Messag ge from thee Institutee Director, Research Geoff Feernie, PhD D, PEng, CEEng, FCAHSS
Research Da y! In the Sp pring of this yyear we receeived our This is our 10th R fourrth review byy a panel of internationaal experts in rehabilitation rese earch. This re eview involvved a detaileed examinatiion of the pu ublications, gran nt support, student enroollment, and other outco omes that w were desccribed in ourr summary rreport plus the findings o of a two‐dayy site visit. The panel concluded: ped into a w world‐class annd unique reesource for “TRII has develop reha abilitation reesearch. It iss one of the top rehabilittation researrch instiitutes in the world, and tthe top institution in Can nada. Levelss of activity and productivityy, both in quaantity and qquality, and tthe pace of tthese achiievements, a are all outstaanding.” Followingg the review w, the UHN R Research & A Analysis Brannch extendeed its comparative studyy of our publications and citaations and co oncluded thaat our publiccation produ uctivity far exceeds any peer rehabilitaation research centre in the world. All of ourr research te eams have co ontributed tto significantt advances, and they aree all poised tto have a huge imp pact on the q quality of life e of a great many peopl e in the nextt few years aas you will read in the summaries below. d Brain Injurry (ABI) and Society Acquired This team m is at the fo orefront of kknowledge in nternational ly that addreesses gendeer, work and brain injury. Th hey have ide entified that at least 50% % of the crim minalized and d the homeless populatiions report a history of brain inju ury. They are e developingg strategies tto improve tthe delivery, planning and outcome es of servicess. These straategies integgrate person al and larger societal facctors as well as the most up to date scientific eviden nce. Artificial Intelligence e (AI) and Ro obotics The first of a series o of electronicss technologiies that use artificial inteelligence hass been licenssed in the form of aa falls monito oring system m. Also, theirr robot for uupper limb reehabilitation n is in pre‐market trials. This team will lead the devvelopment o of advanced smart homee technologies and robo ots to people with cognitive an nd memory cchallenges ccontinuing to o live at hom me. support p Brain Disscovery and Recovery This team m leads the w world in und derstanding tthe problem m of chronic functional d decline follow wing head injury. Th hey will intro oduce effecttive treatments to maxim mize and susstain improvvements in function gained th hrough rehabilitation.
Cardiopulmonary Fitness This team has developed and evaluated a program for rehab of cardiac patients, which halves the chance of a second heart attack. Their educational program is available in print and on computer to aid in optimizing cardiac health across Ontario and internationally. Guidelines have been developed for cardiac rehab standards in Ontario and globally in low and middle‐income countries. Interventions to reduce sedentary behavior and enhance long term physical activity in the community are being developed. Communication This team recently developed a number of novel interventions for those living with speech, language and hearing disorders. These interventions aim to target not only patients but also their caregivers. The emphasis during the next few years will be on moving from development to implementation. Some of these interventions employ robots that are able to communicate; others use game‐based interactive technologies that can be provided over the web or delivered through inpatient and outpatient clinics. Mobility This team has developed and Implemented mobility and falls assessment using advanced technology in the clinic and in the community. They are poised to maximize safe mobility in seniors with a range of challenges. The methods will include portable smart assessment tools and new treatment interventions that can be used in both hospital and community environments. Neural Engineering and Therapeutics The NET team has commercialized its functional electrical stimulation (FES) therapy system called MyndMove. The result is a product and technique that is a huge advance in terms of the level of recovery from hemiplegia resulting from strokes and upper limb paralysis resulting from spinal cord injury. The future for their world‐leading brain monitoring and their electrical stimulating technologies is amazing and includes novel ways of treating depression, preventing decubiti, healing wounds, regulating blood pressure, aiding in balance and gait, managing epilepsy and enhancing memory. The NET team is also internationally recognized for developing therapies and assessments to help improve bone health, and has been leading many international and domestic initiatives aimed at improving best practices in spinal cord injury rehabilitation. Optimization of the Rehabilitation System Optimize has led the development of a coordinated program to prevent secondary fractures by identifying and treating osteoporosis. Other achievements include the staging of plays to teach sensitive caring methods for residents in long term care. The team’s future includes an umbrella program collaborating with most other teams to define who needs rehab services and how they should be delivered most effectively and economically. Sleep Science Sleep apnea (a dangerous condition affecting about 10% of the population) can now be diagnosed accurately at home with a game‐changing affordable device developed here. Their research has discovered that fluid accumulation in the legs during the day contributes to airway obstruction when the fluid moves toward the neck when lying down to sleep. This team is poised to make breakthroughs in the treatment of other respiratory conditions and of heart failure.
Swallowing Science These ressearchers haave co‐developed and te ested a portaable instrum ment to diagnose swallow wing problemss without the need for X X‐rays. In the e next few yeears they wiill revolution nize the asseessment of swallowing and the p prescription of the corre ect liquid connsistency forr safe swallo owing. ogy Technolo Several in nventions haave been reccently launched on the m market by th his team to m make aging aat home safer for seniors and their caregiivers. An important receent success was facilitatting a changee to the Canadian n building co ode to make stairs safer. The team w will revolutio onize footweear to reducce falls indoors aand in outdo oor winter en nvironmentss, introduce advanced siimulator tessting to supp port customizzed driving licenses and introduce a practical an d effective eelectronic syystem to red duce hospital‐acquired inffections. Congratu ulations to e everyone Let us be e proud of ou ur achievements in this ffirst decade and continu ue to work together as O ONE team to contin nue this tradition of exce ellence!
Toronto Rehab’s 10th Annual Research Day Monday, December 1, 2014 University of Toronto Chestnut Residence and Conference Centre 89 Chestnut Street, Toronto ON
PROGRAM OF EVENTS 7:30 – 8:45am
Registration & Poster Set-up (2nd Floor Foyer)
9:00 – 9:15am
Welcome & Introduction (Colony Ballroom) Dr. Geoff Fernie, Institute Director, Research, TRI-UHN
9:15 – 9:40am
Keynote Presentation: What contribution can technology make for the long term care of older people? – Dr. Anthea Tinker, CBE. Ph.D, FKC, AcSS, Professor of Social Gerontology, King’s College London, UK
9:40 – 10:30am
Minute Madness – Session 1 Communication, AI & Robotics, Swallowing Science and Mobility
10:30 – 10:50am
Refreshment & Networking Break (Colony Ballroom & 2nd Floor Foyer)
10:50 – 11:35am
Minute Madness – Session 2 Optimize, Neural Engineering & Therapeutics, Sleep Science and ABI & Society
11:35 – 11:40am
Mindfulness Meditation Break led by the Brain Discovery and Recovery Team
11:40 – 12:15pm
Minute Madness – Session 3 Brain Discovery & Recovery, Cardiopulmonary Fitness and Technology
12:15 – 12:30pm
Student Scholarship & Award Presentations In the presence of The Hon. Elizabeth Dowdeswell, OC, OOnt, Lieutenant Governor of Ontario
Toronto Rehab Team Excellence Awards TD Scholarship for Students with Disabilities Joel Verwegen Award Hallisey Post-Doctoral Fellowship Mark Rochon Leadership Award
12:30 – 1:30pm
Boxed Lunch (available in the Colony Ballroom)
1:30 – 3:00pm
Poster & Interactive Display Sessions (Colony Ballroom, 2nd Floor Foyer, Giovanni Room)
Research Day Award Announcement / Close of Research Day
Best Poster (Undergraduate, Master’s, Doctoral and Postdoctoral) Best Interactive Display People’s Choice Award (Best Minute Madness) TechnoVation Award
Acknowledgements TRI Research Leadership Institute Director, Research: Geoff Fernie TRI Research Team Leaders: Angela Colantonio Alex Mihailidis and Babak Taati Robin Green Paul Oh and David Alter Yana Yanusova and Elizabeth Rochon Avril Mansfield and Bill McIlroy Doug Bradley Catriona Steele Kathy McGilton and Susan Jaglal Milos Popovic and Cathy Craven Tilak Dutta and Jenny Campos
Acquired Brain Injury (ABI) & Society Artificial Intelligence (AI) & Robotics Brain Discovery & Recovery Cardiopulmonary Fitness Communication Mobility Sleep Science Swallowing Science Optimization of the Rehabilitation System Neural Engineering & Therapeutics Technology
Research Day Committee Planning and Logistics Bridgette Murphy Knowledge Translation Officer
Meg Tennant Research Day Coordinator
Dan Smyth CAD Specialist
Lois Ward Manager, Research Operations
Catharine Hancharek Business Development Leader
Geoff Fernie Institute Director, Research
Research Day Volunteers A special thank you to the following staff and trainees who volunteered their time: Cecilia Campolongo Leslie Carlin Aoife Conway Tess Del Mundo Grace El-Khechen Gary Evans Inez Gannicott Tim Giblin
Susan Gorski William Hancharek Pam Holliday Kadeen Johns Mike Johnson Georg Kralik Lesley Ruttan Jahvanna Ryan
Bart Scieranski Adam Sobchak Sandra Sokoloff Shoshana Teitelman Jennifer Tomaszczyk Belinda Vukovich Barry Westhead Jeanie Zabukovec
2014 KEYNOTE SPEAKER Professor Anthea Tinker, CBE, PhD, FKC, AcSS, FRSA Professor of Social Gerontology Institute of Gerontology Department of Social Science Health and Medicine King’s College London
Anthea Tinker has been Professor of Social Gerontology at King’s College London since 1988. She has been on the staff of three Universities and three Government Departments. She chaired the College Research Ethics Committee from 2001 – 2011. Internationally she has been a Consultant to the WHO, EU and OECD. She was awarded the CBE in 2000 in the Queen’s Birthday Honours for Services to Housing for Older People, was elected a Founding Member of the Academy of Learned Societies for the Social Sciences in 1999, elected a Fellow of King’s College London in 1998 and was President of the Section of Geriatrics and Gerontology, Royal Society of Medicine 1998‐2000. She was awarded the title of Fellow of the British Society of Gerontology in 2008. She was one of the Women of the Year in 2002. In 2010 she was awarded the Alan Walker prize by the British Society of Gerontology for her significant and lasting contribution to Social Gerontology. She is the sole author of eleven books and co‐author of twenty one. She has also written over 300 articles. She has undertaken a wide range of research in the field of social policy, specializing since 1974 in Gerontology. Much of her work has been multidisciplinary including scientists from medicine, engineering and architecture and the social sciences. Her research includes studies of long term care, housing, assistive technology (including navigation aids, mobility of older people, introducing assistive technology into older people’s homes and remodelling sheltered housing and residential care homes to extra care housing), family care, older workers, community care, older women, very old people, grandparents, age friendly cities, elder abuse, social isolation, falls and accidents. She is particularly interested in the ethics of research and the contribution of older people.
LIST OF ABSTRACTS Communication Abstracts 1 – 8
Page 3 - 6
Artificial Intelligence (AI) & Robotics Abstracts 9 - 20
Page 7 - 12
Swallowing Science Abstracts 21 - 23
Page 13 - 14
Mobility Abstracts 24 - 38
Page 15 - 22
Optimization of the Rehabilitation System Abstracts 39 – 51
Page 23 - 30
Neural Engineering & Therapeutics Abstracts 52 - 64
Page 31 - 38
Sleep Science Abstracts 65 – 70
Page 39 - 42
Acquired Brain Injury (ABI) & Society Abstracts 71 - 77
Page 43 - 46
Brain Discovery & Recovery Abstracts 78 – 85
Page 47 - 51
Cardiopulmonary Fitness Abstracts 86 – 91
Page 52 - 55
Technology Abstracts 92 - 103
Page 56 - 61
ABSTRACTS FROM THE COMMUNICATION TEAM Communication Team researchers are involved in projects focused on assessment and treatment of communication deficits in aging generally and in neurological populations in particular (hearing loss, dementia, stroke, Parkinsonâ€™s disease). Their overriding philosophy is that the most significant advances will come from approaches that incorporate research spanning the continuum from laboratory to clinic and to the real world. Another basic premise is that communication deficits are not only multifaceted but also pervasive and ubiquitous. They are constituents in many diseases and disorders, and affect many aspects and types of interactions.
1. Automatic identification of linguistic features using EEG and MEG signals Y Aliyari1, F Rudzicz1,2 1 Toronto Rehab â€“ UHN; 2 University of Toronto, Dept. of Computer Science,
We automatically classify speech stimuli as either synonymous or non-synonymous with a prior prime in a speech-receptive task given only EEG data with up to 86.84% accuracy. An analysis of variance reveals no significant difference among support vector machine and k-nearest neighbours classifiers, but a significant effect of the individual subject on accuracy. In other work, we identify the language being received during auditory stimuli in English and Romanian in 11 subjects before and after a period of learning 50 words in the latter using only magnetoencephalographic measures. We also identify significant effects of semantic word category and the subject ability to play a musical instrument on classification accuracy. 2. A usability study of Internet-based Phonological Components Analysis therapy T Simic1, C Leonard 1,2,3, L Laird1, E Rochon1,3,4 1 University of Toronto, Dept. of Speech-Language Pathology; 2 University of Ottawa, School of Rehabilitation Sciences; 3 Heart and Stroke Foundation Canadian Partnership for Stroke Recovery; 4 Toronto Rehab - UHN
Though the literature increasingly suggests that individuals with chronic aphasia can make continued improvements in their language, speech-therapy services are of relatively short duration and of limited access to those who are housebound or living in remote areas. We have incorporated the stimuli and procedure of our treatment for naming deficits, the Phonological Components Analysis (PCA), as part of a more comprehensive Internet-based speech-therapy portal, in an attempt to make PCA more accessible. The present study evaluates the usability of the Internet-based PCA therapy for individuals with aphasia. Six participants with mildmoderate aphasia each underwent six hours of observation, and performance metrics (e.g., task success, number of errors) were collected across a series of defined tasks (e.g. typing website URL, logging in, etc). Participants also completed interviews and an aphasia-friendly version of the System Usability Scale (SUS) after 3
therapy. Results suggest that individuals with aphasia can use Internet-based PCA therapy successfully, accurately and efficiently, though minor audio and video improvements are necessary to optimize usability. Participant interviews and the SUS revealed overall satisfaction with Internet-based PCA. All participants expressed a willingness to use Internet-based PCA therapy again, and viewed remotely-delivered speech therapy as useful and convenient. 3. MMG detection of intentional movement in the presence of dyskinetic movements M Correa Villada, T Chau University of Toronto, IBBME, Bloorview Research Institute; University of Toronto, IBBME, Bloorview Research Institute
The contraction of individual motor units can be detected through the lateral movements of muscle fibers in different muscle sites in the body. For children and youth with severe physical disabilities, these sites can be used as an access pathway to translate the individual s functional intent into a functional activity. Mechanomyogram (MMG) is a system used for the study of muscle activity. However, when using MMG with an individual who has hyperkinetic or dyskinetic movements, one of the most daunting challenges is to locate a muscle site where the MMG signal is unaffected by unwanted muscle contractions. This study aims to investigate ways in which information from a group of muscles during a specific task can enhance detection of intention amid dyskinetic movements. We will recruit a control group of typically developing children and a group of children and youth with dyskinetic cerebral palsy. MMG signals of 6 main muscles involved in a reaching task will be simultaneously recorded to compare the influence of each muscle in the movement. This research will eventually allow individuals with disabilities to communicate and interact with their environment. 4. Selective Deficits in Automatic Mimicry of Facial Expressions in Parkinsonâ€™s Disease E Vezer1, SR Livingstone1,2, FA Russo1,2 1 Ryerson University, Department of Psychology; 2 Toronto Rehab - UHN
Patients with Parkinson's disease often exhibit blunted facial expressions, a phenomenon referred to as the masked face syndrome, due to the impact of the disease on motor function. When neurotypicals are exposed to emotional facial expressions, even subconsciously, they react with spontaneous mirroring of others faces. Mimicry is associated with a range of emotional tasks and appears to improve accuracy and response times of emotional recognition, as well as increase feelings of empathy. Such a deficit may partly explain emotional issues in PD patients. To date, however, there has been no investigation of mimicry in PD patients. The present study used electromyography to measure facial mimicry in 28 PD patients and 28 healthy age- and gender-matched controls. Participants observed videos of actors displaying a range of emotional facial expressions. PD patients demonstrated impaired mimicry of happy expressions compared to controls, as measured by activity in the zygomaticus (smiling) muscle region, whereas no significant differences were observed between groups in corrugator (frowning) muscle activity. These findings support the existence of mimicry deficits in PD, but suggest that the deficit is limited to mimicry of smiling. This may lead to a new understanding of the masked face syndrome and inform future interventions. 4
5. Automatic detection of expressed emotion in Parkinson's disease S Zhao1, F Rudzicz1,2, LG Carvalho1, C Marquez-Chin2, S Livingstone2,3 1 University of Toronto, Dept. of Computer Science; 2 Toronto Rehab - UHN; 3 Ryerson University, Dept. of Psychology
Patients with Parkinson's Disease (PD) frequently exhibit deficits in the production of emotional speech. In this project, we examine the classification of emotional speech in patients with PD and the classification of PD speech. Participants were recorded speaking short statements with different emotional prosody which were classified with three methods (naove Bayes, random forests, and support vector machines) using 209 unique auditory features. Feature sets were reduced using simple statistical testing. We achieve accuracies of 65.5% and 73.33% on classifying between the emotions and between PD vs. control, respectively. These results may assist in the future development of automated early detection systems for diagnosing patients with PD. 6. Visual feedback fidelity in serious games for motor speech rehabilitation of older adults with Parkinson s Disease MB Haworth1,3, E Kearney2,3, Y Yunusova2,3, P Faloutsos1,3, M Baljko1,3 1 York University, Dept. of Electrical Engineering and Computer Science; 2 University of Toronto, Dept. of Speech-Language Pathology; 3 Toronto Rehab - UHN
The fidelity of visual feedback in games ranges according to a variety of both subjective and objective factors. This study explores the development of visual feedback in a system for delivering kinematic tongue games for speech rehabilitation. We employ a recently designed game system in an experimental training protocol to address the visual feedback design space of speech rehabilitation for older adults with Parkinson s Disease. Two visual feedback scenarios provide low and high fidelity representations of growth in Articulatory Working Space (AWS) volume. Both visualizations display a set of graphical representations of parameters and a visual change upon success. These include a representation of a goal as a bandwidth (-5% to +15%) about the target AWS volume and the participant s current progress towards that goal. The low fidelity visualization displays only 2D shapes, and the high fidelity visualization displays detailed 3D polygonal meshes, particle, lighting and screen effects in a rendered scenario. We investigate engagement, exertion and achievement by employing the self-assessment manikin (SAM) and the Borg CR10 Scale for each visualization and measure success, sensor trajectory distance, and AWS volume for each task. Two sentence level training stimuli, /sh/ and /t/, are paired with the visualizations to elicit speech in sets of repetitions 7. An examination of age-related differences in performance on a dual ''listening while walking'' task S Lau1, V Nieborowska2,3, E Alexandrov2, L Truong5, A Novak1, MK PichoraFuller1,3,4, KZH Li2,3, J Campos 1,3,4 1 Toronto Rehab - University Health Network; 2 Concordia University, Dept. of Psychology; 3 Centre de Recherche en Development Humain; 4 University of Toronto, Dept. of Psychology; 5 Ryerson University, Dept. of Psychology
Older adults experience difficulty with listening in challenging auditory environments. Recent studies have found that those with poorer hearing acuity 5
have a higher risk of falling. The study objective was to examine the relationship between listening and gait stability by comparing the performance of 19 younger and 16 older adults (mean age of 27.2 and 68.4 years, respectively) with normal hearing on three tasks: listening only, walking only, and listening while walking. In the listening task, three sentences (1 target, 2 maskers) were presented simultaneously from the left, center, and right side of participants. Participants were informed of whether the target would a) always be presented from the center location, or b) could occur from one of the three locations. Participants were asked to identify parts of the target sentence. During the walking task, participants cross an intersection in the virtual environment using a treadmill. Results demonstrated that older adults performed more poorly on the listening task than did younger adults and that this effect was particularly apparent when they had to listen and walk simultaneously. Older adults also exhibited different walking strategies under dual-task demands compared to younger adults, with a tendency to prioritize gait stability over listening accuracy. 8. Development of a Robust Multi-modal Brain Computer Interface A Rezazadeh Sereshkeh1, 2, B Schultz1, 3, T Chau1, 2 1 Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital; 2 University of Toronto, Institute of Biomaterials and Biomedical Engineering; 3 Flinders University, The Medical Device Research Institute, School of Computer Science, Engineering and Mathematics,
The main goal of Brain-Computer Interface (BCI) research is to provide communication capabilities to people with severe motor impairments, such as patients with locked-in-syndrome (LIS). Despite significant advances, the specificity and sensitivity of brain activity detection in BCIs are limited by the shortcomings of measurement modalities. Electroencephalography (EEG)-based measurements benefit from having good temporal resolution, but suffer from poor spatial resolution and noise susceptibility. Near-Infrared-Spectroscopy (NIRS) modality is, in comparison, robust to myogenic noise and has greater spatial resolution, but exhibits modest temporal resolution and slow response time. The goal of this research is to design and implement a hybrid BCI based on simultaneous EEG and NIRS measurements to preserve the advantages of both non-invasive modalities. This hybrid BCI will be developed based on active cognitive tasks and evaluated on able-bodied participants. In order to validate the robustness of this BCI, the specificity and sensitivity will be determined using NIRS or EEG signals exclusively, compared with recognition using a combination of the two. This research will demonstrate the value of multimodal BCIs, particularly in increasing the machine determination of intentional brain activation. This BCI could be extended to other BCI applications, such as controlling a wheelchair for people with LIS.
ABSTRACTS FROM THE AI & ROBOTICS TEAM The Artificial Intelligence & Robotics team works to facilitate access to rehabilitation services outside of traditional contexts by developing zero-effort technologies that can be used by clients at home. Their work involves research and development in the areas of advanced sensing (e.g. computer vision), artificial intelligence (e.g. machine learning), and robotics (e.g. stationary, mobile and autonomous robots). Their goal is to improve the delivery and outcomes of rehabilitation, and help people with disabilities and older adults to live more independently.
