20 patients and 36 staff. Post-implementation survey results will be presented.

Conclusions: Preliminary findings suggest that an integrated, interprofessional process for goal setting, patient education, and transition planning enhances the overall patient experience in SCI rehabilitation and improves team communication. Patients have increased awareness of the scope of learning possible during and after rehabilitation.

Acknowledgements: Brain and Spinal Cord Rehab Program, Toronto Rehab, UHN Grant Number: N/A

Abstract ID: 3

IMPLEMENTATIONOF A PRESSURE ULCER PREVENTION EDUCATION BEST PRACTICE FOR PERSONS WITH SPINAL CORD INJURY.

Stacey Guy¹, Anna Kras-Dupuis², Dalton Wolfe^1,3

¹Lawson Health Research Institute, ²St. Joseph's Healthcare, London, ³Western University

Background/objective: As part of SCI KMN nationwide effort to facilitate best practice within the area of spinal cord injury, an education practice to prevent pressure ulcers was implemented in an inpatient rehabilitation setting.

Methods/overview: Based on network consensus regarding essential practice components, an inter-professional team of clinicians used implementation science principles to develop this practice with focus on self-management. Practice principles are based on standardized content, adult learning strategies, patient self-direction, reinforcement methods, and individualized education. Attention is focused on key drivers of implementation, including stakeholder engagement, improvement cycles, and on sustainability through robust, non-person-dependent processes. Descriptive analysis of patient evaluation surveys and healthcare provider process documentation was undertaken to examine practice adherence and to inform practice improvements.

Results: Implemented in December 2012, this practice includes patient participation in a 30-minute interactive skin health session, receiving a resource kit and guidance to take ownership of daily skin checks. The team reinforces key prevention strategies throughout the patients' daily activities. Over the 6 months of the initial practice implementation, 98% (N = 59) of patients received formalized education with kit within 2 weeks of admission. Seventy-three percent of these patients had documentation of structured education in their health record. This represents an opportunity for improvement. Inpatient feedback (N = 49) indicates 94% received and understood information about personalized skin-care and learned relevant skills, 92% felt that this educational information was presented in a way that satisfied their individual needs, and 90% reported that they would apply this knowledge in their everyday lives. As well, 89% reported that they would use learned skills in their daily life post-discharge. At follow-up (N = 12), 42% of the patients reported using the skills and information presented about skin care after they were discharged.

Conclusions: An inter-professional, self-management focused practice has been instituted. Initial results suggest structured and individualized skin health education has been integrated into clinical practice with fidelity. Consistent, standardized, non-person dependent processes and regular adherence feedback to clinicians have been the key to sustainability of this practice.

Acknowledgements: Ontario Neurotrauma Foundation Grant Number: 2010-ONF-BPI-833

Abstract ID: 4

INCORPORATINGEVIDENCE-BASED PRACTICE INTO LIFE CARE PLANS THROUGH SCHOLARLY PRACTICE

Stephanie Hadi¹, B. Catharine Craven^1,2

¹Toronto Rehabilitation Institute – UHN, ²Department of Medicine, University of Toronto

Background/objective: Spinal cord injury (SCI) disrupts sensory, physical, and autonomic function leading to secondary health condtions that significantly impact an individual's quality of life. Life care plans (LCP) are medico-legal documents intended to ensure sufficient resources to support an individual's evolving medical and rehabilitation needs as they age. LCP include “standard treatments” and rarely include “experimental” therapies or devices. Scholarly practitioners routinely critically appraise the SCI literature to determine which therapies and/or technologies are proven or promising for LCP inclusion. We sought to address the conundrum of critically appraising SCI relevant therapies and/or technologies prior to LCP incorporation; and, to describe products of this process for five specific therapies and technologies: functional electrical stimulation therapy (FES-T), locomotor training, transanal irrigation, hydrophilic coated catheters and intravesicular botulinum toxin.

Methods/overview: A targeted literature search was conducted using Ovid MEDLINE^® for each of the five investigated therapies and technologies. Studies were reviewed to determine patient outcomes and were then classified using SCIRE Project's “Methods of Systematic Review: Five Levels of Evidence” (www.scireproject.com). Information about resources (personnel and costs) were extrapolated from the literature, company websites and personal communication with experts in the field. The level of research evidence, anticipated expenditures, frequency, and intensity of five specific therapies and technologies are reported and their potential or proven efficacy was rated for LCP inclusion.

Results: FES-T (levels 1a and 2) requires a minimum of 40 treatment sessions and costs ∼$5000 to access ($1000 for electrodes, and $4000 for therapist salary). Intravesicular botulinum toxin (level 1a) requires 30 intramuscular injections (1 ml) and costs $400/vial (10 ml). Transanal irrigation (level 1a) costs approximately $4050/annum total, and $320/month for supplies. Hydrophillic coated catheters (levels 1 and 2) costs ∼$150 for 30 catheters/box. Locomotor training (levels 4 and 5) has shown potential in improving balance, walking speed, and community ambulation, and requires 200 Toronto Rehabilitation Institute – UHN 220 sessions and costs $150 Toronto Rehabilitation Institute - UHN170/session.

Conclusions: There is merit in allocating funds in LCP for innovative therapies and technologies that have either proven or have shown promising results in augmenting function and/or ameliorating multimorbidity following SCI.

Acknowledgements: Support from the Toronto Rehabilitation Institute – University Health Network

Abstract ID: 5

ADAPTINGEXERCISE EQUIPMENT WITH COMMON FASTENERS IMPROVES ACCESSIBILITY

Judy Lugar^1,2

¹Neurorehabilitation Program, Nova Scotia Rehabilitation Centre, QEII Health Sciences Centre, ²Physiotherapy Dynamics

Background/objective: Medical grade and specialty exercise equipment are very expensive and often designed to be used with assistance. Independent use of many modalities is restricted by the availability of assistance and can be a limiting factor for primary users. Snowboard bindings are strong, commonly available and easy to modify. Industry standard click straps are designed to be used with gloved or mittened hands. These straps are used in adaptations in many sporting applications. This specialized equipment can make independent exercise possible for people with impaired grasp function.

Methods/overview: An aging stim cycle's leg-securing system required assistance for positioning and securing the 12 original velcro fasteners. These awkward fasteners prevented independent use by the owner. We replaced the foot-positioning system with snowboard bindings and all velcro fasteners with click straps.

Results: Adaptations permitted independent use and prevented purchase of a more modern and very expensive device.

Conclusions: Well-designed common equipment can be utilized to improve accessibility and independent use of specialized exercise equipment. Warrantee limitiations and safety considerations must be considered. Exercise equipment accessibility modifications can be inexpensive, safe, and achieved with common tools.

Acknowledgements: Self funded

Abstract ID: 6

FRAGILITYFRACTURES AFTER SPINAL CORD INJURY: INSIGHTS FROM THE BONE QUALITY IN INDIVIDUALS WITH CHRONIC SCI STUDY

Cheryl Lynch^1,2, Lora Giangregorio^1,2, Rick Adachi^1,2, Neil McCartney³, Alexandra Papaioannou⁴, Milos Popovic^2,5, Lehana Thabane⁴, B. Catharine Craven^2,5

¹University of Waterloo, ²Toronto Rehabilitation Institute – UHN, ³Brock University, ⁴McMaster University, ⁵University of Toronto

Background/objective: Sublesional osteoporosis (SLOP) is common after spinal cord injury (SCI). Wide confidence intervals exist for fragility fracture prevalence and incidence (50–75%) after SCI. Lower extremity (LE) fracture care best practice is conservative management of below knee fractures and operative management of above knee fractures. This abstract describes the incidence, prevalence, and management of LE fragility fractures in a cohort of Ontarians with chronic SCI.

Methods/overview: Adults (age >18 years) with chronic SCI (C2–T12, ASIA Impairment Scale (AIS) A–D of >2 years duration) consented to prospective BMD monitoring and LE fracture surveillance. Participants with bisphosphonate exposure were not excluded, but those with secondary osteoporosis were excluded. Participants attended site visits every 6 months for 24 months for medical, fracture, and serious adverse event screening and bone density assessment. Fracture surveillance included quarterly telephone screening and incident fracture verification by X-ray or chart review. Descriptive statistics were used to report fracture management, prevalence, and incidence at baseline and during follow-up.

Results: Data were collected from 70 participants (50 men) of mean age 49 ± 12 years and SCI duration 16 ± 10 years. Impairment distribution was 33% paraplegia AIS A–B, 31% tetraplegia AIS A–B, 17% paraplegia AIS C–D, and 19% tetraplegia AIS C–D. Many participants (33%) reported prevalent fragility fractures at baseline, most of whom were motor complete (87%). During follow-up, 18 (15 LE) fragility fractures occurred. Most participants who fractured were motor complete (93%) and current bisphosphonate users (67%). A minority reported SLOP diagnosis after fracture (39%). Transfers (39%), followed by low-velocity falls from sitting height (28%), were the most frequent causes of fracture. Half of participants with incident fractures reported ER visits, and 36% reported requiring in-patient care (median LOS 7 days, range 3–29 days). Reported fracture care included casting (36%), splinting (22%), surgery (21%), or no stabilization (21%).

Conclusions: The study cohort reported a high prevalence and incidence of LE fragility fractures. The incident fracture rate was highest for motor complete participants, many of whom (66%) were bisphosphonate users. The discordance between the incidence of LE fragility fracture and reported SLOP diagnosis is striking, and represents a gap in SLOP health services. The spectrum of reported fracture care was consistent with current best practices.

Acknowledgements: The authors acknowledge the support of the Ontario Neurotrauma Foundation (#2009-SCI-MA-684), the Canadian Institutes of Health Research (#86521), and the Spinal Cord Injury Solutions Network (RHI) (#2010-43). Toronto Rehabilitation Institute – UHN receives funding from the Ontario Ministry of Health and Long-Term Care. The views expressed herein do not necessarily reflect those of the funders.

Abstract ID: 7

THELONG-TERM CLINICAL BENEFITS OF PARTICIPATING IN RESEARCH: A LONG-TERM FOLLOW-UP, CASE STUDY OF A PARTICIPANT AND SEVERAL CLINICIANS' INVOLVEMENT IN “FEASIBILITY OF AN INTERNET CLINIC FOR TREATING AND PREVENTING PRESSURE ULCERS”?

Brenda MacAlpine

Stan Cassidy Centre for Rehabilitation

Background/objective: The Stan Cassidy Centre for Rehabilitation was a site in The Feasibility of an Internet Clinic for Treating and Preventing Pressure Ulcers, a multi-site pilot study to assess the feasibility of integrating several information technologies, each deployed over the internet within the practices associated with clinical management and prevention of pressure ulcers in persons with spinal cord injury (Wolfe et al., 2012). It was hoped that assessment, treatment, and prevention services could be delivered effectively over the internet and that they would be accepted by the clients and the clinicians involved. This case study examines the longer-term effects on one participant and the impact on the clinical practice for the clinicians.

Methods/overview: At completion of the study, the client was invited to remain in contact with the study OT via email to assist with prevention of ulcers. This client was of particular concern as prior to the study he had not adopted an active role in the monitoring of his skin health, and was unsure how to manage problems. Approximately 6 months post-discharge from services, he contacted the study OT via email including a picture of reddened area he developed since restarting basketball. The OT referred to the seating clinic. The information sent via internet prior enabled the clinicians to be prepared such that solutions could be presented in first visit. Several months after this he emailed the study OT with concerns regarding new symptoms to find his needs are medically derived and he has been referred onto his physiatrist.

Results: The client was empowered to contact a central source and ask for help on how to prevent pressure ulcers. The personal and healthcare costs of a pressure ulcer were avoided. Since the completion of the study, community clinicians have continued to consult the study OT and RN regarding clients with wounds. There is now discussion regarding a more formal internet clinic.

Conclusions: The costs of treating ulcers are a staggering burden to the healthcare system. Access to specialized services can be limited especially for rural clients or those restricted to bed rest as part of their treatment. Studies have shown that extended travel may exacerbate ulcers (Matheson et al. 2000). An internet clinic makes clinical and fiscal sense. Studies with a primary focus on increasing access and efficiency for the client should be explored by clinicians. The impact long term can be profound.

Acknowledgements: No funding for case study.

Abstract ID: 8

THESWING SLING

Dianna Mah-Jones

Vancouver Coastal Health-G.F Strong Rehabilitation Centre

Background/objective: Independence in transfers is a common goal in spinal cord rehabilitation. The sliding technique, with or without a board, is used when individuals do not have the capacity to weight-bear through the legs to move from Point A to Point B. The procedure requires the client to lean forward to off-load weight from the buttocks, then to push through the arms to shift the body upwards and laterally. Momentum for the manoeuvre is amplified when the head and upper body turn in the opposite direction of the hips. Challenges with transfers occur in the acute rehabilitation phase as well as with chronic spinal cord injury due to client factors such as strength, balance, pain, size, and confidence. Poorly performed transfers can result in pressure wounds and shoulder strains. From a staff perspective, transfers requiring moderate-to-maximum assistance increase the risk of musculo-skeletal injuries. The swing sling technique was developed to facilitate functional training with at-risk clients and to provide an alternative approach to self-managed transfers.

Methods/overview: A canvas transfer sling was modified with vertical straps to attach to the arms of the overhead mechanical lift. The client's upper thighs and buttocks are centred on the sling, and one or both vertical straps run behind the shoulders to reduce the risk of the client falling backwards. An anterior chest strap serves as a light restraint and a kinesthetic cue for the flexed position. The client is raised to a height commensurate to his/her arm strength to shift the body between surfaces. As the client becomes stronger, less fearful, and more skilled in the sliding procedure, the sling is weaned off.

Results: Three case examples are provided of the swing sling being used as an interim step in learning sliding board transfers and of being the method of choice for use at home by both a newly injured client and client with chronic spinal cord injury.

