Abstracts

Abstract ID: #1310 (Clinical/Best Practice Application)

The potential effects of concomitant traumatic brain injury (TBI) on the survival, and neurological and functional recovery after traumatic spinal cord injury (SCI): An analysis of a cohort of 499 cases

Julio C. Furlan, MD,LLB,MBA,MSc,PhD,FRCPC^{1, 2, 3, 4, 5}

¹Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, CA; ²KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ³Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, CA; ⁴Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, CA; ⁵Institute of Medical Sciences, University of Toronto, Toronto, ON, CA.

Objective: Concomitant traumatic brain injury (TBI) is relatively common among individuals with acute traumatic spinal cord injury (tSCI), but the potential effects of TBI on the outcomes post-tSCI remain under-studied. This study examined the potential effects of concomitant TBI on clinical, neurological and functional outcomes at 1 year following acute tSCI.

Design/Methods: TBI was defined as a Glasgow coma score below 15 at admission. Individuals with dual diagnosis (tSCI+TBI) were compared with the individuals with tSCI alone regarding survival, and neurological and functional outcomes within the first year post-tSCI. Survival was analyzed using Kaplan-Meier curve and log-rank test. Data were analyzed using multiple regression models adjusted for the major potential confounders.

Participants: This retrospective cohort study included all 499 individuals who were enrolled in the Third National Spinal Cord Injury Study (NASCIS-3).

Results: There were 76 females and 423 males with mean age of 35.7 years (range age of 14 to 92 years) who were grouped into individuals with tSCI (n=413) and individuals with tSCI+TBI (n=86) who were admitted in an acute care facility with an initial GCS between 10 and 14. Both groups were comparable regarding age (p=0.7101) and sex distribution (p=0.6207). However, the dual-diagnosis group had higher proportion of complete (p=0.0059) and cervical tSCI (p=0.0031) and more often received 48-hour methylprednisolone treatment (p=0.0384) than tSCI-only group. There was no significant difference between the groups regarding survival post-SCI (p=0.7676). Among the survivors, the dual-diagnosis group showed significantly lower neurological scores and functional scores at 1-year post-tSCI than the tSCI-only group. After adjusting for the major potential confounders, neurological outcomes (motor, sensory and pain scores) and functional outcome (total FIM score) at 1-year post-tSCI were not significantly affected by the concomitant TBI.

Conclusions: Individuals with tSCI+TBI had more severe tSCI and more often sustained cervical tSCI that resulted in less favorable neurological and functional outcomes than individuals with tSCI alone. Nevertheless, the coexistence of TBI and tSCI did not appear to intrinsically affect their survival, and neurological and functional recovery within the first year after trauma when data analyses were adjusted for major confounders.

Keywords: Rehabilitation Outcome, Physical Medicine and Rehabilitation, Clinical Marker

Abstract ID: #1314 (Clinical/Best Practice Application)

Activity-based therapy for individuals with spinal cord injury/disease: perspectives of acute care therapists

Hope Jervis Rademeyer^{1, 2}, Nicole Gastle³, Kris Walden⁴, Jean-Francois Lemay^{5, 6}, Chester Ho⁷, Kristin Musselman^{2, 3}

¹Rehabilitation Sciences Institute, University of Toronto, ON, CA; ²KITE Research Institute-Toronto Rehab-University Health Network, Toronto, ON, CA; ³Physical Therapy Department, University of Toronto, ON, CA; ⁴Praxis Spinal Cord Institute, Vancouver, BC; ⁵Université de Montréal (École de réadaptation), Montreal, QC, CA; ⁶Institut de réadaptation Gingras-Linsay-de-Montréal, Montreal, QC, CA; ⁷Division of Physical Medicine & Rehabilitation, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, CA

Background: Neuroplasticity begins shortly following damage to the spinal cord.¹ To direct neuroplasticity, there is a general desire to start rehabilitation as early as feasible. Thus, the window of opportunity likely starts while an individual is hospitalized after spinal cord injury/disease (SCI/D). Activity-based therapy (ABT), which involves high intensity, repetitive neuromuscular activation below the neurological level of lesion, is a helpful rehabilitative technique to guide neuroplasticity². However, if and how ABT is implemented clinically within the acute care setting is unknown.

Objectives: To discover if and how therapists use and perceive ABT in the rehabilitation of individuals with SCI/D in the acute care setting.

Methods: We conducted semi-structured interviews with licensed physical (n=5) and occupational (n=2) therapists who work with individuals with SCI/D in acute care settings across Canada. Interview questions queried topics such as ABT use, perception, and implementation in acute spinal rehabilitation. Transcribed interviews were analyzed using the interpretive description methodology.

Results: Four main themes were identified regarding acute care therapists’ ABT use, perception, and implementation for individuals with SCI/D. These themes were (1)Acuity: Therapists were limited in ABT use by acuity of their patient, as they had to consider patient safety, tolerance, and medical complexity; (2)Acute care-specific ABT: Conducting ABT in acute care was limited to specific treatments. To support ABT use, therapists suggested setting specific acute care guidelines and acquiring education; (3)Therapy practice: Therapists’ ability to integrate ABT into clinical practice was contingent on factors that influenced goal/ caseload balance and site-specific personnel; and (4) Continuum of care: therapists had limited communication, knowledge, and participation in continuity in the continuum of care after patient discharge from acute care.

Conclusion: Acute care therapists face significant challenges to ABT implementation due to the acuity of the patient, the nature of the acute care environment, and their involvement in the continuum of care. To facilitate clinical decision-making, acute care therapists need specific guidelines that can be used with a simple, portable modality. This approach will allow these therapists to balance goals related to acuity or discharge against ABT delivery. Furthermore, acute care therapists need to be included in an ABT strategy that involves reciprocal communication across the continuum of care.

Funding: Canadian Institutes of Health Research

Keywords: Physical Medicine and Rehabilitation, Health Care, TechnologyTherapies

Abstract ID: #1321 (Clinical/Best Practice Application)

Building the bridge from hospital to home: Phase II in the development of a pilot program to support patients with spinal cord injury/disorder (SCI/D) transition back into the community

Jocelyn Brady¹, Magda Mouneimne², Jason Knox², Rebecca Charbonneau^{1, 2}

¹University of Calgary, Calgary, AB, CA; ²Alberta Health Services

Background: This project is the second phase of a clinical quality improvement (QI) project, which aims to develop a pilot program to provide transitional services to persons with spinal cord injury (SCI).

Transitional services refer to those provided during the acute period post-discharge from inpatient rehabilitation, as persons with SCI reintegrate to community living. The first phase of the QI project is documented elsewhere.

Objectives: To contribute to the holistic understanding of the barriers and facilitators that influence the transition process, and ways of supporting persons with spinal cord injury (SCI) through the transition.

Methods: This project includes analysis of surveys that were distributed under the previous phase of the QI project as well as development, administration, and analysis of second round surveys. This project also includes an environmental scan and researching evaluation methods for similar projects in the published literature. Provision of services during the COVID-19 pandemic was researched.

Results: There are a variety of transitional models of care from outpatient clinics to in-home and community-based services. Survey respondents described challenges during their transition experience with emergent challenges noted by those who discharged during the COVID-19 pandemic. Community services in Calgary were described to identify gaps in support for persons with SCI during the transition.

Conclusions: The transition from hospital to home must be bolstered, and context-relevant rehabilitation is needed. Future programs must be developed to weather uncertain circumstances, such as a global pandemic or inclement weather, to ensure continuous support for persons with SCI.

Funding: Mitacs grant

Keywords: Physiatry, Physical Medicine and Rehabilitation, Rehabilitation Outcome

Abstract ID: #1325 (Clinical/Best Practice Application)

Development and implementation of the Mobility Clinic COVID-19 pandemic patient outreach program

James Milligan^{1, 2}, Ruchi Parikh¹, Lindsay Beuermann¹, Daniel Labach¹, Craig Bauman¹, Lissa Kuzych¹

¹Centre for Family Medicine, Kitchener, ON, CA; ²McMaster University, Department of Family Medicine, Hamilton, ON, CA

Background: At the beginning of the COVID-19 pandemic, there was uncertainty if individuals with spinal cord injury (SCI) were at greater risk for adverse health events. Certainly, there was great concern over direct effects (e.g. physical illness, hospitalization) but also fear of indirect effects (e.g. mental health, isolation, caregiver disruption) due to COVID-19 and the public health measures to contain it. Since individuals with SCI often have limited or tenuous access to healthcare and resources, they are at greater risk than the general population of destabilization.

Objective: To proactively identify risks that may be exacerbated by the pandemic and mitigate them where possible, a primary care outreach program was developed.

Methods: A screening algorithm was developed by our interdisciplinary Mobility Clinic team, and focuses on 5 domains: health destabilization, mental health, access to services and supports, social isolation, and caregiver stress. The algorithm was administered by phone to a total of 107 individuals, who were identified as past and current Mobility Clinic patients. Any risks identified received further investigation by the team. We used the opportunity to educate patients about the risks of COVID-19 and protective measures. Follow-up with patients continued every 6-8 weeks throughout the duration of the pandemic. An evaluation of this outreach program involved a description of the patient population contacted, the identification of common risks for patients, and patient satisfaction with the program.