9. Generalized Linear Models of Home Activity for Automatic Detection of Mild Cognitive Impairment in Older Adults A Akl1,2, J Snoek3, A Mihailidis1,2 1 University of Toronto, Institute of Biomaterials and Biomedical Engineering; 2 Toronto Rehab â€“ UHN; 3 Harvard University, Harvard School of Engineering and Applied Science
With a globally aging population, the burden of care of cognitively impaired older adults is becoming increasingly concerning. Instances of Alzheimer's disease and other forms of dementia are becoming ever more frequent. Earlier detection of cognitive impairment offers significant benefits, but remains difficult to do in practice. In this work, we develop statistical models of the behavior of older adults within their homes using sensor data in order to detect the early onset of cognitive decline. Specifically, we use in-homogenous Poisson processes to model the presence of subjects within different rooms throughout the day in the home using unobtrusive sensing technologies. We compare the distributions learned from cognitively intact and impaired subjects using information theoretic tools and observe statistical differences between the two populations which we believe can be used to help detect the onset of cognitive decline. 10. The People and Technology at Home (PaTH) Project: Views from Developers T Jiancaro1,2,3, A Mihailidis1,3,4 1 Toronto Rehab - UHN;2 University of Toronto, Graduate Dept. of Rehabilitation Science; 3 University of Toronto, Institute of Biomaterials and Biomedical Engineering; 4 University of Toronto, Dept. of Occupational Science and Occupational Therapy
Despite the rising prevalence of Alzheimer s disease (AD) in Canada and around the world, little is known about the design of everyday technologies for people with the disease. This is a dire problem, given the need for effective in-home support. To address this problem, a two-part Design Guide is being developed to help designers analyze the multiple factors at play; understand the constraints of a problem; and establish relevant and specific design requirements for a home technology. Unique to this project is its 360 perspective, which includes the views of developers, caregivers, and, crucially, people with AD. To investigate the views of developers on design factors and practices, an online survey was administered. Respondents included technical and clinical specialists who design or evaluate technologies for 7
people with AD. In total, 40 specialists completed the survey. Importance ratings were obtained using a Likert-type response format. Amongst the characteristics studied, usability, learnability, cost, and self-confidence (during use) were considered very important aspects of technology acceptance based on median results. These initial ratings represent potential starting points for developers, as they analyze a situation in the early phases of a project; and determine appropriate outcome measures in later phases. 11. Automated monitoring of cognitive status by video analysis of handwashing behavior in older adults A Ashraf1, B Taati1,2 1 Toronto Rehab - UHN; 2 Department of Computer Science, University of Toronto
The identification of different stages of cognitive impairment can allow older adults to receive timely care and plan for the level of caregiving. People with existing diagnosis of cognitive impairment go through episodic phases of dementia requiring different levels of care at different times. Monitoring the cognitive status of existing patients is thus critical to deciding the level of care required by older adults. In this paper, we present a system to assess the cognitive status of older adults by monitoring a common activity of daily living (ADL), namely handwashing. Specifically, we extract features from handwashing trials of participants diagnosed with different levels of dementia ranging from cognitively intact to severe cognitive impairment, as assessed by the mini mental state exam (MMSE). Based on videos of handwashing trials, we extract two classes of features: one characterizing the occupancy of different sink regions by the participant, and the other capturing the path tortuosity of the motion trajectory of participant s hands. We perform correlation analysis to assess univariate capacity of individual features to predict MMSE scores. To assess multivariate performance, we use machine learning methods to train models that predict the cognitive status (aware, mild, moderate, severe), as well as the MMSE scores. We present results demonstrating that features derived from hand washing behavior can be potential surrogate markers of a person s dementia, which can be instrumental in developing automated tools for continuously monitoring the cognitive status of older adults. 12. Co-Design with Clinicians: A Process to Envision Future Cognitive Rehabilitation Technologies TV How1, AS Hwang2, RE Green2,3, and A Mihailidis1,2,3 1 University of Toronto, Institute of Biomaterials & Biomedical Engineering; 2 University of Toronto, Graduate Department of Rehabilitation Sciences; 3 Toronto Rehab - UHN
Background: With the increase of mobile devices, sensors, and novel humancomputer interfaces, new possibilities are emerging to expand the outpatient cognitive rehabilitation paradigm. However, there are challenges when envisioning new rehabilitation technologies, as they require both clinical and technical expertise. We present a co-design process to address these challenges and to opportunistically envision new rehabilitation technologies. Methods: Our co-design process was conducted with traumatic brain injury (TBI) clinicians and technology researchers. To facilitate ideation and dialogue between these two groups, we used a number of co-design scaffolds, such as: design cards, field kits, and design groups. 8 TBI clinicians and 2 technology researchers participated in our co-design process. Results: Overall our co-design process was well received. From the process, 30 ideas were created that were grounded in the realities of cognitive 8
rehabilitation and technical limitations. Potential opportunities for new cognitive rehabilitation technologies included areas of: communication competency, executive function, emotional regulation, energy management, assessment, and skill training. Conclusions: The continued drive to understand how emerging technologies can improve broad healthcare areas is an important space for further methodological development. We created a co-design process that may help future researchers opportunistically explore technology applications in other areas of healthcare. 13. Game Design Focus For Greater Motivation In Stroke Rehab: Realism Or Fantasy? HT Chiam1,2, R Wang1,2, A Mihailidis1,2 1 Toronto Rehab - UHN; 2 University of Toronto
Background/Rationale: Appropriately-designed games can motivate stroke patients to carry out therapy, thereby improving outcomes. Combining games with robots in upper-limb therapy enables patients to do therapy without therapists constantly present. Previous studies have used either games simulating everyday activities, or fantasy games, and have not specifically addressed whether a fantasy design helps to better maintain motivation and adherence. Objective: This study compares which of two rehabilitation game design foci, realism or fantasy , better motivates patients to engage in robotic therapy for motor recovery. Methods: This study applies a quantitative and qualitative study design that compares realistic and fantasy game types while involving the same therapeutic movements facilitated by an upper-limb rehabilitation robot. Motivation will be analyzed through user feedback with usability assessments (custom questionnaires, interviews, System Usability Scale) and robot game use data. Ten therapists and 20 stroke survivors (subacute and chronic, moderate upper-limb disability) will be recruited. Agreement/discrepancies between inter-user preferences and measurements will be analyzed and evaluated. Significance: This study aims to identify rehabilitation game characteristics that result in stronger adherence and motivation. Findings from this study will be applied in future work to compare these game foci's outcomes in motor recovery and transferability to real-life activities. 14. Passive Physiological Monitoring via Ambient Sensors Embedded in a Home Environment Sung Jae Isaac Chang1, Amaya Arcelus2, and Alex Mihailidis1,2 1 Institute of Biomaterials and Biomedical Engineering, University of Toronto, Canada; 2 AI & Robotics team, Toronto Rehab - UHN, Toronto, Canada.
Issues with current wearable forms of residential medical monitoring devices include forgetting to wear the device and/or using the device incorrectly. One approach to counter these problems is to use passive monitoring, where sensors embedded into the environment measure signals unobtrusively with little or no effort on the part of the user. As one of the passive monitoring devices, the smart floor tile aims to measure heart rate and systolic blood pressure (SBP) of the user while the person is standing on the tile. The measurement is done via collection of a ballistocardiogram (BCG) and an electrocardiogram (ECG). Based on the analysis of 52 participantâ€™s data, SBP and R-J interval showed a definite pattern of an inverse proportionality. Linear, quadratic, and exponential regressions on the SBP and R-J interval resulted in the R2 value of 0.519, 0.595, and 0.528 respectively. Further improvements were made by applying time shift to the data set. By shifting R-J 9
interval data to match the SBP, the R2 values were improved to 0.602, 0.691, and 0.613 for linear, quadratic, and exponential regression respectively. 15. Comparative Analysis of Prominent Middleware Platforms in the Domain of Ambient Assisted Living R Phull1, A Mihailidis1,2 1 University of Toronto, Institute of Biomaterials & Biomedical Engineering; 2 University of Toronto, Department of Occupational Science & Occupational Therapy
Background: The anticipation of a demographic shift towards an aging community has triggered extensive research into the development of Ambient Assisted Living (AAL) technologies, which comprise of sensors and actuators that monitor the behavior and activity of the elderly and provide assistance in an appropriate manner. Developing individualized AAL solutions for patients with varying incapacitating diseases and living environments is crucial but financially unrealistic. Thus, multiple European projects are developing middleware platforms that aim to ease the development of customized AAL applications, using a common data exchange and repositories of shared functionalities. Despite these efforts, widespread adoption of the middleware platforms from application developers is lacking and studies comparing these platforms are scarce. Methods: This study has conducted a survey to inquire the needs of developers regarding key aspects of the available middleware platforms. Survey questions were focused on the quality attributes of AAL platforms that include reliability, security, maintainability, efficiency and safety. Results: Reliability was ranked as the most significant of the quality attributes, while maintainability was moderately ranked but deemed highly insufficient. Conclusion: Future work involves hands-on testing of the AAL platforms using a standard use-case application and determining specific functions and features required for future middleware development. 16. Development of a Smartphone App for the Management of Mild Traumatic Brain Injury H Sandhu1,2, A Mihailidis1,2,3 1 Toronto Rehab - UHN; 2 University of Toronto; 3 University of Toronto, Department of Occupational Science and Occupational Therapy
Following mild traumatic brain injury (mBTI), inappropriately timed physical and cognitive exertion can result in delayed recovery, prolonged functional deficits, or more serious injuries. Management of post-concussion symptoms can prevent the aforementioned delays in recovery. There is a critical need of evidence-based guidelines for the management of return to activity. Heart rate variability (HRV) has been successfully used to measure physical exertion for athletes, and it may be indicative of readiness for activity following mTBI. The purpose of this study is to develop a smartphone application that accurately collects, analyzes, and displays meaningful HRV data to the user. The application will encompass HRV data analysis and motion correction algorithms. A participatory design approach will be used to determine the content and features of the application. Application precision will be measured by comparing HRV values between two testing sessions, 7 days apart, and application accuracy by comparing HRV measurements from a standard ECG device to the smartphone application s HRV measurements. To determine the acceptance, usability and meaningfulness of the application, Likert-scale questionnaires framed by Nielsen s ten usability heuristics will be used. Ultimately, 10
this application will help address problems encountered during the management of return to activity following mTBI. 17. A Table-Docking Feature for Intelligent Powered Wheelchairs: Defining User Needs G Foley1,2, E Zambalde1,3, P Viswanathan1,4, A Mihailidis1,2,4 1 Toronto Rehab - UHN; 2 Institute of Biomaterials & Biomedical Engineering, University of Toronto; 3 Department of Biomedical Engineering, Instituto Nacional de Telecomunicagues, Brazil; 4 Department of Occupational Science & Occupational Therapy, University of Toronto
Several groups including mobility impaired older adults are no longer independent in manual wheelchairs and are denied powered wheelchairs due to cognitive or physical impairments. Loss of independent mobility has important implications on quality of life (QOL) and caregiver workload. Intelligent powered wheelchairs (IPW), powered wheelchairs with sensors to prevent collisions and aid in navigation, can restore independent mobility despite physical or cognitive limitations. Docking at a table is a challenging daily living activity unaddressed by IPW designs. This study aimed to define user needs for a table-docking feature to be implemented into an IPW. Ten older adults (>50 years-old) with mobility and mild-to-moderate cognitive impairments were asked to dock at a table using a mock setup where a teleoperator simulated â€œintelligentâ€? behavior of the wheelchair. Three modes with varying degrees of shared-control between user and tele-operator were investigated. Qualitative interviews revealed strengths, weaknesses, and requirements for each mode. Participants recognized the usefulness of the tabledocking feature. Findings include the need for a system capable of adapting to user and context, which also maximizes user control and engagement, and allows position adjustments by the user. These results will inform the design of a tabledocking feature for an intelligent powered wheelchair. 18. Non-Contact Monitoring of Physiological Signals in Different Sleeping Positions MH Li1,2, A Yadollahi1,2, B Taati1,3 1 Toronto Rehab - UHN; 2 University of Toronto, Institute of Biomaterials and Biomedical Engineering; 3 University of Toronto, Department of Computer Science
Sleep apnea is a breathing disorder characterized by cessations or reductions of breathing during sleep. Individuals with sleep apnea are at higher risk of developing a host of conditions including heart disease, hypertension, and depression. The gold standard for diagnosing sleep apnea is polysomnography (PSG), which is uncomfortable and expensive. The goal of this project is the design and validation of a non-contact system for physiological monitoring during sleep. The system is composed of an infrared (IR) sensitive video camera mounted above the bed and a source of IR illumination. Testing is performed under five different sleep scenarios. Motions are extracted from video by tracking distinctive points over time. Component analysis is applied to reduce the data set to a smaller set of representative signals. Respiratory rate (RR) and heart rate (HR) are determined by analyzing the extracted motions for periodic signals in the expected frequency ranges. System performance was compared against HR and RR from PSG. RR estimation was accurate within 1 breath/minute for 94.4% of estimates while HR estimation was accurate within 5 beats per minute for 87.0% of estimates. This system presents an affordable and convenient alternative to PSG for physiological monitoring during sleep. 11
19. Assessing a Fall Detection System for Night-Time Use in a Hospital Setting M Coahran1, R Churchyard2, L Hillier3, A Mihailidis1,4, L VanBussel3 1 Toronto Rehab - UHN; 2 Faculty of Social Work, University of Toronto; 3 St Joseph's Health Care - London; 4 Department of Rehabilitation Sciences, University of Toronto
Falling is a major challenge to the independence of older adults. We have developed a fall detection system for night-time use in a hospital setting, and installed the system in 5 patient rooms on 2 geriatric wards in a mental health hospital for a 3month study period. When potential falls were detected, nurses were alerted via an Android app on cell phones they carried. The study aims to assess the accuracy of the system and elicit the views of clinical staff regarding the system. Surprisingly few falls occurred during the study period, so our data regarding fall detection accuracy is sparse. Nine nurses participated in interview sessions after the study period, providing feedback on their experiences with the system. We present preliminary findings from the nurse interviews. Some highlights: nurses experienced frustration with false alarms, but they liked that alert notifications were sent directly to them without alarming the patients. Nurses would have preferred a system that alerted them to night-time activity in the room, which would allow them to assist non-ambulatory patients and perhaps prevent falls. Some nurses suggested collecting data and sending monthly reports regarding patients' nighttime habits, which could also potentially be used to prevent falls. 20. Validating the Accuracy of the Microsoft Kinect for Windows v2 for Measuring Spatio-temporal Gait Parameters E Dolatabadi, B Taati, A Mihailidis University of Toronto, Toronto Rehab - UHN
This poster presents a study to evaluate the accuracy of the Microsoft Kinect for Windows v2 for measuring the spatio-temporal parameters of gait. Twenty healthy adults (age: 28.817.1 years, height: 171.21+10.5 cm, weight: 66+16 kg) performed 10 sequences of walks across a GAITRite mat at three different conditions: usual pace, dual task and fast pace. Each walking sequence was simultaneously captured with the Kinect for Windows v2 and the GAITRite system. An automated algorithm was employed to extract various spatio-temporal features including gait velocity, gait cycle, step length, and step time from the recorded Kinect v2 sequences. Accuracy in terms of reliability and limits of agreement was examined for each gait feature at different walking conditions. The 95% Bland and Altman limits of agreement were narrow enough for the Kinect v2 to be a valid tool for measuring all reported spatio-temporal parameters of gait in all three conditions. An excellent intraclass correlation coefficient (ICC) ranging from 0.91 to 0.99 was observed for all gait measures across different walking condition. The results of this study suggest that the Kinect for Windows v2 has the capacity to measure selected spatio-temporal gait parameters for healthy adults.
ABSTRACTS FROM THE SWALLOWING SCIENCE TEAM The Swallowing Science Team focuses on the diagnosis and treatment of swallowing impairment (dysphagia), which is common following stroke, acquired brain injury and in neurodegenerative disease. Their main emphases are completing the regulatory testing necessary in order to make our non-invasive device to detect aspiration (entry of foreign material into the airway) widely available. This invention is based on the analysis of swallowing vibrations, and work exploring the role of tongue function (both sensory and motor) in healthy swallowing.
21. Efficacy of Thickened Liquids at Eliminating Aspiration in Head and Neck Cancer Patients: A Systematic Review CEA Barbon1,2, CM Steele1,2,3,4 1Toronto Rehab - UHN; 2University of Toronto, Department of Speech-Language Pathology; 3University of Toronto, Institute for Biomaterials and Biomedical Engineering; 4 Bloorview Research Institute
Purpose: Currently, little is known about the effectiveness of thickened liquids as an intervention to eliminate aspiration in individuals with head and neck cancer (HNC). Specifically, aspiration is an underdiagnosed and underreported phenomena in the HNC patient post (chemo) radiation therapy. We conducted a systematic review to appraise the current videofluoroscopic evidence on the reduction of aspiration using thickened liquids in the HNC population.Method(s): A multi-engine literature search identified 337 non-duplicate articles of which 6 were judged to be relevant. These underwent detailed review for study quality, rating for level of evidence, and data extraction. Result(s): Rates of aspiration were typically not reported by bolus consistency, despite the fact that a variety of stimulus consistencies were used during VFSS. Studies confirmed that aspiration is a major concern in the HNC population and reported a trend towards more frequent aspiration post(chemo)radiotherapy. Conclusions: Overall, the literature on thickened liquids as an intervention to eliminate aspiration in the HNC population is lacking. Because aspiration is known to be prevalent in the HNC population and thickened liquids are known to eliminate aspiration in other populations, it is important to determine the effectiveness of thickened liquids for reducing aspiration in the HNC population. 22. Inter-rater Reliability of Videofluoroscopy Rating Using Standardized Definitions and Methods A Nagy1, CM Steele1,2,3 1 Toronto Rehab - UHN; 2 Bloorview Research Institute, Holland Bloorview Kids Rehab; 3 University of Toronto
PURPOSE: The primary objective of the videofluoroscopic swallowing study procedure (VF) is to identify the presence, severity and pathophysiology of impaired swallowing safety and efficiency. Impaired safety is defined as the entry of food or liquid into the airway during swallowing, best measured by the PenetrationAspiration Scale (PAS). Impaired swallowing efficiency is defined as a situation 13
where residue is left behind in the pharynx, and can be measured using an ordinal scale, the modified Eisenhuber Rating Scale. Historically, studies have shown poor inter-rater agreement for VF interpretation. Our goal was to establish a standardized rating method that would yield good inter-rater agreement.METHODS: We adopted clear operational definitions and a stepwise process for rating VF examinations. The swallowing rehabilitation research laboratory developed a standardized protocol for rating (VF) examinations. Independent duplicate ratings were performed for 1270 bolus swallowing recordings from research participants. Inter-rater reliability was calculated for measures of swallowing safety and efficiency. RESULTS: Our rating system demonstrated perfect agreement for binary ratings was seen in 88% of cases for swallowing safety, 92% for vallecular residue, and 95% for pharyngeal residue. These results indicate good inter-rater reliability. 23. Malnutrition and dysphagia in long term care: A systematic review AM Namasivayam 1,2, CM Steele 1,2,3 1University of Toronto, Department of Speech-Language Pathology; 2 Toronto Rehab - UHN - University Health Network; 3 Bloorview Research Institute, Holland Bloorview Kids Rehab
Elderly adults living in long term care (LTC) facilities, including long term care homes, assisted living, and dementia care units, are nutritionally vulnerable; 3060% are malnourished, which impacts their health, well-being and quality of life. Approximately 74% of residents in LTC also have swallowing disorders. A systematic review was conducted to elucidate the association between malnutrition and dysphagia in the elderly residing in long term care. A literature search identified 614 publications that mentioned dysphagia and malnutrition in the context of long term care. Of these, 16 were judged to be relevant and went through a detailed review. Evidence of the co-occurrence of the two diagnoses emerged. However, due to discrepancies used to describe and measure both malnutrition and dysphagia in each study, it is difficult to determine the prevalence of either condition separately, or in combination.
ABSTRACTS FROM THE MOBILITY TEAM Mobility Team members develop therapeutic techniques and assistive technologies to improve independent mobility, maximize meaningful activity and reduce the risk of falling. Their research is focused in three broad areas: advanced assessment and therapies for gait and balance disorders; exercise influence on rehabilitation and health; and smart mobility aids and environments. Their researchers are developing advanced diagnostic techniques (and tools) for gait, balance and fall risk; new exercise based interventions to target neurologic, cardiorespiratory and musculoskeletal health; and new technologies to improve gait and mobility and reduce fall risk in everyday situations. A hallmark of the work of this team has been the development and implementation of the Balance, Mobility and Falls Clinic (BMFC). The BMFC is a cross between clinical practice and research; incorporating training programs that are tailored to the needs and interests of the patient. This clinic helps to develop confidence and progress recovery.
24. Physiotherapists' perspectives on the determinants of aerobic exercise prescription and implementation early after stroke EC Prout1,3, WE McIlroy1-6, A Mansfield1-5, D Brooks1-4 1 Graduate Department of Rehabilitation Sciences and 2 Department of Physical Therapy, University of Toronto, Toronto, ON, Canada; 3 Toronto Rehab - UHN; 4Heart and Stroke Foundation Canadian Partnership for Stroke Recovery; 5 Sunnybrook Health Sciences Centre; 6 Department of Kinesiology, Faculty of Applied Health Sciences, University of Waterloo
Purpose: To identify physiotherapist perspectives on aerobic exercise prescription and implementation at in-patient stroke rehabilitation centers with and without a structured aerobic exercise program. Methods: A cross-sectional survey was conducted at three Canadian rehabilitation centers to evaluate physiotherapist education and perceptions regarding individuals recovering from stroke and the practice environment. Results: Physiotherapists at centers with a structured aerobic exercise program (n = 6) had received continuing education in aerobic training after stroke. They reported concerns for the individual's safety (cardiovascular status) and therapy selection (lack of time) as the greatest barriers to prescription and implementation. In contrast, physiotherapists at centers without a structured aerobic exercise program (n = 10) had not received any continuing education in aerobic training. They reported the individual' s inability to perform aerobic exercise (physical impairments, non-cardiac comorbidities, and fatigue) and lack of resources (lack of equipment to screen or monitor safety, space, and therapeutic support staff) as the greatest barriers. Conclusions: The lack of resources at rehabilitation centers without a structured aerobic exercise program need to be addressed. After resource limitations have been met, there remains a need for continuing education, ongoing support, and changes in healthcare delivery at centers with a structured aerobic exercise program.