Conclusions: The swing sling transfer enables a graduated approach to transfer training and allows persons with weight, arm or skin issues to perform transfers safely on their own. The sling design positions the client in an active sitting posture and the arms are free to push, pull and reach. With the mechanical assist, staff can start sliding transfer training earlier and with minimal burden in terms of effort and manpower. The swing sling transfer is appropriate for newly injured clients and for those with a chronic injury.

Acknowledgements: NA

Abstract ID: 9

PERINATALCARE FOR WOMEN WITH SPINAL CORD INJURIES

Kate McBride¹, Lynsey Hamilton², Melanie Basso³, Stacy Elliott^4,5, Shea Hocaloski⁴, Karen Hodge, Vanessa Noonan²

¹GF Strong Rehabilitation Centre, ²Rick Hansen Institute, ³BC Women's Hospital and Health Centre, ⁴Blusson Spinal Cord Centre, ⁵Vancouver Coastal Health

Background/objective: To determine gaps in the provision of perinatal care to women with spinal cord injury (SCI).

Methods/overview: Content experts and stakeholders from across Canada were identified and invited to participate in a one-day workshop held in Vancouver, BC (November 2013). An online pre-workshop survey was sent to 30 participants to elicit anonymously their opinions related to the needs of women with SCI at each stage of perinatal care. Nineteen responses were received, representing clinicians, researchers, and consumers. Four team members individually reviewed the results for thematic content then met to compare emerging concepts. Resulting themes were summarized and presented to the 25 workshop participants who further analyzed and distilled the survey findings through group processes and consensus building conducted on the day of the workshop.

Results: Three central themes emerged from the survey data: knowledge, access and collaboration. Participants determined that the first step in improving perinatal care for women with SCI is to use the findings from this project to create a “roadmap” outlining the key areas of need at each stage of perinatal care for women with SCI.

Conclusions: This study sparked connections and call to action within the SCI/rehab/OBS community. The proposed roadmap will inform clinical care, research, education, policy change, and social reform via collaborations between clinicians, researchers, and consumers.

Acknowledgements: Granting Agency/Funding Source: Rick Hansen Institute Grant number: NA.

Abstract ID: 10

MINIMIZINGERRORS IN TRAUMATIC SPINAL CORD INJURY CLINICAL TRIALS BY ACKNOWLEDGING THE HETEROGENEITY OF SPINAL CORD ANATOMY AND INJURY SEVERITY: AN OBSERVATIONAL CANADIAN COHORT ANALYSIS

Vanessa Noonan^1,2, Marcel F Dvorak^1,2, Nader Fallah^1,2, Charles G Fisher², Carly S Rivers¹, Henry Ahn^3,4, Eve C Tsai^5,6,7, A Gary Linassi⁸, Sean D Christie⁹, Najmedden Attabib^9,10,11, RJohn Hurlbert¹², Daryl R Fourney¹³, Michael G Johnson¹⁴, Michael G Fehlings⁴, Brian Drew^15,16, Christopher S Bailey¹⁷, Jerome Paquet^18,19, Stefan Parent^20,21,22, Andrea Townson², Chester Ho¹², B. Catharine Craven^4,23, Dany Gagnon22, Deborah Tsui²⁴, Richard Fox²⁵, Jean-Marc Mac-Thiong^20,21, Brian K Kwon², RHSCIR Network

¹Rick Hansen Institute, ²University of British Columbia, ³St. Michael's Hospital, ⁴University of Toronto, ⁵The Ottawa Hospital, ⁶Ottawa Hospital Research Institute, ⁷University of Ottawa, ⁸University of Saskatchewan, ⁹ Dalhousie University, ¹⁰Horizon Health Network, ¹¹Saint John Regional Hospital, ¹²University of Calgary, ¹³University of Saskatchewan, ¹⁴University of Manitoba, ¹⁵Hamilton General, ¹⁶McMaster University, ¹⁷Western University, ¹⁸Hôpital Enfant-Jésus, ¹⁹Laval University, ²⁰Hôpital du Sacré-Coeur de Montréal, ²¹Hôpital Ste-Justine, ²²Université de Montréal, ²³Toronto Rehabilitation Institute – UHN, ²⁴Hamilton Health Sciences, ²⁵Royal Alexandra Hospital

Background/objective: Clinical trials of therapies for acute traumatic spinal cord injury (tSCI) have failed to convincingly demonstrate efficacy in improving neurologic function. Failing to acknowledge the heterogeneity of these injuries and under-appreciating the impact of the most important baseline prognostic variables likely contributes to this translational failure. Our hypothesis was that neurological level and severity of initial injury (measured by ASIA Impairment Scale, AIS) act jointly and are the major determinants of motor recovery. Our objective was to quantify the influence of these variables, when considered together on early motor score recovery following acute tSCI.

Methods/overview: Eight hundred and thirty-six participants from the Rick Hansen Spinal Cord Injury Registry were analyzed for motor score improvement from baseline to follow-up.

Results: In AIS A, B, and C patients, cervical and thoracic injuries displayed significantly different motor score recovery. AIS A patients with thoracic (T2–T10) and thoracolumbar (T11–L2) injuries had significantly different motor improvement. High (C1–C4) and low (C5–T1) cervical injuries demonstrated differences in upper extremity motor recovery in AIS B, C, and D. A hypothetical clinical trial example demonstrated the benefits of stratifying on neurological level and severity of injury.

Conclusions: Clinically meaningful motor score recovery is predictably related to the neurological level of injury and the severity of the baseline neurological impairment. Stratifying clinical trial cohorts using a joint distribution of these two variables will enhance a study's chance of identifying a true treatment effect and minimize the risk of misattributed treatment effects. Clinical studies should stratify participants based on these factors and record the number of participants and their mean baseline motor scores for each category of this joint distribution as part of the reporting of participant characteristics. Improved clinical trial design is a high priority as new therapies and interventions for tSCI emerge.

Acknowledgements: Rick Hansen Institute, Health Canada

Abstract ID: 11

CURRENTTREATMENT OF INDIVIDUALS WITH TRAUMATIC SPINAL CORD INJURY: DO WE NEED AGE-SPECIFIC GUIDELINES?

Vanessa Noonan^1,2, Henry Ahn^3,4, Christopher S Bailey⁵, Sean D Christie⁶, Neil Dugga^l7, Michael G Fehlings⁸, Joel Finkelstein^8,9, Daryl R Fourney¹⁰, R John Hurlbert¹¹, Brian K Kwon², Andrea Townson², Eve C Tsai¹², Najmedden Attabib^6,13, Jason Chen¹, Marcel Dvorak^2,14, Vanessa K Noonan^1,2, Carly S Rivers¹, RHSCIRNetwork

¹Rick Hansen Institute, ²University of British Columbia, ³St. Michael's Hospital, ⁴University of Toronto, ⁵Western University, ⁶Dalhousie University, ⁷London Health Sciences Centre, ⁸University of Toronto, ⁹Sunnybrook Health Sciences Centre, ¹⁰University of Saskatchewan, ¹¹University of Calgary, ¹²The Ottawa Hospital, ¹³ Horizon Health Network, ¹⁴Vancouver General Hospital

Background/objective: The elderly are increasingly at risk for traumatic spinal cord injury (tSCI) from falls compared with younger patients. However, it is unknown if this translates into different management and outcomes. Our objective was to determine whether age affected management decisions and outcomes.

Methods/overview: tSCI patients with complete records prospectively recruited from 2004 to 2013 for the Rick Hansen Spinal Cord Injury Registry were included. Demographic/injury differences between age groups (<70/ ≥70y) were assessed. Age (<70/ ≥70y), sex, injury etiology (falls vs other), energy of injury (high/low), injury level (cervical vs. thoracolumbar), admission ASIA Impairment Scale (AIS) (A&B vs. C&D), and Injury Severity Score

Results: Of 1440 participants with operative data, 167 (11.6%) were >70 years at the time of injury. Older patients were more likely to have been injured by falling compared with higher-energy mechanisms (83.1% vs. 37.4%), p70 did not affect odds of having operative treatment with multivariate analysis; high energy of injury and AIS of A/B increased the odds of having surgery (2.3 and 5.0, respectively). Older patients had longer time from injury to surgery, and longer acute (but not rehabilitation) length of stay. Age over 70 years was associated with higher in-hospital mortality (25.5% vs. 5.6%).

Conclusions: Practice patterns in Canada demonstrate that age in of itself, does not impact the odds of having surgery. However, older patients wait longer for surgery and have substantially higher in-hospital mortality rates despite less severe injuries. Surgical guidelines for older patients could reverse these trends.

Acknowledgements: Rick Hansen Institute, Health Canada

Abstract ID: 12

MEDICATION-RELATED PROBLEMS AND ACTIVITIES AMONG SPINAL CORD INJURY PATIENTS AT A PRIMARY CARE BASED INTERDISCIPLINARY CLINIC

Tejal Patel¹, Mikaela Klie¹, James Milligan², F. Joseph Lee²

¹University of Waterloo School of Pharmacy, ²Centre for Family Medicine Family Health Team

Background/objective: The family health team model enables pharmacist participation in the direct provision of care to patients. Currently, there is no published literature describing the medication related problems (MRPs) and pharmacist activities in an interdisciplinary clinic providing care to a patient population with a spinal cord injury (SCI). The study objectives were to describe the demographics, MRPs, and medication-related activities of the SCI patients presenting at the Centre for Family Medicine Family Health Team Mobility Clinic (CFFM-MC).

Methods/overview: This investigation was a retrospective medical records review of all patients with SCI seen in CFFM-MC from August 2012 through April 2013.

Results: A total of 84 patients were seen in the CFFM-MC during this period, of which 19 had a SCI (23%). The mean age of SCI patients was 47 years (range: 1889 years), and 74% were male. During this period, most patients were seen once, while 3 were seen 1 for a total of 23 visits. The most frequent comorbid conditions noted in the medical records were depression/anxiety (37%), and osteoporosis, hypertension, dyslipidemia, and osteoarthritis (21% each). Of the 71 medical problems addressed during clinic visits, pain (17%), spasticity (11%), bowel (8%), and bladder problems (7%) were the most frequent concerns. On review, most commonly encountered medications included pain (58%), natural health products, minerals and vitamins, (58%), anticonvulsants (frequently used for pain, 47%), antihypertensive/cardiac medications (42%), laxatives (37%), skeletal muscle relaxants (37%), and antidepressants (32%). A total of 34 MRPs were noted among the 19 patients with SCI. The most common MRPs identified were an untreated condition (41%), minimally effective/ineffective medication (21%), and adverse drug reaction (21%). Under-dosage, patient non-compliance and over-dosage each were reported (10%). The pharmacist was involved in the care of 5 of 19 patients (26%). The pharmacist noted 16 MRPs (47%) among these patients (mean 3 MRPs/patient). A total of 18 MRPS (53%) were noted for those patients not assessed by a pharmacist (mean 1 MRP/patient).

Conclusions: MRPs are common among patients with SCI who present to a primary care-based Mobility Clinic. A greater mean MRPs/visit was noted when the pharmacist was involved in the care although this may have been due to a greater need. Further prospective research is needed to describe the pharmacist impact on this population.

Acknowledgements: No funding.

Abstract ID: 13

IMMEDIATEEFFECT OF WHOLE-BODY VIBRATION ON GAIT IN PATIENTS WITH INCOMPLETE SPINAL CORD INJURY

Diane Patzer¹, Phuong Vu¹, Vicky Pardo², Sujay Galen²

¹Rehabilitation Institute of Michigan, ²Wayne State University

Background/objective: Whole-body vibration (WBV) is relatively a new intervention that is being increasingly used in the rehabilitation of patients with spinal cord injuries (SCI). To date there have been no scientific investigations that have studied the immediate effect of reduction in spasticity following WBV on walking in patients with incomplete SCI (ISCI).The aim of this study was to investigate the immediate effects of WBV on gait in patients with ISCI.

Methods/overview: A cross-over design was adopted to research the immediate effects of WBV following two types of WBV interventions (type A and type B). All subjects received the two types of intervention twice over a 4-week period; however, the order in which these interventions were delivered were randomized. Type A intervention consisted of four bouts of WBV lasting 45 seconds each with three 60-second rest periods interspersed between each bout. Type B intervention consisted of a WBV dosage (number of bouts of WBV) matched to the severity of the subjects lower extremity spasticity. A rest period of 60 seconds was interspersed between each bout of WBV. The spatio-termporal gait parameters (walking speed, stride length, stance time, swing time, double support time, and foot contact pattern) were recorded before and after WBV intervention using an insole-based wireless gait assessment tool (Wi-GAT). Subjects were randomly tested either immediately after the WBV intervention (test 1) or following a 15-minute delay (test 2). Subjects are currently being recruited into this ongoing study. A total of four subjects have completed the study to date.

Results: Preliminary analysis showed a greater decrease in stance time following WBV. This may indicate that following WBV the subjects were able to spend less time with their feet on the ground during walking, indicating a shift toward a more normal pattern of walking. The swing time also increased, as they were now able to keep their feet off the ground longer while walking. As a result their double support time (duration when both feet were on the ground) decreased. The changes in gait seem to be more pronounced in subjects who had moderate-to-severe spasticity in their lower extremity compared to subjects with milder spasticity.

Conclusions: These are preliminary results and therefore must be interpreted with caution. The results so far seem to suggest that WBV as a pre-gait intervention may be useful for patients with high level of spasticity in their lower extremity.

Acknowledgements: Wayne State University, Physical Therapy Program.

Abstract ID: 14

COMPARISONOF THE LENGTH-OF-STAY TARGETS IN SPINAL CORD REHABILITATION BASED ON ADMISSION FUNCTIONAL ABILITY VERSUS SPINAL CORD DIAGNOSTIC GROUP

Heather Flett, Jennifer Mokry, Anthony Burns, Kristina Guy, Igor Milicic, Mark Bayley, Joanne Zee

Toronto Rehabilitation Institute - UHN

Background/objective: To compare the mean length of stay (LOS) and the proportion of patients discharged within projected LOS using functionally-based versus diagnosis-based LOS targets in spinal cord rehabilitation.