Results: The contacted patient population consisted of 76 males and 31 females. 74 patients were identified as having a spinal cord injury. Some of the most common questionnaire responses by patients with SCI included feelings of stress and/or anxiety and a reduction in Personal Support Worker services leading to increased caregiver stress. A patient satisfaction survey demonstrated that 83% of patients (n=12) were very satisfied with the phone call and the care received.

Conclusion: The outreach program helps us to proactively identify risks for individuals with SCI and address any healthcare needs they have. Risk assessment and care at the primary care level can mitigate adverse events and hospitalizations, which is especially important during a pandemic situation when healthcare and hospital resources are limited.

Keywords: Multidisciplinary Approaches, Healthcare Delivery, Clinical Application

Abstract ID: #1326 – Award Recipient – Third Place General Submission

Program ID: P10 (Clinical/Best Practice Application)

Development of the Canadian activity-based therapy strategy for spinal cord injury or disease

Kristin E. Musselman^{1, 2, 3}, Kristen Walden⁴, Laurent Bouyer^{5, 6}, Brian Chan^{2, 7}, Sophie Ebsary⁴, Cindy Gauthier^{1, 2}, Sarah J. Donkers⁸, Tara Jeji⁹, Anita Kaiser^{2, 3, 10}, Jean-François Lemay^{11, 12}, Sandi Marshall¹³, Shane McCullum¹⁴, Vivian Mushahwar^{15, 16, 17}, Vanessa Noonan⁴, Dalton Wolfe^{18, 19}

¹Dept. of Physical Therapy, University of Toronto, Toronto, ON, CA; ²KITE-University Health Network, Toronto, ON, CA; ³Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, CA; ⁴Praxis Spinal Cord Institute, Vancouver, BC, CA; ⁵Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Quebec City, QC, CA; ⁶Dept. of Rehabilitation, Laval University, Quebec City, QC, CA; ⁷Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, CA; ⁸School of Rehabilitation Science, University of Saskatchewan, Saskatoon, SK, CA; ⁹Ontario Neurotrauma Foundation, Toronto, ON, CA; ¹⁰Canadian Spinal Research Organization, Toronto, ON, CA; ¹¹CIUSSS du Centre-Sud-de-l ‘Île-de-Montréal (Installation Gingras-Lindsay), Montréal, QC, CA; ¹²École de réadaptation, Université de Montréal, Montréal, QC, CA; ¹³First Steps Wellness Centre, Regina, SK, CA; ¹⁴Stan Cassidy Centre for Rehabilitation, Horizon Health Network, Fredericton, NB, CA; ¹⁵Department of Medicine, University of Alberta, Edmonton, AB, CA; ¹⁶Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, CA; ¹⁷Sensory Motor Adaptive Rehabilitation Technology (SMART) Network, University of Alberta, Edmonton, AB, CA; ¹⁸Parkwood Institute Research, Parkwood Institute, London, ON, CA; ¹⁹Health Sciences, Western University, London, ON, CA

Background: In March 2019, the Canadian Activity-Based Therapy (ABT) Summit brought together stakeholders with an interest in advancing ABT for Canadians with spinal cord injury and disease (SCI/D). Five priorities for clinical care and research were identified to form the Canadian ABT Strategy for SCI/D. In the fall of 2020, meetings of the newly formed Canadian ABT Community of Practice (CoP) provided an opportunity to re-examine the priorities, which direct the goals and activities of the CoP.

Objective: To re-evaluate the priorities of the Canadian ABT Strategy for SCI/D.

Methods: A Delphi survey was created to query the importance and feasibility of the initial five priorities identified at the ABT Summit. An electronic survey was distributed to members of the CoP (n=27), which included clinicians, researchers, administrators and individuals with SCI/D from across Canada. A 9-point Likert scale was used to rate importance and feasibility separately, with ratings of ≥7 considered important/feasible to address over four years. Respondents were invited to suggest new priorities, which were evaluated in the second iteration of the survey. A priority was retained if ≥70% of respondents rated it as important and feasible.

Results: Twenty members completed the survey. All of the original five priorities were rated important (i.e. 80-100% of respondents assigned a rating ≥7). Five new priorities were identified by respondents, three of which met the importance criterion for inclusion (i.e. 82-100% of respondents assigned an importance rating ≥7). Less than 70% (i.e. 45-60%) of respondents rated three of the eight priorities as feasible, suggesting a need to narrow the scope of these priorities. The finalized priorities were as follows: 1) Identify current ABT activities across the continuum of care, 2) Create a network to facilitate dialogue across the continuum of care, 3) Track engagement in ABT activities across the continuum of care, 4) Develop and implement best practice recommendations for ABT, 5) Study optimal timing, methods, and dose of ABT to promote desired outcomes, 6) Educate clinicians from across the continuum of care about ABT, 7) Identify optimal methods for promoting engagement in ABT activities across the continuum of care, 8) Identify methods for delivering ABT in rural and remote contexts.

Conclusion: Eight priorities were identified for the revised Canadian ABT Strategy for SCI/D. These priorities will direct the activities of the Canadian ABT CoP for the next four years.

Funding: Praxis Spinal Cord Institute

Keywords: Physical Medicine and Rehabilitation, Healthcare Delivery, Therapies

Abstract ID: #1328 (Clinical/Best Practice Application)

Development of a collaborative primary care spinal cord injury network

James Milligan^{1, 2}, Joseph Lee^{1, 2}, Patricia Nistor¹, Ruchi Parikh¹, Lindsay Beuermann¹

¹Centre for Family Medicine, Kitchener, ON, CA; ²McMaster University, Dept. of Family Medicine, Hamilton, ON, CA

Background: There have been advances in recent years in primary care for individuals with spinal cord injury (SCI) in Ontario, Canada particularly with the introduction of the Centre for Family Medicine Primary Care Mobility Clinic (Mobility Clinic). Though numerous gaps still exist, including equal access, proper equipment and preventative screening, there also is a need for a coordinated strategy. While some health care organizations have implemented strategies for improving care for this population, these strategies remain heterogeneous. In order to better organize and prioritize primary care initiatives, the Mobility Clinic team sought to develop and formalize a Collaborative Primary Care Spinal Cord Injury Network (CPC SCIN). The network representation includes people with lived experience, funders, advocacy agencies, care partners, clinicians, researchers and educators. This network is grounded in previous work done by the Mobility Clinic including SCI Primary Care Summits held in 2016 and 2020, and various primary care projects.

Objectives: The main objective of this ongoing project is to create a network of key stakeholders to organize, facilitate and give a platform to SCI primary care initiatives and inform best practice guidelines and improve knowledge translation.

Methods/Overview: An introductory key stakeholder meeting was held to discuss the structure, objectives and terms of reference of the network and develop its steering committee. The CPC SCIN Steering Committee is to decide on goals and future projects.

Results/Findings: The CPC SCIN has hosted 4 SCI related webinars with good attendance by network participants. The Steering Committee is planning another summit. Further engagement of the network and the community have been planned to occur through social media and other communication channels, collective research, and the development of national primary care guidelines for SCI.

Conclusions: The improvement and equity of SCI primary and community care can be advanced through the input and expertise of the key stakeholders. A network that brings these voices together will help facilitate research and priorities for SCI care.

Funding: Praxis Spinal Cord Institute Grant Number: Praxis Grant G2020-30

Keywords: Knowledge Translation, Multidisciplinary Approaches, Healthcare Delivery

Abstract ID: #1330 – Award Recipient – Second Place (Tied) General Submission

Program ID: P8 (Clinical/Best Practice Application)

2021 Update to the CanPainSCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord injury

Eldon Loh^{1, 2}, Magdalena Mirkowski², Alexandria Roa Agudelo², Brooke Benton³, David Allison², Swati Mehta², the CanPainSCI Development Group¹

¹Dept. of Physical Medicine and Rehabilitation, Western University, London, ON, CA; ²Parkwood Institute Research, Lawson Health Research Institute, Parkwood Institute, London, ON, CA; ³Icahn School of Medicine at Mount Sinai, New York, NY, USA

Background: The CanPainSCI Clinical Practice Guidelines (CPG) for neuropathic pain (NP) after spinal cord injury (SCI) were originally published in 2016. This CPG focused on screening/diagnosis, treatment, and models of care for SCI NP management. The objective of this project was to update the CanPainSCI CPG for 2021.

Methods: The CPG update was developed in accordance with the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool, following a similar process as the 2016 CPG. A literature search was conducted for articles published from Nov. 1, 2013 to Oct. 30, 2018. Methodological quality of included studies was assessed using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach; pain intensity was the primary outcome evaluated. The expert panel discussed new studies in a series of small group virtual meetings from January to April 2020. New/modified recommendations were proposed at these meetings. A final meeting was held over two days in June 2020, with final voting to approve new and modified recommendations in July/August 2020. Any recommendation achieving 75% or more agreement from the panel was included in the 2021 update.