25. Deficits in Far Target Reaching in Individuals with Elbow Flexor Spasticity after Stroke T-T Yeh1,2, SH Scott3,4,5, G Mochizuki1,2,6,7 1 Toronto Rehab - UHN; 2 Brain Sciences Research Program, Sunnybrook Research Institute; 3 Centre for Neuroscience Studies, Queen's University; 4 Department of Anatomy and Cell Biology, Queen's University; 5 School of Medicine, Queen's University; 6 Department of Physical Therapy, University of Toronto; 7 Heart and Stroke Foundation Canadian Partnership for Stroke Recovery
Spasticity occurs following injury to the brain or spinal cord. The damage causes an increased sensitivity to muscle stretch and excessive activity in the affected muscles, which interferes with performance of daily activities. Clinical measurements of spasticity are often challenged as being subjective and do not describe the impact of spasticity on active, functional movement. My goal was to identify the impact of spasticity on active movement in stroke survivors. I used a reaching task to assess how spasticity affects voluntary movement. The results indicate that patients with spasticity of the elbow flexor muscles showed higher reaching variability than patients without spasticity. They also showed greater variability at the further targets compared to the closer targets, suggesting that active tasks requiring a lengthened muscle are more likely to be impacted by spasticity. The work helps us to better understand the impact of post-stroke spasticity on active movement. 26. Handrail Cueing Device to Reduce Risk of Falling AM Hart1,2, SA Jones1, SM McKay1,3, JE Fraser1, BE Maki1,4 1 Toronto Rehab - UHN; 2 University of Waterloo; 3 VHA Home Healthcare; 4 University of Toronto
Balance-recovery reactions involving the grasping of a handrail in response to sudden loss of balance (LOB) play a vital role in fall prevention; however, older adults often appear to have difficulty in executing these reactions effectively. Such problems can be avoided if the handrail is held proactively (before LOB can occur). Our previous studies have shown that the introduction of a verbal audio cue can increase proactive use of the handrail. This project involves the development of a prototype audio-cue device. The device uses infrared technology to detect a passerby and determine their direction of movement with respect to a handrail. If the passerby is approaching the handrail, an audio cue is generated: ''Attention, use the handrail''. The device is designed to be inexpensive (<$75), battery powered and easily installed adjacent to any handrail. The introduction of this device into settings where individuals are at a higher risk of falling should reduce the incidence of serious but preventable injuries. 27. Validation of the Actigraph activity monitor for individuals with recent stroke VG DePaul1,2, S Sivakumaran1,2, C Campos1,2, S Knorr1, A Mansfield1,3, KK Patterson1,3 1 Toronto Rehab â€“ UHN; 2 Department of Kinesiology, University of Waterloo; 3 Department of Physical Therapy, University of Toronto
Background: While physiotherapists commonly assess ability to walk, it can be challenging to measure actual participation in walking activities. The emergence of wearable technology allows quantification of walking activity over hours or days. 16
The purpose of this study is to validate the Actigraph monitor in individuals with stroke. Methods: Inpatients were recruited from the stroke rehabilitation unit at Toronto Rehab. Steps were counted over a single day using the Actigraph worn at the waist and ankle, and a validated accelerometer system on the ankle. Stroke recovery, balance, mobility and gait were also assessed. Agreement between Actigraph and Accelerometer was determined using Intraclass correlation coefficient (ICC). The relationship between accuracy and gait speed was explored using correlation analysis. Results: In the initial 14 participants, there was excellent agreement between Actigraph-ankle and accelerometer (ICC 2,1 = 0.97; 95% CI 0.89, 0.99), and poor agreement between the Actigraph-waist and the accelerometer (ICC2, 1 = 0.51; 95% CI -0.08, 0.85). A moderate correlation was found between the accuracy of the Actigraph-ankle and gait velocity. Conclusions: In patients with recent stroke, accuracy of the Actigraph seems dependent on monitor position and gait velocity. Ongoing work will inform future use of the Actigraph in research and clinical settings. 28. What is the role of augmented feedback in learning reactive balance control? R Rajachandrakumar1,2, K Patterson1,2, B Lakhani5,A Mansfield1-4 1 Toronto Rehab - UHN; 2 University of Toronto; 3 Sunnybrook Health Sciences Centre; 4 Canadian Partnership for Stroke Recovery; 5 University of British Columbia
Introduction: Augmented feedback of performance on novel motor skills can improve learning, but the use of augmented feedback to improve learning of reactive balance control is not fully understood. This study aimed to determine if augmented visual feedback can be used to improve reactive balance control, and what type of visual feedback is the most effective. Methods: Participants were 27 healthy older adults (60-75 years). Participants were allocated to one of three groups: feedback of the centre of mass (COMf), feedback of the centre of pressure (COPf), or no feedback (NoFB). Participants stood on a moving platform that translated continuously in a pseudorandom manner for 30s. Two sessions were completed on two consecutive days; participants completed 25 practice trials in the first session followed immediately by test 5 trials with no feedback, and test 5 trials with no feedback in the second session. Results: All three groups improved balance control with practice, and retained these improvements in the second session. The COPf group appeared to show greater reduction in the difference between the COP and COM in the immediate test trials. Conclusions: Preliminary results suggest that augmented feedback of the COP might be best for improving reactive balance control. 29. Do falls experienced during in-patient stroke rehabilitation affect length of stay and functional recovery? JS Wong1,2, D Brooks1-3, A Mansfield1-3 1 Toronto Rehab - UHN; 2 University of Toronto; 3 Canadian Partnership for Stroke Recovery
Background: Falls are common post-stroke and have significant immediate physical and psychosocial consequences. These negative effects of falls could delay stroke recovery. The objective of this study was to determine the impact of falls on length of stay (LOS) and change in functional status of individuals receiving rehabilitation. Methods: A retrospective chart review of participants attending in-patient stroke rehabilitation was conducted. In total, 106 non-fallers (median age = 69 years, IQR 17
= 18) were matched with 106 fallers (median age = 68 years, IQR = 18) based on age and the Rehabilitation Patient Group algorithm. Fallers were individuals who fell at least once, as reported by incident reports and nursing notes. The Functional Independence Measure (FIM) and the Berg Balance Scale (BBS) were assessed at admission and discharge. Non-parametric tests for independent samples were used to compare the 2 groups. Results: The median LOS for fallers was 10.5 days longer than non-fallers (p=0.0002). The 2 groups did not differ at discharge on the FIM (p=0.56) or BBS (p=0.39). Conclusions: These results suggest that falls experienced during in-patient rehabilitation may have contributed to a longer length of stay. However, falls did not have a significant impact on functional recovery. 30. The role of the arms and hands in reacting to sudden loss of balance: A new perspective for preventing falls and injury in seniors J Borrelli1, J Zabukovec1, S Jones1, B Maki1,2 1 Toronto Rehab â€“ UHN; 2 University of Toronto
Falling is a leading cause of serious injury, loss of independence and nursing-home admission in seniors. Reactions to sudden loss of balance involving the arms or hands can play an important role in preventing falls and protecting against injury; however, the control of these reactions is very complex and likely to be impaired by aging. For arm reactions to be effective, the brain has to rapidly make several critical decisions, which are dependent on situational factors such as the direction and speed of the fall and the proximity of objects that can be touched or grasped. A fundamental decision is whether to attempt to use the arms to aid in recovering balance or to prepare for a pending fall. This study will determine age-related changes in the capacity to select and execute effective arm reactions and effects related to environmental features (handrails, obstacles), using sudden unpredictable platform motion to evoke the arm reactions. To date, 12 young and 6 older adults have been tested; data analysis is in progress. The study is expected to provide important new information about age-related risk factors for falls and injury, and to lay the groundwork for development of new interventions to counter these problems. 31. A new tool for assessing balance reactions J Borrelli1, S Jones1, J Zabukovec1, B.Maki 1,2 1 Toronto Rehab - UHN; 2 University of Toronto
Forty percent of hospital admissions in seniors are a result of fall-related injuries and approximately half of those hospitalized are discharged to nursing homes. Many studies demonstrate associations between falling risk and measures pertaining to balance control while standing with feet kept "in place". Although these reactions are important in providing an early defense against loss of balance, the capacity to avoid falling is dependent on a type of balance control that involves moving the limbs rapidly to alter the base of support (change-in-support reactions). Most commercially-available tools used to assess change-in-support reactions are prohibitively expensive; those that are in clinical use typically have little cost associated with them but suffer from questions of repeatability and precision. The aim of this project is to translate research concepts into two systems, for use by clinicians, to assess change-in-support reactions in a safe, well-controlled and repeatable manner. We have currently developed several design concepts based on systems used at various research facilities. During the next phase of the project, a 18
multi-disciplinary team will identify the key characteristics to be incorporated in two (2) devices that we plan to build and validate. These new tools will allow clinicians to identify high risk individuals and specific balance problems. 32. Inter-limb postural synchronization is increased prior to bouts of external perturbations. O Habib Perez1,2,4, G Mochizuki1-4 1 Graduate Department of Rehabilitation Science, University of Toronto; 2 Heart and Stroke Foundation Canadian Partnership for Stroke Recovery; 3 Department of Physical Therapy, University of Toronto; 4 Toronto Rehab - UHN
Anticipatory control is critical for daily motor tasks and is dependent on the readiness of the CNS. This readiness minimizes the postural threat associated with postural instability to optimize balance reactions. Inter-limb synchronization is a sensitive measure of postural control during quite standing; however, little is known about the inter-limb coordination immediately prior to postural instability during the time associated with movement preparation. Methods: Centre-of-pressure (COP) force platform data from 13 healthy young adults (27.5 13.3 years) were collected. Internal and external balance perturbations were evoked under blocked and randomized conditions with two perturbation magnitudes. Cross-correlation function was calculated using the COP excursion from the left and right foot for three seconds prior to perturbation onset. Results: At zero phase lag the cross-correlation coefficient was the highest for the most predictable perturbations (blocked conditions) over the less predictable perturbations (randomized conditions). Internal perturbations produced greater COP variability compared to external perturbations despite equal foot placement. Conclusion: Inter-limb synchrony decreases as perturbation magnitude increases and becomes more unpredictable, and is lower during internally generated stepping perturbations. We speculate that enhanced synchrony during external perturbations may demonstrate elevated levels of control in anticipation of imminent bouts of instability. 33. Investigating balance, plantar pressure, and foot sensitivity in diabetic individuals during stair gait PJ Antonio1,2, SD Perry1,2,3 1 University of Toronto, Graduate Department of Rehabilitation Science;2 Toronto Rehab â€“ UHN; 3 Wilfrid Laurier University, Department of Kinesiology and Physical Education
Introduction: Diabetic peripheral neuropathy (DPN) is a result of diabetes mellitus. DPN is a dysfunction of the peripheral nerves that restricts sensation from the limbs, which constrain one s mobility and quality of life. Furthermore, the plantar cutaneous sensation of DPN individuals is reduced, compromising their balance. To compensate, they generate greater foot pressures while walking - often leading to tissue ulcerations, or possibly lower-extremity amputations if left untreated. As well, foot pressures during stair gait are greater than level walking. Currently, there are diabetic insole devices that offload foot pressures and limit ulcer formation; however these devices fail to address concurrent issues of balance and fall risks. Aim: 1) Investigate stair gait balance and plantar pressure in individuals with DPN, 2) Identify features that will uniquely characterize DPN during mobility, 3) Develop guidelines and assistive devices to optimize ulceration prevention and balance stability for DPN individuals. Methods: DPN individuals and an age-matched healthy control will traverse a 6-step staircase, while instrumented with pressure sensor insoles and reflective markers to record balance and plantar pressure. Expected 19
Results: DPN individuals will demonstrate more instability and higher plantar pressures versus the age-matched control group. 34. Sensorimotor Contributions to Navigation in Younger and Older Adults C Baker 1,2, J Campos 1 1 Toronto Rehab – UHN; 2 Wilfrid Laurier University
Falls-incidence and falls-related injury are prevalent in older adults. This may be due to a non-optimal use of dynamic visual information (optic flow) during walking. Purpose: To determine how younger and older adults use optic flow when making judgments related to navigation. Methods: 17 younger adults (23.9±3.0 years) and 6 older adults (73.7±4.8 years) were instructed to walk on a treadmill down a hallway in StreetLab which contained a set of elevator doors. At some point along the trajectory, the doors began to close and participants were asked to judge whether they could safely pass through the gap. Across trials, optic flow rate was manipulated to move faster, equal to, or slower than participants walking speed (1m/s). Results: A main effect of age was found whereby younger adults judged they could pass through narrower gaps than older adults. A main effect of optic flow rate was found whereby all participants judged safe passage through narrower gaps at the optic flow rate that was slower than their actual walking speed. An interaction effect indicated that older adults were more affected by the change in optic flow rates and judged they could not pass through narrower gaps at the faster optic flow rate. Significance: Older adults were more influenced by the visual manipulation, resulting in a safer navigation strategy. Such age-related differences may be used to identify how the use of dynamic visual cues may be related to gait stability during locomotion and could ultimately help to inform intervention strategies. 35. The Impact of Botulinum Toxin and Upper Limb Rehabilitation on Spasticity, Pain and Function: A Systematic Review P Eftekhar1,2,3,6, C Phadke1,4,5, K Patterson1,5, D Brooks1,2,4,5, G Mochizuki1,2,3,5,6 1 Graduate Department of Rehabilitation Science, University of Toronto; 2Toronto Rehab UHN; 3 Sunnybrook Research Institute; 4 West Park Healthcare Centre; 5 Department of Physical Therapy, University of Toronto; 6 Heart & Stroke Foundation Canadian Partnership for Stroke Recovery
The purpose of this systematic review was to examine the impact of botulinum toxin A (BoNTA) and upper limb (UL) rehabilitation on spasticity, UL function, and pain after stroke. Randomized controlled trials that compared the effect of BoNTA combined with UL rehabilitation to UL rehabilitation plus placebo or only rehabilitation were selected. Five randomized controlled trials with a total of 446 patients with UL spasticity were included in the systematic review. The assessments were performed 4 weeks and 12 weeks after BoNTA injection. Compared to UL rehabilitation only, BoNTA and UL rehabilitation resulted in decreased UL spasticity at 4 weeks after injection using the Modified Ashworth Scale (weighted mean difference; (WMD -0.59, 95% CI -0.81 to 0.37). At 12 weeks, the difference in spasticity was not significant (WMD 0.26, 95% CI 0.09 to 0.43). There was no difference for measures of UL function or pain at 4 weeks and 12 weeks. The combination of BoNTA with UL rehabilitation decreased spasticity to a greater extent than UL rehabilitation plus placebo or UL rehabilitation alone at the 4 week time point only. BoNTA administration did not impact UL function or pain at either 20
the 4 or 12 week post-intervention time point. Key Words: stroke, spasticity, upper limb, function, pain, botulinum toxin 36. Evaluating the Effectiveness of Perturbation-based Training Programs in the Developing “SEA LEGS” To SIMULATED SEA Motions CA Duncan1,2, A Mansfield1, JM Byrne3, WE McIlroy1,2 1Toronto Rehab – UHN; 2 Department of Kinesiology, University of Waterloo; 3 School of Human Kinetics and Recreation, Memorial University
Slips, trips, and falls (STFs) are a major concern in occupational environments, accounting for a significant portion of all reported work-related injuries in Newfoundland and Labrador’s offshore petroleum industry. Perturbation-based training has been shown as an effective measure in developing appropriate postural responses for young and older adults. This research aims to address the industry’s STF concerns through the development of a perturbation-based training program that will help prepare new workers to better adapt to motion-induced stressors of their work environments. Development of this program involved two research experiments. In the first study the postural responses of experienced maritime workers were compared to those of individual with no experience in maritime environments. For the second study a perturbation-based training program designed to develop postural responses inexperienced individuals that are similar to those observed in experienced was developed using simulated wave-induced platform motions. Results of these first two project phases suggest: 1. Experienced workers appear to have developed postural control strategies for moving environments that result in fewer CS reactions being performed in the simulated environments. 2. Perturbation-based training using simulated wave-like motion perturbation-based produces rapid gains in learning and responses that are similar to those of experienced workers. Thus, training may be beneficial in reducing occupational falls in maritime environments. 37. Reactive stepping after stroke: determinants of paretic and nonparetic step initiation EL Inness, 1,2, A Mansfield, 1-4, WE McIlroy1-4 1 Toronto Rehab - UHN - UHN, Toronto, ON; 2 University of Toronto, Toronto, ON; 3 Canadian Partnership for Stroke Recovery; 4 University of Waterloo, Waterloo, ON
Background/Rationale: Impaired features of reactive stepping, specifically delays in step initiation, i.e. time to foot off (TFO), are associated with increased fall rates after stroke. The purpose of this study was to: 1) determine factors associated with timing of paretic and nonparetic limb TFO, and; 2) determine if paretic and/or nonparetic TFO were associated with ‘falls’ during clinical testing. Methods: A retrospective review of 105 patients within stroke rehabilitation who received a lean-and-release reactive balance control assessment. Results: Despite significant limb impairment, there were no significant differences in TFO between paretic (351 ms; 95%CI [334,368]) and nonparetic (365 ms;95%CI [346,384] limbs. The amplitude of perturbation (cable load) and capacity to weight shift laterally were associated with paretic TFO (R2=0.24;p<0.0001). Cable load and the preperturbation load under the nonparetic limb were associated with nonparetic TFO (R2=0.23;p<0.0001). The likelihood of a ‘fall’ was associated with nonparetic limb TFO (odds ratio=1.009; 95%CI(1.001,1.015;p=-.003) but not paretic limb TFO (odds ratio=1.00; (95%CI (0.994,1.006);p=0.95).Conclusions: This study demonstrates the unique stroke-related impairments that influence reactive step 21
initiation of the paretic and nonparetic limb. The link between ‘falls’ and nonparetic TFO highlights importance of other factors such as ability to control weight bearing and balance in the stance phases of stepping. 38. Investigating the Effect of Instruction Type on Motor Learning in a Lower Extremity Motor Task in Stroke Patients G Shaw1, S Knorr1, G Mochizuki2,3 , KK Patterson1,2 1 Toronto Rehab - UHN; 2 Department of Physical Therapy, University of Toronto; 3 Sunnybrook Research Institute
Motor learning is associated with practice leading to relatively permanent changes in movement capability and is the foundation for stroke rehabilitation. However, it is unclear if motor learning post-stroke is similar to that observed in healthy adults. This study’s purpose was to determine if the type of task instruction affects motor learning after stroke. Eleven participants with stroke were randomly assigned to manual, verbal or visual type of instruction for a seated bilateral lower extremity (LE) tapping task. Participants performed up to 50 trials of the task during an acquisition session. The number and accuracy of taps were recorded with force plates and electrodermal activity was used to measure level of effort. Motor learning was assessed at a retention session 24-48hrs later. Repeated measures ANOVA revealed all participants increased number of taps at retention (p=0.005) with a significant effect for instruction (p=0.03). Level of effort increased over acquisition (p<0.001) with a significant interaction with instruction (p=0.013). These preliminary results suggest all participants learned the LE task and visual instruction produced superior motor learning. Verbal instructions may be associated with increased effort during task practice. The final results of this ongoing study may inform how instructions are delivered during therapy.
ABSTRACTS FROM THE OPTIMIZATION OF THE REHABILITATION SYSTEM TEAM Members of the Optimization of the Rehabilitation System Team conduct research on health services, health policy, and knowledge translation with particular emphasis in chronic disease management and person-centred care. Their team members use a wide variety of research methods encompassing both qualitative and quantitative and spanning the continuum of care from acute care to integration into the community and long-term care. Since much of their research is directly relevant to decision-makers they often use an integrated knowledge translation approach and work with stakeholders through the knowledge production cycle from collaboratively setting of the research questions through to dissemination of the research results.
39. Do QOL, physical function, or the Wheatley Index at diagnosis predict 1 year survival during Intensive Chemotherapy (IN) in AML patients? N Timilshina 1, H Breunis1, SMH Alibhai 1,2 1 Department of Medicine, University Health Network 2 Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto
Background: Acute myeloid leukemia (AML) is an aggressive malignant blood disorder, with a 1-year survival of <50% in older adults (age 60+). Our objective was to investigate the predictive value of baseline QOL, physical performance measures (PPMs), and the Wheatley Index at diagnosis on 1-year survival in younger (<60 years) and older (60+ years) patients. Methods: 140 younger and 97 older AML patients undergoing IC at the Princess Margaret Cancer Centre were enrolled and completed EORTC QLQ-30 and 3 PPMs at baseline (pre-IC). The prognostic risk categories ware categorized according to the index defined by Wheatley et al. Cox proportional hazards regression was used to analyzed the 1year survival. Results: Overall 1-year mortality was 22.1% in younger and 37.1 % in older patients. Survival was significantly lower among the poor Wheatley risk category than the other 2 risk categories. Global health and PPMs were not predictive of 1-year survival. Poor Wheatley risk category was the most significant predictor in multivariate survival models in both older and younger groups. Conclusion: QOL and PPMs at diagnosis were not good predictors of 1-year survival among younger and older patients; the Wheatley index may help inform clinicians and patients about up-front therapy in AML.
40. Personal and Environmental Factors Influence Survivors Participation in Activities One-year Post-Stroke: A Mixed Method Study A Grigorovich1,2, G Naglie1, M Gignac3, M Huijbregts4, F Silver5, M Bayley1, A Cheung6, J Hoch7, H Finestone8, G Warner9, S Phillips9, T Green10, N Weir10, M Suddes10, J Cameron1,2 1 Toronto Rehab - UHN; 2 University of Toronto;3 Toronto Western Research Institute;4 Baycrest; 5 Toronto Western Hospital; 6 University Health Network; 7 St Michael s Hospital; 8 University of Ottawa;9 Dalhousie University; 10 Foothills Medical Centre
The objective of this study was to investigate the influence of caregiver (CG) and stroke survivor (SS) factors on SSs participation in activities at 1-year post-stroke. This was a mixed-method study with a paper survey component, followed by an optional phone interview and was also a sub-study of a randomized control trial of an intervention for caregivers. 103 SSs and CGs across Canada participated. The correlation analysis showed that SSs participation was associated with their age, initial disability level, functional impairment, social support, depression, mastery, level of assistance provided by the CG, and CGs level of lifestyle interference. The multivariate regression found that SSs had higher participation when they were younger, had less initial disability, were less functionally impaired, had higher levels of social support and needed less assistance from CGs. Qualitative data confirmed these findings and identified additional factors influencing participation: the environment, previous activity interests, communication and cognition, fatigue, and social support. These findings reveal that participation is a complex construct influenced by both personal and environmental factors. This study highlights the importance of CGs support for enabling SSs outcomes. The qualitative results also suggest that existing quantitative measures may not capture important barriers to SSs participation. 41. Characterizing Community Exercise Programs Delivered by Recreation Providers for People with Neurological Conditions: A Scoping Review S Merali1, JI Cameron1,2,3, R Barclay4, NM Salbach1,3,4 1 Graduate Department of Rehabilitation Science, University of Toronto; 2 Department of Occupational Science and Occupational Therapy, University of Toronto; 3 Toronto Rehab â€“ UHN; 4 Department of Physical Therapy, University of Manitoba; 5 Department of Physical Therapy, University of Toronto
Purpose: To characterize evaluations described in the research and grey literature of community-based exercise programs (CBEPs) delivered by fitness instructors to people with neurological conditions. Methods: A scoping review of literature published since 1946 was conducted using MEDLINE, EMBASE, CINAHL, and Cochrane Database of Systematic Reviews. Search terms included community, program, exercise, adult, brain disease, spinal cord disease. Results: After screening 1782 studies, 16 (0.90%) studies met the inclusion criteria. The following program features were most common: 1) populations: stroke (44%), Parkinson s disease (44%); 2) frequency of classes per week: 2 (44%); 3) class duration: 1 hour (44%); 4) program duration: 12 weeks (44%); 5) type of exercise programs: stand-alone (87%), group-based (63%); 6) exercise mode: combination of strength and aerobic training (38%); 7) involvement of a healthcare professional (HCP): 56%; 8) study outcome: health-related quality of life (63%), and mobility (63%). Conclusions: Results will identify recommendations for future research to evaluate: 1) populations beyond stroke and PD; 2) CBEPs for individuals with limited or no ambulatory ability; 3) CBEPs involving task-oriented training; 4) study outcomes targeting participation, cost, healthcare utilization, caregiver health; 5) involvement 24
of HCP; 6) CBEPs and evaluations of these programs would benefit from quantitative and qualitative methodologies. 42. A Phase II RCT and Economic Analysis of Three Exercise Delivery Models in Men with Prostate Cancer on ADT: Study Protocol M O'Neill1,2, SN Culos-Reed6, D Santa Mina3, P Ritvo4, C Sabiston2, M Krahn2, G Tomlinson2, A Matthew1, R Segal5, P Warde1, S Durbano1, SMH Alibhai1,2 1 University Health Network; 2 University of Toronto; 3 University of Guelph; 4 York University; 5 University of Ottawa; 6 University of Calgary
Prostate cancer (PC) is the most common cancer in men. Androgen deprivation therapy (ADT) is a common treatment; however, side effects can lead to worsening well-being. Existing evidence shows that exercise provides numerous benefits for this population and the exercise delivery model (supervised, home-based) may be important, yet few studies have compared them or their costs. Additionally, longterm exercise adherence is critical for sustained benefits, however adherence data are lacking. The study aim is to determine whether three exercise training delivery models are equivalent in terms of benefits (health, well-being), additionally examining long-term adherence and cost-effectiveness. Men diagnosed with PC, starting or continuing on ADT for at least 6 months, fluent in English, and living in close proximity to Toronto or Calgary study centres are eligible. Participants complete five assessments over one year incorporating fitness assessment, selfreport questionnaires, bone mineral density and blood work. Participants are randomized into 1:1 supervised, group supervised, or home-based training and complete 4 to 5 exercise sessions per week (aerobic, resistance and flexibility training). The goals of this study are to gain a better understanding of benefits and costs associated with common exercise delivery models, adherence during and after exercise interventions, and predictors of adherence. 43. System Level Factors Influencing the Implementation of Family Caregiver Education and Support Programs in the Ontario Stroke System V Tseung1, SB Jaglal2,3, NM Salbach2,3, JI Cameron2,4 1 University of Toronto, Graduate Department of Rehabilitation Science; 2 Toronto Rehab UHN; 3 University of Toronto, Department of Physical Therapy; 4 University of Toronto, Department of Occupational Science and Occupational Therapy
Background: Family caregivers are essential to ensuring a successful transition home for stroke survivors. Despite literature showing that caregiver programs help to improve caregiver skill and well-being, these programs have not been formally implemented in the healthcare system. This study aims to describe the system level factors and considerations for implementing caregiver programs. Methods: Focus groups were conducted with four stakeholder groups within the Ontario Stroke System: Regional Program Directors/District Stroke Coordinators, Regional Community and Long-Term Care Coordinators, Regional Education Coordinators, and Regional Rehabilitation Coordinators. Qualitative interviews were conducted with Regional Medical Directors, health care professionals, Local Health Integration Network executives and primary care leads. The focus groups and interviews were audiotaped, professionally transcribed and reviewed for accuracy. Transcripts were coded, data were analyzed using a constant comparison approach and themes were identified. Results: Four focus groups and twenty-nine interviews were conducted. Data analysis yielded two themes: 1) The need for a shared understanding regarding the implementation of caregiver programs within an integrated 25
healthcare system; and 2) Regional variations challenge the implementation of caregiver programs. Conclusions: The study results can inform the development of implementation strategies for caregiver programs, thus enabling family caregivers to be adequately prepared for this role. 44. Quality Improvement for Patient Transitions: A Comparative Case Study in England and Ontario JA Shaw1,2,3, PK Kontos1, W Martin3, C Victor3 1 Toronto Rehab - UHN; 2 University of Toronto, Institute of Health Policy, Management and Evaluation; 3 Brunel University, School of Health and Social Care.