Methods/overview: In March 2010, objective LOS targets were implemented using national comparator data from the Canadian Institute for Health Information Rehabilitation Patient Groups (RPG). RPGs are based on admission functional ability as measured by the motor functional independence measure (FIM) and further divided by spinal cord injury etiology (trauma, non-trauma). A “tentative discharge date” calculator was created using a standardized formula to establish objective LOS targets for specific RPGs. In June 2013, new LOS targets were implemented based on spinal cord diagnostic groups combined with admission FIM. Average LOS and the proportion of patients discharged within target LOS were examined.

Results: From 1 April 2012 – 28 February 2013, 263 patients were admitted for spinal cord rehabilitation with a mean LOS of 69 days. Forty-seven percent of patients (n = 124) were discharged within projected LOS using RPG-based targets. Following implementation of the new diagnosis-based targets, 115 patients were admitted from 1 June 2013 and 1 December 2013. Mean LOS was reduced to 51 days with 70% of all patients being discharged within projected LOS. Although the change in methodology for determining LOS targets appears to have had significant impact on mean LOS, case mix variation over this time period has also contributed to LOS reduction and will be described.

Conclusions: The use of objective LOS targets has improved rehabilitation efficiency while increasing standardization in practice and transparency in LOS determination. Preliminary findings suggest that new LOS targets that incorporate greater specificity with regard to spinal cord injury diagnosis result in greater accuracy in LOS determination and reduced frequency of LOS extensions in comparison to RPG-based targets based on admission functional ability and spinal cord injury etiology (trauma/non-trauma).

Acknowledgements: No external funding. Project supported by Toronto Rehabilitation – UHN Brain and Spinal Cord Rehab clinical program

Abstract ID: 15

WHYDO I STICK TO THE PROGRAM? A QUALITATIVE ANALYSIS OF THE DETERMINANTS OF ADHERENCE TO COMMUNITY-BASED PHYSICAL ACTIVITY SUPPORT PROGRAMS BY PERSONS WITH SCI AND CONTRAST WITH GENERAL POPULATION WITH DISABILITIES

Kelly P. Arbour-Nicitopoulos^1,2,3, Marie-Eve Lamontagne^2,4,5, Jennifer Tomasone^3,6, Eva Pila^1,3, Isabelle Cumming^4,5, Amy E. Latimer-Cheung⁷, Franois Routhier^2,4,5

¹University of Toronto, ²COM-QoL, ³SCI Action Canada, ⁴Université Laval, ⁵CIRRIS - IRDPQ, ⁶McMaster University, ⁷Queen's University

Background/objective: Health behaviour change is a difficult process for many individuals including those with spinal cord injury (SCI). Providing community-based telephone counseling services, such as Get In Motion (GIM) and its French adaptation Passez a l'action (PAL), may be one strategy for assisting individuals with SCI through the behaviour change process (Eakin et al., 2007). Despite the empirical research to support the benefits of the GIM counseling service on increasing the physical activity participation levels of its SCI consumers, little research has been directed toward examining consumers experiences. The objective of this study is to explore the facilitators and barriers to consumers ability to adhere to the GIM and PAL services.

Methods/overview: We performed individual telephone interviews with a total of 39 adults with SCI (n = 19 for GIM and n = 20 for PAL; M age = 51.3 years 11.2 years; 41% male; 59% paraplegia (GIM), various disabilities (PAL). Participants were classified as being non-users (n = 13), non-adopters (n = 8), and users (n = 18) of the GIM and PAL services. The interview grid informing the questions for the telephone interviews were based on Michie et al. (2005) Theoretical Domains Framework (TDF). All interviews were audio recorded, transcribed, and submitted to a content analysis using NVivo 9.0.

Results: Greater promotional resources need to be directed toward informing future consumers about the GIM and PAL services. For those who use the GIM and PAL services, an increased emphasis should be placed on enhancing clients self-efficacy and motivation throughout their counseling sessions.

Conclusions: We performed individual telephone interviews with a total of 39 adults with SCI (n = 19 for GIM and n = 20 for PAL; M age = 51.3 years 11.2 years; 41% male; 59% paraplegia (GIM), various disabilities (PAL)). Participants were classified as being non-users (n = 13), non-adopters (n = 8), and users (n = 18) of the GIM and PAL services. The interview grid informing the questions for the telephone interviews were based on Michie et al. (2005) Theoretical Domains Framework (TDF). All interviews were audio recorded, transcribed, and submitted to a content analysis using NVivo 9.0.

Acknowledgements: COM-QOL is funded through the Ontario Neurotrauma Foundation and the Provincial Rehabilitation Research Network (REPAR) Ontario/Quebec Inter-Provincial Partnership grant. Internal Faculty of Kinesiology and Physical Education research grant (awarded to KAN) for the financial support for this study.

Abstract ID: 16

THEEFFECT OF SKIN MOVEMENT ARTIFACTS ON MULTI-SEGMENT TRUNK MOTION ANALYSIS

Sara Ayatollahzadeh^1,2,3, Hossein Rouhani^1,2, Richard Preuss^4,5, Kei Masani^1,2, Milos R. Popovic^1,2

¹Toronto Rehabilitation Institute – UHN, ²University of Toronto, ³The Edward S. Rogers Sr. Department of Electrical & Computer Engineering (ECE), ⁴McGill University, ⁵The Constance Lethbridge Rehabilitation Centre site of the Centre de Recherche Interdisciplinaire en Réadaptation (CRIR)

Background/objective: Postural stability during sitting is critical for people with spinal cord injury to perform their daily activities. Motion analysis, using optical camera systems, is a key tool to assess postural stability. Previous studies on lower-limb kinematic assessment have found that errors induced by skin movement are the major source of error in motion analysis. However, no study, to date, has investigated the effect of skin artifacts in multi-segment trunk motion analysis. We hypothesized that, due to small ranges of angular displacement between segments, skin artifacts could considerably affect kinematic measurements. Our goal was to investigate the relative errors induced by skin artifacts during 3D joint angle assessments using a seven-segment trunk model.

Methods/overview: Eleven able-bodied subjects performed seated trunk bending, in five directions (left, anterior-left, anterior, anterior-right, and right), to a 45° angle (angle of the trunk modeled as a single segment). A motion capture system, with six cameras, recorded the trajectory of 22 reflective markers mounted on the back of the trunk. We simulated errors induced by the skin artifacts. The error in the coordinates of each marker in the maximum excursion point of the bending for each trial was modeled as an independent variable with Gaussian distribution properties. The mean and standard deviation of the Gaussian variables were selected based on the measured maximum skin movements for that marker at the point of peak trunk motion. These errors were scaled based on the movement for the entire trajectory. The simulated skin artifacts were added to the original marker trajectories, and the relative errors for each joint's range of motion(ROM) were calculated in 3D space. The relative error of each ROM was compared to the coefficient of variation for the ROM for the same angle, for the entire subject population.

Results: Average inter-subject variability of the joint ROMs was around 40%. The induced errors in the sagittal, transverse and frontal planes were 15, 15, and 500%, respectively. Errors in the transverse plane, for sacral joints, were the exception, with values of ∼100%.

Conclusions: From the above analysis we can conclude that kinematic assessments of the trunk, in the sagittal and transverse planes, can be used in clinical evaluations, as the error range is less than the inter-subject variability. Kinematic assessments in the frontal plane, however, have substantial errors, and should be used with caution for clinical decision making.

Acknowledgements: None.

Abstract ID: 17

CLINICALEVALUATION BASED ON MULTI-SEGMENT TRUNK KINEMATICS: EFFECT OF ANATOMICAL LANDMARK MISPLACEMENT ERRORS

Sara Ayatollahzadeh^1,2,3, Hossein Rouhani^1,2, Richard Preuss^4,5, Kei Masani^1,2, Milos R. Popovic^1,2

¹Toronto Rehabilitation Institute – UHN, ²University of Toronto, ³The Edward S. Rogers Sr. Department of Electrical & Computer Engineering (ECE), ⁴McGill University, ⁵The Constance Lethbridge Rehabilitation Centre site of the Centre de Recherche Interdisciplinaire en Réadaptation (CRIR)

Background/objective: Postural stability during sitting is critical for people with spinal cord injury to perform their daily activities. Motion capture, using optical camera systems, is a key tool to assess postural stability of trunk movement. Because of the small ranges of inter-segmental angular motion that occur in a multi-segmental trunk, even small measurement errors may be relatively important. One potential source of measurement error is the misplacement of markers in relation to anatomical landmarks. The present study investigated the effect of anatomical landmark misplacement errors on the assessment of 3D inter-segmental angles in a multi-segment trunk model.

Methods/overview: Eleven healthy subjects performed three repetitions of seated, forward trunk bending to 45° (angle of the trunk modeled as a single segment). Six cameras recorded the trajectory of 22 reflective markers, placed over anatomical landmarks, representing seven trunk segments. Simulated markers misplacement errors were added to the original recorded data, and the resulting relative errors in the 3D range of inter-segmental angular motion were calculated. Each simulation was repeated 1000 times, and the 95th percentile of the 1000 values was considered as the induced error. The induced errors were then averaged for all trials, and the median for all subjects was calculated.

Results: The range of inter-segmental angular motions of the trunk was between 4.1° and 15.2° in the sagittal plane, and between 1.2° and 2.3° in the frontal and transverse planes. The inter-subject coefficient of variation of these angles, in the three anatomical planes, was between 25 and 60%, indicating high inter-subject variability. The relative errors induced by the simulation in the sagittal ranges of motion, for all inter-segmental levels, were small (less than 3.5%). The induced relative errors in the frontal and transverse planes, however, were much larger (up to 57%), due primarily to the smaller movements that occurred in these planes.

Conclusions: During seated, forward trunk bending, the errors in trunk kinematics that result from marker misplacement relative to anatomical landmarks, using a multi-segment trunk model, are likely to be negligible for inter-segmental angles in the sagittal plane. Errors in calculated inter-segmental angles in the frontal and transverse planes, however, are relative large, and these measures should be considered with caution in clinical evaluations.

Acknowledgements: None.

Abstract ID: 18

CLIENTAND STAFF PERCEPTIONS ON THE WII AS A REHABILITATION INTERVENTION FOR SPINAL CORD INJURY

Amélie Fuchs¹, Ketsia Proulx^2,3, Désirée Maltais^2,3,4, Dalton Wolfe^5,6, Sander Hitzig⁷

¹Fondation Groupama pour la Santé, ²Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), ³Institut de réadaptation en déficience physique de Québec (IRDPQ), ⁴Université Laval, ⁵Lawson Health Research Institute, ⁶Western University, ⁷University of Toronto

Background/objective: The Nintendo Wii has been used as an adjunct to conventional rehabilitation (i.e. stroke, cerebral palsy, etc.). Most of the evidence for efficacy, however, is based off pilot work or anecdotal reports, with no work-to-date examining the feasibility of using the Wii as an intervention for spinal cord injury (SCI). The purpose of this study was to obtain the perceptions of patients with SCI and therapists who participated in a Wii-based intervention to determine its clinical value post-SCI.

Methods/overview: Twelve in-patients with SCI participated in a 12-week Wii intervention (1 session × week ∼ 30 minutes) at a rehabilitation hospital. The intervention was implemented by two recreational therapists using the Wii sports software packages (i.e. bowling, fishing, badminton, etc.). Patients either played with a therapist, another patient, or a family member/friend. The patients' (n = 12) and therapists' (n = 2) perspectives were collected via semi-structured interviews (∼30 minutes) post-intervention. Data were analyzed using fundamental qualitative description methodology.

Results: Seven main themes were identified. The themes were: (1) Expectations; (2) Benefits/Positive Effects (3) Negative Effects; (4) Wii Features Toronto Rehabilitation Institute – UHN Positive; (5) Wii Features Toronto Rehabilitation Institute - UHN Negative; (6) Wii Therapeutic Benefits; and (7) Elements for Improvement. Overall, a number of positive elements of using the Wii post-SCI were identified, which included some participants reporting perceived gains in balance, endurance, and improved self-confidence. As well, it fostered positive social interactions. Although perceived as a fun and motivating modality, some participants reported developing aches/pain from the Wii, and that the therapy did not meet their expectations for improved function. In terms of its perception as a “therapy,” there was uncertainty with regard to its benefits as a stand-alone intervention, but many participants reported that they would use the Wii in the community given its recreational value.

Conclusions: Preliminary evidence indicates a number of positive benefits of using the Wii as an adjunct to conventional SCI rehabilitation. However, further work is needed to better tailor the intervention for SCI (i.e. minimize shoulder pain) and to collect physiological data to better determine its clinical value for this population.

Acknowledgements: Funding provided by the Ontario Neurotrauma Foundation and the Quebec Rehabilitation Research Network (REPAR)

Abstract ID: 19

THEPOTENTIAL INFLUENCE OF AGE AT THE TIME OF TRAUMA ON THE INFLAMMATORY RESPONSE, GLIAL AND AXONAL SURVIVAL AFTER TRAUMATIC SPINAL CORD INJURY

Julio Furlan^1,2,3, Yang Liu¹, W. Dalton Dietrich^4,5, Michael Norenberg^4,5, Sydney Croul^2,6, Michael Fehlings^1,2,7

¹Toronto Western Research Institute - University Health Network, ²University of Toronto, ³Toronto Rehabilitation Institute - UHN, ⁴University of Miami, ⁵Miami Project to Cure Paralysis, ⁶Toronto General Hospital - UHN, ⁷Krembil Neuroscience Centre

Background/objective: This study examines whether age is a key determinant for inflammatory response, oligodendroglial apoptosis and axonal survival after traumatic spinal cord injury (SCI).

Methods/overview: This study includes post-mortem spinal cord tissue from 64 cases of SCI (at cervical or high-thoracic level) and 38 controls cases. Each group was subdivided into younger and elderly individuals (≥65 years). Alternating 6-μm sections from two to three segments caudal to the SCI and age/sex/level-matched segments from controls were stained for: (i) neuroinflammation (neutrophils, macrophages, cytotoxic-T/natural-killer cells, helper/regulator-T cells, B-cell lymphocytes); (ii) apoptotic oligodendrocytes; (iii) axons; (iv) extent of degeneration. The number of cells or axons was counted in the motor and sensory areas within the spinal cord using unbiased stereological techniques.