Results: 46 new articles for the 2021 update were included. 3 applied to screening/diagnosis category, and 43 investigated treatment modalities. 38 of the treatment articles were moderate to very low in quality. 3 new screening and diagnosis recommendations and 8 new treatment recommendations were included in the updated CPG. 5 of the new treatment recommendations were classified as general treatment principles providing practical guidance for NP management, while the remaining 3 provide new management options including oxcarbazepine, botulinum toxin A, and cannabinoids. Existing recommendations from the 2016 CPG for screening and diagnosis, treatment, and models of care remain unchanged in the 2021 update. Given the overall low quality of evidence for available treatments, the panel restructured the classification of treatment options from the previous hierarchical approach; first-line therapy was unchanged, but second- to fourth-line treatments were reclassified as B to D treatments based on level of evidence and strength of recommendation, and can be used interchangeably based on individualized clinical factors.

Conclusion: The 2021 CPG update is intended to replace the original 2016 version. Next steps include refinement of clinical algorithms, point-of-care/patient versions of the CPG, incorporation of pain interference outcomes, and an implementation plan.

Funding: Ontario Neurotrauma Foundation Grant Number: 2018-RHI-GUIDE-1049

Keywords: Best Practice Implementation, Treatment Effectiveness, Multidisciplinary Approaches

Abstract ID: #1335 (Clinical/Best Practice Application)

Making the grade: A spinal cord injury program report card on emotional well-being practice

Colleen M O'Connell^{1, 2}, Shane A McCullum¹, Joanne Savoie¹

¹Stan Cassidy Centre for Rehabilitation, Horizon Health Network, Fredericton, NB, CA; ²Dalhousie University Faculty of Medicine New Brunswick, Saint John, NB, CA

Background: As New Brunswick’s neurologic rehabilitation centre, the Stan Cassidy Centre for Rehabilitation (SCCR) has worked to develop strong alliances with Spinal Cord Injury (SCI) stakeholders across Canada in efforts to build and maintain capacity in best practice implementation (BPI). Several Quality Improvement initiatives evaluated the effectiveness of our BPI on service delivery, which then led to practice change; the creation of pain management groups followed pain BPI. The SCCR has recently joined the SCI Implementation and Evaluation Quality Care Consortium (SCI-IEQCC) as part of advancing best practices and aligning with national benchmarks. Priorities for our region across care, community and research domains were identified through SCI Network for the Atlantic Provinces (SCINAPS) engagement activities 2018-2020. Emotional health and well-being (EWB) of persons with SCI during hospitalization and community living remains a priority concern across all stakeholder groups and has been selected as a primary target for our SCI-IEQCC implementation and data collection. To evaluate and monitor implementation outcomes, our past and current practice in EWB must be described.

Objective: Determine historical EWB practice and outcomes for inpatient rehabilitation and community follow-up, to inform on current practice, guide EWB implementation strategies and provide a baseline for future evaluation of EWB implementation.

Methods: Data abstraction by chart review of admissions 2014-19 and the rehabilitation and community follow-up (9+ months) of Rick Hansen Spinal Cord Injury Registry (RHSCIR) data for participants enrolled at our site between 2014-2019. Emotional status, history of mood disorder, behavioral difficulties, substance use and potential barriers to participation are gathered on admission. Psychological outcomes, including the Hospital Anxiety and Depression Scale and Life Satisfaction Scale are routinely collected on admission and discharge. Quality of Life and related measures included in the CFU will be evaluated and referenced to EWB measures documented during inpatient rehabilitation. A SCI-EWB current practice Report Card on indicators and outcomes will be generated.

Expected Results: This project will be completed by 08/2021, with a report-card on our current practice strengths and gaps. The analyzed data will be used to inform the planned EWB implementation strategy, and as a comparator to evaluate implementation effectiveness.

Funding: Praxis Spinal Cord Institute Grant Number: G2020-07

Keywords: Rehabilitation Outcome, Healthcare Delivery, Best Practice Implementation

Abstract ID: #1338 – Award Recipient – First Place General Submission

Program ID: P7 (Clinical/Best Practice Application)

Wound rounds: A hands-on interdisciplinary team approach to tissue integrity management in Inpatient Spinal Cord Injury Rehabilitation

Leanne Michelle Read¹, Diana L. Herrington¹, Alison R. Smith¹, Dorinda M. Taylor¹, Stephanie L. Lemke¹, Shannon K. O’Dwyer¹

¹Inpatient Spinal Cord Injury Rehab Program, Hamilton Health Sciences, Hamilton, ON, CA

Background: The Inpatient SCI Rehabilitation Program was looking to improve prevention and outcomes of patients with wounds, as well as increase treatment efficiency. An interdisciplinary skin rounds was implemented to focus team care delivery and monitor skin and wounds.

Objectives: The purpose of the rounds is to decrease the incidence of wounds, to improve outcomes related to wound healing and to create a custom form that would fulfill documentation and SCI database collection requirements. The team uses an interdisciplinary approach that addresses all aspects of wound management at a single time point.

Methods: All SCI patients with identified wounds are reviewed weekly, at bedside, by the interdisciplinary team (RN, PT, OT, RD). The team discusses the status of the wound, appropriate dressings, and available supporting measures (ie. nutrition, incontinence management, positioning, equipment optimization, electrical-stimulation) The team documents the wounds with photographs, completes a skin tracking form and updates patient kardexes to ensure continuity of care.

Results: The interdisciplinary wound rounds have fostered a more collaborative team approach to tissue integrity management. The team, including the patient, are better informed about the wound status and plan of care related to wound healing. The focus of the team has shifted from wound care to wound healing and has allowed the team to adopt best practice and more innovative modalities, such as electrical stimulation, for wound healing. Threatened areas are identified quickly and the team feels that they are able to avoid the development of more significant wounds. The rounds allowed the program to begin tracking pressure injury incidence and to use that information as a key performance indicator within the Continuous Quality Improvement framework. With careful monitoring, patients are able to demonstrate wound healing while simultaneously participating in an intensive inpatient rehabilitation program.

Conclusions: The management of skin wounds is a complex and challenging issue that requires the coordination of multiple disciplines. An interdisciplinary team rounds is an efficient way to approach skin health. The rounds provide an opportunity for education to the patient and care providers about skin health. Further research to determine the effectiveness of interdisciplinary wound rounds on incidence, cost, prevalence and length of time to heal wounds compared to more traditional wound management protocols and best practice guidelines is warranted.

Keywords: Multidisciplinary Approaches, Best Practice Implementation, Knowledge Translation

Abstract ID: #1340 (Clinical/Best Practice Application)

A new framework for weekly gait and balance testing in an Inpatient SCI Rehabilitation Program: Optimizing physiotherapy resources, use of outcome measures and documentation

Diana L. Herrington¹, Leanne Michelle Read¹, Anastasia Stojakovic¹, Jacklyn D. Penner¹, Suzanne Anthony¹, Jennifer M. Duley¹, Stephen Patton¹

¹Inpatient Spinal Cord Injury Rehab Program - Hamilton Health Sciences, Hamilton, ON, CA

Background: The implementation of best practice guidelines and research related to standing and walking was a priority for the Inpatient SCI Rehabilitation Program. The inpatient physiotherapists (PTs) identified two major challenges related to data collection; there was a need to problem solve how to complete the added work and documentation, as well as difficulty with consistently identifying when patients met functional thresholds that required additional assessments to be completed.

Objectives: The physiotherapy team decided to develop a designated weekly time for gait and balance outcome measurement that could be completed by physiotherapy assistants (PTAs) while the PTs were inpatient conference. This would allow the PTs to attend vital patient conferences while the PTAs were able to utilize their skill set more effectively during this time to complete assigned outcome measures with the patients. The plan would ensure more consistent completion and documentation of the Standing and Walking Assessment Tool (SWAT), as well as serve as a reminder for PTs to complete regular staging for the SWAT.

Methods: The PTAs would use the dedicated time to complete the assigned SWAT outcome measures for appropriate SCI patients identified by the PTs. A SWAT tracking form was developed to document for each patient throughout their rehabilitation admission. The form provided one clear and concise source that the PTs could use to pull data that needed to be collected for Praxis, the SCI Consortium, and patient discharge reports.

Results: The project resulted in team members being better informed regarding each patient’s mobility status. The patients report enjoying seeing their progress in a tangible way and they are eager to improve their weekly scores as they work to achieve their functional goals. Collection and documentation of the data is more consistent and efficient. The PTs have more outcome measure data available to analyze and track the progress of a patient’s mobility and are less likely to miss thresholds that would require additional outcomes to be measured.

Conclusion: Finding ways to improve efficiency is critical in today’s health care environment. Involving the PTAs in this Inpatient SCI Rehabilitation project has created more ways for their role to contribute significantly to the team and patient population. The PTs are better able to complete documentation requirements in a timely manner and the team is better able to implement best practices, as well as to continue to be able to contribute to quality improvement and research.