Poorly managed transitions out of inpatient hospital wards for elderly patients with complex needs often further exacerbate detriments to health and function. The objective of this study was to explore key factors driving quality in patient transitions in two international regions. We completed a comparative case study of care transitions in London, England and Toronto, Ontario, illuminating common themes that were essential for high quality transitions out of hospital. Case study methods included observing discharge planning rounds (n=43), interviewing leaders (n=20), practitioners (n=30), and patients/families (n=4), reviewing patient records (n=4) and analyzing policy documents (n=5). Qualitative data was analyzed using thematic analysis, and key themes emerging from each method of data collection were brought together into an overall thematic summary. Findings suggest three key factors drive quality in patient transitions: (1) The quality of interpersonal relationships between practitioners responsible for transitions, (2) Assigning responsibility for transitions work to a particular practitioner, and (3) Attending to patients post-discharge social environments. Further research will explore the impact of quality improvement initiatives that focus on enhancing these three domains to improve the quality of patient care transitions. 45. â€œSend in the Clowns!'': Exploring an Arts-based Approach to Dementia Care R Colobong1, P Kontos1,2, K-L Miller1,2, G Mitchell3, J Stirling-Twist4, L Palma Lazgare2, M Binns5,2, L-F Low6, C Surr7, G Naglie5,1,2 1 Toronto Rehab - UHN; 2 University of Toronto; 3 York University, School of Nursing; 4 Independent Consultant; 5 Baycrest Health Sciences; 6 University of Sydney; 7 University of Bradford
Elder-clowns are professional clowns/artists who use spontaneity, humor and empathy, as well as song, musical instruments, and improvisation to engage individuals with dementia. They are the most recent innovation in arts-based dementia care, yet little is known about the relational dynamics of elder-clowning and the impacts on residents with dementia. This mixed methods study examined an elder-clown intervention with 23 long-term care residents with moderate to severe dementia in central Canada. The objective was to better understand elderclown interactions and their impact on residents with dementia. Each resident received 2 interactions/week with a pair of elder-clowns (approximately 9.5 minutes/visit) for 12 weeks. Qualitative data included videotaped clown-resident interactions and their reflections on their practice during the intervention, and postintervention elder-clown interviews. Quantitative data included measures of neuropsychiatric symptoms (e.g. agitation) and quality of life. Our qualitative analyses found that elder-clowns were acutely responsive to the joy and playfulness of the residents, and validated/supported residents' sadness. Quantitative analyses 26
found a significant decrease in residents' neuropsychiatric symptoms and a significant increase in their quality of life. These findings highlight overlooked capacities of those with dementia that should be supported, and the power of elderclowning for improving resident well-being. 46. Quality indicators for hip fracture patients: A scoping review KB Pitzul1, SEP Munce2, L Perrier1, L Beaupre3, S Morin4, R McGlasson5, SB Jaglal1,2,6 1 Institute of Health Policy, Management, and Evaluation, University of Toronto; 2 Toronto Rehab â€“ UHN; 3 Departments of Physical Therapy and Surgery, University of Alberta; 4 Department of Medicine, McGill University; 5 Bone and Joint Canada; 6 Department of Physical Therapy, University of Toronto
Background: Over 30,000 hip fractures (hip#) occur annually in Canada and the number of hip#s are expected to increase by 2031, when approximately 25% of Canadians will be 65 years or older. Care for these patients must therefore be optimized; and mechanisms for measuring the quality of care must therefore be implemented. There are currently no standardized measures for quality of care in Canada for hip# patients. The purpose of this study was to synthesize the evidence surrounding quality of care indicators for hip# patients. Methods: We employed methodological frameworks used by Arksey and O Malley (2005) and Levac et al (2010). All English peer-reviewed studies published from the year 2000 and onwards were included. Literature search strategies were developed and peerreviewed. Abstracted data included study characteristics and indicator definitions. Results & Discussion: 2,053 studies were found and data extraction occurred for 201 articles. Most validated quality of care indicators were developed and used within acute care. There were few validated measures of quality of care delivery used in post-acute care. In an effort to improve quality of care for patients and create a more efficient healthcare system, quality of care indicators should be in place in both acute and post-acute settings. 47. Web-based Health Interventions for Family Caregivers: A Scoping Review M Bastawrous1, J Stinson2, JI Cameron1,3 1 Graduate Department of Rehabilitation Science, University of Toronto
Background: The 'greying' of the population will increasingly result in reliance on the family for care in the community. Family caregivers help elders to "age at home" but require support in order to maintain their health and caregiving role. The time and geographic restrictions that caregivers face have given way to the development of many web-based interventions. However, our understanding of the extent and nature of web-based caregiver interventions across aging-related illnesses remains limited. Objective: To examine the extent, range, and nature of research activity on web-based health interventions for caregivers. Methods: A scoping review was conducted. Medline, PsychINFO, EMBASE and CINAHL databases (January 1990-December, 2013) were systematically searched for studies that investigated web-based interventions for family caregivers to elderly individuals. Only empirical research was included. Inclusion/exclusion criteria were applied, the data was charted and a narrative synthesis conducted. Results: Thirtyseven studies met our inclusion criteria. Studies mostly investigated Alzheimer's disease or dementia (48.6%) with the remainder focused on cancer, stroke and various neurodegenerative diseases. No web-based interventions for COPD or 27
diabetes caregivers were found. Almost half of the studies focused on the development/ implementation of the intervention. Only 7 studies were experimental and, further, only 4 studies employed an RCT design. Samples consisted of mainly female spousal caregivers. The goal/purpose of the interventions was vague, with a typical intervention consisting of educational support and chat with peers and healthcare professionals. Studies demonstrated significant results in favor of webbased interventions and their positive effect on health and social outcomes (e.g. depression, burden). Caregivers displayed moderate usage (based on logins and postings)and qualitative findings demonstrated that caregivers appreciate the chat function for social support and tailored education information. Conclusion: A need for research on web-based support for caregivers to those with cancer, stroke, COPD and diabetes is noted. Future research should focus on evaluating these interventions using rigorous RCT designs. 48. Engaging patients and families to develop safety indicators for rehabilitation G Tardif1, C Fancott1,2, A Andreoli1, M Lowe1, S Sharpe2, F Schwartz1, S Solway3, J MacNeil4 1 Toronto Rehab - UHN; 2 University of Toronto; 3 Public Health Ontario; 4 Patient representative
Background: Safety in hospitals is often measured in terms of adverse events such as falls and pressure ulcers. While important, these indicators offer a limited view of safety in rehabilitation, and do not necessarily reflect the goals and priorities important to patients and families, who often have broader view of safety. Purpose: This project engaged patients, families, clinicians and leaders to develop safety indicators relevant to a rehabilitation setting. Methods: Key stakeholders (n=39) engaged in a series of focus groups to help identify safety concerns, then gathered for a consensus-building q-sort process to refine and prioritize safety indicators important to rehabilitation. Results: Nine safety indicators emerged in areas related to communication, care transitions, coordination of care, staffing, and physical environment. Data for these indicators were collected over a 6-month period as part of a new ''safety card''. So what? These qualitative sessions created opportunities to discuss salient healthcare issues, to hear the perspectives of a broad range of stakeholders, and to inform decision-making about safety priorities in rehabilitation. This project represents a new level of engagement with patients and families to co-design systems and processes of care together with staff and leaders, to improve the safety and quality of rehabilitative care, moving us further along the continuum of patient engagement. 49. Looking at the Acceptability and Feasibility of the Clinical Care Coordinator in Long-term Care M Kennedy 1, C Chu 1,2, K McGilton 1,2 1Toronto Rehab - UHN; 2 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto
Background: Registered Nurses (RNs) are the supervisors of Personal Support Workers (PSWs) in long-term care. However, the RNâ€™s ability to be a supportive supervisor is limited because of their expanding span of control and heavy workload. Thus, a new role called the Clinical Care Coordinator (CCC) was developed that consists of a Registered Practical Nurse (RPN) with extra training. Purpose: To describe the CCC role and evaluate the acceptability of CCCs among 28
nursing home staff. Method: Structured interviews were conducted with 28 staff members (CCCs, RNs, RPNs, PSWs, managers, and administrators). A thematic analysis using NVivo was completed by two independent coders. Results: The CCC role was comprised of a large number of clinical, supportive and managerial tasks. The role was highly accepted by PSWs, RPNs and RNs as a means to improve resident and family care, access resources, and gain mentorship and support for nurses and PSWs. PSWs and nurses reported that the RPN scope of practice and clinical expertise was beneficial to their everyday tasks. No conflict was found between RPNs and RNs. Conclusions: This role offers a possibility for LTCHs to expand the potential of RPNs by means of career advancement that supports PSWs and nurses. 50. Managers' Perspectives on the Barriers and Facilitators to the Implementation of the Stroke Canada Optimization of Rehabilitation by Evidence Implementation Trial (SCORE-IT): A Qualitative Descriptive Study SEP Munce 1, SCORE-IT Team, MT Bayley1 1 Toronto Rehab - UHN
Objective: The objective of the current study was to understand the barriers and facilitators to the implementation of the Stroke Canada Optimization of Rehabilitation by Evidence Implementation Trial (SCORE-IT) from the perspective of nurses, occupational therapists (OTs) and physical therapists (PTs), and clinical managers. Methods: A qualitative descriptive approach was adopted and involved in-person interviews. Semi-structured interviews were conducted with participants from rehabilitation centres across Canada. Thematic analysis was employed. A taxonomy of barriers and facilitators identified by an extended version of the Clinical Practice Guidelines Framework for Improvement was applied. Results: A total of 33 participants were interviewed. The following four facilitators to implementation emerged: leadership/having a champion, team communication and interdisciplinary collaboration, familiarity with the intervention, and agreement with the intervention practical. The following five barriers to implementation emerged: environmental factors, including time pressure, insufficient staff, lack of space and equipment, and organizational constraints, lack of agreement with the intervention not practical, lack of leadership, lack of team communication and interdisciplinary collaboration, and lack of familiarity with the intervention. Conclusions: The current barriers and facilitators could be used to tailor future strategies to enhance and sustain the uptake of evidence-based recommendations in stroke and ultimately improve patient outcomes. 51. Calcium and Vitamin D to promote bone health and muscle strength: How much is appropriate and how much is too much? H Wilk Toronto Rehab - UHN
This project reviewed the evidence for vitamin D and calcium supplementation in adults (over 50 years) to optimize bone health and help prevent falls and fractures. Strong evidence supports supplementation of vitamin D (800-1000 IU) to enhance muscle function and decrease falls risk. Calcium requirements (1200 mg), met through diet alone or a combination of diet and supplements, serves to strengthen bones and reduces fracture risk after a fall. Part way through the project, it was discovered that some tube fed patients were receiving high doses of calcium 29
supplements. RDs collaborated with physicians and pharmacists to implement immediate changes. Vitamin D toxicity is rare and has been observed with 40 000 IU vitamin D3 daily for 5-6 months; however, gastrointestinal disturbances from calcium supplementation are more common with daily supplementation above 2000-3000 mg. In conclusion vitamin D requirements cannot be met from diet alone. Individual assessment is required to determine the need for calcium supplementation. Interprofessional collaboration was key to the success of this initiative, especially for implementation of change in clinical practice.
ABSTRACTS FROM THE NEURAL ENGINEERING & THERAPEUTICS TEAM The Neural Engineering and Therapeutics Team is focused on discovery of new knowledge, approaches and technologies to advance our understanding, assessment and therapeutics for neurological recovery and neurorehabilitation for persons with spinal cord injury (SCI) and other neurological disorders. They conduct research to improve participation in daily life for older individuals and those who have experienced a stroke, spinal cord injury or traumatic brain injury. They also evaluate the impact of these interventions on patients and their families. Most of their current interventions have potential for clinical application within five years. Using Functional Electrical Stimulation (FES) they have helped patients with paralyzed limbs â€œrelearnâ€? basic tasks such as grasping and walking, leading to the regaining of function. They have also created a brain-computer interface system that enables people to control assistive devices without touching them.
52. Trunk Strength and Function in Individuals with Non-Traumatic Spinal Cord Injury S Gabison1,3, M Verrier1,2,3, BC Craven1, S Nadeau4,5, Cyril Duclos4,5, D Gagnon4,5, Audrey Roy5 UHN - Toronto Rehab - UHN: 1SCI Mobility Lab, University of Toronto; 2 Department of Physical Therapy; 3Institute of Medical Science; 4 Ecole de readaptation, U de Montreal
Introduction: Static and dynamic trunk control through force generating capacity is essential for functional activities1,2. Trunk function has not been studied in individuals with Non-Traumatic Spinal Cord Injury (NTSCI). The Spinal Cord Independence Measure (SCIM-III) is used to evaluate functional and mobility status in individuals with SCI, however its relationship to trunk function has not been explored. Objectives: To characterize trunk strength and determine if there is a relationship between isometric trunk strength and the SCIM-III Mobility Subscore in individuals with NTSCI. Subjects: 31 individuals with subacute NTSCI. Methods: Admission measures of isometric trunk strength and SCIM-III scores. Analyses: Descriptive statistics, multivariate analysis of variance for between group comparisons of walkers and wheelchair users and Spearman s Correlations Coefficient for trunk strength and SCIM-III Mobility Subscore. Results: Isometric trunk strength was significantly greater in walkers (p<0.05). There was no significant correlation between trunk strength and SCIM-III Mobility Subscore. Discussion: Trunk strength has been evaluated minimally in individuals with SCI. This study characterizes and compares isometric trunk strength of walkers and wheelchair users in individuals with NTSCI. Conclusion: Further studies with larger sample sizes are required to determine the relationship between trunk strength and functional activities in individuals with NTSCI. 31
53. A Validated model for the Simulation of Multi-Contact Nerve Cuff Recordings P Garai1,2, J Zariffa1,2 1 Institute of Biomaterials and Biomedical Engineering, University of Toronto; 2 Toronto Rehab - UHN
To help individuals with spinal cord injury regain functional movements, implanted functional electrical stimulation (FES) systems can be used to cause a group of muscles to contract in a functional sequence. However, current FES systems fail to reproduce fine motor movements due in part to the absence of sensory feedback. The sensory information from peripheral nerves could be used as feedback signals. Current nerve cuff electrodes are unable to discriminate the activity of different sensory pathways and need improvement to get accurate feedback signals to the FES controller. To optimize the electrodes and signal processing approaches, detailed simulation studies are warranted. Therefore, we propose to construct an anatomically accurate finite element (FE) model of a rat s sciatic nerve that can quantitatively reproduce in vivo electrophysiological recordings. For this, acute experiments on Long Evans rats are used to record sensory signals using an 8channel nerve cuff electrode by providing mechanical stimulation to the heel and ankle. After recording, the nerve is harvested and imaged for volume reconstruction and FE analysis. The FE model will be validated by optimizing its parameters until it reproduces the in vivo recordings. The model can then be used for re-designing a more efficient peripheral nerve interface. 54. Single Neuron Control in a Brain-Machine Interface: Cell Type Differences MG Garcia 1,2,3, H Vargas-Perez 4, MR Popovic 1,2,3 1 University of Toronto, Institute of Biomaterials and Biomedical Engineering; 2 Toronto Rehab - UHN, Rehabilitation Engineering Laboratory; 3 University of Toronto, Collaborative Program in Neuroscience; 4 University of Toronto, Department of Molecular Genetics
Operant conditioning of single neuron activity is a novel paradigm that has emerged as an alternative to create brain-machine interfaces (BMIs) that feel natural and intuitive to the user. This paradigm relies on volitional modulation of cortical neurons, which are able to generate complex patterns of activity without peripheral input. We recorded single neuron activity and trained a rat in a BMI task to increase the firing rate for one second to obtain a reward. The rat received biofeedback about the activity of the neuron in real-time throughout the experiments. We incremented the target every 5-10 minutes as the rat mastered the task. We conditioned 7 neurons, which were classified into fast-spiking and regular-spiking neurons. We found that the rat was able to control the BMI only with fast-spiking neurons as it showed performance improvement (p < 0.007) and activity upregulation (p < 0.01) within minutes of practice. In conclusion, rats could learn to control a one degree-of-freedom BMI quickly and reliably because our paradigm exploits the natural motor learning circuitry of the brain. In the future, we will expand the project to multiple neuron/DOF control.
55. A wearable computer vision system for monitoring hand use at home J Likitlersuang1,2, J Zariffa1,2,3 1 Institute of Biomaterials and Biomedical Engineering, University of Toronto; 2 Toronto Rehab â€“ UHN; 3. Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto
The restoration of upper limb function is usually rated as the top priority for individuals suffering from cervical spinal cord injuries. In order to develop effective rehabilitation therapies as well as modify current treatments to best suit an individual s needs, it is important to assess hand function throughout the rehabilitation process. The success of these treatments is usually measured by standardized assessments performed by a trained clinician in a controlled setting; however there is no information collection method reflecting the patient s function at home, which is important in assessing their level of independence following rehabilitation. The objective of this research is to develop a computer vision-based wearable sensor using an egocentric camera system that would allow researchers and clinicians to monitor interactions of the hand with objects in the environment. The system will automatically process video data to produce a log of hand use (e.g. number and duration of interaction events). The current version of the algorithm, based on a dataset of 20 able-bodied participants, focuses on the segmentation and detection of the hand as well as interaction detection using a classifier based on the analysis of motion cues (optical flow) and the shape of the hand. 56. Effect of Auditory Cues on the Fractal Dynamics of Human Gait during Treadmill Walking H Rouhani1,2, MR Popovic1,2, K Masani1,2 1 Toronto Rehab - UHN; 2 University of Toronto, Institute of Biomaterials and Biomedical Engineering
Stride interval fluctuation during walking has unique dynamics called long-range correlation or fractal dynamics. The effects of auditory cues on fractal dynamics of human gait are not conclusive and have been intensively studied, especially on the standpoint of integration of auditory sensory cues with motor control. This study aimed at quantitatively investigating the dynamics of the stride interval fluctuations during treadmill walking with auditory cues. 12 young healthy subjects walked on a treadmill for 20-min once with natural cadence/speed and another time with an auditory cue. We identified stride interval fluctuations based on heel-strike detected using a foot-switch on their right heel for each fee walking and metronome walking condition. Then, we applied the detrended fluctuation analysis (DFA) for stride interval fluctuations. Stride interval fluctuations during treadmill walking with rhythmic auditory cue lost long-range correlation, and its fractal dynamics disappeared. However, dynamics of stride interval fluctuations during metronome walking was not random noise. The difference series of stride interval fluctuations (especially 4-6 strides) during free walking mimicked dynamics during metronome walking quite well. This suggests that it takes 4-6 strides to correct deviation of stride interval from the auditory cue. The results contribute to understanding sensory-motor coordination during walking.