Results: There were 25 women and 77 men with a mean age of 58.6 years (range: 16–90 years). Younger and elderly individuals had statistically similar number of neutrophils, macrophages, and lymphocytes in most of the stages post-SCI. Yet, younger individuals showed significantly greater number of B-cell lymphocytes within the lateral corticospinal tracts in the subacute stage post-SCI than elderly individuals. Younger and elderly individuals had statistically similar number of oligodendrocytes in apoptosis in all stages post-SCI. The number of preserved axons did not significantly differ between younger and elderly individuals with SCI and without prior central nervous system injury. Extend of degeneration within the spinal cord white matter did not significantly differ between the two groups.

Conclusions: Our results indicate that age at the time of injury does not adversely affect the cellular inflammatory response, oligodendroglial apoptosis, and axonal survival after traumatic SCI. Those results are consistent with prior clinical studies that have shown no significant effects of age on neurological and functional recovery following traumatic SCI when data analysis is adjusted for potential confounders. Indeed, our results support the notion that elderly individuals can potentially have similar benefits of the ongoing translational studies focused on neuroprotective strategies based on modulation of neuroinflammation. Based on our study, protocols of future translational studies and clinical trials for neuroprotective strategies focused on oligodendrocyte preservation of adults with traumatic SCI should include elderly individuals.

Acknowledgements: Christopher & Dana Reeve Foundation.

Abstract ID: 20

USEOF MOBILITY ASSISTIVE DEVICES AMONG INDIVIDUALS WITH A SPINAL CORD INJURY UPON DISCHARGE FROM INPATIENT REHABILITATION: A CANADIAN PERSPECTIVE

Dany Gagnon¹, Maria Kandiloitis¹, Molly C. Verrier², B. Catharine Craven², Karen Ethans³, Vanessa Noonan^4,5, Carly Rivers⁵

¹Université de Montréal, ²Toronto Rehabilitation Institute - UHN, ³University of Manitoba, ⁴University of British Columbia, ⁵Rick Hansen Institute

Background/objective: The provision of mobility assistive devices (MADs), such as power wheelchairs, manual wheelchairs, or walking aids, is an effective rehabilitation intervention to alleviate the impact of mobility limitations in individuals with spinal cord injury (SCI). Surprisingly, there is only sparse data describing their provision in this population in Canada.This study aims to calculate the percentage of individuals with SCI who are provided with at least one MAD at discharge from inpatient rehabilitation and to determine the amount and type of MAD(s) provided to individuals with SCI in Canada.

Methods/overview: Socio-demographic and clinic-administrative data were obtained via chart abstraction at rehabilitation discharge from Rick Hansen SCI Registry (RHSCIR) sites across Canada. The variable of most interest for the present study was the type and the number of mobility aid(s) (i.e. walking aid, manual wheelchair, power wheelchair, scooter, and other). Descriptive statistics were computed.

Results: Data were obtained from 1275 individuals with a SCI who had agreed to participate in RHSCIR. Almost all individuals with SCI classified in AIS A, B, or C were provided with at least one MAD (≥95%) whereas 82.3% of those classified in AIS D were provided with at least one MAD. A total of 1527 MADs were provided to individuals with a SCI upon discharge from inpatient rehabilitation. Among those, manual wheelchairs (n = 702; 46.3%), power wheelchairs (n = 410; 27.1%), and walking aids (n = 390; 25.8%) were the most commonly provided MADs. Independently of the level of neurological impairments, the majority of individuals with SCI (range: 45.7–69.6%) were provided with a single MAD upon discharge from rehabilitation whereas a substantial amount of individuals used two (range: 28.1–37.1%) or three (range: 0.8–5.6%) MADs. The combined use of manual and power wheelchair was most frequently observed among individual with cervical or high thoracic neurological level of SCI whereas the combined use of manual wheelchair and walking aid was most frequently observed in individuals with low thoracic or lumbar neurological level of SCI.

Conclusions: The majority of individuals with SCI are provided with at least one MAD, and to a lesser extent with two or three MADs, at discharge from inpatient rehabilitation. Future studies focusing on the effects of personal and environmental factors on the type(s) of MAD(s) provided and on their trajectory of use and are needed.

Acknowledgements: Rick Hansen Institute.

Abstract ID: 21

THEUSE OF ANALYTICS TO EVALUATE THE UPTAKE OF THE PARTICIPATION AND QUALITY OF LIFE (PAR-QOL) TOOL-KIT

Sander Hitzig¹, Anne-Marie Belley^2,3, Dahlia Kairy^4,5, Lynda Atack⁶, François Routhier^2,7,8, Luc Noreau^2,7,8

¹University of Toronto, ²Centre for Interdisciplinary Research in Rehabilitation and Social Integration, ³Institut de réadaptation en déficience physique de Québec (IRDPQ), ⁴Université de Montréal, ⁵Center for Interdisciplinary Research in Rehabilitation (CRIR), ⁶Centennial College, ⁷Université Laval, ⁸Institut de réadaptation en déficience physique de Québec (IRDPQ)

Background/objective: Although the spinal cord injury (SCI) field is seeing a plethora of web-based knowledge mobilization initiatives, it is imperative that targeted implementation strategies are utilized to ensure their effective uptake by key stakeholders. An important marker of uptake are web analytics, which is the measurement, collection, analysis, and reporting of internet data for purposes of understanding and optimizing web usage. The current report provides an overview of the uptake of the Participation and Quality of Life (PAR-QoL) tool-kit (www.parqol.com), an online resource designed to support SCI researchers and clinicians with the QoL outcome measure selection process.

Methods/overview: The PAR-QoL tool-kit core content provides information on which outcome measures (a) have been used to assess a particular secondary health condition, (b) are sensitive to its impact, (c) are psychometrically valid for the SCI population, and (d) describe which QoL domain(s) they measure. In addition, the site hosts a number of “dynamic” features to promote continued usage, which includes a monthly blog, news and events, newsletter, ask-an-expert spotlight, and forum. The site was launched in November 2011, and Google analytics were installed in April 2012.

Results: Between April 2012 and November 2013, the PAR-QoL website received 70 185 visitors (15% return visitors), and showed an increase (P = 0.001) in the number of visitors over time. The heaviest users are from the United States (28%), United Kingdom (12%), and Canada (10%). The most popular content were pages describing outcome tools, with the Profile of Mood States, Modified Barthel Index, and Coping Strategies Questionnaire being the most viewed. Top keywords for referral have been for outcome measures. The dynamic features are accessed more by returning than unique visitors (1713 page views vs. 699 views, respectively). Analytics on the expert-spotlight events and newsletters showed that promotion activities have been effective, with corresponding increases in access when these events were posted on-line.

Conclusions: Web analytics demonstrate that the PAR-QoL tool-kit has been largely effective in reaching a significant number of users across the world. Further work is required to identify strategies that will be effective for promoting greater usage of dynamic features by first-time visitors to the site.

Acknowledgements: Funding provided by the Ontario Neurotrauma Foundation and the Quebec Rehabilitation Research Network (REPAR).

Abstract ID: 22

ANEVALUATION OF A MODIFIED YOGA PROGRAM FOR SPINAL CORD INJURY

Sander Hitzig¹, Kathryn Curtis², Nicole Leong³, Claire Wicks², David Ditor⁴, Joel Katz²

¹University of Toronto, ²York University, ³Toronto Rehabilitation Institute – UHN, ⁴Brock University

Background/objective: Yoga has been found to be a promising leisure intervention for improving health and well-being in a number of clinical populations (i.e. stroke, multiple sclerosis). At this time, there is no clinical evidence on the benefits of yoga for spinal cord injury (SCI). The purpose of this study was to evaluate a yoga program for people with SCI to determine its outcomes on health and well-being.

Methods/overview: Eleven persons (in-patients and people from the community) were recruited into a mixed-methods program evaluation of an 8-week (1 × week; approximately 45 minutes) modified yoga program offered at a SCI rehabilitation center. Only five community-dwelling persons (four women) completed the baseline and exit assessments. The sample (mean age = 44.6 years; mean months post-injury/onset = 276.4 months) included three persons with traumatic etiologies. Participants were evaluated on mood (Positive Affect and Negative Affect scale), coping/cognitions (General Self-Efficacy Scale, Pain Catastrophizing Scale, Cognitive and Affective Mindfulness Scale-Revised), and health (Fatigue Severity Scale, Brief Pain Inventory). Participants' perceptions on the yoga intervention were assessed by surveys after each class (1 = strongly disagree to 10 = strongly agree), and via semi-structured interviews at the end of the 8-week intervention. Survey data were analyzed using descriptive statistics and Wilcoxin signed rank tests. Qualitative data were analyzed via content analysis.

Results: Both per-protocol (n = 11) and intent-to-treat analyses (n = 5) revealed no significant changes in scores on any of the outcomes from baseline to exit. People from the community were more likely (P < 0.05) to complete the program than in-patients. No adverse events occurred, and participants' reported high levels of satisfaction for each class (M = 8.3 + 0.8). Qualitative analysis revealed three main themes: (1) expectations, (2) program benefits, and (3) self-growth.

Conclusions: Although no significant changes in health and well-being were noted on the surveys from baseline to exit, participants reported highly enjoying the yoga intervention, and the qualitative data indicated a number of therapeutic benefits (i.e. decreased stress, pain relief). Yoga appears to be a feasible and safe intervention post-SCI but a larger clinical trial is required to conclusively demonstrate its benefits on health and well-being.

Acknowledgements: Funding provided by the Ontario Neurotrauma Foundation, Rick Hansen Institute, and Toronto Rehabilitation Institute.

Abstract ID: 23

ANINTENDO WII-BASED REHABILITATION PROGRAM FOR SPINAL CORD INJURY: FEASIBILITY AND OUTCOMES

Sander Hitzig¹, Ketsia Proulx^2,3, Amélie Fuchs⁴, Dalton Wolfe^5,6, Désirée Maltais^2,3,7

¹University of Toronto, ²Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), ³Institut de réadaptation en déficience physique de Québec (IRDPQ), ⁴Fondation Groupama pour la Santé, ⁵Lawson Health Research Institute, ⁶Western University, ⁷Université Laval

Background/objective: The popularity of using commercially available virtual reality (VR) systems within rehabilitation settings, such as the Nintendo Wii, is growing. In addition to physical gains noted in various clinical populations (i.e. stroke, cerebral palsy), the use of VR systems has been found to improve psychological well-being (i.e. self-efficacy). However, there is a lack of evidence on the feasibility and efficacy of the Wii for use in spinal cord injury (SCI). The purpose of this study was to describe the implementation of a Wii-based rehabilitation intervention in patients with SCI, and to evaluate its psychological impact to determine its clinical value.

Methods/overview: Twelve inpatients with SCI participated in a 12-week Wii intervention (1 session per week for ∼30 minutes) at a rehabilitation hospital. The intervention was implemented by two recreational therapists using the Wii sports software packages (i.e. bowling, fishing, badminton, etc.). Patients either played with a therapist, another patient, or a family member/friend. Outcomes were assessed at baseline (week 0), mid-point (week 6), and exit (week 12) on the Modified Physical Activity Enjoyment Scale (PACES), the Positive Affect and Negative Affect Schedule (PANAS), and the SCI Exercise Self-Efficacy Scale (ESES). Weekly Wii use was documented by the therapists using the Wii Perception Survey. Friedman tests were used to assess changes over time in the outcomes.

Results: Over the 12-week period, the three most common therapeutic objectives for each session were (1) balance, (2) trunk controlm and (3) upper-extremity strength. Therapists provided favorable ratings on set up and operation of the Wii, as well as perceived client enjoyment. Perception of Wii equivalency to conventional rehabilitation by therapists also yielded favorable ratings. No adverse events were reported during sessions except for pain at weeks 3 (n = 1), 5 (n = 2), and 9 (n = 1). No changes in scores were detected over time in the PACES, PANAS, or ESES.

Conclusions: Use of the Nintendo Wii as an adjunct to conventional rehabilitation appears to be a feasible and safe intervention for SCI. Therapists' viewed the Wii as an easy and enjoyable modality for their patients. The lack in changes in outcomes (PACES, PANAS, ESES) might be due to the small sample size, and to possible adjustment issues early post-injury. A more intense and standardized Wii program, along with a comparison group, is warranted to better determine its efficacy on psychological outcomes post-SCI.

Acknowledgements: Funding provided by the Ontario Neurotrauma Foundation (ONF) and the Quebec Rehabilitation Research Network (REPAR).

Abstract ID: 24

RESPONSIVENESSAND MINIMALLY DETECTABLE DIFFERENCES OF A CLINICAL IMPAIRMENT MEASURE SPECIFIC FOR TRAUMATIC TETRAPLEGIA: A CANADIAN MULTI-CENTRE ASSESSMENT OF THE GRASSP VERSION 1.0

Sukhvinder Kalsi-Ryan

University Health Network

Background/objective: GRASSP version 1.0 is a clinical impairment measure designed specifically to assess the upper limb after traumatic cervical spinal cord injury (SCI). The GRASSP consists of five subtest scores that characterize the upper limb; it captures subtle changes in neurological impairment during the acute, sub-acute, and chronic phases of recovery. Psychometric properties of reliability (inter/test retest) and validity are well established. Responsiveness and minimally detectable difference (MDD) testing is required to establish use in efficacy and interventional studies. Scientific aims: (1) develop responsiveness and MDD of the GRASSP; (2) to establish how the measure can be applied in clinical trials and interventional studies as a tool to define effectiveness of new therapies.

Methods/overview: A prospective longitudinal study including 55 individuals with acute traumatic cervical SCI was conducted as a multi-center study. Serial testing consisted of GRASSP, International Standards for Neurological Classification for Spinal Cord Injury (ISNCSCI), Spinal Cord Independence Measure (SCIM), Capabilities of Upper Extremity Questionnaire (CUE) administered 0–10 days, 1, 3, 6, and 12 months post injury.