Keywords: Rehabilitation Outcome, Best Practice Implementation, Behaviour Change

Abstract ID: #1348 (Clinical/Best Practice Application)

Development of an interprofessional peripheral nerve transfer program for individuals with traumatic cervical spinal cord injury: A quality improvement initiative

Julia Rybkina^{1, 2}, Kelly Bishop³, Jana Dengler⁴, Parvin Eftekhar^{2, 5, 6}, Julio C. Furlan^{1, 2, 7, 8}, Sivakumar Gulasingam^{2, 8}, Kristina Guy², Sukhvinder Kalsi-Ryan^{2, 10}, Sharmeen Siddique², Jordan Silverman⁸, Larry Robinson^{2, 8, 11}, B. Catharine Craven^{1, 2, 8}

¹Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, CA; ²KITE- Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ³Ambulatory Rehab Hand Therapy Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, CA; ⁴Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, CA; ⁵Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, ON, CA; ⁶Stroke Program, Spasticity Management Clinic, Rehabilitation Institute - University Health Network, Toronto, ON, CA; ⁷Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, CA; ⁸Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, CA; ⁹Institute of Medical Science, University of Toronto, Toronto, ON, CA; ¹⁰Department of Physical Therapy, University of Toronto, Toronto, ON, CA; ¹¹Sunnybrook Health Sciences Centre, Toronto, ON, CA

Background: Loss of upper extremity (UE) function impacts almost every aspect of daily life and upper limb recovery is reported to be a major priority of individuals living with tetraplegia [1-3]. Surgical peripheral nerve transfer (PNT) offers the potential to restore volitional control of elbow, wrist and hand function of individuals with C5-C8 tetraplegia AIS A-C [4-7]. Unfortunately, there are currently no consensus-derived best practices for provision of PNT following SCI and few programs have focused on interdisciplinary collaboration during patient selection, surgical decision making, management of medial comorbidities and postoperative rehabilitation.

Objectives: This quality improvement project aimed to establish a novel interdisciplinary PNT program with the goal of optimizing UE recovery and function in individuals with tetraplegia in Canada.

Methods: An interprofessional team (n=14) assembled to generate an optimal structure and function of the program. The team included specialists in Physical Medicine & Rehabilitation, Plastic Surgeons, a neurologist, physiotherapists, and occupational therapists. Development of the PNT program followed a procedure similar to modified Delphi method [8,9]. Informed by literature reviews and multiple cycles of the Plan, Do, Study, Act (PDSA) framework and Behavior Change Model [10,11], the team completed a detailed exploration of care segments, organizing and sequencing care delivery.

Results: Figure 1 presents a care map of planned interprofessional services and their optimal timing across the continuum of care. Table 1 presents the clinical outcomes of the program to-be collected longitudinally at baseline, preoperatively, and 6-24 months post-surgery. To date, 3 individuals were enrolled into the program. The team meets on a quarterly basis to identify PNT candidates, plan for service delivery and examine clinical outcomes.

Conclusions: The PNT service was designed to be a unique, comprehensive and interdisciplinary program offering PNT to restore UE function after SCI in Canada. Program evaluation is ongoing, and further work to mitigate barriers and develop educational materials around PNT surgery for patients and healthcare providers are intended to improve medical decision making and best practice implementation.

Keywords: Best Practice Implementation, Physical Medicine and Rehabilitation. Healthcare Delivery

Abstract ID: #1353 - Award Recipient – Second Place Post-doc Submission

Program ID: PD2 (Clinical/Best Practice Application)

Towards a better approach to personalized self-management: Adapting the health education impact questionnaire to measure self-management skill acquisition among adults with spinal cord injury or disease.

Gaya Jeyathevan¹, Susan B. Jaglal^{1, 2, 3}, Sander L. Hitzig^{4, 5, 6}, Gary Linassi⁷, Sandra Mills⁸, Vanessa K. Noonan⁹, Karen Anzai¹⁰, Teren Clarke¹¹, Dalton Wolfe^{12, 13}, Mary Bayley^{1, 8, 14}, Lubna Aslam¹⁵, Farnoosh Farahani¹, S. Mohammad Alavinia¹, Maryam Omidvar¹, B. Catharine Craven^{1, 8, 14}

¹KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ²Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, CA; ³Department of Physical Therapy, University of Toronto, Toronto, ON, CA; ⁴St. John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, CA; ⁵Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, CA; ⁶Rehabilitation Sciences Institute, Department of Medicine, University of Toronto, Toronto, ON, CA; ⁷College of Medicine, Rehabilitation Centre, University of Saskatchewan, Saskatoon, SK, CA; ⁸Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ⁹Praxis Spinal Cord Institute, Vancouver, BC, CA; ¹⁰GF Strong Rehab Centre, Vancouver, BC, CA; ¹¹Spinal Cord Injury Alberta, Edmonton, AB, CA; ¹²Parkwood Institute Research, Lawson Health Research Institute, London, ON, CA; ¹³School of Health Studies, University of Western ON, London, ON, CA; ¹⁴Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, CA; ¹⁵Spinal Cord Injury Ontario, Toronto, ON, CA; Impact: The heiQ offers a new approach to promoting self-management education as a rehabilitation priority, as well as enable personalization of skills related to the individual’s self-management goal(s). It further has reliable measures of key dimensions related to self-management behaviours, which could be used in quality improvement and easily incorporated into assessment practice in a rehabilitation setting in order to assist individuals with varying SCI/D acquire relevant skills and attain multiple personalized self-management goals.

Background: It is imperative to ensure a broader approach to self-management to address current gaps in care and advance self-management within spinal cord injury and disease (SCI/D) rehabilitation settings across Canada. However, there is no “gold standard” on what constitutes self-management in SCI/D, indicating that it is a complex and multifaceted construct, which makes it challenging to measure self-management skill acquisition.

Objectives: To identify, appraise and adapt a single quality of care outcome indicator used to assess self-management skills among adults with SCI/D prior to rehabilitation discharge and 18 months post-rehabilitation admission, with the goal of promoting self-management so the individuals with SCI/D can manage their health and daily activities toward successful community integration.

Methods: Experts in self-management across Canada (i.e. Working Group) completed the following the tasks: 1) defined the Self-Management construct; 2) conducted a thorough systematic review of available outcome measures and their psychometric properties; 3) identified key skills required by individuals with SCI/D post-discharge into the community; 4) filtered and appraised the available outcome measures based on the identified skills; and 5) adapted an outcome indicator that could be used in quality improvement.

Results: Twenty-one outcome measures were identified and appraised. The following skills were further identified: information gathering, medication management, self-monitoring/symptom management, emotional management, and self-advocacy. The Working Group reached a consensus that the Health Education Impact Questionnaire (heiQ) was the most relevant tool to measure the effect of self-management/health education programs based on the identified skills. Subscores of the heiQ (Skill and Technique Acquisition, and Self-Monitoring and Insight) were selected and simplified to address our goal of acquisition of specific self-management skills required by individuals with SCI/D.

Funding: Praxis Spinal Research Institute Grant Number: G2015-33 Ontario Neurotrauma Foundation Grant Number: 2018-RHI-HIGH-105 and Parkwood Central Consortium Grant Number: 2019-RHI-IMPLEM-1064 Granting Agency: TRI C

Keywords: Healthcare Delivery, Self-Management, Knowledge Implementation

Abstract ID: #1355 (Clinical/Best Practice Application)

The effects of the COVID-19 pandemic on inpatient length of stay at Toronto Rehabilitation -Lyndhurst Centre following traumatic spinal cord injury

Louise Michelle Brisbois¹, Maryam Omidvar¹, Beverley Catharine Craven^{1, 2}

¹KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ²Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, CA

Objective: To describe the effects of the COVID-19 pandemic on inpatient length of stay (LOS) during traumatic spinal cord injury (t-SCI) rehabilitation, and to compare this to the same time period in the previous year.

Methods: T-SCI patients admitted to Toronto Rehabilitation-Lyndhurst Centre, University Health Network between March 1-Nov 30, 2020 were considered as the study population during the COVID-19 pandemic. The same time period in 2019 was selected as the comparison group before the pandemic began. Data was collected as part of the Rick Hansen Spinal Cord Injury Registry study. Appropriate descriptive analysis was used to describe the demographic and impairment characteristics of the two cohorts. The Chi-square test was used to compare the number of admissions before and during the pandemic. The Shapiro-Wilk test was applied to test the normality of the samples, and the two independent sample t-test was used to compare mean LOS between groups. Multiple linear regression was used to explore the possible changes to inpatient rehabilitation LOS during the pandemic. SPSS 22.0 was used to perform the analysis and α=0.05 was considered as level of significance.

Results: During the 2020 study period 37 t-SCI patients were admitted to rehab; 73% male, mean age of 52.8 years and mean LOS of 75.4 days, excluding 3 patients who had not been discharged yet. In the 2019 comparison period 70 t-SCI patients were admitted; 76% male, mean age of 53.8 years and mean LOS of 76.3 days after exclusion of three outliers. The number of t-SCI rehab admissions was significantly lower during the pandemic (P-value= 0.001). The Shapiro-Wilk test showed a normal distribution for LOS in both samples (2019: P-value=0.33, 2020: P-value=0.52). The two sample t-test showed no statistically significant change in mean LOS before and during pandemic (t=0.14, df=105, P-value=0.89). Linear regression showed no effect of year on LOS, adjusted for age, gender, and level of injury/AIS.

Conclusions: The number of t-SCI patients admitted to inpatient rehabilitation was reduced during the COVID-19 pandemic (March - November 2020), but their LOS remained unchanged. Despite multiple health system pressures LOS was maintained during the pandemic for these patients.