57. Developing an objective approach to clinical walking assessment in children KE Musselman1,2,3, D Bisaro3, K Kane3, A Oates4, J Lanovaz4, J Bidonde3, T Treen3,4 1 Toronto Rehab - UHN; 2 University of Toronto, Department of Physical Therapy; 3 University of Saskatchewan, College of Medicine; 4 University of Saskatchewan, College of Kinesiology
Walking is an important goal for children with spina bifida (SB) or cerebral palsy (CP). As a result, walking is often targeted in medical management, rehabilitation, and research studies. To assess the effects of interventions on walking, we need measures that are objective, valid, reliable, and feasible in clinical settings. Despite the abundance of psychometrically-sound, walking measures for adults, few such measures exist for children. The overall objective was to identify clinical measures of walking that are valid and reliable for children. First, a systematic review was completed to describe current measurement practice for walking in children with SB. We found that rating scales are overwhelmingly used, with little investigation into their psychometric properties. Second, the reliability and validity of timed walking measures were assessed in 16 children with SB or CP (aged 2-13 years) and 16 age- and gender-matched typically-developing (TD) children. Test-retest reliability was high, and the scores could discriminate between the two groups (p<0.05). Lastly, the criterion validity of wearable sensors was assessed in 13 TD children (aged 2-7 years). Agreement between the sensors and a 3D motion capture system was good to excellent for spatiotemporal parameters. We have identified psychometrically-sound measures of walking for children. 58. Exploring the Associations between Arterial Stiffness and Spinal Cord Impairment M Miyatani1, M Szeto1, CD Moore1,2, PI Oh3,4, C McGillivray1,4, BC Craven1,4 1 Toronto Rehab - UHN, Brain and Spinal Cord Rehabilitation Program; 2 Department of Kinesiology, University of Waterloo; 3 Toronto Rehab - UHN, Cardiovascular Prevention and Rehabilitation Program, 4 Department of Medicine, University of Toronto
Objective: 1) to compare aPWV values between participants with tetraplegia (TETRA) and paraplegia (PARA); and, 2) to contrast the reported aPWV values with age-specific general population normative values. Methods: aPWV and potential confounders of aPWV [age, gender, HR, MAP, treated - hypertension, lipidemia or diabetes, and impairment (AIS)] were assessed in adults with chronic spinal cord injury (TETRA, n=37 and PARA, n=50). Subjects aPWV values were contrasted with age-specific reference values; and the prevalence of abnormal aPWV, defined as aPWV above ≥ the age-specific 90th percentile in m/sec are reported. Results: After adjusting for cofounders, the mean aPWV values were higher in those in the PARA group versus the TETRA group [TETRA: 8.0 m/sec (95% CI: 8.6-9.5); PARA: 9.0 m/sec (95% CI: 7.5-8.5), p=0.008]. Abnormal aPWV values (n= 21/87) and metabolic syndrome (n=24/76) were with different distributions; the prevalence of abnormal aPWV was significantly higher in the PARA group (37%) versus the TETRA (11%) group (p=0.005). Conclusions: Participants with paraplegia had higher aPWV values, and a higher frequency of abnormal aPWV, than participants with tetraplegia. Traditional metabolic syndrome risk factors do not explain abnormal aPWV among some SCI participants. Elevated aPWV values, particularly among paraplegics, may impart significant adverse cardiovascular consequences. 34
59. Determinants of Calf Muscle Cross-Sectional Area and Density after Chronic Spinal Cord Injury Moore C1,2, Craven BC1,2, Thabane L3, Laing AC2, Frank-Wilson A4, Kontulainen SA4, Papaioanno A3,5, Adachi JD5, Giangregorio LM1,2 1 Brain and Spinal Cord Rehabilitation Program, UHN - Toronto Rehab; 2 Department of Kinesiology, University of Waterloo; 3 Department of Clinical Epidemiology and Biostatistics, McMaster University; 4 College of Kinesiology, University of Saskatchewan; 5 Department of Medicine, McMaster University
Background: Atrophy and fatty-infiltration of skeletal muscle after spinal cord injury (SCI) predisposes individuals to metabolic disease and related mortality. Objective: To determine the magnitude of atrophy and fatty-infiltration of lower-extremity muscles and related factors in a group of individuals with chronic SCI and diverse impairment. Methods: Muscle cross-sectional area (CSA) and density were calculated from peripheral quantitative computed tomography scans of the 66% site of the calf of 70 participants [50 male, age (standard deviation) 48 (12) years] with chronic SCI (C2-T12, AIS A-D) and 70 age, gender, and height matched ablebodied controls. Regression models for muscle CSA and density were formed using 16 potential modifiable and non-modifiable correlates of muscle status selected a priori. Results: Lower muscle CSA and density values were observed in participants with complete (32-43%) and incomplete (14%) SCI relative to controls. Bodyweight, motor function, ambulation ability, spasticity, vigorous physical activity, age, and waist circumference were identified as potential clinical predictors of muscle status. Conclusions: There are modifiable factors related to muscle size, body composition, and activity level that may offer therapeutic targets for preserving metabolic health after SCI. 60. Development of Neuroprosthesis for Improved Trunk Stability after Spinal Cord Injury (SCI) K Patel1,3, M Milosevic2,3, K Masani2,3, M Popovic 2, 3 1 Department of Engineering Science, University of Toronto, 2 Institute of Biomaterials and Biomedical Engineering, 3 Rehabilitation Engineering Laboratory, Toronto Rehab - UHN
Trunk instability is a problem for people with thoracic and cervical spinal cord injury (SCI), since their lumbar muscles cannot produce sufficient forces to stabilize the spine. Functional electrical stimulation (FES) can artificially contract these muscles using small current impulses which, if sequenced properly, can be used to perform useful body movements and increase trunk stiffness. Research has shown that the central nervous system responds to external perturbations using a directionally dependent combination of muscle responses. However existing research on improving trunk stability with FES is limited to co-contraction of the trunk muscles, which is both unnatural and fatigue inducing. This study aims at creating a feedforward FES controller that can stimulate the trunk muscles in a directionally dependent manner to increase trunk stability in external perturbations, such as those of a powered wheelchair. To do this, an instrumented wheelchair was engineered to perturb subjects while activating the relevant muscles in an attempt to stabilize the trunk. Portable inertial motion sensors were used to evaluate the response to perturbations with and without FES. A pilot study performed on a single able-bodied subject showed considerable reduction in body sway (22%) in the FES trials.
61. Fragility Fractures after Spinal Cord Injury: Insights from the Bone Quality in Individuals with Chronic SCI Study CL Lynch1,2, L Giangregorio1,2, JD Adachi3, A Papaioannou3, L Thabane4, BC Craven1,2,5 1 Department of Kinesiology, University of Waterloo; 2 Brain and Spinal Cord Rehabilitation Program, Toronto Rehab - UHN; 3 Department of Medicine, McMaster University, Hamilton, Canada; 4 Department of Clinical Epidemiology and Biostatistics, McMaster University; 5 Division of Physiatry, Department of Medicine, University of Toronto
Wide confidence intervals exist for fragility fracture prevalence and incidence (5075%) following spinal cord injury (SCI). This abstract describes the incidence, prevalence, and management of lower extremity (LE) fragility fractures in a cohort of adults with chronic SCI. Adults with chronic SCI (C2-T12, AIS A-D, > 2 years) consented to prospective BMD monitoring and fracture surveillance. Participants attended site visits semi-annually for 24 months for medical and fracture screening and bone density assessment and quarterly telephone fracture surveillance. Seventy participants (50 males, mean age 49 +/- 12 years, SCI duration 16 +/- 10 years) were followed. Impairment distribution was 33% paraplegia AIS A-B, 31% tetraplegia AIS A-B, 17% paraplegia AIS C-D, and 19% tetraplegia AIS C-D. Thirty three percent of participants reported prevalent fragility fractures at baseline, most of whom were motor complete (87%). During follow-up, 18 (15 LE) fragility fractures occurred. A minority (39%) reported sublesional osteoporosis (SLOP) diagnosis after fracture. Reported fracture care included: casting (36%), splinting (22%), surgery (21%), or no stabilization (21%). A high prevalence and incidence of LE fragility fractures was noted; the reported discordance between LE fragility fracture incidence and reported sublesional osteoporosis diagnosis is striking, and represents a gap in SLOP health services. 62. The influence of the aquatic environment on the control of standing posture A Marinho-Buzelli1,4, H Rouhani4, GTB Fernandes4, K Masani2,4, MR Popovic2,4, MC Verrier1,3,4 1 Graduate Department of Rehabilitation Science, University of Toronto; 2 Institute of Biomaterials and Biomedical Engineering, University of Toronto; 3 Department of Physical Therapy; 4 Neural Engineering and Therapeutics Team - Toronto Rehab - UHN; 5 Universidade Federal de Santa Catarina, Brazil
Introduction: Postural sway parameters have been emerged as a sensitive paradigm of investigation of postural stability. Although quiet standing has been vastly investigated in several sensorial manipulation tests, none has been reported during immersion in water. To investigate and quantify center of pressure (COP) parameters of body sway and trunk acceleration during quiet standing, comparing performance in water and on dry land. Methods: Six able-bodied subjects were requested to stand over a waterproof force plate with arms crossed and feet in comfortable position. Ten quiet standing trials were performed in water and on dry land: 5 with eyes open and 5 with eyes closed. Time- and frequency-domain parameters of COP and trunk acceleration were measured. A 5-question interview investigated participantsâ€™ perception of standing in water compared to land. Results: COP parameters of postural sway were increased in water compared to land, except frequency at 80% of power spectrum. Upper trunk centroidal frequency was increased on land compared to water. Participantsâ€™ perception of standing in water differs from quantitative analysis of postural sway. Conclusion: 36
Postural sway is increased in water compared to land. Quantitative and qualitative analysis of postural sway seem to differ in water. Frequency parameters should be further explored. 63. Modeling of multi-directional muscle activity patterns during standing Eric Ma1,2, Daniel Chung2,3, Kai-Lon Fok2,4, Kei Masani1,2 1 Rehabilitation Engineering Laboratory, Institute of Biomaterials and Biomedical Engineering, University of Toronto; 2 Rehabilitation Engineering Laboratory, Toronto Rehab â€“ UHN; Health Sciences, McMaster University; 4 Division of Engineering Science, University of Toronto
Functional electrical stimulation (FES) is a promising technology for restoring standing balance in persons with motor disabilities. For the development of future FES standing neuroprostheses, it is essential to first identify the natural postural response to perturbations during standing. As such, the goal of this study was to model the muscle activity patterns evoked by multi-directional perturbations in standing with respect to direction and time. In 9 young healthy adults, mechanical impulse perturbations were applied at trunk-level for 10 trials in each of the 8 directions, randomized for timing and direction. EMG activity was recorded for 16 lower leg and trunk muscle groups. The EMG data was filtered, rectified, and normalized before averaging into 6 time bins across all subjects following perturbation onset. A 3D model of the muscle activity pattern was constructed using a Gaussian fit with respect to time and direction. The model demonstrates a high level of goodness of fit (R^2 = 0.91 +/- 0.15). The resulting model can be implemented into FES neuroprosthesis controllers to help persons with motor disabilities mimic the muscle activity patterns of able-bodied persons during standing. 64. The impact of best practice implementation for pressure ulcer prevention following spinal cord injury (SCI) in an inpatient rehabilitation program CY Scovil1,2, HM Flett1,3, LT McMillan1, JJ Delparte1, DJ Leber1, J Brown4, AS Burns1,5, on behalf of the Spinal Cord Injury Knowledge Mobilization Network (SCI KMN) 1 Brain and Spinal Cord Rehabilitation Program, Toronto Rehab - UHN; 2 Dept. of Occupational Science and Occupational Therapy, University of Toronto; 3 Dept. of Physical Therapy, University of Toronto; 4 National Implementation Research Network, University of North Carolina, Chapel Hill; 5 Division of Physiatry, Dept. of Medicine, University of Toronto.
Background/Objectives: Toronto Rehab is a member of the pan-Canadian SCI Knowledge Mobilization Network (SCI KMN) addressing Best Practice Implementation (BPI) in SCI rehabilitation. Pressure Ulcer (PU) prevention was the initial focus for BPI, with two targeted practices: (1) Comprehensive PU risk assessment (RA) using a structured RA tool and individualized, inter-professional PU prevention plans (PUPP); (2) Provide structured PU prevention education to patients. Methods/Overview: Implementation Science was employed to support sustainable BPI. Two tools were introduced: (1) the SCI-specific PU RA scale (SCIPUS); and (2) a new inter-professional PUPP for use in team rounds. The SCIPUS replaced the Braden RA. The PUPP was created with extensive clinician involvement and centralizes PU risk factors for interprofessional communication. Comprehensive patient education was already in place at our site, and efforts were focused on improving documentation. Results/Conclusion: PU RA completion rates 37
increased to 81% from 29% following SCIPUS implementation. In the year following implementation, PUPP rates were 76%. Documented PU education increased to 74% from 26% pre-implementation. PU Incidence decreased to 9% from 13% in the year after the SCIPUS was implemented. PU incidence was 12% the following year. Targeted PU practices have been implemented successfully. Additional BPI can support continued PU reduction.
ABSTRACTS FROM THE SLEEP SCIENCE TEAM The Sleep Science Team focuses on the diagnosis and treatment of sleep apnea which is a very common condition and which we have shown is a frequent cause of stroke and cardiac events. The main initiatives of our work in the area of sleep apnea are determining causes, and the effects on health and rehabilitation outcomes of treating sleep apnea in patients with cardiovascular and cerebrovascular diseases. To increase diagnosis and reduce the serious effects associated with sleep apnea, they have developed a portable device to detect obstructive sleep apnea that will allow diagnosis to be achieved at the comfort of the patientâ€™s home.
65. Developing Automatic Algorithms for non-Invasive Assessment of the Upper Airway Resistance D Zhi, M Popovic, A Yadollahi Toronto Rehab - UHN
Increased upper airway resistance and the associated inspiratory flow limitation are important means to assess both the cause and the consequences of sleep disorder breathing. Gold standard assessment of upper airway resistance requires invasive measurement of pharyngeal pressure. Some researchers have developed noninvasive techniques based on the contour of nasal airflow to detect flow-limited breaths during sleep with accuracies of 70-80%.The objective of this study is to develop automatic and highly accurate algorithms based on the contour and temporal patterns of nasal airflow for non-invasive detection of increased upper airway resistance during sleep. Previously recorded data during sleep will be used to categorize each inspiratory flow signal into 3 types: normal, intermediate and flow-limited. For each inspiration, features such as number and location of peaks and the plateau in the flow contour will be extracted. Also, algorithms such as Kalman filter and Markov process will be employed to assess the extracted features and the temporal pattern of the nasal flow contour to determine breath with increased resistance. The proposed algorithms will improve assessment of the physiological cause and consequences of sleep disordered breathing and be used to develop more sensitive measures for analysis of upper airway narrowing during sleep. 66. Investigating the Effects of Neck Fluid Volume on the Snoring Sound Characteristics S Saha1,2, Z Moussavi1, A Yadollahi2 1 University of Manitoba, Department of Biomedical Engineering; 2 Toronto Rehab - UHN;
Recent studies have shown that increases in neck fluid volume (NFV) narrows the upper airway and increases its resistance. These changes could increase turbulence of airflow passing in the upper airway and consequently induce snoring. The 39
objective of this study is to investigate whether acoustic features of snores change with increases in NFV. We hypothesize that fluid accumulation in the neck changes the snore features in time and frequency domains, and more NFV would increase snore sound complexity. Available data from TRI-Sleep Lab that includes snore sounds and NFV measurements will be used. Snore features such as duration and occurrence, intensity, formants, pitch and bi-spectral frequencies will be investigated in various sleep stages and total sleep time. Statistical analysis will be performed to determine the snore features that change significantly with increases in the NFV and neck circumference and narrowing of the upper airway. We anticipate that subjects with more increases in NFV during sleep have more snores, higher snore intensity and more complex snores as assessed by formants and bispectral features. If we could show that snore features change with NFV, a convenient device could be developed to assess the effects of NFV on the sleep apnea physiology 67. Design and Validation of a Portable and Affordable Device to Measure Body Composition B Gavrilovic 1,2, M Popovic 2,3, A Yadollahi 1 1 Toronto Rehab - UHN; 2 University of Toronto; 3 Rehabilitation Engineering Laboratory
Different researchers have investigated various methods to assess the electrical properties of tissues. Bioelectrical impedance analysis/spectroscopy (BIA/BIS) are non-invasive methods to assess various body compositions, including total body water, extra/intracellular fluid, fat and muscle mass. Such information can be used to evaluate the hydration status of patients with heart or renal failure, predict their mortality risk, and to assess the sleep apnea pathophysiology. The available devices to measure bioelectrical impedance are either expensive, cannot measure body composition in various body segments, or cannot measure fluid changes continuously. The objective of this study is to design and develop an affordable, accurate, and portable device that can measure electrical tissue properties. The device will be used by clinicians and patients to monitor their hydration status, and other tissue properties. This proposed device will accurately measure total body as well as leg and neck tissue properties continuously and simultaneously. Recorded data will be wirelessly transmitted to a smart phone or tablet for further processing. This device can be used to assess and to evaluate different treatments to reduce fluid retention and improve body composition. This can significantly improve health outcomes and mortality risks in fluid retaining and sedentary patients. 68. Design and implementation new portable device for Sleep Apnea diagnosis P Hadi Mohammadabadi, A Yadollahi, F Rudzicz Toronto Rehab - UHN
Sleep apnea (SA) is common in 10% of adults; it increases risk of heart disease and stroke, and costs billions of dollars annually. However, less than 10% of those with SA are diagnosed. Furthermore, the underlying mechanisms of SA are not fully understood. Polysomnography, the gold standard for SA diagnosis, is costly and time consuming. Therefore, portable devices are proposed for SA diagnosis at home. However, they require data recording from multiple sensors, and cannot provide information about the upper airway collapse mechanisms. The objective of this research is to develop a compact and convenient device that can record 40
multiple physiological signals, diagnose SA and investigate the variations in upper airway physiology. The proposed device includes a microphone and an accelerometer, and will be attached to the neck to record respiratory sounds, heart sounds, and neck position. The data will be wirelessly transmitted to a smart phone for analysis. Based on our previous results, respiratory sounds will be used to detect SA severity and neck edema. Heart sounds will be used to estimate cardiac function. The proposed device is a convenient and affordable device which can record data for multiple nights with minimal effect on the subject s sleeping pattern. 69. Snoring is Not a Reliable Sign of Sleep Apnea H Alshaer, R Hummel, TD Bradley Sleep Research Laboratory, Toronto Rehab - UHN
Introduction: Snoring has been considered one of the cardinal symptoms of obstructive sleep apnea (OSA) and is frequently associated with it. The relation between accurately identified snoring the diagnosis of sleep apnea was not thoroughly evaluated. Methods: Subjects used a portable device for capturing breath sounds (ApneaDx), simultaneously with the polysomnography (PSG). The obstructive apnea hypopnea index (AHI) was calculated from PSG. Snoring was detected and quantified from ApneaDx breath sound recordings using a novel algorithm that analyzes multiple acoustic features rather than amplitude only, with reported 97% validation accuracy. The snore index (SI) was calculated as the number of snores per hour of recording. Results and Discussion: Using an objective and accurate method for identification and quantification of snoring, a very weak correlation (r=054) was observed OSA severity. Among those with OSA, more than 1/3 had mild or almost no snoring, similar to those without sleep apnea, while a substantial proportion of subjects without OSA had a SI similar to that in subjects with severe OSA. This leads to the conclusion that snoring as a symptom of sleep apnea should be interpreted with caution given that its presence or absence does not always indicate or exclude OSA. 70. Effect of fluid overload and fluid removal by ultrafiltration on sleep apnea severity in renal failure OD Lyons1,2, A Yadollahi1, CT Chan3, TD Bradley1,2,3 1 Sleep Research Laboratory, Toronto Rehab â€“ UHN; 2Centre for Sleep Medicine and Circadian Biology of the University of Toronto; 3 Department of Medicine of the University Health Network Toronto General Hospital
Rationale: Obstructive and central sleep apnea (OSA and CSA, respectively) are highly prevalent in end stage renal disease (ESRD). We postulated that: 1) ESRD patients with sleep apnea would have higher total body and segmental fluid volumes than ESRD patients without sleep apnea and 2) fluid removal by ultrafiltration (UF) would reduce severity of both OSA and CSA. Methods: ESRD patients on thrice-weekly hemodialysis had overnight polysomnography (PSG) performed to assess sleep apnea severity. Using bioelectrical impedance, total body extracellular fluid volume (ECFV) was measured prior to sleep and on awakening in the morning. The following week, subjects with an AHI?20 had fluid removed by UF, followed by repeat overnight PSG with fluid measurements. Results: Fifteen patients had an AHI20 (10 OSA, 5 CSA) and 11 had an AHI of <15. Total body ECFV was 2.4 L higher in the group with AHI20 (p = 0.036). Following removal of 41
2.17 ± 0.45 litres by UF, the AHI decreased by 36% (43.8±20.3 to 28.0±17.7, p=0.0003). The reduction in AHI correlated with the reduction in total body ECFV (r=0.567, p=0.027). Conclusions: These findings support a key role for fluid overload in the pathogenesis of both OSA and CSA in ESRD.
ABSTRACTS FROM THE ACQUIRED BRAIN INJURY (ABI) & SOCIETY TEAM The Acquired Brain Injury (ABI) & Society Team works to improve the quality of life of people with acquired brain injury. The program is structured along the following key research foci: population based studies, girls and women with ABI, TBI in vulnerable populations (e.g. elderly, forensic and homeless populations), work-related TBI and research based theatre. These findings have led to new approaches that are helping people with a brain injury function better in the community and reach greater potential.
71. The relationship between sleep, depression, and traumatic brain injury: a study of Ontario workers with head trauma M Scherer1, T Belben2, P Thurairajah3, A Colantonio2,4, T Mollayeva4,5 1 Southlake Regional Health Centre; 2 Occupational Science and Occupational Therapy University of Toronto;3 ABI Research Lab; 4 Toronto Rehab - UHN-University of Toronto; 5 Graduate Department of Rehabilitation Science Collaborative Program of Neuroscience University of Toronto
While literature reports associations between psychiatric illnesses and sleep dysfunction, traumatic brain injury (TBI) and sleep dysfunction, and TBI and psychiatric illnesses, the relationship between all three variables has not been examined. This cross-sectional study aimed to investigate brain injury, sleep complaints, and other clinical variables in individuals presenting with work-related head injury in conjunction. A medical record review of a consecutive sample of 106 head injured workers was performed. Abstracted data included that related to occupation, mechanism of injury, diagnoses of TBI, self-reported sleep complaints, mental health diagnoses, and demographic characteristics. The majority of workers with head trauma were diagnosed with mild TBI or concussion. Diagnosis of TBI was associated with increased odds of post-injury worsening of sleep (OR 5.8, 95% CI: 1.8 18.9). Among those with TBI, those with worsened sleep were significantly more likely to experience depression (p=0.003). The potential implications of our findings are significant: self-perceived worsening of sleep after head trauma is strongly associated with brain injury. A diagnosis of depressive disorder was significantly related to self-perceived sleep quality in those with TBI. Therefore, it is critical that sleep complaints in persons with head trauma are thoroughly investigated in order to apply appropriate intervention.
72. A systematic review of fatigue in patients with traumatic brain injury: the course, predictors and consequences. T Mollayeva1,2,3, T Kendzerska4, S Mollayeva5,6, C Shapiro7,8, A Colantonio3,9, JD Cassidy10,11,12 1 Graduate Department of Rehabilitation Science, Faculty of Medicine, University of Toronto; 2 Collaborative Program in Neuroscience, University of Toronto; 3Toronto Rehab â€“ UHN; 4 Department of Medicine, Division of Respirology, Sunnybrook Research Institute, University of Toronto; 5 Faculty of Arts and Science, University of Toronto; 6 Aquired Brain Injury Research Lab, University of Toronto; 7 Toronto Western Hospital â€“ UHN; 8 Youthdale Child & Adolescent Sleep Clinic; 9 Department of Occupational Science and Occupational Therapy, University of Toronto; 10 Faculty of Health, Institute of Sport Sciences and Clinical Biomechanics, University of Southern Denmark; 11 Division of Health Care and Outcomes Research, University Health Network; 12 Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto
Background: Fatigue is common after traumatic brain injury (TBI). Its risk factors, natural history and consequences are uncertain. Best-evidence synthesis was used to address the gaps. Methods: Five databases were searched for relevant peerreviewed studies. Of the 33 articles appraised, 22 longitudinal studies were selected. Results were reported separately based on their timing of baseline assessment. Results: All studies document changes in fatigue frequency and severity with time, irrespective of setting or TBI severity. There is limited evidence for certain clinical and psychosocial variables as predictors of fatigue severity at follow up. Early fatigue severity predicted persistent post-concussive symptoms and Glasgow outcome score at follow up. Conclusions: Fatigue is present before and immediately following injury, and can persist long term. The variation in findings supports the idea of fatigue in TBI as a nonhomogeneous entity, with different factors influencing the course of new onset or chronic fatigue. To decrease the heterogeneity, we emphasize the need for agreement on a core set of relevant fatigue predictors, definitions and outcome criteria. 73. Rehabilitation service utilization following a work-related traumatic brain injury: A sex-based examination of workers compensation claims in Victoria, Australia EN Guerriero1, P Smith1,2, M Stergiou-Kita1, A Colantonio1,3 1 University of Toronto; 2 Monash University; 3 Toronto Rehab - UHN
Background: Work-related traumatic brain injury (wrTBI) is one of the most serious types of workplace injuries that may lead to long-term utilization of rehab services. Objective: To examine the utilization of four types of rehab services used by men and women within the first year following a wrTBI. Methods: The post-injury rehab use of 1848 workers compensation claims in Victoria, Australia between 2004 and 2012 was analyzed. Results: Out of 1794 claims (64% male, 36% female), 13% used occupational therapy (OT), 23% used physiotherapy (PT), 9% used psychology, and 3% used speech therapy (ST) within the first year. 29% used at least one type of rehab service. Women were more likely to use PT. Men were more likely to use OT and ST. Service use varied by age group, income group, occupation, geographic remoteness, hospitalization, and time loss from work, with some differences by sex. Conclusion: Men and women use rehab service differently within the first year following a wrTBI and their service use varies differently by various factors. Further research is needed to determine whether the type/amount of rehab services used by an individual is appropriate and associated with different health outcomes. 44
74. Comorbidities in the Inpatient Rehabilitation Traumatic Brain Injury Population: Differences by Sex? V Chan1,2, M Mollayeva1,2, K Ottenbacher3, A Colantonio1,2 1 Toronto Rehab - UHN; 2 University of Toronto; 3 University of Texas Medical Branch
Objective: To present an overview of the comorbid health conditions in the traumatic brain injury (TBI) population in inpatient rehabilitation, by sex and age, from a population-based perspective. Method: The National Rehabilitation Reporting System (NRS) was used to identify patients with TBI and their comorbid health conditions in inpatient rehabilitation in Ontario, Canada. Results: Between 2004/05 and 2007/08, there were 1,791 patients with an initial TBI diagnosis in the NRS. Comorbidity was common in males and females of all ages. Prevalent comorbid health conditions included mental health, nervous system, and circulatory system in the younger adult age group (<65 years). In the older adult age group (65+ years), conditions of the circulatory system, endocrine function, nutrition, metabolic and immune system, and the musculoskeletal system were more common. Across sex and age groups, the majority of patients with TBI had at least one comorbid health condition. Conclusion: There are sex differences in the types of comorbidities of patients with TBI in inpatient rehabilitation, many of which reflect those found in the older adults. Rehabilitation should take into account these differences and complexities to ensure best possible outcomes. 75. A systematic review of comorbidity measurement methods for patients with non-traumatic brain injury in inpatient rehabilitation settings W Khuu1,2, V Chan1,3, A Colantonio1,2,3 1 Toronto Rehab - UHN; 2 Dalla Lana School of Public Health, University of Toronto; 3 Graduate Department of Rehabilitation Science, University of Toronto
Comorbidities are common among rehabilitation patients and need to be rigorously assessed in studies to determine their influence in patient outcomes. The aim of this study is to systematically review the comorbidity measurements used for an inpatient rehabilitation population of non-traumatic brain injuries (nTBIs), where our understanding of the influence of comorbidities is limited. Academic databases and grey literature were searched using the concepts 'non-traumatic brain injury', 'comorbidity', and 'rehabilitation'. Results were screened according to pre-defined criteria. Data were extracted using a standard table. After duplicate removal, 83 of 9476 articles were screened using full-text and 15 articles were included. Comorbidity has been measured using a variety of methods, such as the number and type according to the International Disease Classification system, the Charlson Comorbidity Index, Centers for Medicare and Medicaid Services Comorbidity Tiers, Patient Comorbidity and Complexity Level, and other subsets of comorbidity within individual studies. The predictive validity of these comorbidity measurements has not been assessed. The identification of an appropriate comorbidity measurement for the inpatient rehabilitation population with nTBI is important; it will help to predict patient outcomes more accurately and has implications for health service planning and delivery.