Analysis: The standardized response mean (SRM) for GRASSP, ISNCSCI, and SCIM III was calculated for the 0- to 3-month and 0- to 6-month pairs of data. Smallest real difference (SRD) was calculated for each subtest of the GRASSP. Pearson correlation coefficients were calculated to define concurrent validity across the recovery profile.

Results: SRM values for GRASSP subtest scores are larger by 20–30% than ISNCSCI SRM values for upper extremity strength and sensation scores at the 0 to 3, 0 to 6, and 0 to 12 month pairs of data. SRD values for all subtests range between 2.76 and 9.23. Concurrent validity between SCIM/CUE and GRASSP range between 0.632 and 0.874 across the recovery profile, validity increases with chronicity of injury.

Conclusions: Subtleties that the GRASSP characterizes are valuable in elucidating the underlying approaches to improve concomitant upper limb function. GRASSP version 1.0 provides the field with a responsive upper limb impairment measure that is useful in determining change over time; optimizing the field's ability to detect new efficacious treatments.

Acknowledgements: Ontario Neurotrauma Foundation, Rick Hansen Institute, Physiotherapy Foundation of Canada, CIHR, Craig Neilsen Foundation.

Abstract ID: 25

THEIMPACT OF PRESSURE ULCERS ON INDIVIDUALS LIVING WITH A SPINAL CORD INJURY

Deena Lala¹, Frédéric S Dumont², Jean Leblond², Pamela E Houghton^3,4, Luc Noreau^2,5

¹Western University, ²Centre for Interdisciplinary Research in Rehabilitation and Social Integration, ³Western University, ⁴Lawson Health Research Institute, ⁵Laval University

Background/objective: Pressure ulcers are one of the most common secondary health complications among individuals living with a spinal cord injury (SCI). The primary objective of this study was to describe the impact of pressure ulcers on various activities and overall quality of life among individuals living with SCI. The secondary objective was to compare the health care utilization in those people with and without a pressure ulcer.

Methods/overview: Participants were invited to participate in a Canada-wide online or telephone survey. Outcome measures were obtained from the Rick Hansen Spinal Cord Injury Registry Community Follow-up version 2.0 (RHSCIR CFQ-V2.0).

Results: A total of 1137 participants (806 males; 331 females) with traumatic SCI and living in the community for at least 1 year were recruited of which 381 (33.5%, 95% confidence interval = 30.8 − 36.3%) had at least one pressure ulcer over the last 12 months. Presence of pressure ulcers was found to have a negative association with the ability of individuals with SCI to participate (activities of daily living and social roles) as much as they want. Approximately 29.7% of individuals with pressure ulcers were dissatisfied with their ability to perform their main activity compared with those without a pressure ulcer (24.3%). The overall quality of life was also significantly lower among individuals with pressure ulcers compared to those who did not have a pressure ulcer (P = 0.005). In addition, individuals with pressure ulcers had significantly higher health care utilization compared to those without a pressure ulcer (P < 0.05). The most common health care professionals involved with pressure ulcer care were family doctors (82.8% vs. 77.9%), occupational therapists (46.9% vs. 29.6%), nurses (46.9% vs. 29.0%), urologists (45.5% vs. 36.0%), and wound care nurse (41.6% vs. 9.8%).

Conclusions: This is the first nation-wide survey to document the impact that pressure ulcers have on individuals living with SCI. Our findings highlight the need to implement pressure ulcer prevention and management programs for this high-risk population.

Acknowledgements: Granting Agency/Funding Source: Rick Hansen Institute Grant Number: 2010-03.

Abstract ID: 26

FROMGET IN MOTION TO PASSEZ A L'ACTION: CHALLENGES ASSOCIATED WITH THE IMPLEMENTATION OF A THEORETICALLY-BASED PROGRAM TO INCREASE PHYSICAL ACTIVITY IN ADULTS WITH SPINAL CORD INJURY

Marie-Eve Lamontagne^1,2,3, Kelly Arbour-Nicitopoulos^2,4,5, Jennifer R. Tomasone^5,6, Isabelle Cumming^1,3, Amy Latimer-Cheung^2,5,7, Franois Routhier^1,2,3

¹Université Laval, ²COM-QOL, ³CIRRIS-IRDPQ, ⁴University of Toronto, ⁵SCI Action Canada, ⁶McMaster University, ⁷Queen's University

Background/objective: Clinicians and researchers increasingly seek out effective strategies and interventions to help individuals with disabilities engage in physical activity (PA). A theoretically based, telephone counseling program, Get In Motion (GIM), was created in 2008 to increase PA participation among Canadian adults with spinal cord injury (SCI), with the establishment of a French adaptation (Passez a l'action (PAL)) in 2011. The goal of this study is to explore the facilitators and barriers of GIM and PALs implementation within two distinct community-based settings.

Methods/overview: We performed focus groups with GIM and PAL providers (n = 8) using the Consolidated Framework for the Advancement of Implementation Science as a guide for developing the focus group questions. The focus groups were audio recorded, transcribed and submitted to a content analysis using NVivo 9.0.

Results: Proviers of GIM and PAL encountered very different barriers and facilitators in the implementation of the two services. GIM implementation facilitators were often related to the strong evidence-based nature of the program, while the barriers were mainly related to the external environment in which GIM operates. Meanwhile, PAL implementation facilitators were deemed to be centered around the individuals, while the scarcity of the implementation process was seen as an obstacle.

Conclusions: Implementation of empirically tested and theory-based PA programs may encounter important challenges that vary according to the context and implementation processes. It is critical to carefully analyze the specific context within which a program is implemented to determine the most suitable strategy for enhancing the programs implementation.

Acknowledgements: COM-QOL is funded through the Ontario Neurotrauma Foundation (ONF) and the Provincial Rehabilitation Research Network (REPAR) Ontario/Quebec Inter-Provincial Partnership grant. Internal Faculty of Kinesiology and Physical Education research grant (awarded to KAN) for the financial support for this study.

Abstract ID: 27

ANOVEL METHOD TO REDUCE MUSCLE FATIGUE DURING FUNCTIONAL ELECTRICAL STIMULATION FOR PEOPLE WITH SPINAL CORD INJURY

Kei Masani^1,2, Dimitry G. Sayenko³, Robert Nguyen⁴, Milos R. Popovic^1,2

¹Toronto Rehabilitation Institute – UHN, ²University of Toronto, ³University of Louisville, ⁴ETH Zurich, Zurich, Switzerland

Background/objective: Functional electrical stimulation (FES) is limited by the rapid onset of muscle fatigue caused by localized nerve excitation repeatedly activating only a subset of motor units. We have developed a novel method called spatially distributed sequential stimulation (SDSS) to reduce muscle fatigue during FES compared with a conventional single electrode stimulation (SES), and tested that with an individual with spinal cord injury when applied for plantar flexors. The purpose of this study is to explore the fatigue-reducing ability of SDSS for major lower limb muscle groups in the able-bodied population, as well as individuals with spinal cord injury (SCI).

Methods/overview: SDSS was delivered through four active electrodes applied to the muscle of interest, sending a stimulation pulse to each electrode one after another with 90° phase shift between successive electrodes. For comparison, SES was delivered through one active electrode. For both modes of stimulation, the resultant frequency to the muscle as a whole was 40 Hz. Three minutes fatiguing stimulation was applied to participants' (1) knee extensors, (2) knee flexors, (3) plantarflexors, and (4) dorsiflexors in 15 able-bodied individuals as well as 12 individuals with SCI. Three fatigue measures were used for comparison: fatigue index (final torque normalized to maximum torque), fatigue time (time for torque to drop by 3 dB), and torque-time integral (over the entire trial).

Results: There were significant differences in all measures between SDSS and SES for knee extensors, knee flexors, and knee flexors in both experimental groups, indicating that muscle fatigue was less when using SDSS for these muscle groups.

Conclusions: The present work verifies and extends reported findings on the effectiveness of using SDSS in the leg muscles to reduce muscle fatigue. Application of this technique can be easily incorporated in the clinical setup and facilitate the usefulness of FES.

Acknowledgements: Granting Agency/Funding Source: Canadian Institutes of Health Research Grant Number: MOP 111225.

Abstract ID: 28

PILOTTESTING OF FUNCTIONAL ELECTRICAL STIMULATION (FES) CYCLING ON SPASTICITY IN PERSONS WITH SPINAL CORD INJURY: FES BIKE STUDY

Shane McCullum, Melony Jones, Colleen O'Connell

Stan Cassidy Centre for Rehabilitation

Background/objective: Functional electrical stimulation (FES) is widely acknowledged as a promising treatment for a number of chronic health conditions related to muscle paralysis. FES can provide coordinated electrical stimulation to muscles of the paretic limb, thus enabling the limb to move through a functional range of motion, without the external aid of a therapist or artificial robotic device. FES has shown benefits for improved walking ability in childhood cerebral palsy, foot-ankle function in patients with post-stroke chronic hemiplegia, as well as upper-extremity function in stroke survivors. The purpose of this pilot study is to quantify the short-term fixed-dose response of FES cycling on muscle spasticity.

Methods/overview: Spasticity measurements take place at seven pre-set intervals over a 30-hour period, commencing 4 hours prior to the cycling session, and finishing 24 hours post-cycling. The main outcome measure being used is the Pendulum Test (using a Portable Pendulum Test System developed at the Institute of Biomedical Engineering at the University of New Brunswick). Secondary outcome measures include the Modified Ashworth Scale and the Numeric Rating Scale. All patients have previously used an FES cycle, and therefore have their own program prepared. Electrodes are placed bilaterally over the Quadriceps, Hamstrings, and Gluteus Maximus muscle groups. The stimulation occurs at set angles to create a cycling motion. After a brief warm-up, the stimulation level ramps up to create aid in pedalling the cycle. Each FES session continues for a minimum of 15 minutes, with a maximum length of 60 minutes.

Results: The main outcome used for this study is the relaxation index (RI), measured using the portable pendulum test. An RI between 1.5 and 1.8 is considered normal, 1.0–1.5 is considered mild spasticity, and 0–1.0 is indicative of severe spasticity. Taking the average RI for completed subjects, the RI increases by 0.488 for the right leg, and by 0.288 for the left leg (an increase in RI indicates a decrease in spasticity).

Conclusions: We have completed 5 of 10 subjects to date. Although the study is ongoing, there is a trend toward a reduction in spasticity immediately after the FES cycling session. This appears to be a short-term reduction, as spasticity levels return for subsequent measurement sessions. The remaining subjects will be recruited, and their data analyzed in time for dissemination at this conference.

Acknowledgements: Granting Agency: Stan Cassidy Research and Development Fund (no external funding for this study).

Abstract ID: 29

HOWTHE INTENSITY OF THE OCCUPATIONAL THERAPY IMPACTS THE FUNCTIONAL OUTCOMES IN SUB-ACUTE SPINAL CORD INJURY

Milos Popovic^1,2, Naaz Kapadia², Shaghayegh Bagher²

¹University of Toronto, ²Toronto Rehabilitation Institute – UHN

Background/objective: Primary objective of this retrospective analysis was to compare the benefits of single (COT1) versus double (COT2) dose of conventional occupational therapy (COT) in improving voluntary hand function in individuals with incomplete, sub-acute C3–C7 spinal cord injury (SCI). The secondary objective was to compare these two interventions versus functional electrical stimulation therapy plus conventional occupational therapy (FES + COT).

Methods/Overview: Data from Phase I and Phase II randomized control trials, that recruited individuals with traumatic incomplete sub acute SCI, were pooled together for the purpose of this study. Participants in COT1 group received 45 hours of therapy, in COT2 group received 80 hours of therapy, and in FES + COT group received 40 hours of COT therapy +40 hours of FES therapy. Primary outcome measure was Functional Independence Measure (FIM) self-care sub-score. Secondary outcome measures were Spinal Cord Independence Measure (SCIM) self-care sub-score and Toronto Rehabilitation Institute Hand Function Test. In this study we analyzed FIM and SCIM self-care sub-scores.

Results: There were no significant differences in the mean FIM and SCIM self-care sub-scores between the COT1 and COT2 groups. However, participants in FES + COT showed a considerable improvement in FIM self-care sub-score and a six-fold increase in SCIM self-care sub-score, as compared with both COT1 and COT2 groups (P = 0.062 and 0.000, respectively).

Conclusions: Increased intensity of rehabilitation alone may not always be beneficial, type of intervention plays a significant role in determining change, in this instance FES therapy in combination with COT yielded much better outcomes.

Acknowledgements: The Physicians' ServicesIncorporated Foundation (PSI Grant #05-06) and Christopher and Dana Reeve Foundation (PAC 1-0706-2).

Abstract ID: 30

IMPROVINGVOLUNTARY UPPER LIMB FUNCTION IN INDIVIDUALS WITH CHRONIC INCOMPLETE SPINAL CORD INJURY

Milos Popovic^1,2, Naaz Kapadia², Vera Zivanovic²

¹University of Toronto, ²Toronto Rehabilitation Institute – UHN

Background/objective: Functional electrical stimulation (FES) therapy has been demonstrated to be one of the most promising interventions for improving voluntary grasping function in individuals with subacute cervical spinal cord injury (SCI). The objective of this study was to determine the effectiveness of FES therapy in improving voluntary hand function in individuals with chronic (≥24 months post injury), incomplete C4 to C7 SCI (AIS B-D), as compared to conventional occupational therapy (COT).

Methods/overview: Eight participants were randomized to the intervention (FES therapy) (n = 5) and control (COT) group (n = 3). Both groups received 39 hours of therapy over 13–16 weeks. Outcome assessments were performed at baseline, discharge, and 6 months follow-up. The Toronto Rehabilitation Institute-Hand Function Test (TRI-HFT) was the primary outcome measure and the secondary outcome measures were the Functional Independence Measure's (FIM), the Spinal Cord Independence Measure's self care sub-scores and the Graded Redefined Assessment of Strength Sensibility and Prehension. Pre and post therapy scores were compared using Wilcoxon Signed Rank test and means of the two groups were compared using the Mann–Whitney U test.