Funding: Praxis Spinal Cord Institute Grant number: G2020-19

Keywords: Rehabilitation Outcome, Physical Medicine and Rehabilitation, Healthcare Delivery

Abstract ID: #1359 (Clinical/Best Practice Application)

View from the front lines: The Spinal Cord Injury Implementation and Evaluation Quality Care Consortium

Andrea Chase¹, Stephanie Cornell², MaryJo Demers³, Jennifer Duley⁴, Brianne Floriancic², Charlie Giurleo², Carrie Mizzoni⁵, Kristina Plourde⁵, Carol Scovil⁵, Jaclyn Vanderwyngaert², Anellina Ventre⁵, Chelsea Wong⁵, Heather Flett⁵, Anna KrasDupuis², Ivie Evbuomwan², Farnoosh Farahani⁵, Cathy Craven⁵, Dalton Wolfe²

¹The Ottawa Hospital Rehabilitation Centre, Ottawa, ON CA; ²Parkwood Institute, St. Joseph’s Health Care London, London, ON CA; ³Providence Care Hospital, Kingston, ON CA; ⁴Hamilton Health Sciences, Hamilton, ON CA; ⁵Brain and Spinal Cord Rehabilitation Program Toronto Rehabilitation Institute - University Health Network, Toronto, ON CA

Background: The SCI Implementation and Evaluation Quality Care Consortium is a network focused on achieving optimal and equitable health care services through implementation and benchmarking of indicators and related best practices within SCI rehabilitative care across Ontario. Implementation and Evaluation Specialist (IESs) have been the champions and facilitators of these efforts in working with leaders, frontline staff and persons with lived experience. This abstract outlines the key findings of an evaluation conducted at the end of the first mandate of the Consortium (i.e., 18 months) with a focus on primary outputs and intangible benefits seen on the front lines of clinical practice. Objective: To describe experiences and benefits realized across the various rehabilitation sites through the lens of the IESs as they worked together both at a site level, and at a provincial level, to implement indicators and related best practices.

Methods: After initial training in implementation science, IES’s worked to implement indicators and related best practices through the following general activities: leading local Site Implementation Teams through key implementation activities across 6 domains of care; coordination with data clerks relating to data capture and submission of indicator information to central repository; and virtual central biweekly meetings supported by mentors to share progress and problem solve.

Results: Some key metrics associated with IES outputs and deliverables included: 12 trained IES members supported by 4 IES mentors; 127 staff members across 5 sites engaged by IES’s that contributed to >250 site implementation teams meetings; local educational activities including site lunch & learn or best practice rounds (n=18) or central summits / trainings (n=7). Less tangible benefits identified by IES’s included: increased sharing with colleagues which scaled beyond Consortium activities; ability to share information / resources with immediate impact (e.g. shared resources adapted to local site context and amidst adapting to Covid challenges); connections with leading clinicians and researchers across the province; personal professional development and capacity building to improve problem solving and implementation skills.

Conclusion: Although IES’s achieved many specific outputs and deliverables, activities that enabled external connections with peers and rehabilitation leaders were regarded equally, if not greater, as a significant benefit of Consortium participation (albeit less tangible).

Funding: Ontario Neurotrauma Foundation 2019-RHI-!MPLEM-1064

Keywords: Healthcare Delivery, Knowledge Translation, Rehabilitation Outcome

Abstract ID: #1360 (Clinical/Best Practice Application)

Network initiation, structure, and progress in rehabilitation care: the spinal cord injury implementation and evaluation quality care consortium

Farnoosh Farahani¹, Dalton L Wolfe², Ivie K Evbuomwan², B. Catharine Craven^{1, 3, 4}, the SCI IEQCC Group¹

¹KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ²Parkwood Institute Research, Lawson Health Research Institute, London, ON, CA; ³Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ⁴Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, CA

Background: The Spinal Cord Injury Implementation and Evaluation Quality Care Consortium (SCI IEQCC) is a collaborative network consisting of rehabilitation programs, community organizations, stakeholders, and individuals with lived experience with Spinal Cord Injury or Disease (SCI/D), who support the translation of knowledge into practice using quality improvement and implementation science methods. Objective: SCI IEQCC aims to advance rehabilitation care by delivering optimal and equitable health care services for all Ontarians regardless of where they live, to ensure the functional recovery, health and wellbeing for individuals living with SCI/D.

Methods: Leadership and policy was provided through a central operations team, steering committee, and a leadership team comprised of health system leaders from participating organizations. Implementation of selected indicators and related best practices within 6 prioritized domains was championed by Implementation and Evaluation Specialists at each participating organization and supported through local Site Implementation Teams. Structure, process, and outcome indicators were collected locally. De-identified data was transferred to the central site for analysis and provincial report card distribution.

Results: Engagement and collaboration between network members including 22 individuals with lived experience were facilitated through 5 network meetings, 3 newsletters, utilization of MS Teams platform, project website (www.sciconsortium.ca) and twitter (@SCIEQCC). Monthly leadership team meetings (n=24) and bi-weekly implementation meetings (n=32) provided a forum to exchange ideas, information and evidence. Practice variations and internal program needs were identified through creation of 29 practice profiles. Inter-professional integration of service delivery was established through the development of 15 local site implementation teams who worked to implement site specific quality improvement strategies, best practice tools and resources (n=62). Seven virtual education and training workshops were presented by national content experts to support the learning needs of network members and staff involved with the provision of care across the participating rehab sites.

Conclusions: The SCI IEQCC, a collaborative goal-directed network, has fostered a “learning health system culture” with a high degree of organizational engagement and commitment to common goals. As we expand from a provincial to a national Consortium, maintaining high engagement will be critical to our sustainability and success.

Funding: The SCI IEQCC was funded by the Ontario Neurotrauma Foundation (Grants #2018-RHI-HIGH-1057; #2019-RHI-IMPLEM-1064; #2019-RHI-SITE1-1065; #2019-RHI-SITE2-1068; #2019-RHI-SITE3-1067; #2019-RHI-SITE4-1066; #2019-RHI-SITE5-1069)and the Toronto Rehab Foundation

Keywords: Rehabilitation Outcome, Best Practice Implementation, Knowledge Translation

Abstract ID: #1361 (Clinical/Best Practice Application)

Development and evaluation of a training & coaching model with a focus on promoting neurorecovery through activity-based therapies

Stephanie Cornell¹, Zeina Abu-Jurji^{1, 2}, Anthony Le², Neal McKinnon¹, Deena Lala¹, Stephanie Marrocco^{1, 2}, Dalton L. Wolfe^{1, 2}

¹Parkwood Institute, London, ON CA; ²Western University, London, ON CA

Background: Spinal cord injury rehabilitation programs often take very ad hoc and silo’d approaches to training therapists and other supporting personnel in delivering advanced therapies - and this is especially the case for new and emerging technologies targeting neurorecovery. At Parkwood Institute (London, ON), we have developed a more integrated model for training and coaching, based in implementation science. Currently, we are in the midst of finalizing development and evaluation of this model applied to various therapeutic modalities including FES-assisted stepping, Lokomat and robotic exoskeleton.

Overall Objective: To support implementation and continuous practice improvement in activity-based therapies that support neurorecovery.

Specific Objective: To summarize development, implementation and initial evaluation of an integrated training and coaching model.

Methods: The model, configured as a manual that is a living document, has involved an end-user, iterative design approach incorporating: application of key best practices in implementation science; varying tiers of competency; enablement of a general model that can be customized to meet local, specific needs; and embedded certification and performance assessment processes. Evaluation involves both process and outcome components. Process evaluations consisted of iterative satisfaction/feedback surveys throughout the design and development phases. The outcome evaluation will involve a group of end-users (n∼10) having undergone several bouts of training and coaching and then reviewing the model in manual form completing a customized survey based on Bowens et al. (2009) feasibility and limited efficacy framework.

Results: Key components of the manual developed using this approach include: a comprehensive model that describes practical concepts such as facilitative administration (logistics), selection considerations and performance assessment informing coaching and ongoing evaluation and improvement; competency tiers including technician, clinical user, trainer, coach and champion, with a view to how these might support increased practice intensity; and 2 parallel streams of training and coaching. Findings from the outcome evaluation, still to be conducted, will be presented at the 2021 CSCIRA meeting.

Conclusion: Preliminary feedback associated with the process evaluation have indicated an increased sense of usability, satisfaction and more confidence with uptake of new practices going forward as the training and coaching model has evolved.

Keywords: Best Practice Implementation, Knowledge Translation, Clinical Application

Abstract ID: #1362 (Clinical/Best Practice Application)

ASIA/ASCIP primary care resources for spinal cord injury

James Milligan¹, Suzanne Groah², Indira Lanig³, Philipines Cabahug⁴, Lisa Beck⁵, Cody Unser⁶

¹McMaster University, Hamilton, Ontario, Canada; ²MedStar National Rehabilitation Hospital, Washington, DC; ³Northern Colorado Rehabilitation Hospital, Johnstown, Colorado; ⁴International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, Maryland; ⁵Mayo Clinic, Rochester, Minnesota; ⁶The Cody Unser First Step Foundation, Albuquerque, New Mexico; Funding: Craig Neilsen Foundation

Objective: To present new resources for primary care providers (PCP) to guide them in a systematic approach to health promotion, disease prevention and episodic care in people with SCI.