76. Practice-Based Evidence: Rehabilitation Characteristics & Traumatic Brain Injury S Zarshenas1, N Cullen1,2, A Ho2 1 University of Toronto, Department of Rehabilitation Science; 2 Toronto Rehab - UHN
Introduction: Traumatic brain injury (TBI) can result in significant limitations in independent functional performance including; activities of daily living, productivity and leisure. Over the past few years, interdisciplinary rehabilitation has been considered as the best practice for increasing the potential of independent function among these patients. However, little research has been conducted on the interventional characteristics of inter-professional rehabilitation in Canada and US. Objective: This observational study investigates the characteristics of interprofessional rehabilitation in TBI patients according to Practice Based Evidence (PBE) research project data. Methodology: Participants: 1573 TBI inpatients in rehabilitation programs in Canada and USA >14 years between 2009- 2011. Measures: Point of care (POC) forms to document specific contents of intervention for each discipline, Functional Independence Measurement (FIM) as an outcome measure. Results: FIM score changes significantly from admission to discharge and after 3 months follow-up (p<0/05). Physical therapists mostly spent about an average of 120 min/week on gait and therapeutic exercise, occupational therapists spent 120 min/week on Self-care and cognitive activities and speech language pathologists therapists spent 70 min/ week on memory/ orientation and problemsolving. Conclusion: This research is the first comprehensive study focusing on content of inter-professional intervention among TBI patients in Canada and USA. This study confirmed that Intensity and types of activities in each discipline have direct correlation with TBI inpatient's function. 77. An Investigation into the Construct Validity of Motivation in an Acquired Brain Injury Inpatient Sample using Mixed Methods Techniques. A Kusec1,2, J Harris 1 1 McMaster University; 2 Toronto Rehab - UHN
Motivation to engage in rehabilitation-related activities is a field that is slowly gaining more attention in rehabilitation research. It is recognized to be an important component to rehabilitation in patients who have suffered am acquired brain injury (ABI), as it is common for ABI patients to have decreases of awareness and insight into the severity of their injury, which might lead to reduced engagement in therapy or not understanding why they are undergoing rehabilitative services. Therefore, it is imperative to understand and accurately measure levels of motivation in ABI patients undergoing rehabilitation so that clinicians might address any engagement issues and improve the quality of recovery for ABI patients.​The present study will investigate the construct of motivation in an ABI sample using a longitudinal mixed methods design, and will aim to understand motivation from three unique perspectives from the patient, a clinician that works with the patient, and a primary caregiver of the patient. Results from this study will inform current research on how to improve levels of engagement in an ABI sample undergoing rehabilitative services, as well as offer perspectives on how levels of motivation change over time in an ABI sample.
ABSTRACTS FROM THE BRAIN DISCOVERY AND RECOVERY TEAM The Brain Discovery and Recovery Teamâ€™s central focus is traumatic brain injury (TBI). They conduct research to develop state of the art approaches to diagnose and characterize brain injury and to understand neurological causes of poor recovery after injury in order to design interventions that maximize recovery and minimize disability. A core focus of this teamâ€™s work is to improve cognitive and neural recovery by offsetting deterioration using environmental enrichment in concert with other clinical interventions.
78. Use of diffusion tensor imaging for diagnosing and characterizing complex TBI populations C Bradbury1, B Budsin2, B Sharma2, D Mikulis3, J Corbie1, S Hitzig1, C Craven1, R Green1,4 1 Spinal Cord Rehab Program, Toronto Rehab-UHN; 2 Toronto Rehab-UHN; 3 Toronto Western Hospital-UHN; 4 Dep't of Psychiatry (Neurosciences), University of Toronto
Objectives: (1a) To describe prevalence rates of traumatic brain injury (TBI) in a large traumatic spinal cord injury (tSCI) sample in a study designed to obviate methodological issues that likely caused disparate prevalence rates across previous studies. (1b) To compare prevalence rates using two different calculations. (2) To measure risk-factors for co-morbid TBI, including cervical vs. sub-cervical injuries. (3) To determine the prevalence of missed diagnoses in TBI. Methods: 100 Adults with tTSCI, three- to six-months post-injury were recruited from a tertiary inpatient rehabilitation program. TBI diagnosis entailed clinical neurological, neuroimaging, and neuropsychological measures, while carefully controlling for confounds. Results: Objective 1a: 44.2% of tTSCI patients sustained a concomitant TBI. Objective 1b: When all ambiguous TBI-negative patients (i.e., classified with low confidence) were removed, prevalence rose to 57.6%. Objective 2: tTSCI patients in motor vehicle collisions (MVC) were most likely to sustain a comorbid TBI, but 37.1% of falls nonetheless had TBI. Cervical and thoracic patients showed an equal prevalence of co-morbid TBI (44%). The frequency of missed traumatic brain injury diagnoses was 58.5%. Conclusions: Regardless of inclusion or exclusion of ambiguous TBI-negative cases, prevalence of TBI in people with SCI is high. Differing management of ambiguous cases significantly affects rates, and may partly explain past disparities in the literature. The prevailing assumption that dualdiagnosis is more common with cervical spine injuries was disconfirmed. In more than half of the traumatic SCI patients referred for in-patient rehabilitation, acute care diagnoses of traumatic brain injury were missed.
79. In the chronic stages of moderate-severe TBI, many symptoms are getting worse not better JC Tomaszczyk1, B Sharma1,2, D Frasca1,2, A Terpstra1,2, REA Green 1,2 1 Toronto Rehab - UHN; 2 University of Toronto
Background: For moderate-severe traumatic brain injury (TBI), most clinical services are provided within the first weeks and months of injury and most research focuses on mitigating acute injury effects or maximizing recovery within the first months of injury. Less attention is paid to the large numbers living with chronic TBI, for whom capacities often worsen. Findings: In a longitudinal study following adults from 2-24+ months post-injury, we found: (1) that the number of people with moderate-severe symptoms of depression increases across time, with depression rates tripling from 2 to 24+ months post-injury; (2) that anxiety shows a similar pattern, with the number of people with moderate-severe symptoms of anxiety nearly doubling from 2 to 24+ months post-injury; and (3) that despite community integration increases for home and productivity, social integration shows a steady decline across time. Discussion: These findings illustrate the critical importance of large, high-retention, longitudinal studies that illustrate progression of symptoms from the sub-acute to chronic stages of injury. The findings also highlight the need to understand the underlying mechanisms of these problems, and to provide interventions that focus on the chronic stages of injury. Our lab is testing interventions to offset decline, and to deliver these interventions to patients across Canada, regardless of geographical location or mobility restrictions. 80. In the chronic stages of moderate-severe TBI, the brain is losing volume and white matter integrity B Colella1, D Mikulis,2,4, A Crawley2, J Maller3 J Glazer1, M Dabcek1,4, REA Green1,4 1 Toronto Rehab â€“ UHN; 2 Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospial; 3 Monash University; 4 University of Toronto
Background: It is typically assumed that the brains of people with moderate to severe traumatic brain injury are stable throughout the chronic stages of injury. However, there is growing evidence from our lab and elsewhere that following the resolution of acute neurological insult, there are losses to brain volume and white matter integrity. Objectives: To illustrate these losses from 5 to 12 to 24 months post-injury using volumetric MRI and diffusion tensor imaging. To correlate losses with cognitive changes. To demonstrate the ubiquity of changes. Results: Significant declines in total brain volume, hippocampal volume and corpus callosum volume were observed across time as were changes in white matter integrity. Changes were correlated with memory function. The majority of patients showed significant losses. Implications: Our previous research shows that brain changes may be the result of â€œpost-injuryâ€? factors, such as the degree of environmental stimulation. Interventions that increase environmental enrichment may help to offset these deleterious brain changes. Our lab is currently piloting interventions and measuring their impact on the brain.
81. Multiple concussions in retired pro football players: what are the core neuropsychiatric and cognitive deficits? REA Green1,2,3, AR Terpstra2,4, MC Tartaglia1,5,6, CH Tator1,7, D Mikulis1,8, KD Davis1,10,11,12,13, R Wennberg1,5, B Colella2 1 Canadian Sports Concussion Project; 2 Cognitive Neurorehabilitation Sciences Laboratory, Research Department, Toronto Rehab - UHN; 3 Department of Psychiatry, Neurosciences, University of Toronto; 4 Graduate Department of Rehabilitation Science, Faculty of Medicine, University of Toronto; 5 Division of Neurology, Krembil Neuroscience Centre, UHN, University of Toronto; 6 Tanz Centre for Research in Neurodegenerative Disease, University of Toronto; 7 Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital; 8 Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital; 9 Department of Laboratory Medicine and Pathobiology, University of Toronto; 10 Division of Neurosurgery, UHN; 11 Division of Brain, Imaging and Behaviour Systems Neuroscience, Toronto Western Research Institute â€“UHN; 12 Department of Surgery, University of Toronto; 13 Institute of Medical Science, University of Toronto
Background. Repetitive concussion in contact sports is associated with cognitive and psychiatric changes, and has been linked aetiologically with accelerated aging and neurodegeneration. Retired professional football players are an increasingly studied group with high exposure to concussions; however, there has yet to be a comprehensive neuropsychiatric and cognitive characterization of this population. Methods: In the current study, 22 CFL alumni were compared to healthy controls on neuropsychiatric and cognitive measures. These comparisons were made again after dividing CFL alumni into memory sub-groups based on discrepancy between intelligence quotient (IQ) and memory quotient (MQ): IQ-MQ-split-positive (memory impaired) and IQ-MQ-split-negative (memory unimpaired).Results. The CFL alumni displayed significantly higher Somatic Complaints, Mania, and Aggression scores on the Personality Assessment Inventory scale, and significantly lower performance on a stop-signal Go/No-Go task sensitive to response inhibition. The IQ-MQ-split-positive group, but not the IQ-MQ-split-negative group, differed significantly from respective controls for Mania, Aggression and Somatic Complaints scores, plus commission errors and response time on the stop-signal Go/No-Go task. Discussion: Findings suggest that reduced inhibitory capacity (higher Mania and Aggression scale scores, and reduced response inhibition) characterizes the observed pattern of dysfunction. It appears that a memory-impaired sub-set largely drives observed dysfunction. These findings offer an early target for treatment and research. 82. Offsetting neurodegeneration in TBI: Home-based, internet delivery of environmental enrichment B Sharma1,2, J Tomaszczyk1, B Colella1, D Dawson3, G Turner4, G Noack1, RE Green1,2 1 Toronto Rehab-UHN; 2 University of Toronto; 3 Rotman Research Institute; 4 York University, Psychology; 2 Toronto Western â€“ UHN; 3 Monash University; 4 University of Toronto; 3 Monash University and Alfred Hospital, Melbourne, Australia; 4 Department of Psychiatry, University of Toronto
Objective: Recent studies in our lab and elsewhere show progressive cognitive and neural decline in chronic moderate-to-severe TBI. Offsetting neurodegeneration may enhance clinical outcomes. We have shown that cognitive environmental enrichment (C-EE; continuously novel, challenging, and engaging cognitive stimulation) is a strong candidate therapy for offsetting decline. We therefore investigated feasibility and preliminary efficacy of a home-based, self-administered, 49
internet-delivered C-EE intervention that was delivered over 12 weeks, at 60 minutes/day. Results: In 11 TBI patients, weekly adherence was modest (range: 7.7-90.1%), with a modal frequency of approximately 50%. Acceptability was high, as evidenced by retention of 7/11 patients, with drop outs due to non-intervention factors in 3/4 cases (i.e., return-to-school, loss of Internet access, return-to-work). Moreover, data available for six patients showed post-training increases in Sense of Accomplishment and Confidence (6/6), and reductions in Boredom (5/6). Neuropsychological findings (n = 8) supported feasibility, with pre-post behavioural changes in the expected directions. Conclusions: With no environmental supports, moderate-severe TBI patients were able to participate in regular internet-based CEE. Adherence may be improved by providing patients with daily reminders to participate in cognitive training. These findings indicate a promising route for delivering needed C-EE to patients regardless of injury severity or geographic location. 83. Offsetting the enduring symptoms of TBI: Face to face and internetbased group therapies B Colella1, L Ruttan1, S Lombardi3, L Meusel2, RE Green1,3 1 Toronto Rehab - UHN; 2 Rotman Research Institute; 3 University of Toronto
Background: Some patients experience persistent symptoms following concussion(s), including depression, anxiety, and cognitive impairment. Moderateto-severe brain injury also causes higher incidence of such impairments that can worsen in the chronic stages of injury; neurodegeneration also occurs. We are using a multifaceted approach to address mood symptoms and cognitive impairments in all groups, and the downstream atrophy in more severely injured patients. Methods: Therapeutic protocols: (1) concussion education support group, comprising a two-night educational workshop for enduring effects of concussion(s), (2) group-based combination therapy, either (i) face-to-face or (ii) via internet for retired professional athletes and individuals with moderate-to-severe TBI. This intervention includes 20-weeks of goal-management training and cognitive behavioural therapy, and ongoing environmental enrichment. Results: To date, we have run three support groups (50 participants in total) and one course of face-toface combination therapy group (with 5 of 6 participants completing the program). Findings included high recruitment, retention and acceptability ratings. Patients also self-reported improvements in symptom management. Discussion: These preliminary findings suggest that both therapeutic approaches are highly feasible. Next steps include further efficacy measurements, including brain structure and function, followed by scaling of delivery via the internet to patients across Canada. 84. Facial Emotion Research: Implications for Social Functioning after Traumatic Brain Injury A Oatley1,2, R Green2,3 1 York University; 2 Toronto Rehab-UHN; 3 University of Toronto
Purpose: Decreased social integration is a commonly reported but untreated after TBI. Given the relationship between facial emotion perception (FEP), and community integration, our purpose is to better understand FEP in order to advance treatment research. Methodology: The aim of this project is to better understand the mechanisms underlying FEP, by studying visual attention with eye-tracking. We have employed a novel eye-tracking paradigm to examine visual attention in emotional faces among a group of individuals with TBI (N=12) and a group of 50
adults without TBI (N=30). This paradigm permitted examination of a range of facial emotions, and the pattern of visual scanning of these faces, including the amount of time spent on informative versus uninformative facial features (e.g., eyes and mouth vs. nose and cheeks, respectively). Two facial emotion perception tasks were employed. Summary of Findings: The key findings were: (1) participants with TBI were significantly slower to scan all emotional faces than controls (between â€“subjects main effect = p<.05); (2) controls attended to eyes on fearful faces more so than on other emotional faces (within-subjects, main effects of emotion = p<.05); and, (3) participants with TBI attended proportionately less to the eyes of emotional faces relative to controls (group by task interaction=p<.05). Implication for TBI patients: These findings offer an understanding of how TBI patients scan emotional faces relative to controls, and how differences may contribute to their impairments in reading facial emotions. Given that such impairments are increasingly implicated in poor social integration, the findings critically open new avenues for FEP treatment that may serve to improve quality of life. How contributes to rehab practice: The specificity of these findings suggests specific rehabilitation treatments to improve social integration. These include incorporation of techniques that enhance attentional functioning, such as mindfulness meditation, which would additionally increase emotional regulation. Further research is needed to validate these benefits. 85. iPad Tablet Technology for Home Rehabilitation in Patients After Stroke G Saposnik1,2, CM Chow 1, L Langer 3, M Bayley 2,3 1 St Michael's Hospital; 2 University of Toronto; 3 Toronto Rehab - UHN
Background: Repetitive, intensive and task-specific functional training is the current neurorehabilitation strategy after stroke to facilitate motor relearning and consequently improvement of function. This is possible due to cortical reorganization and rewiring in the injured brain (brain plasticity) and by engaging the mirror neuron system, long-term potentiation effects and the brain reward system. While conventional rehabilitation (i.e., physiotherapy and occupational therapy) helps improve motor function after stroke the magnitude of its benefit has limitations. Conventional rehabilitation is time consuming, labor- and resourceintensive, dependent on patient adherence, limited in its availability depending on geography, and in some patients it has modest and delayed effects. Our group recently showed the potential benefits of novel approaches using virtual reality technology for in-patient stroke rehabilitation. Virtual reality gaming showed practice-dependent enhancement of the affected arm through the facilitation of cortical reorganization.
ABSTRACTS FROM THE CARDIOPULMONARY FITNESS TEAM The Cardiopulmonary Fitness Team is engaged in a collaborative research program focused on the design, implementation, and evaluation of strategies that identify, target, and engage, the highest-risk, highest yield populations for cardiovascular preventative strategies. By definition, such populations are those who are least-engaged, least adherent, and most vulnerable - they are the most challenging populations to treat - the populations who lie â€œbeneath the tip of the icebergâ€? for whom the risk of mortality, morbidity, and health care expenditures are greatest. The interdisciplinary research program incorporates cutting-edge observational research methodology through data-linkage between TRI-UHN (and other cardiac rehabilitation programs) and the Institute for Clinical Evaluative Sciences.
86. Depressive symptoms predict non-completion of exercise-based rehabilitation for participants with type 2 diabetes mellitus W Swardfager1,2,4, P Yang4, N Herrmann1,3, KL Lanctot1,2,3,4, BR Shah1, A Kiss1, PI Oh1,4 1 Sunnybrook Health Sciences Centre; 2 University of Toronto, Department of Pharmacology & Toxicology; 3 University of Toronto, Department of Psychiatry; 4 Toronto Rehab - UHN
Exercise recommendations are inconsistently adopted and poorly adhered to by people with type 2 diabetes mellitus (T2DM). Interventions may be needed to improve adoption of exercise; however, depressive symptoms highly prevalent in T2DM may interfere with participation. This prospective cohort study of consecutive participants with T2DM entering a 6-month tailored exercise-based rehabilitation program aimed to qualify the impact of depressive symptoms on adherence. Depressive symptoms were quantified at baseline using the Center for Epidemiological Studies Scale for Depression (CES-D). Among participants (n=624), 26.8% endorsed significant depressive symptoms (CES-D>/=16) at intake and 68.2% completed the program. A CES-D score >/= 16 increased the risk of non-completion by 49% (HR=1.49, 95% CI [1.10 2.03], p=.010) due to disinterest (17.4%) and medical complications (13.2%). A cutoff score of CESD>/=10 (48.4% of participants) predicted non-completion with optimal accuracy (HR 1.60, 95% CI [1.19 2.17], p=.002), consistent in women and men. Even mild depressive symptoms increased risk of non-completion. Further development of sensitive screening instruments and targeted retention strategies may be required to optimize the impact of exercise interventions for participants with T2DM.