Results: At discharge the Intervention Group improved by 4.4 points on the TRI-HFT's Object Manipulation Task, whereas the Control Group changed by 0.1 point only. Similarly, at discharge the Intervention Group improved by 4.6 points on the FIM self care sub-score, whereas the Control Group did not change at all.

Conclusions: FES therapy has a greater impact in improving voluntary hand function in individuals with chronic incomplete tetraplegia, as compared with conventional occupational therapy alone.

Acknowledgements: SCISN(2009-36)

Abstract ID: 31

DEVELOPMENTAND VALIDATION OF AN EVIDENCE-BASED PROGRAM FOR CHRONIC PAIN MANAGEMENT IN INDIVIDUALS WITH SPINAL CORD INJURY

René Quirion¹, David Rodrigue¹, Marie-Eve Lamontagne^2,3,4, Francois Routhier^2,3,4

¹IRDPQ, ²Université Laval, ³COM-QoL, ⁴CIRRIS-IRDPQ

Background/objective: A majority of people with spinal cord injury (SCI) lives with chronic pain. Many rate chronic pain as one of the most difficult problems to manage, that influence their function, mood, and quality of life. There is a need for an evidence-based pain management program, adapted to the context of a supra-regional, tertiary rehabilitation center. The aim of this study was to develop and validate a multidisciplinary pain management program for people who live with SCI and chronic pain in the East of Quebec Province.

Methods/overview: A systematic review was first conducted to develop a theoretical model of Chronic Pain Self-Management group program. In a second step, the Technique for Research of Information by Animation of a Group of Expert was used with 11 experts to validate the proposed logic model of the program. Thereafter, users acceptability of the logic model was evaluated. To ensure the representativeness of the patient sample, telephone interviews were conducted with people with SCI and their proxy who lived far away from IRDPQ, and a focus group was conducted with those living in Quebec city area. A qualitative analysis of this consultation was performed to adapt a final logical model of a multidisciplinary Chronic Pain Self-Management Program for SCI.

Results: This program combines physical, pharmacological, and cognitive-behavioral interventions. It combines group interventions given locally at IRDPQ and individual interventions given at IRDPQ and/or at distance for those who live far away from Quebec City. This program will last for three months, and it will be followed by three booster sessions over a period of six month. This program will be pilot-tested and evaluated in Fall 2014 with a group of six to eight individuals with SCI who live with chronic pain.

Conclusions: Our approach combines three types of evidences to produce an solid program adapted to the need of the users and the IRDPQ context. Further studies will be required to evaluate the program accessibility, effectiveness, and competitive advantage.

Acknowledgements: COM-QOL is funded through the Ontario Neurotrauma Foundation (ONF) and the Provincial Rehabilitation Research Network (REPAR) Ontario/Quebec Inter-Provincial Partnership grant.

Abstract ID: 32

NEUROPROSTHESISDESIGN WITH OPTIMIZED FES PARAMETERS TO MINIMIZE MUSCLE FATIGUE

Hossein Rouhani^1,2, Karen E. Rodriguez^1,2, Kei Masani^1,2, Milos R. Popovic^1,2

¹Toronto Rehabilitation Institute – UHN, ²University of Toronto

Background/objective: Design of neuroprostheses for individuals with spinal cord injury is confined by rapid onset of muscle fatigue in response to functional electrical stimulation (FES). We introduced an algorithm to choose optimal pulse shape parameters for FES pulse that attained certain levels of muscle force for longer time periods and resulted in minimal muscle fatigue.

Methods/overview: We measured the generated ankle torque of three individuals with different levels (33) of pulse duration (150, 300, 450 µs) and pulse amplitude (40, 50, 60 mA) of the biphasic, asymmetric, balanced rectangular pulse wave, applied to ankle plantarflexor muscles. We calculated the maximum torque and two muscle fatigue measures (i.e. fatigue time and torque time integral) during 3 minutes of continuous FES. Then, we interpolated the obtained muscle fatigue measures and maximum torque over the range of pulse duration and amplitude. For each level of the generated maximum torque, we chose the pulse duration and amplitude combination that resulted in the minimum muscle fatigue among all combinations that resulted in such a maximum torque level.

Results: The fatigue performance of the left and right ankle plantarflexors was similar for each subject, even when measurements of the left and right ankles were done on different days (median correlation coefficient was over 0.95 for all subjects and parameter levels). This indicated that the obtained choice of pulse duration and pulse amplitude could be later used in clinical applications. The fatigue performance did not show high inter-subject repeatability with median coefficient of multiple correlations of 0.71 for all parameter levels and all subjects. This suggests that the results obtained for one individual cannot necessarily be applied to another individual.

Conclusions: We suggested an algorithm to empirically obtain the generated torque and muscle fatigue measures based on pulse duration and pulse amplitude of rectangular FES pulses. In order to generate each level of an ankle joint torque, we found optimum choices of pulse duration and pulse amplitude that resulted in the minimum muscle fatigue among all choices. In order to design neuroprostheses with optimal muscle fatigue performance, we suggest modulating the pulse duration and pulse amplitude along the line formed by the calculated optimal choices to obtain different torque levels. Similar algorithm to optimize FES pulse shapes can be applied for other muscles in design of variety of neuroprostheses.

Acknowledgements: Granting Agency: Swiss National Science Foundation (SNSF) Grant Number: PBELP3-137539.

Abstract ID: 33

IMPROVINGSTANDING STABILITY USING CLOSED-LOOP CONTROL OF FUNCTIONAL ELECTRICAL STIMULATION

Michael Same^1,2, Hossein Rouhani^1,2, Kei Masani^1,2, Milos Popovic^1,2

¹Toronto Rehabilitation Institute – UHN, ²University of Toronto

Background/objective: Enhancing standing ability in individuals with spinal cord injury (SCI) would facilitate improved quality of life and independence, whilst also minimizing secondary complications. To this end, applying functional electrical stimulation (FES) to muscles of the lower limbs in closed loop has shown promise. In particular, it has been suggested that a proportional-integral-derivative (PID) control strategy could provide functional benefits to stability by mimicking the neural control strategy employed in able-bodied stance.

Methods/overview: We examined the potential of a PID control strategy with gravity compensation to effectively maintain balance during quiet stance by regulating FES-induced contractions of the ankle plantarflexors and dorsiflexors in eight able-bodied subjects. In experiments, the subjects' feet were attached to an inverted pendulum which rotated in the subjects' sagittal plane in response to torque applied by the ankle muscles, thus simulating quiet stance. However, the subjects' bodies were fixed in an upright, stationary posture throughout, thus minimizing sensory information and disrupting voluntary control. The ability of the PID controller to maintain the inverted pendulum about a reference angle of 5 degrees was examined during 5-minute trials. Performance metrics including those pertaining to stability during quiet stance (mean error signal, root mean square error), and ability to transition from an offset initial position (rise time, settling time, percent overshoot), were examined. Using the Wilcoxon signed rank test, the results were compared with performance during voluntary control trials, in which the subject attempted to balance the inverted pendulum using their voluntary control.

Results: The PID controller was able to maintain the inverted pendulum about the reference angle successfully and reliably in all eight subjects. Moreover, significant improvements over the voluntary control condition were observed for settling time (P < 0.01), mean error signal (P < 0.02), and root mean square error (P < 0.02).

Conclusions: Our results demonstrate that FES-assisted balance that is regulated using a PID control strategy is capable of reliably improving stability in able-bodied individuals. Therefore, the proposed closed-loop controlled FES system could potentially be applied to the problem of restoring or improving standing ability in patients with SCI.

Acknowledgements: Granting Agency: Natural Sciences and Engineering Research Council of Canada Grant Number: 249669.

Abstract ID: 34

SENSITIVITYAND SPECIFICITY OF DIFFUSION TENSOR IMAGING FOR DIAGNOSING TRAUMATIC BRAIN INJURY IN PATIENTS WITH SPINAL CORD INJURY

Bhanu Sharma^1,2, Cheryl Bradbury¹, David Mikulis³, Robin Green¹, Bojana Budisin¹

¹Toronto Rehabilitation Institute – UHN, ²University of Toronto, ³Toronto Western – UHN

Background/objective: Anecdotally, clinicians in our spinal cord injury (SCI) rehabilitation center reported a suspicion of undiagnosed traumatic brain injury (TBI) in patients with SCI. A seminal study (n = 33) investigated the frequency of missed TBI diagnosis in patients with SCI and found, in a European setting, that 60.9% of TBIs in patients with SCI were not detected in acute care; our lab, in a larger study (n = 92) and Canadian context, recently corroborated this finding by demonstrating that a TBI diagnosis is missed in 58.5% of patients with SCI. Given that many TBI diagnoses are missed in acute care, we discuss the added and alternative value of diffusion tensor imaging (DTI) as a TBI diagnostic tool in SCI. We assessed the sensitivity and specificity of DTI for detecting TBI in patients with SCI using, as a gold standard of diagnosis, a combination of conventional imaging (computed tomography (CT) and structural magnetic resonance imaging (MRI)), neurological indices, and neuropsychological assessment.

Methods/overview: Ninety-two patients with a clinical SCI diagnosis were consecutively recruited from a large, urban, spinal cord rehabilitation program. At 3–6 months post-injury, each patient was classified as TBI positive or not using our gold standard of diagnosis. We carefully controlled for confounds. (See Sharma et al., in press for details.) A subset of patients also received DTI. DTI classification was based on the use of normative data; a positive TBI diagnosis on DTI necessitated that patients demonstrate a fractional anisotropy discrepancy, relative to age-matched healthy controls, of 1.5 z-scores in two or more regions of interest (selected for their vulnerability to TBI and resistance to SCI-related transneuronal degeneration) or ≥2 z-scores in one region of interest. The diagnostic sensitivity and specificity of DTI was compared to our gold standard.

Results: Twenty-four patients received DTI. Our gold standard showed that of these 24 patients, 10 were TBI positive, and the remaining 14 were negative for TBI. The 10 cases classified as TBI positive by our gold standard were also found to be TBI positive on the basis of our DTI analysis. Of the 14 cases diagnosed as TBI negative by our gold standard, DTI classified 12 similarly; the remaining 2 were TBI positive on DTI.

Conclusions: Both sensitivity and specificity of DTI were high against our gold standard. As CT and structural MRI have limited sensitivity to milder TBIs, neurological indices are often unreliably recorded, and neuropsychological assessment is often compromised by psychoactive pain medications, DTI may be of diagnostic value in the context of SCI.

Acknowledgements: Ontario Neurotrauma Foundation & Canada Research Chair.

Abstract ID: 35

PHYSICALACTIVITY PARTICIPATION OF ADULTS WITH SCI LIVING IN QUBEC AND ITS ASSOCIATION WITH LIFE SATISFACTION

Shane N. Sweet¹, Isabelle Cummings^2,3, Amy E. Latimer-Cheung⁴, Anne-Marie Belley³, Francois Routhier^2,3, Luc Noreau^2,3

¹McGill University, ²Université Laval, ³CIRRIS, ⁴Queen's University

Background/objective: SCI Action Canada launched the physical activity (PA) guidelines for adults with spinal cord injury (SCI) in 2011. To date, no study has investigated the extent to which adults with SCI living in Qubec meet the population-specific PA guidelines. The study sought to determine the percentage of adults with SCI who meet the PA guidelines and the specific aerobic and resistance recommendations. We also examined the relationship between aerobic and resistance PA with life satisfaction.

Methods/overview: A sample of adults with SCI (N = 73) living in Qubec answered over the telephone a set of questionnaires relating to their PA participation and life satisfaction. Individuals who participated in at least 40 minutes of moderate-to-vigorous aerobic PA over the past week were considered to meet the aerobic PA recommendation while participation in at least two sessions of resistance PA was coded as meeting the resistance recommendation. Individuals who met both the aerobic and resistance recommendations were classified as following the PA guidelines. Total minutes of moderate-to-vigorous aerobic and strenuous PA were entered separately in a multiple regression to predict life satisfaction.

Results: Participants were primarily male (75%) with an average age of 53 years (12.56), had a high school (46%) or college education (31%), were single (32%) or married (38%), and used a manual wheelchair (61%). Majority of the participants reported an ASIA classification of A (46%) or D (21%) and a motor vehicle accident as the cause of injury (46%). Forty-four percent and 24% of adults with SCI participated in sufficient PA to be in line with the aerobic and resistance recommendations, respectively. Only 15% of the sample met the recommended PA guidelines. Total minutes of aerobic PA predicted life satisfaction (β = 0.33, P = 0.01) while total minutes of resistance PA did not (β = 0.10, P = 0.43). Both variables explained 14% of the variance in life satisfaction.

Conclusions: Very few adults with SCI living in Qubec participate in sufficient amount of PA for health benefits. Aerobic PA appears to better predict life satisfaction; however, these results could be explained by the higher overall PA dose (i.e. more activity). A study comparing these results to other Canadian provinces would help with the generalizability of these findings.

Acknowledgements: We thank COM-QOL for the financial support for this study.

Abstract ID: 36

MEASURESOF ARTERIAL STRUCTURE AND FUNCTION IN INDIVIDUALS WITH CHRONIC SPINAL CORD INJURY

Julia Totosy de Zepetnek, Maureen MacDonald

McMaster University

Background/objective: Models based on traditional risk factor assessment fail to predict cardiovascular disease (CVD) in 50% of cases. A reason for this gap in CVD prediction may be due to the exclusion of emerging and novel risk factors, such as assessment of peripheral vascular structure and function. Assessing arterial stiffness and endothelial function might increase the predictive accuracy of CVD risk stratification, particularly in a sedentary population. This study assessed arterial structure and function in individuals with chronic spinal cord injury (SCI).