Methods: The Academy of Spinal Cord Injury Professionals (ASCIP) and American Spinal Injury Association (ASIA) have partnered to develop a package of resources to manage the unique health needs of people with SCI/D and the PCPs who treat them. 19 topics were chosen, a team of primary care provider, physiatrist and person with lived experience reviewed the literature and wrote each topic article. Participants: ASIA/ASCIP Primary Care Committee. Each article was researched and written by a team including: primary care provider, physiatrist and person with lived experience.

Results: 19 articles were published in Topics of Spinal Cord Rehabilitation special edition aimed towards primary care utilization. A PCP SCI Healthcare Resource webpage was developed as part of the ASIA website which contains accessible, point-of-care resources that address relevant issues for this population, checklists for both routine periodic evaluations and episodic care, and organizational models to facilitate efficient health care utilization for patients with complex care needs. Topics include preventative health, sexual health, accessibility/durable medical equipment needs and bowel, bladder and pulmonary complications for people with SCI.

Conclusion: Optimization of SCI healthcare in primary care requires comprehensive strategies to provide accessible education and practice resources. It is imperative that we as SCI specialists collaborate with SCI stakeholders, disseminate information and leverage technology to improve lifelong outcomes of those with SCI.

Funding: Craig H. Neilsen Foundation

Keywords: Best Practice Implementation, Clinical Application, Clinical Decision Support Systems

Abstract ID: #1363 - Award Recipient – Second Place (Tied) General Submission

Program ID: P9 (Clinical/Best Practice Application)

Mindfulness Meditation Program in Inpatient Spinal Cord Injury Setting

Sussan Askari^{1, 2}, Rachel Holthof², Maciej Zaborowski², Heather Brown²

¹Queen's University, Department of Physical Medicine and Rehabilitation, Kingston, ON, CA; ²Providence Care Hospital, Kingston, ON, CA

Objectives: There are four constituents of well-being that people can be trained in: awareness, connection, insight, and purpose. Well-being is a skill. Research is shown that interventions to strengthen these components are linked with potentially health-promoting changes inside the brain. Emotional well-being is recognized as one of the six indicators by Spinal cord Injury Implementation and Evaluation Quality Care Consortium. Benefits of mindfulness include reduced stress, less anxiety, a great sense of calm and increased focus and attention. The objective of this program is to cultivate the practice of mindfulness meditation as a skill to address emotional well-being following a spinal cord injury.

Methods: A mindfulness meditation program is offered for inpatient spinal cord injury (SCI)/disease at Providence Care Hospital in Kingston, Ontario. This program started in January 2019, however the program interrupted for a few months due to COVID 19 pandemic. This program is guided by three rehabilitation team members including spiritual care provider, social worker and behavioral technologist. The session is held once weekly for four consecutive weeks and each session lasts 60 minutes. The sessions are not dependent on each other. The goal of the program is to learn about mindfulness and stress tolerance skills and to begin developing a personal practice. The participants fill out a feedback questionnaire at the end of fourth session.

Results: The feedback from patients was positive. Patients rated the program is helpful (8-10/10). The participants found the most helpful part of the program; “being in the moment with yourself”, “connecting with people being present”, “connection”, “finding peace in your mind” and “take time to regenerate energy”.

Conclusion: In the rehabilitation setting a holistic approach is the key to success and emotional well-being is underestimated. The patient’s health outcome can be maximized not only through physical activity but also through strengthening of their mind by practicing mindfulness. The notion that our mind and mental processes are influenced by the health of our bodies requires further exploration in the SCI population.

Keywords: Integrative Approaches, Knowledge Implementation, Rehabilitation Outcome

Abstract ID: #1365 (Clinical/Best Practice Application)

Patient perspectives regarding a 7-day therapy model during the onset of COVID-19.

B. Catharine Craven^{1, 2, 3}, Mohammadreza Amiri², Kristina Guy¹, Heather M. Flett^{1, 4}, Farnoosh Farahani², Gaya Jeyathevan², Iona MacRitchie¹, Greta Mighty¹, Sandra Mills¹, Carrie Mizzonie¹, Carol Scovil¹, Chelsea Wong¹, Anellina Ventre¹, Paula Cripps-McMartin¹

¹Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ²KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ³Department of Medicine, University of Toronto, Toronto, ON, CA; ⁴Department of Physical Therapy, University of Toronto, ON, CA

Background: COVID-19 presented unique challenges for patient wellbeing in tertiary SCI rehabilitation settings. Patients had long evening and weekend stretches to occupy themselves while isolated from their family and support network without access to volunteers, peer mentors, recreational outings or weekend passes.

Objective: To describe the outcomes of a 7-day therapy model implemented during COVID-19 (Apr-Aug2020) from a patient perspective.

Method: The pandemic provided an opportunity to redeploy outpatient staff to the inpatient program, and provide therapy services 7-days/week for 12 hours/day (vs. 5 days/week for 8 hrs) to: 1) enhance physical distancing ; 2) intensify inpatient therapy; 3) create opportunity to practice skills prior to discharge; 4) facilitate daily e-visits (visitor restrictions); 5) increase recreation/leisure offerings; and, 6) increase supportive care on units. In total 6 PT’s, 4 OT’s, 2 Assistive Technology Staff (ATS) were redeployed. Enhanced recreation therapy evening programs (bocce, movies, relaxation, adapted sport, etc.) and extended gym hours were provided. Supports for feeding, laundry, activities of daily living (ADL), 2, and e-visits were established. Leadership team worked extended hours and weekends. Seating clinic staff supported wheelchair prescription and ADP processes. Patient surveys were designed and piloted by the Toronto IES team to evaluate the effectiveness and impact of the enhanced therapy schedule. Data were analyzed by postdoctoral fellows (GJ and RA) using appropriate descriptive statistics or qualitative methods.

Participants: Patients & tertiary academic staff.

Findings: Thirty inpatients, 77% male, 6 paraplegics and 24 tetraplegics, majority of non-traumatic etiology, with a median 57-80 day LOS indicated their preference for a 6-day (vs 7-day) therapy model. Weekend recreational programs had the best attendance, while recreational programming attendance was a predictor of greater program satisfaction. A majority of inpatients indicated their preference for 6-day per week programming indicating they would “appreciate a day of relaxation (which could still be therapeutic, just less physical and more recreational perhaps).”

Conclusion: Temporary redeployment of staff resulted in increased inpatient support services and therapy availability. Study results underscore the importance of role clarity and goal setting, therapeutic recreation services, especially on weekends; the potential value of a 6-day therapy model; and, our reliance on volunteer and family caregiver services, therapeutic and weekend passes as essential components of care.

Funding: Support for the enclosed statistical analysis was provided by the Ontario Neurotrauma Foundation (#2018-RHI-HIGH-1057; # Grant # 2019-RHI-SITE1-1065)and the Toronto Rehab Foundation.

Keywords: Physical Medicine and Rehabilitation, Healthcare Delivery, Rehabilitation Outcome

Abstract ID: #1371 (Clinical/Best Practice Application)

Prevalence of cardiometabolic disease in inpatients with spinal cord injury: An opportunity for health promotion

Emma A. Bateman¹, Heather M. MacKenzie¹, Eldon Loh¹, Keith Sequeira¹

¹Parkwood Institute, St Joseph's Health Care London, London, ON, CA

Background: Cardiometabolic disease (CMD) is a leading cause of mortality and morbidity for persons with spinal cord injury/disease (SCI/D). Persons with SCI/D are at significantly increased risk of developing early, accelerated CMD and are less likely to receive appropriate evidence-based screening for CMD risk factors. As a result, they may experience serious, preventable medical harm as well as reduced quality and length of life. Studies suggest that CMD and its risk factors are highly prevalent in persons with SCI/D, but little is known about the epidemiology of CMD risk factors in Canadians living with SCI/D.

Objective: Determine the prevalence of established cardiovascular disease (prior myocardial infarction, stroke, and/or peripheral arterial disease) and key modifiable CMD risk factors (hypertension, obesity, dyslipidemia, and diabetes mellitus) amongst persons with SCI/D admitted for inpatient rehabilitation.

Methods: Retrospective chart review.

Participants: Persons with traumatic and nontraumatic SCI/D admitted for inpatient rehabilitation from October 2019 to September 2020 inclusive.

Results: 98 patients (70.4% male) with traumatic (49.0%) or nontraumatic SCI/D (51.0%) were admitted over the study period. The average age was 61.3 years (range 18-92). 33.7% of patients had known cardiovascular disease. 79.6% of patients had at least 1 CMD risk factor, and 41.8% of patients had 3 or more. Hypertension was the most common CMD risk factor (56.1%), followed by obesity (45.9%), dyslipidemia (42.9%), and diabetes mellitus (27.6%). 2 patients had myocardial infarctions during their SCI/D admission.