87. Determining the cost-benefit yields of participating in a cardiac rehabilitation program A Biswas1, P Oh2, G Faulkner3, D Alter1,2,4 1 University of Toronto, Institute of Health Policy, Management & Evaluation; 2 Toronto Rehab - UHN; 3 University of Toronto, Faculty of Kinesiology and Physical Education; 4 Institute for Clinical Evaluative Sciences;
Regular cardiac rehabilitation (CR) participation has shown to significantly improve the risk of adverse events among cardiac patients. Assuming that CR efficacy is similar across subpopulations, program effectiveness is based on two factors: baseline risk and behavioral attrition. No study has quantified thresholds of baseline risk and behavioral attrition beyond which the CR cost-benefits become economically unattractive from a health services perspective. We aimed to determine how CR cost-benefits CR vary across baseline risk and behavioral attrition patterns amongst actual CR patients. Data was obtained from 11,998 consecutive patient intakes to TRI Cardiac Rehabilitation Program (1995-2010). Baseline risk defined as the likelihood of death/hospitalization at 3 years following program termination and behavioral attrition as the likelihood of program dropout. Multiple logistic regression models were used to generate predictive models. Both models had good discriminative ability (baseline risk, c-statistic=0.66; behavioral attrition, c-statistic=0.85). Correlation between models was weak (r=0.22, p<0.001). For each quartile of cost-yield, the relative risk (RR) for 10% behavioral attrition increase was 0.87 (95% CI: 0.85-1.89). For each 10% baseline risk increase, RR=1.36 (95% CI: 1.34, 1.37). This research recommends a dual stratification approach to CR delivery and that intensifying CR to particular populations is economically attractive. 88. A feasibility study of financial incentives to increase exercise among Canadian cardiac rehabilitation patients MS Mitchell1,2, JM Goodman1, DA Alter2,3, PI Oh 2, TM Leahey3, GEJ Faulkner1 1 Faculty of Kinesiology and Physical Education, University of Toronto; 2 Toronto Rehab â€“ UHN; 3 Institute for Clinical Evaluative Sciences; 4 Weight Control and Diabetes Research Center, Brown Medical School
Purpose: To examine the feasibility of conducting a randomized trial investigating the effectiveness of financial incentives for exercise self-monitoring in cardiac rehabilitation (CR). Methods: A 12-week, two parallel-arm, single-blind feasibility study design was employed. CR program graduates were randomly assigned to an exercise self-monitoring intervention only (control; n=14), or an exercise selfmonitoring plus incentives approach (incentive; n=13). Control group participants received a home-based exercise self-monitoring program following CR program completion. Incentive group participants received the home-based program, plus voucher-based incentives for exercise diary submissions ($2/day). A range of feasibility outcomes is presented, including recruitment/retention rates and intervention acceptability. Data for the proposed primary outcome of a definitive trial, aerobic fitness, are also reported. Results: Seventy-four CR graduates were potentially eligible to participate, 27 were enrolled. Intervention acceptability was high with three-quarters of participants indicating they would likely sign-up for an incentive program at baseline. While group differences in exercise self-monitoring (the incentive target ) were not observed, modest changes in aerobic fitness were noted (control: -0.68ml/kg/min, incentive: +0.23ml/kg/min, p>0.05) Conclusion: This study demonstrates the feasibility of studying incentives in a CR context, and 53
the potential for incentives to be readily accepted in the broader context of the Canadian healthcare system. 89. Behavior determinants among cardiac rehabilitation patients receiving educational interventions: an application of the health action process approach GL de Melo Ghisi1,2, SL Grace2,3, S Thomas1, MF Evans4, P Oh2 1 Exercise Sciences Department, Faculty of Kinesiology & Physical Education, University of Toronto, Toronto; 2 Cardiac Rehabilitation and Prevention Program, Toronto Rehab â€“ UHN; 3 School of Kinesiology and Health Science, York University; 4 Health Design Lab, St Michael s Hospital
Objectives: To investigate: (1) changes in knowledge and health action practice approach (HAPA) constructs among cardiac rehabilitation (CR) patients following participation in one of two educational programs; and, (2) the theoretical correlates of exercise behavior change among CR patients receiving educational interventions. Methods: CR patients were assessed before and 6 months after exposure to an existing or new HAPA and evidence-based education curriculum. Participants were invited to complete a survey including scales to assess exercise behavior, HAPA constructs, and knowledge. Results: Three hundred and six patients consented to participate, of which 146(47.7%) were exposed to the new educational curriculum. There was a significant improvement in patients overall knowledge from pre- to post-CR, as well as in some HAPA constructs (risk awareness, outcomes expectancies, task self-efficacy, action and coping planning) and exercise behavior, regardless of curriculum (p<0.05). Path analysis revealed that knowledge was a significant construct leading to intention formation, and intentions to engage in physical activity were not directly related to behavior, needing especially action planning. Conclusions: Educational interventions in CR effectively improve knowledge and theory-implied constructs of exercise behavior. Practice implications: Educational strategies needed to be plan to not only to increase patientsâ€™ knowledge but also enhance intentions, self-efficacy, and action planning. 90. The association between endothelial dysfunction and memory performance in patients with coronary artery disease M Saleem1,2, G Mazeereuw1,2, A Dinoff1,2, N Herrmann1,2, W Swardfager1,2,3, C Santiago1,2, PI Oh3, KL Lanctot1,2,3 1 Sunnybrook Health Sciences Centre; 2 University of Toronto; 3 Toronto Rehab - UHN
Background: Endothelial dysfunction is a common feature of coronary artery disease (CAD) and is associated with memory impairment, a key predictor of cognitive decline in CAD. Endothelial dysfunction is also implicated in the etiology of depression, which is associated with poorer cognitive outcomes in CAD patients. Despite these links, the relationship between endothelial dysfunction and memory in depressed CAD patients remains unexplored. Methods: CAD patients were interviewed at entry into cardiac rehabilitation. Depression was diagnosed using DSM-IV criteria. Memory performance (California Verbal Learning test 2nd ed.) and executive function (Digit Symbol-Coding test and Trail Making Test B) were assessed. Composite cognitive domain scores were calculated by summing individual test Z-scores. Endothelial function was measured by reactive hyperemia index (RHI) via peripheral arterial tonometry. Results: In 54 participants (mean+/SD age=64+/-18 years, 89% male), lower RHI was significantly associated with lower composite memory Z-scores (F1,47=4.29, p=0.04) but not composite 54
executive function Z-scores (F1,47=2.72, p=0.11) in depressed (n=19) compared to non-depressed CAD patients (n=35).Conclusion: Endothelial dysfunction may be an important correlate of worse memory performance in depressed CAD patients. Endothelial dysfunction can be reversed by exercise interventions, suggesting a need to explore its relationship with cognition following exercise in CAD patients. 91. Cardiac Rehabilitation: No Longer One Size Fits All TJ Yeo1, J McKinney1, S Marzolini1, P Oh1, D Alter1,2 1 Cardiovascular Prevention and Rehabilitation Program, Toronto Rehab Institute; 2 Institute for Clinical Evaluative Sciences
Purpose: We assessed the impact of age and fitness on adherence, hospitalization and mortality rates in patients undergoing cardiac rehabilitation (CR). Methods: 17,000 consecutive patients referred for CR in Ontario were followed for 3 years. The primary outcome was a composite of all-cause mortality or re-hospitalization at 3-years. Secondary outcomes were change in VO2 and attendance rates Results: 12,440 patients who attended ≥1 on-site visits were included. Compared to patients ≥80 years, those <50 years old had lower attendance (65.89 vs 71.79%, p<0.001) and higher dropout rates due to non-medical reasons (31.05 vs 16.57%, p<0.001). Those <50 years had the highest mean baseline VO2 (21.29±5.84 vs 14.12±3.55 ml/kg/min, p<0.001) and largest mean absolute and relative increases in VO2 (3.66±4.33 vs 1.61±2.92 ml/kg/min, p<0.001 and 18.75 vs 12.73%, p<0.001). Patients who completed CR had lower 3-year all-cause mortality or readmission rates (p<0.001 for all except those ≥80 years).Conclusions: CR engagement is poor in young patients despite greatest fitness gains and lowest mortality rates. Conversely, the elderly, while most engaged, experience the least gains in fitness with minimal improvement in mortality. To maximize CR effectiveness, future strategies should focus on improving program adherence and dropout reduction in the young while enhancing fitness in the elderly.
ABSTRACTS FROM THE TECHNOLOGY TEAM The Technology Team focuses on 1) the prevention of injuries due to falls and vehicle accidents, chronic disease induced by untreated sleep apnea and hospital acquired infections; 2) reducing the physical burdens on professional and family caregivers; 3) increasing safe mobility of older people and people with disabilities. We use sophisticated simulators to understand how aging affects walking and driving in challenging environments, with the objective of informing policies and product design .We continue to work on commissioning the new iDAPT laboratory spaces in tandem with launching research studies in these spaces. This year we will launch a major new research program to develop valid driver testing methods using challenging but safe simulator technology to support a program of customized driving licenses and to develop new functional standards for the performance of incar entertainment, information and communications systems. This teamâ€™s mission is to get new products on the market; make changes to policy; and introduce new therapies to clinical practice.
92. Preventing falls on stairs: Recent success to improve the National Building Code of Canada AC Novak1, V Komisar1,2, BE Maki1,2,3, GR Fernie1,2,3 1 Toronto Rehab â€“ UHN; 2 Institute of Biomaterials and Biomedical Engineering, University of Toronto; 3 Department of Surgery, University of Toronto
Stairways are amongst the most hazardous location of any home environment, particularly for older adults or persons with mobility impairment. Increasing accessibility of the built environment and improving stair design is an important avenue by which to address the very large incident rate of stair-related falls. Lasting change to the built environment often relies on changes at the level of policy, standards and regulation. With this is mind, we have focused our research efforts on providing empirical data to inform changes to the National Building Code of Canada (NBCC). Data collected in StairLab, CEAL, was disseminated alongside other published literature to advocate for longer step run lengths in homes. Our recommendation to increase the minimum run length of stairs in a private dwelling is expected to be adopted this year by the NBCC. As indicated by injury surveillance data, an increased run length from 210 mm to 255 mm will result in a three-fold reduction in the risk of stair-related falls in homes. Merging the health and building sectors will help to create a safer and more accessible built environment for persons of all ages.
93. Promoting in-home rehab and falls prevention: Design of a home-based balance support system S Wiebe2, T Dutta1, GR Fernie1,2 1 iDAPT Technology R&D Team, Toronto Rehab - UHN; 2 University of Toronto
Falls are the leading cause of unintentional injuries in Canadian seniors (SMARTRISK, 2009). Perturbation-based balance recovery training has shown to be effective for improving compensatory stepping responses in older adults following discharge from rehabilitation (Mansfield, 2010). Perturbation training involves intentionally causing the patient to lose balance, forcing them to react to recover balance. This training has an inherent risk of falling for the patient in the event the balance recovery actions are ineffective. To remove this risk, patients are strapped into a harness support system. Currently, modified commercial systems intended for other purposes are used; there is a need for a system that is specific to perturbation training. A focus group composed of patients, occupational and physical therapists will be assembled and participate in the iterative design of a solution. The final design will be prototyped and evaluated for efficacy and patient perception. We expect that by making safe perturbation-based balance training systems accessible to seniors across the country, this project will help to reduce their risk of a fall and associated injury, and allow them to continue to live independently in the community. 94. Design of an Armrest to optimize Sit-to-Stand Activities for Older Adults A Mezil, D Vena, T Dutta Toronto Rehab - UHN
Standing from a seated position is a challenge for many older adults. In fact, sit-tostand activities are one of the major risk factors for institutionalization. Pressure-fit grab bars (also called transfer poles) are helpful for increasing independent mobility for many older adults; however these may not be appropriate in all locations. The aim of this research is thus to design specialized armrests that can be used as a passive sit-to-stand assist device to help mobility limited older adults stand safely while maintaining the therapeutic goal of using the upper and lower-limbs. We will investigate the efficacy of the device against standard armrests and transfer poles in a mobility limited older adult population. Experimentation will include conducting a 3-dimensional biomechanical analysis of the upper- and lower-extremities. Outcomes will include kinetics and kinematics to examine user effort and stability throughout the movement across the different experimental conditions. The end goal is to create an adjustable armrest that will maximize the use of the upperextremities to minimize effort in the lower-extremities and maximize stability during the movement. 95. Why is labelling footwear Slip Resistance important? S Ravindran1,3, Y Li1, T Dutta1,2, GR Fernie1,2 1 iDAPT Technology R&D Team, Toronto Rehab - UHN; 2 University of Toronto, Department of Surgery; 3 University of Toronto, Division of Engineering Science
Need: Falls remain the leading cause of hospitalization of seniors in Canada, with 61% of falls occurring while walking. Slipping is a common cause of falls. The primary factors that induce a slip are poor grip and low friction between the footwear and walking surface, which indicates slip-resistant footwear can reduce 57
the number of falls experienced by pedestrians. However, credible methods of testing footwear slip resistance that account for dynamic human movement and could inform consumer footwear purchasing decisions do not yet exist. Protocol: We have a developed a protocol where participants walk up and down different surfaces. After each successful trial, the slope of the room was increased by 10 until the participant experienced a two-foot slip. That maximum incline is the critical angle for that footwear and surface combination. Next steps: Use the critical angle results from the maximum incline approach to develop rating and labeling systems that are easy to understand and allow consumers to compare the slip resistance between two sets of footwear. Significance: The labelling system will make it easier for consumers to purchase slip resistant footwear and as a result increase their balance and safety. 96. Preventing slips and falls on ice through better footwear materials R Rizvi 1, T Dutta 1, G Fernie 1, H Naguib 2 1 iDAPT Technology R&D Team, Toronto Rehab â€“ UHN; 2 Mechanical and Industrial Engineering, University of Toronto
Slip and fall related injuries and the fear associated with them is a major barrier to mobility and outdoors activities during the winter months for the general public and more so for the disabled and the elderly. If viewed with the motivation of reducing slips and falls, the design of footwear outsoles has remained largely unchanged over the past fifty years. Most of the design effort is on introducing treads and lugs of various shapes, sizes and patterns - the evolution of which has progressed so slowly in an iterative trial and error fashion that one might be forgiven for thinking it to be more of an art than engineering. Through our systematic approach, involving new fiber composite materials and designs, we are revolutionizing footwear technologies with the aim of remarkably increasing the slip resistance of winter footwear. Preliminary results suggest that the materials we have produced maintain a high friction on ice similar in performance to sandpapers or metal cleats. Furthermore, the method of manufacturing that we use is simple and scalable for high volume production. Further improvements are underway as well as efforts to develop a clearer understanding of the basic mechanisms behind the remarkable performance. 97. Multisensory driving simulation and older drivers R Ramkhalawansingh1,2, B Keshavarz2, B Haycock2, J.Campos1,2 1 University of Toronto, Department of Psychology; 2 Toronto Rehab - UHN
When we drive, we combine what we see, what we hear, and the motion that we feel in order to understand and control the movements of our vehicle. However, the process by which combine sensory signals changes as we age. Thus our goal was to determine how age differences in multisensory integration influence driving performance. We recruited younger (19-35) and older (65+) adults to drive in CEALâ€™s StreetLab, a state-of-the-art simulator that features a 2400 projection system, surround sound, and the capacity to convey the physical forces of driving a real car via CEAL s hydraulic motion platform. We simulated a rural driving environment in which drivers were to maintain the center of their lane and a speed limit of 80 Km/h. We then manipulated the availability of driving sounds and physical motion to observe how performance would change with or without these important sensory cues. We found evidence to suggest that compared to younger adults, older adults rely more heavily on the capacity to combine multiple sensory 58
cues in order to manage their speed and their steering effectively. This has implications for driving simulator and real vehicle design, where missing or inaccurate sensory cues may undermine how older drivers perform. 98. Using Immersive Virtual Reality technologies to study the perception and control of upper limb movements G El-Khechen Richandi, B Taati, B Keshavarz, J Campos Toronto Rehab - UHN
Body ownership and location are driven by combined feedback from vision, proprioception, tactile and vestibular sensory systems. However, changes in perception can occur due to particular disorders or behavioural manipulations. We are examining the effects of healthy aging and stroke on perceptions of body ownership and location by using a) a well-validated body-illusion (rubber hand illusion RHI) and b) our recently developed virtual reality (VR), head mounted display system. The RHI is a phenomenon whereby an observer views an artificial hand being stroked at the same time as their own hidden hand is stroked. This simultaneous visual-tactile feedback causes the observer to feel as though the rubber hand now belongs to their own body. In our study we collected questionnaire data, proprioceptive drift measurements (i.e., participantsâ€™ estimated real hand position), and body temperature. The RHI was successfully induced in 86% of healthy younger participants. We are now collecting data in older adults and stroke patients and are extending this paradigm to use within our customized, multisensory VR system. Overall, our findings will shed light on how the human brain integrates sensory and motor information to perceive and coordinate body movements, helping to develop multisensory interfaces to improve motor recovery. 99. Posture matters: Caregiver coaching using wearable technology to prevent low back pain T Kajaks1, J Wee2, A Patel2, MA Parahoo2, E King1,3, K Ray4, T Dutta1,3 1 Toronto Rehab - UHN; 2 University of Toronto, Department of Clinical Engineering; 3 University of Toronto, Department of Mechanical and Industrial Engineering;4 Saint Elizabeth Home Care
Low back-related injuries account for the majority of injuries sustained by caregivers due to tasks such as transferring from bed to toilet, patient lifting, and bathing. Thus, there is a need to provide caregivers with better tools to reduce the risk of injury. Our team has recently completed a prototype of a wearable system that provides real-time feedback to warn caregivers when they bend or twist too far in a similar way to the feedback provided by a coach to an athlete. The tool uses two Shimmer accelerometer-based sensors, which are embedded into a wearable vest, to collect upper and lower back posture data for processing and biofeedback via an Android phone. The next phase of our research program is to: 1) Evaluate the angle-measurement accuracy of this wearable posture feedback system for caregivers against a Vicon motion capture system, and 2) determine if this coaching system is an effective coaching system for caregivers, as defined by reduced time spent in high risk postures, using 20 paid and unpaid caregivers both in simulated (TRI-UHN HomeLab) and real home environments. Overall, we expect to reduce the caregiver injury burden by preventing low back pain through coaching-like training during high injury-related tasks.
100. Quantitative Analysis of Caregiving Activities using Microsoft Kinect: A Marker Based Approach M Parahoo1,2, T Dutta2,3, GR Fernie2,4 1 University of Toronto, Institute of Biomaterials and Biomedical Engineering, Toronto Rehab - UHN;2 Toronto Rehab - UHN;3 University of Toronto, Mechanical & Industrial Engineering Department, Toronto Rehab - UHN; 4 University of Toronto, Department of Surgery, Toronto Rehab - UHN
The risk of caregivers developing musculoskeletal injuries, particularly in the lower back during patient handling is high. [1, 2] With an increasing population of older adults in Canada, more seniors are being treated at home instead of the hospital. In a home environment, the care-giver is usually asked to work alone in confined spaces leading to awkward positioning of the body that accentuates the problem. To improve the ergonomic conditions in which the home care giver operates, it is necessary to record movements and gestures in those confined spaces. Existing 3D motion capture systems are expensive, bulky and cannot be installed in the confined spaces of the home environment. The first objective of this study is to determine the accuracy of the Kinect for Windows v2 sensor to existing 3D labbased motion capture systems. The second objective of the study is to develop a mobile marker-based motion capture system using the Kinect for Windows v2 that allows ergonomic assessment to be made in a simple and inexpensive way in the confined spaces of the home environment. 101. A Quality Improvement Initiative to Evaluate an Electronic System to Improve Hand Hygiene Across Healthcare Settings S Pong 1,2, PJ Holliday 1,3, G Fernie 1,3 1 Toronto Rehab - UHN; 2 University of Toronto, Mechanical & Industrial Engineering; 3 University of Toronto, Department of Surgery
Healthcare worker hand hygiene reduces healthcare-associated infections, but compliance is not optimal. We developed and patented an automated system that assists caregivers by providing gentle reminders to wash their hands. This system more than doubled the rate of hand washing during a clinical trial in a 50-bed Complex Continuing Care unit and provided continuous objective auditing. We are now ready to evaluate the system as a Quality Improvement initiative where participation is no longer voluntary and, therefore, representative of actual practice. Objectives: to adapt the system for easier installation and evaluate its effectiveness across a wider range of hospital environments. Outcomes: include wearability, hand hygiene compliance rates and cost. Progress: Installation is underway for the largest clinical trial ever, for 800 users at 5 sites. Expected impact: This is the final step before commercialization. Use of our hand hygiene technology will increase hand hygiene compliance and thereby reduce additional inpatient days caused by healthcare-associated infections. We will demonstrate that the system can be installed easily and affordably, and used effectively across the span of hospital environments. The cost of our system is lower than competitive solutions and installation does not require any changes in hospital infrastructure.
102. Application of Electrical Stimulation to Reduce Daytime Leg Fluid Accumulation and Alleviate Sleep Apnea: Experimental Protocol D Vena1,2, G Fernie1,2 A Yadollahi1 1 Toronto Rehabilitation Institute; 2 University of Toronto; 2 University of Toronto, Institute of Biomaterials and Biomedical Engineering; 3 University of Toronto, Department of Medicine
Obstructive sleep apnea (OSA) is a common disorder affecting 6% of the adult population and increases risk of cardiovascular morbidity and mortality. OSA occurs due to repeated full or partial collapse of the upper airway during sleep. The cause of airway collapse is still unclear, but the Sleep Team postulate that overnight rostral fluid shift from the legs into the neck can increase pressure on the upperairway, predispose it to collapse and thereby increase sleep apnea severity. A sedentary lifestyle is one means by which fluid can accumulate in the legs during the day and then increase rostral fluid shift into the neck. The first study in my PhD investigates the effect of electrical stimulation (ES) of the calf muscle while seated against quiet sitting controls. The study is a double cross-over protocol in which participants sit for four hours and receive either ES or sham ES (control). After one week, participants return to complete the other study arm. Outcome measurements will be compared between ES and control and include, rostral fluid shift after seated period, and sleep apnea severity. This research will inform development of an ES device to treat sleep apnea by reducing daytime leg fluid accumulation. 103. Using Reverse Trade Shows to Enhance Patient Care at the Glenrose Rehabilitation Hospital G Faulkner Rehabilitation Research and Technology Development, Alberta Health Services - Glenrose Rehabilitation Hospital
Technology holds tremendous promise for enhancing care and improving quality of life during rehabilitation. However, assessing, testing and integrating technological solutions is complex. Clinical care challenges must be identified and articulated; innovative technological responses found or developed, and new innovations integrated into a highly regulated and risk adverse clinical setting. The Glenrose deployed a dedicated team of multidisciplinary professionals, the Innovation Working Group, to build the internal capacity of clinicians and hospital administrators to effectively engage and collaborate with the innovation community. In 2013, the Group introduced the Reverse Trade Show, a successful engagement process, predicated on the concept of â€œmarket pullâ€?. Nineteen clinical care challenges were presented to innovators by Glenrose clinicians at two separate workshops. Innovators were encouraged to showcase existing or prototype solutions or collaborate with Glenrose staff to develop technology prototypes to address these care challenges. Of the challenges presented, two resulted in the development of new devices that are now commercially available, several products are in the design stage, and several useful products already available in the market, were showcased. In addition, the Reverse Trade Show process has helped identify and overcome system level constraints to assessing and integrating technological solutions into the hospital.
SCHOLARSHIPS & AWARDS Toronto Rehab Team Excellence Awards
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Hallisey Post-Doctoral Fellowship in Technology for Family Caregivers
TD Scholarship for Graduate Students with Disabilities
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Joel Verwegen Award
Mark Rochon Leadership Award in Rehabilitation Sciences
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2014 TEAM EXCELLENCE AWARDS Toronto Rehabâ€™s Team Excellence Awards are granted annually to graduate students from our 11 research teams who have performed exceptionally in the last year. Recipients are nominated by their team leaders. The 2014 Team Excellence Award winners are:
ACQUIRED BRAIN INJURY (ABI) & SOCIETY TEAM Wayne Khuu Wayne Khuu is a Master of Public Health Student specializing in Epidemiology at the Dalla Lana School of Public Health at the University of Toronto. His main area of interest is the use of big data to study human behaviour, mental and physical health, and the broader socioeconomic and political forces which impact them. He is currently working in the ABI Research Lab at U of T/Toronto Rehab. Wayne is investigating sex differences in comorbidities in the brain injury inpatient rehabilitation population using population level administrative data from Ontario. Wayne has received several academic awards including an entrance scholarship to the MPH program awarded to the top 10% of incoming students. His work has contributed to 3 peer review publications including one first author publication (submitted) and several conference abstracts and presentations. In addition to his academic accomplishments, Wayne is involved in several leadership activities including the Public Health Students' Association.
ARTIFICIAL INTELLIGENCE (AI) & ROBOTICS TEAM Ahmad Akl Ahmad Akl is a PhD student in the Institute of Biomaterials and Biomedical Engineering at the U of T. His current research focuses on developing algorithms that can predict who may have a cognitive impairment (CI) based on motion sensors that are installed in a home. As part of this project Ahmad has had to work very diligently on new algorithms and techniques, many of which are outside of his area of expertise. Even so, he has been able to tackle this challenge and develop algorithms that are currently operating with an accuracy of approximately 90%. This is a 63
2014 TEAM EXCELLENCE AWARDS remarkable accomplishment considering the complexity of CI and the little data that he is working with. In addition, Ahmad has been very active on other projects that are part of the AIRR team. For example, he has been working closely with a fellow on the use of thermal imaging to measure muscle fatigue during stroke rehabilitation. In his short time on this project, he has already developed a working system and has collected data that proves the efficacy of this approach.