Methods/overview: Thirty-four individuals (n = 32 male, n = 2 female) with SCI who had lesions from C1–T11, AIS A–D, and 12.7 ± 9.9 YPI participated; age: 40.1 ± 10.9 years, body mass index (BMI): 26.6. ± 4.7 kg/m2, and waist circumference (WC): 93.0 ± 13.6 cm. Eight able-bodied (AB) men matched for age: 42.8 ± 7.2 years, BMI: 25.8 ± 3.8 kg/m2, and WC: 91.9 ± 9.5 cm participated. Central arterial stiffness was assessed via pulse wave velocity from carotid to femoral artery (cPWV), while endothelial function was assessed via flow-mediated dilation of the brachial artery (baFMD).

Results: cPWV was 8.98 ± 4.73 and 7.39 ± 1.77 m/s and relative baFMD was 7.37 ± 2.95 and 8.36 ± 5.25% for SCI and AB, respectively. Stratified based on level of lesion, cPWV was 8.53 ± 4.59 and 9.77 ± 5.06 m/s for those with tetraplegia (≥T1; n = 22) and paraplegia (less than T1; n = 12), respectively. baFMD was 8.01 ± 2.97% and 6.21 ± 2.62% for tetraplegia and paraplegia, respectively. No differences were found between groups for cPWV (P = 0.47 tetra vs. para; P = 0.37 SCI vs. AB) or baFMD (P = 0.09 tetra vs. para; P = 0.47 SCI vs. AB).

Conclusions: No differences in cPWV between groups could be due to smooth muscle denervation among those with high lesion levels. Individuals with tetraplegia could have increased structural arterial stiffness counterbalanced by decreased functional arterial smooth muscle activation. Although we found no differences between groups for baFMD, there was a trend toward higher values in those with higher lesions. Perhaps the smaller baseline diameter among those with tetraplegia (P = 0.02) resulted in an upregulation of eNOS due to chronically enhanced baseline shear stress. These results indicate that individuals with SCI have preserved cPWV and baFMD when compared to AB controls. Future studies with larger representative groups are necessary to determine the relationship between peripheral arterial vasculature and atherosclerosis in individuals with SCI.

Acknowledgements: Ontario Neurotrauma Foundation (2011-ONF-RHI-MT-888); Natural Sciences and Engineering Research Council (2009-2013-238819-2008).

Abstract ID: 37

PERCEIVEDPHYSICAL ACTIVITY FOR INDIVIDUALS WITH TRAUMATIC AND NON-TRAUMATIC SPINAL CORD INJURY DURING INPATIENT REHABILITATION

Paul Wolfe¹, Molly C. Verrier², Audrey Hicks³

¹University of Waterloo, ²University of Toronto, ³McMaster University

Background/objective: Amount and intensity of physical activity during rehabilitation for individuals with SCI is unclear as are physical activity differences for traumatic (TSCI) and non-traumatic (NTSCI) while rehabilitation includes physical activity for optimizing recovery. This observational study examined the amount and intensity of individuals' physical activity during rehabilitation.

Methods/overview: Twenty-nine of the 74 participants enrolled at two Canadian SCI rehabilitation facilities completed the Perceived Physical Activity Assessment for People with Spinal Cord Injury (PARA-SCI). PARA-SCI quantifies the daily amounts and intensity of physical activity using data from three consecutive days. Total average physical activity/hour was measured for both TSCI (n = 19; age 37 ± 14.7 years) and NTSCI (n = 10; age 47 ± 17.0 years). Levels of physical activity, nothing at all (NAA), mild, moderate, and heavy were categorized. Pearson correlation coefficients were used to determine the relationship between time post-admittance and PARA-SCI scores. Average PARA-SCI scores were examined for the total sample and for TSCI and NTSCI. Participants were assessed on average 245.24 ± 41.14 days after initial admission to an acute care hospital.

Results: There was no relationship between the time from admittance to acute care and PARA-SCI scores. Average perceived physical activity in the total sample was 43.1 ± 10.4 minutes/hour; TSCIs perceived 45.1 ± 6.6 minutes/hour on average and NTSCIs perceived 39.3 ± 15.0 minutse/hour. Only 11 of 29 participants perceived physical activity in the heavy category. Results did suggest that participants with TSCI on average engaged in more minutes of physical activity/hour in a given day than participants with NTSCI. Participants with TSCI perceived more physical activity at intensities above NAA whereas the majority of physical activity in NTSCI participants was perceived as NAA.

Conclusions: No trends were observed for different intensity levels for time since admittance to PARA-SCI assessment. TSCI participants appeared to engage in higher physical activity intensities, while NTSCI participants tended to report NAA more often. Findings were limited by a small sample size. Future research should investigate perceived and actual physical activity levels between TSCI and NTSCI participants to elucidate underlying mechanisms and inform rehabilitation strategies.

Acknowledgements: Granting Agency/Funding Source: Craig H. Neilson Foundation Grant Number: 164422.

Abstract ID: 38

HANDIDENTIFICATION IN WEARABLE CAMERA VIDEO FOR MONITORING HAND USE AT HOME

Jose Zariffa¹, Milos R. Popovic^1,2

¹Toronto Rehabilitation Institute – UHN, ²University of Toronto

Background/objective: Upper limb rehabilitation is of paramount importance for maximizing independence after cervical spinal cord injury (SCI). It is currently difficult to assess the true impact of rehabilitation interventions on upper limb function in the daily life of patients once they have returned home. A wearable sensor that could assess how frequently a patient is using their hand at home, rather than relying on attendant care, would be very helpful in two respects: (1) as an outcome measure for evaluating new interventions, and (2) to provide information that therapists can use to develop more individualized outpatient rehabilitation programs that better adapt to each individuals evolving function. The objective of our research is to develop such a sensor, based on computer vision technology and wearable cameras. Here, we focus on the task of segmenting the hand from the background of the image in wearable camera videos.

Methods/overview: A commercial wearable camera was used to record video from an able-bodied subjects point of view during activities relevant to daily living (eating, brushing teeth, manipulating objects on a table). A two-step image processing algorithm was applied to the videos. First, it was determined whether or not a hand was present in the image, using a priori models of skin colour and a series of decision criteria applied to the resulting skin-coloured regions. Second, the detailed contour of the hand was determined. This was accomplished by adaptively determining, for each frame, the region within a colour histogram that corresponds to hand colours, and backprojecting the image using the reduced histogram. In order to evaluate the results of the contour detection algorithm, the automatically identified contours were compared to manually traced contours in 97 test frames.

Results: In four test videos, the classification accuracy for detecting the presence of a hand in the image was 88.3%. The performance of the contour detection algorithm was evaluated using the F-score metric (harmonic mean of precision and recall), and the median value was found to be 0.86.

Conclusions: An algorithm has been developed that constitutes the first step of a wearable system that will monitor and log the interactions of the hand with its environment, for the purpose of assessing independence and reliance on attendant care in the home after rehabilitation.

Acknowledgements: The authors gratefully acknowledge the financial support of Spinal Cord Injury Ontario and the Toronto Rehabilitation Institute – UHN.

Abstract ID: 39

DETECTINGDIFFERENT HAND GRASPS USING ELECTROENCEPHALOGRAPHY: APPLICATIONS FOR UPPER-LIMB REHABILITATION FOLLOWING SPINAL CORD INJURY

Kathryn Atwell¹, Milos R Popovic^1,2, Cesar Marquez-Chin²

¹University of Toronto, ²Toronto Rehabilitation Institute – UHN

Background/objective: The spinal cord injury (SCI) population of Canada and the USA is approximately 319 000 and 40% of SCI cases have upper and lower limb impairments. Given that regaining hand and arm function has been identified as the highest priority for individuals with SCI, novel post-SCI rehabilitation therapy incorporating the functional reorganization of the brain is being developed. Functional electrical stimulation (FES) therapy has been used successfully to restore hand and arm function for individuals with SCI. This intervention requires a therapist to identify the moment of the patient's intent to move at which point electrical stimulation is triggered to facilitate movement of a paretic limb. It has been hypothesized that the coupling of peripheral stimulation (e.g. by FES) with cortical activation (motor imagery by the patient) could activate a silent corticospinal synaptic connection promoting motor recovery. However, reliance on the therapist to determine the intention to move may be uncertain. The goal of this project is to create a brain-computer interface (BCI) that can identify specific hand grasps using EEG signals. This may have a significant impact on upper limb rehabilitation in SCI as the FES therapy would facilitate the specific grasp intended by the user.

Methods/overview: Electroencephalography (EEG) will be recorded (C1, C2, C3, C4, CZ, F3, F4, and FZ of the 10–20 EEG electrode placement system) from 10 healthy adults while performing 6 different hand grasps. We present here preliminary results for two right-handed participants. Time-resolved power changes in the EEG spectrum unique to each hand grasp were identified using correlation-based feature extraction. These signal features were then classified with a nearest neighbour classifier to determine the grasp executed by the participant.

Results: For the two participants presented here, three of the six grasps were identified correctly with accuracies between 62 and 74% from electrodes: C1, C3, CZ, and F3.

Conclusions: Preliminary results from this study provide early indication that there is a correlation between specific hand grasps and the spectral, spatial, and temporal features of the EEG. As the results reported in this study reflect analysis of EEG data prior to movement, further refinement of this method could be used to develop an EEG-based BCI for FES therapy applications in the SCI population for the purposes of upper limb rehabilitation.

Acknowledgements: Funding Source: The Dana Foundation.

Abstract ID: 40

THEEFFECT OF EXERCISE ON HEART RATE VARIABILITY IN SPINAL CORD INJURY

Rasha El-Kotob^1,2, Molly C. Verrier², Sunita Mathur¹, B. Catharine Craven²

¹University of Toronto, ²Toronto Rehabilitation Institute – UHN

Background/objective: Cardiac autonomic dysfunction, including an impaired heart rate, rhythm, and contractility, is common after a spinal cord injury (SCI). Heart rate variability (HRV) is a non-invasive cardiac autonomic assessment tool as it reflects cardiac regulation via the autonomic nervous system. Regular physical activity has been shown to play a vital role in cardiovascular disease prevention and management. This review paper reports the effects of exercise training on HRV in individuals with SCI.

Methods/overview: A Medline (Pubmed) literature search was performed using a combination of the following terms: “heart rate variability,” “exercise,” “exercise therapy,” “exercise intervention,” “autonomic nervous system,” “autonomic control,” and “spinal cord injury.” Studies included in the review had to fulfill the following criteria: published in English between the years of 1996–2013 as the HRV standardized guidelines were developed in 1996 by a Task Force composed of members from the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. HRV measurement methods had to align with the Task Force guidelines to ensure consistencies among studies, recruited adult human subjects with any type of SCI, and measured HRV pre- and post-exercise intervention.

Results: The search resulted in 32 studies examining HRV and SCI, the 32 abstracts were then reviewed to determine whether they met all the inclusion criteria. A total of three studies were retrieved, two were non-randomized interventional studies involving Body Weight Support Treadmill Training (BWSTT) and one was a randomized cross-over interventional study involving BWSTT and head up tilt training. All studies recruited chronic SCI subjects (n = 8; n = 6; n = 7) AIS A–C, and HRV frequency domain measures were reported. After the exercise interventions, individuals with incomplete tetraplegia had a significant reduction in the low frequency component of HRV. However, the studies that did not restrict the LOI to T5 and above revealed insignificant HRV changes post exercise.

Conclusions: Investigators should consider the NLI and AIS when examining cardiac autonomic function. The review paper revealed that there is insufficient volume of data to infer clear recommendations due to small sample size, lack of impairment heterogeneity, and choice of exercise interventions. Prospective measurement of HRV parameters in a large, representative SCI sample at rest is required prior to assessing HRV in exercise settings.

Acknowledgements: Source: Canadian Institutes of Health Research Grant number: 260877.

Abstract ID: 41

EFFECTOF TRUNK STABILIZATION ON UPPER LIMB PERFORMANCE IN INDIVIDUALS WITH SCI

Murielle Grangeon^1,2, Cyril Duclos^1,2, Dany Gagnon^1,2

¹Université de Montréal, ²Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Institut de réadaptation Gingras-Lindsay-de-Montréal

Background/objective: Sitting balance in individuals with spinal cord injury (SCI) is generally decreased since the strength-generating ability and neuromotor synergies of the trunk and lower extremity muscles controlling the pelvis and trunk are impaired. These impairments also reduce the strength-generating ability of the thoracohumeral, scapulohumeral, and shoulder muscles because no more force can be exerted on a distal segment than the amount that can be counteracted at the proximal segment for the movement not to destabilize the body. This study aimed to quantify the effect of trunk stabilization on upper limb (U/L) performance in individuals with SCI.

Methods/overview: Twenty individuals with thoracic SCI and seven healthy controls were asked to lift the heaviest load possible with their dominant U/L at arm's length. Their trunk was either strapped against a solid backrest or freely moving. Both conditions were tested in a standardized sitting position, with the feet on the floor, and with the non-dominant U/L on their thigh, armchair or crossed on chest (unsupported sitting). The participants with SCI were stratified into two subgroups: (1) those who had partial or total use of their lower back and abdominal muscles (i.e. SCIAbdo subgroup, lesion below the seventh thoracic neurological level (T7), n = 11), and (2) those who had complete paralysis of their lower back and abdominal muscles (i.e. SCINoAbdo subgroup, lesion above T7, n = 9). Analyses of variance were applied to identify differences between the three groups and across the six conditions.

Results: Trunk stabilization during unsupported sitting increased the maximal load lifted (from 6.2 to 9.4 kg, P < 0.01) in the SCINoAbdo subgroup only. Contrarily, trunk stabilization reduced the U/L performance in the healthy controls, irrespective of the U/L support (from 10Toronto Rehabilitation Institute – UHN10.8 kg to 8.3–8.6 kg, P < 0.005). With their trunk moving freely, similar performance was observed across all groups during U/L-supported sitting, except the maximal load was less in the SCINoAbdo subgroup than the two other groups during unsupported sitting.

Conclusions: Trunk stabilization during unsupported sitting increased U/L performance in participants with SCI and likely compensated for trunk sensorimotor impairments. Without U/L support and trunk stabilization, the capability to generate enough U/L strength for transporting heavy objects was limited in participants with SCI. The trunk contribution in lifting heavy objects among healthy controls also suggested that individuals with SCI used sub-optimal strategies when their trunk was not stabilized.