Conclusions: In this Canadian cohort, 1 in every 3 patients admitted for inpatient SCI/D rehabilitation had known cardiovascular disease, and nearly 4 in 5 had at least one risk factor for CMD. This strikingly high prevalence of cardiovascular disease and CMD risk factors coupled with the risk of devastating sequelae of this disease emphasizes that inpatient rehabilitation may offer an important opportunity to address primary and secondary CMD prevention as part of promoting health and wellbeing for all persons with SCI/D.

Keywords: Healthcare Delivery, Practice Equity/Gaps, Burden of Illness

Abstract ID: #1374 – Award Recipient – Third Place Student Submission

Program ID: PS3 (Clinical/Best Practice Application)

Exploring the role of eHealth literacy in an online self-management program for Canadian adults living with spinal cord injury

Miranda Li^{1, 2}, Sonya Allin¹, Sarah E. Skeels³, Diana Pernigotti⁴, John Shepherd¹, Teri Thorson⁵, Paul Gustafson⁶, Susan Jaglal¹

¹Department of Physical Therapy, University of Toronto, Toronto, ON, CA; ²Department of Cell & Systems Biology, University of Toronto, Toronto, ON, CA; ³Department of Occupational Therapy, Tufts University, Medford, MA, USA; ⁴Rehabilitation Services and Outpatient Services, Spinal Cord Injury Program, Gaylord Hospital, Wallingford, CT, USA; ⁵Spinal Cord Injury BC, Vancouver, BC, CA; ⁶Arts and Science Transition Program, University of Saskatchewan, Saskatoon, SK, CA

Objective: Evaluate factors that influence eHealth literacy among Canadians with spinal cord injury who are participating in an online self-management intervention.

Participants: 58 Canadian adults with a spinal cord injury (SCI) of any level of severity who have been living in the community for at least six months. Participants were recruited throughout the country via community organizations (e.g., SCI-BC, SCI-Alberta, SCI-Ontario, Ability New Brunswick).

Methods: Results were derived from a secondary analysis of baseline data gathered as part of a randomized control trial designed to evaluate an online, peer-led, health coaching intervention for Canadians with SCI. At baseline and prior to randomization, all study participants were asked to provide demographic information and complete a series of online self-assessments. Assessments were based on self-report and included 9 measures of eHealth literacy (eHEALS), resilience (SCI-QOL), self-efficacy (UW-SES), and health education impact (HeiQ). Self-reported scores on the eHEALS were stratified into three groups based on literacy levels previously defined in literature (Norman, 2006; Chung, 2015): ‘low’ eHealth literacy corresponded to an eHEALS score < 24; ‘moderate’ to a score between 24-36; and ‘high’ to a score > 36. Analyses of variance (ANOVA) were used to measure associations between self-reported literacy categories and other collected measures.

Results: The average age of participants was 48 years old (std 14). 31 identified as female, 27 as male; 28 identified as paraplegic, 21 as tetraplegic; 38 identified having a traumatic injury, 10 as non-traumatic. Participants were from five Canadian provinces (NB, AB, BC, ON, SK) and reported having lived with an SCI for an average of 22 years (std 19). Average self-reported eHealth literacy on the eHEALS in the group was 30 (std 5), indicating a ‘moderate’ eHealth literacy at baseline. Baseline measures that significantly differentiated ‘low’ from ‘high’ eHealth literacy included resilience and several sub-scales of the HeiQ (e.g. Positive and Active Engagement in Life, Health Services Navigation).

Conclusion: Results demonstrate that self-reported comfort with electronic health information to be positively and significantly associated with other measures of self-efficacy and resilience among Canadians living with SCI. Future interventions that seek to promote eHealth literacy may benefit from consideration of these associated measures and, ultimately, may improve the health management of individuals with SCI in the community.

Funding Source: The Canadian Institutes of Health Research and the Craig Neilsen Foundation

Keywords: Behaviour Change, Computer Software, Health Technology

Abstract ID: #1375 – Award Recipient – First Place Student Submission

Program ID: PS1 (Clinical/Best Practice Application)

Practice pearls for fracture management among individuals with spinal cord injury

Emily A. Newton^{1, 2}, B. Catharine Craven^{1, 3}, PVA Bone Health and Osteoporosis Management Guideline Panel¹

¹KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ²Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, CA; ³Department of Medicine, University of Toronto, Toronto, ON, CA

Background: Following spinal cord injury (SCI), several risk factors contribute to an increased risk of low bone mass and high incidence of lower extremity fragility fracture.

Objective: To share a subset of recommendations of the PVA Bone Health and Osteoporosis Management Clinical Practice Guideline (PVA BHG) which addresses gaps in lower extremity fragility fracture management among individuals with SCI and informs clinicians of best practices in post-fracture rehabilitation care.

Methods: A subset of the PVA BHG used narrative review and expert consultation to inform the development of recommendations pertaining to post fracture management. Expert opinion, and literature supporting management in non-SCI populations were used to inform recommendations where SCI-specific literature was not available. Individual recommendations were assigned an AGREE grade based on the level of evidence supporting the statement, and the strength of endorsement from PVA panel members. Results: Twenty recommendations provide guidance in key areas of post fracture rehabilitation management care - three related to diagnosis of lower extremity fracture, one for change in mobility, two for managing skin integrity, five for venous thromboembolism prophylaxis, four for autonomic dysreflexia management, one for initiation of osteoporosis therapy, and four for rehabilitation care further to initial orthopaedic fracture management.

Conclusion: The recommendations demonstrate the importance of comprehensive fracture management, including interprofessional care provision. The process of monitoring heel and malleolar skin integrity during conservative management of a lower extremity fracture and the role of VTE prevention are emphasized. Recommendations call attention to the importance of rehabilitation care designed to address both the physical and psychosocial implications of an injurious fall and changes in mobility post fracture and the need to assure patients return to their premorbid function. Comprehensive fracture management is required in order to reduce morbidity and mortality, and to achieve return to baseline function post-fracture.

Funding: Paralyzed Veterans of America Department of Defense (L. CarboneMD) Grant Number: SCI50092 and Toronto Rehab Foundation

Keywords: Physical Medicine and Rehabilitation, Best Practice Implementation, Clinical Application

Abstract ID: #1376 (Clinical/Best Practice Application)

Capturing patient experience to support quality improvement initiatives

Carol Y Scovil^{1, 2}, Anellina Ventre¹, Carrie Mizzoni^{1, 2}, Chelsea Wong¹, Kristina Plourde¹, Sandra Mills¹, Farnoosh Farahani³, Kristina Guy¹, Iona MacRitchie¹, Heather M. Flett^{1, 4}

¹Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ²Department of Occupational Science and Occupational Therapy, University of Toronto, ON, CA; ³KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ⁴Department of Physical Therapy, University of Toronto, ON, CA

Background: Patient experience is core to understanding and improving care. Implementation Science recommends that stakeholders be included in all aspects of Quality Improvement (QI), and extensive involvement of both patients and staff were prioritized in all stages of implementation to date. Patient experience has enhanced QI initiatives of one site within the Spinal Cord Injury (SCI) Implementation and Evaluation Quality Care Consortium.

Objective: To describe how patient experience and perspectives were integral to implementation of QI initiatives to support best practices in a tertiary SCI rehabilitation centre.

Design: Five Implementation and Evaluation Specialist (IESs) were identified from a range of clinical disciplines to facilitate QI efforts in working with leaders, frontline staff and persons with lived experience. QI in each domain of SCI rehab was started with an iterative process which included patient experience as integral to development and implementation of clinical tools and education materials. It was important to include methods beyond satisfaction ratings, and patient experience was gathered through surveys, interviews, working groups, as well as direct feedback.

Participants: Patients in a tertiary academic rehabilitation hospital as well as community members with lived experience.

Findings: 106 individuals undergoing inpatient SCI rehabilitation were approached to share their experience, perspectives and personal knowledge of care, to influence QI initiatives and ongoing improvement cycles. Patient experience supported QI in domains of sexual health, tissue integrity and wheeled mobility, as well as for Covid-19 clinical adaptations. Early evidence of success was evident in the documentation completion rates regarding sexual health education, which rose from 30% to 80% upon initial implementation. Tissue integrity and wheeled mobility domains are currently in progress, and patient experience continues to shape QI processes. An unanticipated outcome of IESs’ ability to gather patient perspectives in a timely manner was that patient experience could more easily be incorporated into the rapid adaptations in clinical care required during the Covid-19 challenges.

Conclusion: Intentionally seeking patient perspectives enabled more meaningful QI activities resulting in a robust foundation for implementing successful practice change and greater staff and patient engagement to ultimately maximize patient and family centred care.

Funding: Support for the SCI IEQCC was provided by the Ontario Neurotrauma Foundation (Grants #2018-RHI-HIGH-1057; # 2019-RHI-SITE1-1065).

Keywords: Knowledge Translation, Rehabilitation Outcome, Best Practice Implementation

Abstract ID: #1379 (Clinical/Best Practice Application)

Implementing depression and anxiety screening for inpatient SCI rehabilitation.