BRAIN DISCOVERY AND RECOVERY TEAM Alex Terpstra Alex Terpstra is a Masterâ€™s student at U of T. He has already spearheaded and submitted two manuscripts, one based on a course review paper for which he received 100%, the other an important empirical manuscript that focuses on multiple concussions in former professional athletes. Alex's academic work has been outstanding, and he has a long track record of leadership and service to a variety of organizations and populations near and far, reaching from Toronto (volunteering for the University of Toronto Graduate Student Union), to India (interning in Ajmer with HIV/AIDs adults and special needs populations). Alex is a scholarly young person whose life experiences and capabilities enable him to see the larger context in which his work is placed. His depth of understanding of topics, quick mastery of new methods, and big picture understanding position him to make important contributions to healthcare research.
CARDIOPULMONARY FITNESS TEAM Marc Mitchell Marc is completing his PhD in Kinesiology at the University of Toronto while working as a Cardiac Rehab Supervisor at the University Health Network. The overall aim of Marc's research is to promote healthy behaviours using financial health incentives, like rewarding people with TTC tokens or grocery gift cards to exercise. With his exceptional committee members, Marc has published several papers in the incentives-for-health arena. As well, Marc founded Incentive Avenue Inc. in 2013, a health incentive consulting firm, and has worked with AIR MILES, Green Shield Canada Inc. and others to optimize their incentive programs. 64
2014 TEAM EXCELLENCE AWARDS COMMUNICATION TEAM Sin Tung Lau Over the course of her undergraduate research studies, as a Research Analyst, and now as a part of her MSc thesis, Sin Tung’s research program has focused on characterizing the link between hearing loss, mobility, and falls. In order to do this, she has exploited Virtual Reality technologies to introduce realistic, mobility-related challenges and has used motion capture systems to more precisely measure biomechanics. For instance, she has been instrumental in conducting studies that investigate the effects of dual-tasking (listening while walking) on listening accuracy and walking stability in younger adults, older adults, and older adults with hearing loss. As a part of her MSc work she is further investigating how orienting responses in those with hearing loss (e.g. turning one’s head to increase accessibility to binaural sound cues) affect walking trajectories and walking stability.
MOBILITY TEAM Jennifer Wong Prior to joining the Mobility Team, Jennifer completed a BSc in Health Studies with a minor in Gerontology at the University of Waterloo. At Toronto Rehab, Jenn initially worked on projects aimed and predicting falls in people with stroke and the adverse consequences of immobility in older adults. A true team player, Jenn has always been happy to help out with the Balance Mobility and Falls Clinic and other team members’ research, and has also been keen to support research in other teams. Jenn started an MSc in the Graduate Department of Rehabilitation Science at the University of Toronto in 2013 under the supervision of Drs Avril Mansfield and Dina Brooks. Her thesis research aims to determine the impact of falls early after stroke on the profile of stroke recovery. The results of this work could support the need for improved services for those at risk of functional decline following a fall after stroke. Jenn has authored or co-authored four published papers, with an additional three papers currently in review, and has presented her work at 10 local or national conferences.
2014 TEAM EXCELLENCE AWARDS NEURAL ENGINEERING & THERAPEUTICS TEAM Kathryn Atwell (co-recipient) Kathryn Atwell is a recent graduate from the University of Toronto where she earned her Masters of Applied Science with a thesis project entitled â€œA Brain Computer Interface that Predicts Different Hand Movementsâ€?. Kathryn's work has made significant contributions towards the development of a BMI system for FES applications, and her idea was filed as a patent application in September 2014. Kathryn is currently employed as a Research and Development Engineer at a medical device company in Toronto and is collaborating on several manuscripts which detail the results of her thesis project. To date, the work presented in her thesis represents the first account of the ability to classify several different hand movements using non-invasive electrodes and pre-motor electroencephalography signals. Furthermore, Kathryn helped Dr. Cesar Marquez Chin establish a more permanent presence of the NET team at University Centre.
Martha Garcia (co-recipient) Martha is in the first year of her PhD in Biomedical Engineering at UofT. She completed her BSc in Biomedical Engineering at Universidad Iberoamericana in Mexico City. She completed her MASc in January in which she developed the first asynchronous animal BMI system, where the animal could use its brain signals to control its environment. She is working in two manuscripts at the moment. The first one will describe how the rat used the BMI to control one object in its environment, while the second one will explain how the animal controlled two objects simultaneously. In 2010 she collaborated with the Sleep and Technology Teams on the sleep apnea project, particularly in the development of a system to detect sleep apnea events from breathing sounds. Martha currently hold two awards: CONACYT (Mexico) and NSERC Create Care. She has played a critical role in mobilizing NET team members and engaging them in social activities outside TRI.
2014 TEAM EXCELLENCE AWARDS OPTIMIZATION OF THE REHABILITATION SYSTEM TEAM Saira Merali Saira has worked under the supervision of Dr. Nancy Salbach as a Work Study Student since June 2012. After completing an Honors BSc in Neuroscience and Psychology, she entered the MSc degree program in the Graduate Department of Rehabilitation Science at the U of T in September 2013. Saira demonstrated independence and perseverance by developing a protocol for the conduct of a scoping review to characterize evaluations of community exercise programs delivered by fitness instructors for people with neurological conditions as she handled a full course load. The manuscript is almost ready for journal submission. Scoping review findings highlighted a paucity of research examining how the provision of exercise programs for people with disability can impact not only the exercise participant but also the caregiver. Thus, Saira is currently conducting a descriptive qualitative study to explore how the Together in Movement and Exercise (TIME) Program, developed by physical therapists at TRI-UHN, impacts the health of participants with neurological conditions and their caregivers with a specific focus on participation in valued activities.
SWALLOWING SCIENCE TEAM Carly Barbon Carly began her PhD in September, 2013. In the year since then, she has completed Âž of her required coursework, completed a systematic review study which has been accepted for publication (pending minor edits) and accepted for presentation at the American Speech Language Hearing Association convention this November. Carly has also assisted in another large systematic review project in the lab (accepted for publication), served as a teaching assistant, and led a project on testing the rheological properties of barium stimuli used in videofluoroscopic assessment. Carly exhibits a clear passion for her research topic, which will explore the use of food and liquid texture modification to improve swallowing safety in individuals with swallowing impairment following treatment for head and neck cancer. This is an under-studied and under-serviced area, and Carlyâ€™s research will have important consequences for best practice in the field. 67
2014 TEAM EXCELLENCE AWARDS TECHNOLOGY TEAM Vicki Komisar Vicki embodies many of the values important to the Technology Team. These include a willingness to balance her dual commitments to her PhD thesis project on the optimal design of handrails for fall prevention along with her focus on ensuring the results of her work are translated to the public through policy change and new products. In anticipation of her findings on handrail design, Vicki has begun communication with the committee in charge of defining the national building code. She has also managed the development, testing and creation of marketing materials for two products (the MoveEasy Pole Kit and StandEasy) that are about to be launched on the market. Her hard work on these two products will ensure that easy to install safety poles and clip-on handrails are available for use at home or in hospitals. Vicki also demonstrates a strong commitment to supporting members of her team. Vicki takes her role as a mentor to students in our lab seriously and always takes the time to provide thoughtful guidance and constructive feedback. She is often the first to suggest and organize celebratory events when her colleagues reach key milestones. Vicki is also an excellent ambassador for research at iDAPT. She is regularly asked to give tours of the research facility because of her ability to clearly communicate the importance of our work to the public with a particular focus on younger visitors. For the last two years she was responsible for organizing and running two-week long University of Toronto DEEP (Da Vinci Engineering Enrichment Program) Summer Academy science sessions for high school students.
HALLISEY FELLOWSHIP IN TECHNOLOGY FOR FAMILY CAREGIVERS The Hallisey Fellowship in Technology for Family Caregivers has been created with a generous donation from Mrs. Pamela Hallisey – the focus will be on technology to support the effectiveness and safety of family caregivers. Mrs. Hallisey is particularly interested in the difficulties faced by family caregivers when caring for their loved ones and in helping them to continue to live in their own homes rather than admitting them to an institution. Problems such as helping with bathing and toileting, moving safely around the home environments, are all areas of study at Toronto Rehab that need innovative solutions. Mrs. Hallisey’s donation is supporting a Post-Doctoral Fellow for three years to assist with the development of these solutions. The recipient of the Hallisey Fellowship in Technology for Family Caregiver is:
Tara Kajaks Tara Kajaks is a Post-Doctoral Fellow with the Technology Team where she holds the Hallisey Fellowship in Technology for Family Caregivers. Her research focuses on understanding and addressing the challenges experienced by caregivers in the home environment. Over the course of her Fellowship, Tara hopes to use her background in biomechanics, ergonomics, and work disability prevention to develop new and innovative solutions that will have a positive impact on the quality of life of both caregivers and care recipients. Tara comes from McMaster University where she has studied older driver safety, firefighter ergonomics, occupational risk factors for knee osteoarthritis, and the use of virtual reality for ergonomic assessments in automotive manufacturing. Overall, Tara’s broad research interests focus on injury prevention in both worker and older adult populations.
TD GRANTS IN MEDICAL EXCELLENCE: Scholarship In Rehabilitation-Related Research for Graduate Students with Disabilities Believed to be the first of its kind in Canada, The TD GRANT IN MEDICAL EXCELLENCE: A Scholarship in Rehabilitation-related Research for Students with Disabilities acts as a spur to involving people with disabilities in rehabilitation-related research. The scholarship program bestows awards to exemplary Masters and PhD students to assist them in becoming world-class scientists. Scientists with disabilities understand both the needs and opportunities that exist in science and technology. Their unique knowledge and perspectives enrich research. TD Bank Financial Group has pledged $750,000 to the program since 2006. With TD Bank’s generous funding, the program has supported 14 graduate students with disabilities to date.
The scholarship is “one notable exception to the dearth of Canadian programs working to improve the representation of persons with disabilities in science and technology sectors... Other Canadian institutions should follow the lead of Toronto Rehab and undertake initiatives that actively support students with disabilities in science and technology fields while helping to raise the profile of young scientists.” - National Educational Association of Disabled Students. Success in STEM: Studying and Pursuing a Science or Technology Career as a Post-Secondary Student with a Disability, 2010.
Toronto Rehab and TD Bank Financial Group are proud to announce the 2014/15 recipients.
TD GRANTS IN MEDICAL EXCELLENCE: Scholarship In Rehabilitation-Related Research for Graduate Students with Disabilities Andrea Kusec After graduating with Bachelor of Arts in Psychology at Ryerson University, Andrea was accepted to McMaster University where she is pursuing a Master of Science in Rehabilitation Sciences. Her research will explore how individuals who have suffered an acquired brain injury become motivated to recover and how to use this information to improve motivation in rehabilitation hospitals. Andrea hopes to help those with an acquired brain injury to achieve their goals as inpatients and to continue feeling motivated to engage in outpatient therapy upon discharge. A first-time recipient of the TD Grants in Medical Excellence: A Scholarship in Rehabilitationrelated Research for Graduate Students with Disabilities, Andrea has also received McMaster University’s Graduate Scholarship, Ryerson University’s Faculty of Arts Student Project Grant, and a Travel Bursary from the Canadian Psychological Association. She has presented her own research questions in four different conference abstracts and has been involved in nine others. She has also co-written four different manuscripts for publication. Andrea was diagnosed with epilepsy grand-mal after sustaining a concussion when she was thirteen years old. Andrea strongly believes living with her “invisible disability” allows her unique insight into the day-to-day experiences and challenges of those living with an acquired brain injury, as well as many other individuals with cognitive impairments. Andrea has been volunteering at Toronto Rehabilitation Institute in various capacities for the past three and a half years and is currently the Unit Support Team Leader of the Acquired Brain Injury Unit.
Jirapat Likitlersuang Jirapat Likitlersuang is a Master’s candidate at the University of Toronto’s Institute of Biomaterials and Biomedical Engineering, and a first-time recipient of the TD Grants in Medical Excellence: A Scholarship in Rehabilitation-related Research for Graduate Students with Disabilities. He is working on developing wearable sensors capable of monitoring hand function at home in individuals with upper limb dysfunction, as a result of a spinal cord injury, stroke or other musculoskeletal conditions. The data
TD GRANTS IN MEDICAL EXCELLENCE: Scholarship In Rehabilitation-Related Research for Graduate Students with Disabilities from these sensors would, for the first time, allow researchers and clinicians to gauge the userâ€™s level of independence at home in performing activities involving upper limb function, which is a key consideration in evaluating the outcome of the rehabilitation process. Jirapatâ€™s strong fascination in the research area of rehabilitative treatments and devices for people with disabilities primarily stems from his own experiences living with a language expression difficulty and how assistive devices have significantly helped him. This understanding and personal interest to contribute to the field has led him to pursue a career as a biomedical engineer, in the hope of helping to enable persons living with a disability achieve their potential. Throughout his academic career, Jirapat has worked on various projects, including the development of a tracking microscope for neural studies, an automatic rehabilitation assessment system, educational tools for children with disability, as well as a portable pressure sensor device for studying the biomechanics of mobility assistive devices. Some of his work has been published in scientific journals.
Stefania Moro Stefania Moro is the first to study auditory and visual processing in a rare group of patients who have had one eye surgically removed at a young age due to cancer. Her research addresses crossmodal plasticity or how people with one eye adapt to the loss of binocularity. Her findings suggest that those experiencing the loss of an eye in early life may be able to compensate for their visual loss by using both their remaining eye and other senses. Stefania believes that, with training, people with a sensory deficit can adapt, resulting in rich perceptual experiences and less stress on their remaining senses. Stefania appreciates firsthand the importance of a typically developing visual system, and of achieving a normal sensory experience throughout life. As a child, she suffered a traumatic injury to her left eye. Stefania has held the TD Grants in Medical Excellence: A Scholarship in Rehabilitation-related Research for Graduate Students with Disabilities for four years, having first completed her Masterâ€™s degree and now conducting her PhD in Psychology at York University. She is also a recipient of the Natural Science and Engineering Research Council of Canada Post-Graduate Doctoral Scholarship. Stefania has published her research in Experimental Brain Research,
TD GRANTS IN MEDICAL EXCELLENCE: Scholarship In Rehabilitation-Related Research for Graduate Students with Disabilities Neuroscience Letters and Multisensory Research, and has co-authored a book chapter in Plasticity in Sensory Systems. She has presented her findings at the highly prestigious international conference of the Vision Sciences Society, as well as at the International Multisensory Research Forum, the International Conference on Plastic Vision, and the Society for Neuroscience.
Ivan Solano After training at the top ranked University of the Philippines, Ivan Solano began his career as a physiotherapist. His experience working with clients requiring physical rehabilitation helped him to realize the importance of the built environment design and assistive devices in enabling people with disabilities. Eager to learn more about creating enabling environments, he pursued a Masters in Human Environment Design at Japan’s Kyushu University and researched on how ramp design affects wheelchair performance. Currently a PhD candidate at the University of Toronto’s Graduate Department of Rehabilitation Science, Ivan is investigating the use of rollators on ramps among the elderly, and the role of the upper extremities in maintaining balance and mobility. A two-time recipient of the TD Grants in Medical Excellence: A Scholarship in Rehabilitationrelated Research for Graduate Students with Disabilities, Ivan has also received several other awards, including Civic Action’s DiverseCity Fellows 2014-15— a year-long civic action and project-building training for up-and-coming community builders, the Ontario Graduate Scholarship and the prestigious Panasonic Scholarship Award (Japan), which is awarded to a very select group of young academics in Asia. Ivan has a working memory deficit, a form of a learning disability, which affects processing and recall of information. He strongly believes that despite the challenges that people with disabilities face, they can achieve and use their personal understanding for the benefit of humanity in creating more inclusive and usable environments. An active volunteer, Ivan serves as a role model for people with learning and other disabilities, a current board member of the Students for Barrier-free Action at the University of Toronto and a peer mentor at the Family Care Office of the university.
TD GRANTS IN MEDICAL EXCELLENCE: Scholarship In Rehabilitation-Related Research for Graduate Students with Disabilities Meagan Warnica For the third year, Meagan Warnica has been awarded the TD Grants in Medical Excellence: A Scholarship in Rehabilitation-related Research for Graduate Students with Disabilities to complete her Masters of Science at the University of Waterloo. Working with a professional forensic engineering company, Meagan is investigating the effectiveness of helmets in high-energy impact cycling collisions. She presented the results of a previous study assessing the influences of helmet type, price-point, and repeated impacts on the protective capacity of downhill mountain biking helmets at the 2014 World Congress of Biomechanics in Boston, MA. A top student, Meagan has received several other awards, including the Natural Science and Engineering Research Council of Canada Postgraduate Scholarship, the University of Waterlooâ€™s Deanâ€™s Entrance Scholarship for her undergraduate degree, and an Ontario Graduate Scholarship. Meagan was also recently awarded the Canadian Society of Biomechanics Travel Grant award which she used to travel to Vancouver to work with Dr. Peter Cripton and the Orthopaedic Injury Biomechanics Group at the University of British Columbia. In 2005 Meagan was a passenger in a motor vehicle collision, which resulted in chronic low back pain and a traumatic brain injury. The experience gave her a greater understanding of how injuries and disability can affect quality of life and contributed to her research interests in injury prevention. An insightful student with a long-term commitment to excellence and challenging academic pursuits, she is excited to be able to apply her knowledge to injury and rehabilitation science.
TD GRANTS IN MEDICAL EXCELLENCE: Scholarship In Rehabilitation-Related Research for Graduate Students with Disabilities Robert Shaw Robert Shaw is a first year Masters student studying at McMaster University in Health and Exercise Psychology. His strong application in this yearâ€™s competition garnered him a special award. His passion for research in rehabilitation sciences began after suffering a life-changing cervical spine injury that left him a quadriplegic in 2011. Drawing upon his own experience, Robert is committed to improving the rehabilitation for people with spinal cord injury by increasing sport and physical activity participation during the acute rehabilitation phase of recovery. Robertâ€™s thesis will focus on educating peer mentors living with spinal cord injury about transformational leadership in order to develop effective healthy role models for newly injured individuals to follow. Robert is committed to knowledge mobilization and ensuring that his research is able to reach those who will benefit most from it. He hopes to complete his thesis next year and begin his PhD thereafter.
JOEL VERWEGEN AWARD The Joel Verwegen Award is given by the Cognitive Neurorehabilitation Sciences Lab at Toronto Rehab in memory of Joel Verwegen. Joel was an undergraduate student researcher in the Cognitive Neurorehabilitation Sciences Lab at Toronto Rehab in 2007 and 2008. He had a passion for learning, with a particular interest in cognitive neurosciences as well as evolutionary biology. Joel had an aptitude for research, and in the short time he worked in at Toronto Rehab, he made substantive contributions. Joel possessed an intellect that was not only exceptionally sharp and rigorous, but also creative. He was meticulous and thoughtful in his actions, and he was immeasurably generous and supportive. The recipient of this award will possess a deep interest in research and potential as a future scientist. The purpose of the award is to honour Joel and to inspire other undergraduate students to aim high. The 2014 recipient of this award is:
Natasha Ouslis Natasha Ouslis is an undergraduate student at the University of Toronto where she is completing a Research Specialist program in psychology under the supervision of Emeritus Professor Ian Spence. At the Toronto Rehabilitation Institute, she aims to understand whether action video game training can improve driving performance in older adults. In addition to her StreetLab research at CEAL, she is a lab manager in the Engineering Psychology Laboratory and a Research Assistant in the Cognitive Neuroscience Laboratory at the University of Toronto. After presenting her findings at a national conference this past summer, she is now working on publishing her second year research project with Dr. Spence.
MARK ROCHON LEADERSHIP AWARD IN REHABILITATION SCIENCES The Mark Rochon Leadership Award in Rehabilitation Sciences was established in recognition and celebration of Mark Rochon, Toronto Rehab’s former CEO. A highly respected and influential health care leader, Mr. Rochon was a driving force in the evolution of Toronto Rehab into one of the world’s most prominent health science centres focused on rehabilitation. His passion for, and his belief in, research and the development of the next generation of leaders is the impetus for this important and prestigious award. The goal of establishing this award is to support students in a Master’s or PhD program that aligns with the research mission and goals of the Toronto Rehabilitation Institute. The 2014 recipient of this award is:
Charlene Chu Charlene Chu is a doctoral candidate in the collaborative program at the Lawrence S. Bloomberg Faculty of Nursing and Institute of Life course and Aging, at the University of Toronto under the supervision of Dr. Kathy McGilton. This past year has been productive for Charlene, resulting in the many achievements including eight conference presentations (local and national); published abstracts, and most notably, publication of three peer-reviewed manuscripts including two first-author papers as well as three more in-press publications. She was a highly-qualified personnel for a TVN synthesis grant to conduct a systematic review of outpatient community rehabilitation programs for older adults who experienced a hip fracture with cognitive impairment. She was the lead on a report focused on optimizing nursing practice in long-term care and recommendations to enhance standardized performance assessment of nurses for Canada’s largest network of long-term care homes. She is currently overseeing a Ministry of Health grant for Dr. McGilton examining the structures, processes, and outcomes of leadership by Registered Nurses in long-term care. Charlene is also involved in an initiative between the Faculty of Nursing at U of T and the Toronto Academic Health Science Network, co-leading one of the focus groups on understanding interventions for improving care of seniors in acute care facilities. In recognition of her outstanding academic and research record, Charlene received several prestigious fellowship awards this year including the Unilever/Lipton Graduate Neurosciences fellowship and the Bluma Appel Nursing fellowship, plus two travel awards from the Canadian Association of Gerontology Travel Award and CIHR Institute of Aging.
MARK ROCHON LEADERSHIP AWARD RUNNERS-UP Alana Bartolini Alana Bartolini joined the Tech Team at Toronto Rehab in the fall of 2013 for her MSc in Medical Science. She received her BHSc from McMaster University in 2012 and prior to joining TRI, worked as a research scientist for NASA Ames Research Center, studying the effects of microgravity and radiation on bone. Her current thesis work uses virtual reality simulation to study multimodal learning and behavioural adaption in vehicle automation systems. As an alumnus of the NASA Academy Program and the International Space University Space Studies Program, Alana is dedicated to building awareness and fostering interest in the Canadian space program and its role in our health system, specifically the transferability of research and technology from rehabilitation science to space, and vice versa. In addition, she is a member of TRI’s Young Innovators of Canada, Academic Director of the Institute of Medical Sciences Student Association, and Administrator of the Silhouettes Dance Company at the University of Toronto.
Kristen Pitzul Kristen Pitzul is a PhD candidate in the Health Services Research at the Institute of Health Policy, Management, and Evaluation (IHPME) at the University of Toronto. Kristen holds a Master’s of Science in Physiology and Bachelor of Science in Honours Biology from Western University. Kristen’s research area of interest is in health system performance, including the development of quality metrics and simulation modeling. Her current work is focused on economic analyses, program evaluation, and knowledge syntheses. Kristen is supervised by Dr. Susan Jaglal, and her doctoral thesis is focused on the optimization of post-acute care pathways in hip fracture patients. Kristen is a Fellow of the Health System Performance Research Network and is President of the University of Toronto’s Student Chapter of Academy Health. Kristen has 15 peer-reviewed publications, over 35 conference presentations, and over $145,000 in peer-reviewed research funding. She currently holds the Enid Walker Graduate Student Award in Women’s Health Research from Women’s College Hospital Research Institute, an Ontario Graduate Scholarship Doctoral Award, and the Ted Goldberg Award for most promising health services researcher at IHPME.
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Published on Jun 4, 2015
UHN's Toronto Rehabilitation Institute held it's 10th annual Research Day on December 1, 2014. Here is the online version of the abstract b...