Acknowledgements: Murielle Grangeon is supported by a postdoctoral scholarship from the Multidisciplinary Sensori-Motor Rehabilitation Research Team (SMRRT). Dany Gagnon holds a Junior 1 Research Career Award from the FRQS. The equipment and material required to complete this project was financed in part by the Canada Foundation for Innovation and the SMRRT.

Abstract ID: 42

KNOWLEDGEMOBILIZATION TRAINING SERIES (KMTS) QUALITY IMPROVEMENT STUDY

Samantha Jeske¹, Jennifer Tomasone², Kelly Arbour-Nicitopoulos^1,3, Spero Ginis³, Kathleen Martin Ginis^2,3

¹University of Toronto, ²McMaster University, ³SCI Action Canada

Background/objective: SCI Action Canada is an initiative aimed at promoting physical activity (PA) among Canadians living with spinal cord injury (SCI). As part of this mission, a web-based training tool (Knowledge Mobilization Training Series (KMTS)) was developed in 2011 to provide information and resources for assisting health care professionals in promoting PA participation among adults with SCI. The purpose of this study is to obtain feedback related to the usability and acceptability of the KMTS training tool from previous users.

Methods/overview: An online quality improvement questionnaire was distributed to previous KMTS users (n = 44) consisting of four sections related to (i) usefulness and relevance, (ii) personal learning experiences, (iii) recommended additions, and (iv) intentions to use and promote the KMTS training tool in the future.

Results: Of the 44 KMTS users who were followed-up, 4 (3 health care professionals and 1 individual with an SCI; M age = 44 years ± 13.1; 100% female) have currently completed the questionnaire. Overall, 75% of the respondents indicated the training tool to be very informative and relevant. In terms of the learning experience aspects, the majority of respondents valued the innovativeness of the module (75%), the stimulating nature of the voice-over technique used to deliver the training material (75%), the duration and pace of the learning material (100%), and found the videos easy to upload (100%). Recommendations for improving the training tool included providing more information on goal setting (50% of the respondents), and accessibility and community integration for adults with SCI (50% of the respondents). The majority of respondents (75%) intended on recommending the KMTS training tool to others in the field.

Conclusions: Preliminary evidence supports the usability and acceptability of the KMTS for assisting health care professionals with providing PA information to adults with SCI. Further work is underway to obtain feedback from a larger sample of health care professionals to determine the generalizability of these findings. The findings will be used to assist SCI Action Canada in strategizing how best to engage users in current and future training content. The inclusion of additional online learning techniques may augment users' experience, and thus their use of the KMTS training tool.

Acknowledgements: Granting Agency/Funding Source: Rick Hansen Institute.

Abstract ID: 43

SITTINGPOSTURAL STABILITY IN INDIVIDUALS WITH CERVICAL SPINAL CORD INJURY

Matija Milosevic^1,2, Kei Masani^1,2, Meredith J. Kuipers^1,2, Hossein Rahouni^1,2, Molly C. Verrier^1,2, Kristiina M. V. McConville^1,2,3, Milos R. Popovic^1,2

¹University of Toronto, ²Toronto Rehabilitation Institute – UHN, ³Ryerson University

Background/objective: Individuals with cervical spinal cord injury (SCI) usually sustain impairments of the trunk and lower limbs, resulting in difficulty maintaining upright sitting. In addition, the use of their lower limbs for foot support during sitting is generally underestimated. The objectives of this study were to compare postural stability of individuals with cervical SCI to able-bodied participants and to analyze the effects of foot support on postural stability during sitting.

Methods/overview: Ten able-bodied participants (control group) and six individuals with cervical SCI (SCI group injury between C4 and C6) participated in this study. Center of pressure (COP) for the seat and foot support surfaces were obtained separately using two force plates and then a global COP, which included the upper body and foot support fluctuations were calculated. Comparison of all COP measurements and the vertical and shear forces were performed to evaluate sitting postural stability.

Results: Individuals with cervical SCI had 208% larger postural sway for global COP (P = 0.022) and 269% for the seat COP (P = 0.031), compared to able-bodied participants, which implies that their postural stability is considerably lower. Comparison between global and seat COPs showed that global COP anterior-posterior (AP) sway velocity was 51 and 28% larger for able-bodied (P = 0.028) and SCI (P = 0.005) groups, respectively. These results suggest that foot support caused an increase in AP postural regulatory activity among both groups. Also, the amount of vertical and shear force fluctuations on the foot support surface were not significantly different between the able-bodied and SCI groups, suggesting that both groups used foot support similarly.

Conclusions: Our results show that individuals with cervical SCI have significantly worse postural control during sitting than the able-bodied group. Moreover, foot support was found to affect AP stability of SCI and able-bodied groups. Since people with cervical SCI cannot fully control their lower limbs, their foot support appears to be passive. Our results also indicate that able-bodied people use foot support in a same/passive manner during sitting as individuals with SCI. Therefore, it seems that trunk control is the dominant mechanism contributing to sitting instability among individuals with cervical SCI.

Acknowledgements: Canadian Institutes of Health Research (CIHR) Grant # MOP-97952.

Abstract ID: 44

DETERMINANTSOF CALF MUSCLE CROSS-SECTIONAL AREA AND DENSITY AFTER CHRONIC SPINAL CORD INJURY

Cam Moore¹, B. Catharine Craven^2,3, Lehanna Thabane⁴, Alexandra Papaioannou⁵, Rick Adachi^4,6, Milos Popovic^2,3, Lora Giangregorio^1,2, Neil McCartney⁷

¹University of Waterloo, ²Toronto Rehabilitation Institute – UHN, ³University of Toronto, ⁴McMaster University, ⁵Hamilton Health Sciences, ⁶St. Joseph's Hospital, ⁷Brock University

Background/objective: Atrophy and fatty infiltration of lower-extremity muscle after spinal cord injury (SCI) predisposes individuals to metabolic disease and related mortality. Peripheral quantitative computed tomography (pQCT) can measure muscle cross-sectional area (CSA) and density; the latter being a measure of muscle fatty infiltration. Muscle density is linked to impaired blood sugar regulation, serum lipid and lipoprotein levels, and bone and muscle strength in other populations.

Methods/overview: pQCT scans of the 66% site of the calf were performed after anthropometric and ISNCSCI assessment. Muscle CSA and density were calculated with SliceOmatic v5.0 software (Tomovision, Magog, QC). Clinical covariates in the univariate analyses included: sex (male/female), age (years), height (cm), weight (kg), waist circumference (WC, cm), level of injury (tetra/para), injury duration (years), age at injury (years), calf muscle (L4, L5, S1) lower extremity motor score (cLEMS, /15), serum 25(OH)D (nmol/L), and leg spasm frequency and severity score (SFSS, /7). An interaction term was created to account for a sex effect on WC (WCgen). Correlates associated with muscle CSA and density (α ≤ 0.20) in univariate analyses were entered into multivariate regression models. The best models were selected based on R2 and Mallow's Cp statistics after accounting for multicollinearity between variables.

Results: Of the 61 participants (42 male, age 49 (±12) years, C2–T12, AIS A–D)) with chronic SCI (2 years post-injury, mean duration 15.4 (±10.0) years), 11 had their scans omitted due to movement artifact. Mean values of 52.4(±20.1)  cm² and 56.3 (±11.1) mg/cc were observed for muscle CSA and density. In the univariate analyses, sex, age, height, weight, WC, WCgen, LOI, injury duration, age at injury, and cLEMS were associated with muscle CSA; and height, LOI, injury duration, cLEMS, and SFSS were associated with muscle density (all P ≤ 0.20). The best-fit regression model for muscle CSA (r2 = 0.69, P < 0.0001) included WC, LOI, and cLEMS, whereas the model for muscle density (r2 = 0.29, P < 0.001) included cLEMS and SFSS.

Conclusions: Reduced WC, cLEMS, and paraplegia were related to calf muscle atrophy in a diverse group of individuals with chronic SCI. cLEMS and SFSS were positively related to muscle density; however, the model only explained 29% of the variance. Factors related to atrophy and fat accumulation in paralyzed muscle and their predictive validity for identifying those at greatest risk for heart disease, diabetes, and fracture warrants further investigation.

Acknowledgements: This study was funded by the Canadian Institute of Health Research (Grant #: 86521), SCI Solutions Network (RHI; Grant #: 2010-43), and SCI IMPACT (Grant #: 2011-ONF-REPAR-885).

Abstract ID: 45

SELFREPORT OF ONE-YEAR INCIDENT FRACTURES: FINDINGS FROM THE SCI COMMUNITY SURVEY

Chelsea Pelletier¹, Frederic Dumont², Luc Noreau^2,3, B. Catharine Craven^1,4

¹Toronto Rehabilitation Institute – UHN, ²Centre for Interdisciplinary Research in Rehabilitation and Social Integration, ³Laval University, ⁴University of Toronto

Background/objective: Increased risk for fragility fracture, subsequent medical complications, and hospitalization are recognized consequences of sublesional osteoporosis after spinal cord injury (SCI). We describe the 1-year incidence of fracture, determine the influence of demographic and impairment variables, and describe impact on activity in a cohort of Canadians with chronic traumatic SCI.

Methods/overview: English- or French-speaking adults with traumatic SCI residing in the community for >1 year completed SCI community health survey online or via telephone. The survey intent was to provide a comprehensive assessment of the health and social service needs, participation, and quality of life of the Canadian SCI population, including comorbidity incidence in the prior year, among them fracture. The survey included demographic information and four identified risk factors for fracture: injury duration ≥10 years, age at injury <16 years, motor-complete paraplegia, and female sex. Consenting participants reported fracture incidence, associated treatment, and daily activity limitations. Associations between known risk factors and fracture incidence were analyzed using crosstabs and χ² tests of significance. Odds ratios (OR) and 95% confidence intervals (95% CI) or Spearman's rank correlation (rs) were calculated as appropriate.

Results: Consenting participants included 1137 adults, 70.9% male, age 48.3 ± 13.3 years, 8.4 ± 16.3 years post-injury. Eighty-four (7.4%) participants reported a fracture in the prior year, and 71/84 (84.5%) reported fracture treatment. The variables most strongly associated with fracture were osteoporosis (OR: 4.3, 95%CI: 2.72 Toronto Rehabilitation Institute - UHN 6.89), being female (OR: 1.2, 95%CI: 0.72 Toronto Rehabilitation Institute – UHN 1.88), and having a motor complete injury (rs = 0.08, P < 0.01). Participants with fracture commonly reported activity limitations; 38.1% experienced activity limitations “to a great extent” and 17.9% reported “complete limitation.”

Conclusions: Although relatively rare (7.4%), incident fractures have a profound impact on daily activities. The observed discordance between fracture occurrence and treatment, and the strength of the association between sublesional osteoporosis diagnosis and incident fractures necessitates improved bone health screening and treatment programs, particularly among those with motor-complete SCI.

Acknowledgements: Granting Agency: Rick Hansen Institute Granting Agency: Ontario Neurotrauma Foundation Granting Agency: SCI Ontario.

Abstract ID: 46

INCREASEDCARDIORESPIRATORY DEMANDS FOR OVERWEIGHT AND OBESE MANUAL WHEELCHAIR USERS WITH A SPINAL CORD INJURY WHILE PROPELLING UP SLOPES MEETING CANADIAN BUILDING CODE REQUIREMENTS

Cindy Gauthier¹, Murielle Grangeon¹, Ludivine Ananos¹, Rachel Brosseau², Dany Gagnon¹

¹Institut de réadaptation Gingras-Lindsay-de-Montréal, Pathokinesiology Laboratory, ² Université de Montréal

Background/objective: Many individuals with spinal cord injury (SCI) use a manual wheelchair (MW) for ambulation. Their sedentary lifestyle puts them at higher risk of obesity and cardiorespiratory diseases. However, little is known on the impact of overweight on the cardiorespiratory responses when propelling a MW in community. The objective of this study is to determine if body mass index (BMI) has an effect on cardiorespiratory responses when MW users with a SCI propel up slopes of different inclination angles at different speeds.

Methods/overview: Thirteen MW users with a SCI (T6–T12; AIS A to C) completed 12 two-minute propulsion trials (3 speeds × 4 slopes) on a treadmill with their wheelchair, each separated by a 2-minute rest period. Each trial was characterized by a specific slope (0°, 2.7°, 3.6°, and 4.8°) and a specific speed (0.6, 0.8 and 1.0 m/s). Five key cardiorespiratory measures (heart rate, oxygen uptake (VO₂), respiratory frequency, tidal volume, minute ventilation, and respiratory ratio) were continuously recorded using a Cosmed K4b2 telemetry system and a Polar heart rate monitor. The BMI was calculated and the Physical Activity Scale for Individuals with Physical Disability (PASIPD) questionnaire was completed for each participant. Pearson correlation coefficients were used to quantify associations between BMI, PASIPD, and cardiorespiratory measures.

Results: All participants attained a physiological plateau during the most intense loads, indicating the maximal oxygen uptake (VO_2max) may have been reached. This VO_2max was found to be negatively correlated with the BMI (r(13) = −0.73, P.

Conclusions: Manual wheelchair users with lower BMI have better cardiorespiratory capacity than those with the higher BMI. Propelling a MW over slopes represents a greater effort for overweight than for normal weight individuals. Therefore, maintaining a healthy BMI among MW users with a SCI should be encouraged to minimize relative cardiorespiratory demands and to optimize functional capacity and social participation.

Acknowledgements: Cindy Gauthier is supported by a Master's scholarship from the Fonds de la recherché du Québec-Santé (FRQS). Murielle Grangeon is supported by a postdoctoral scholarship from the Multidisciplinary SensoriMotor Rehabilitation Research Team (SMRRT). Dany Gagnon hold a Junior 1 Research Career Award from the FRQS. The equipment and material required to complete this project was financed in part by the Canada Foundation for Innovation.