Carol Y. Scovil^{1, 2}, Jessica Grummitt¹, Martha McKay¹, Christie Yao¹, Farnoosh Farahani³, Iona MacRitchie¹, Heather M. Flett^{1, 4}

¹Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ²Department of Occupational Science and Occupational Therapy, University of Toronto, ON, CA; ³KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ⁴Department of Physical Therapy, University of Toronto, ON, CA

Background: Emotional Well-Being (EWB) post Spinal Cord Injury (SCI) is a critical aspect of adjustment to disability. The SCI Implementation and Evaluation Quality Care Consortium (SCI IEQCC) has prioritized EWB indicators to both understand and respond to patient needs. Implementation Science frameworks were used to support practice change.

Objective: To describe implementation of Patient Health Questionnaire (PHQ-9) and Depression Anxiety Stress Scales 21 (DASS-21) screening for depression and anxiety at admission and discharge from a tertiary SCI rehabilitation centre.

Design: A local Site Implementation Team consisting of site leadership, implementation specialists, and content experts (2 Clinical Psychologists and Psychometrist) was formed to support implementation, in consultation with the clinical team. Practice profiles were created to determine timing and logistics of screening process, as well as clinical response to patients flagged as having scores above certain threshold values. Screening at admission was trialed on one unit, and the processes adapted to fit the local context. Once established, screening by the Psychometrist implemented Feb 2020 on all three inpatient units, within 2 weeks of admission and discharge.

Participants: Patients tertiary academic rehabilitation.

Findings: To date, 288 admission and 194 discharge screens have been completed. 20.1% screened high for depression, and 24.3% for anxiety. Challenges addressed during implementation included: 1) the requirement for translated forms or translator for 9% of screens; 2) screens being done within final week before discharge, not allowing the clinical team enough time to respond to issues that arose; 3) appropriateness of flagging thresholds to identify safety risk- an improvement cycle is currently in process to address this question. The clinical team has reported that implementation of screening is not identifying more patients at risk for anxiety and depression than were identified previously through clinical practice, e.g., no increase in referral to psychological services, however the screening process may identify them sooner in their rehabilitation stay leading to earlier access to specialized services, as well as provide additional information on their particular needs.

Conclusion: Successful implementation of the PHQ-9 and DASS-21 screens using implementation science methods has provided additional tools for inpatient team to support EWB of patients. Screening data, combined with other SCI IEQCC sites, will help advance care and assure equity in care delivery.

Funding: Support for the SCI IEQCC was provided by the Ontario Neurotrauma Foundation (Grants #2018-RHI-HIGH-1057; # 2019-RHI-SITE1-1065).

Keywords: Best Practice Implementation, Rehabilitation Outcome, Physiologic Monitoring

Abstract ID: #1382 (Clinical/Best Practice Application)

Efficacy of transcutaneous spinal cord stimulation as an adjunctive treatment to activity based therapy: a case series

Maryleen K. Jones^{1, 2}, Rola Kersha², Roberta O’Shea²

¹Next Steps Chicago, Willow Springs, IL, US; ²Governors State University, University Park, IL, US

Objective: To report the efficacy of transcutaneous spinal cord stimulation used as an adjunctive modality to activity based therapeutic training for three patients with spinal cord injuries.

Design/Methods: Case Series Participants: 2 males, 1 female subject. 24 year old male C6 ASIA A, 17 year old male T6 ASIA A, 55 year old female T1 ASIA A, all with chronic spinal cord injuries.

Results: All patients experienced varied degrees of positive responses and outcomes to the therapeutic intervention. Patients received two hours of personalized physical therapy interventions twice per week for 26 weeks without any adverse events. Improvements in the following outcome measures were realized by all patients: Autonomic Function: Resting systolic blood pressure, Mean Arterial Pressure during exercise, improved awareness for bladder voiding; Neuro Recovery Scale for sit up and reverse sit up, and stand adaptability; Function in Sitting, sensation below level of injury on ASIA Impairment Scale. Two participants demonstrated improvement in motor function below level of injury on ASIA impairment Scale and Neuro Recovery Scale for step adaptability.

Conclusion: Partial effectiveness was shown when transcutaneous spinal cord stimulation was used as an adjunctive therapeutic modality when added to activity based therapeutic training for patients with chronic spinal cord injury. Although measurable sensory, motor and autonomic improvements were obtained, patient specific meaningful changes in the patient's quality of life were not realized. This finding suggests that further investigation is needed to best determine approaches that best address functional recovery with quality of life improvement.

Funding: this is a single case that was self-funded by Next Steps Chicago

Keywords: Clinical Application, Rehabilitation Outcome, Treatment Efficacy

Abstract ID: #1331 (Health Services, Economics and Policy Change)

Cost-utility analysis of transcranial direct current stimulation therapy for neuropathic pain for adults with spinal cord injury in Canada

Min Xi^{1, 2}, XiaoWei Shen^{2, 3}, Kamilla Guliyeva², Rebecca Hancock-Howard², Peter C. Coyte², Brian C.F. Chan^{1, 2}

¹KITE - Toronto Rehab Institute - University Health Network, Toronto, ON, CA; ²Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, CA; ³Hoffmann-La Roche Limited, Toronto, ON, CA

Background: Approximately 25 to 80% of individuals with spinal cord injury (SCI) suffer from neuropathic pain (NP). Standard care for NP currently involves pharmacological treatments. Unfortunately, the majority of NP patients do not experience pain relief following first-line pharmacological treatments. Transcranial direct current stimulation has been considered a potential adjuvant therapy for individuals with neuropathic pain. Currently, there is a knowledge gap regarding the cost-utility of tDCS in the SCI population.

Objective: The purpose of this study was to examine the incremental cost per quality adjusted life year (QALY) gained through the use of tDCS therapy in comparison to standard pharmacological care in Ontario, Canada from a societal and public payer (i.e., Ontario Ministry of Health and Long Term Care) perspective over a three-month time horizon.

Participants: Individuals with SCI and NP who are resistant to pharmacological therapy.

Outcome Measures: Outcomes of interest included incremental costs, incremental QALYs and incremental cost effectiveness ratio.

Methods: We conducted a cost-utility analysis using a Markov model with probabilistic sensitivity analysis to simulate a cohort of 1,000 individuals with SCI and severe NP. Over a three-month time horizon, individuals could transition between three health states depending on NP severity: no/mild, moderate, and severe. The Markov model accounted for equipment and personnel costs, drug costs, and healthcare utilization costs, and productivity costs. Scenario analyses using alternative time frames, utilities, and costs were conducted to test the robustness of the results.

Results: From a societal perspective, the incremental cost per QALY gained through the use of tDCS therapy versus pharmacological therapy alone was $33,167 (2020 CAD). From an Ontario public health payer perspective, the incremental cost per QALY was $56,019 and tDCS had a 54% chance of being cost-effective at a willingness to pay threshold of $50,000 per QALY. Our results remained relatively robust over the various scenario analyses.

Conclusion: Our findings suggest that, at three months post-therapy, tDCS therapy was more cost-effective than pharmacological treatments for reducing NP severity in adults with SCI.

Funding: Ontario Neurotrauma Foundation

Keywords: Cost Effectiveness, Physical Medicine and Rehabilitation, Health Technology

Abstract ID: #1349 (Health Services, Economics and Policy Change)

Family Connections: Development and pilot evaluation of a caregiver support program for family members of individuals with spinal cord injury

Gaya Jeyathevan¹, Sheri Upper², Lubna Aslam², B. Catharine Craven¹

¹KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ²Spinal Cord Injury Ontario, Toronto, ON, CA

Background: Family caregivers make a significant contribution to the informal and formal care, as well as the overall quality of life of individuals with spinal cord injury or disease (SCI/D). Ironically, many caregivers do not receive adequate support and experience negative effects of caregiving, which threatens the sustainability of the care provided. Finding ways to support family caregivers will continue to be a critical public health focus.

Objective: To develop and pilot test a SCI family caregiver support program aimed to enhance caregiver competency and self-efficacy in providing support to their family members with SCI/D, as well as provide an opportunity to connect with peers and draw upon the power of peer support.

Methods: Key educational and training modules were developed using parent study identifying SCI caregiver needs necessary to prepare them in their caregiving role. The support program was pilot tested two times through a video conference platform for feasibility and effectiveness (i.e. across a six-week period per pilot) with approximately four to five caregivers in each pilot. Evaluation of the modules included: perceived utility and satisfaction, personal relevance, and design.

Results: The following six modules were developed and incorporated into the caregiver support program, “Family Connections”: Coping with Loss and Grief; Relationship Changes; Sexuality and Intimacy; Stress Management and Communication; Problem-Solving and Boundary-Setting; and System Navigation, and Self-Care. The majority of the caregivers reported high perceived utility and satisfaction (i.e. modules enhanced knowledge/skills to be able to apply in everyday life), and personal relevance. The caregivers also reported that Family Connections allowed for peer support and mentorship (i.e. share concerns/fears of taking on new caregiving roles).

Conclusion: Family Connections is a novel initiative aiming to assist family members in sustaining the caregiving role long term in the community. In an environment with scarce resource for SCI family caregivers, the developed modules could enhance caregiver knowledge and skills through the delivery of robust training and peer support. The findings from the evaluations should further alert healthcare professionals and community-based service providers as to the need for education and training as well as counseling/peer mentorship prior to discharge to assist caregivers: 1) with adaptation to new life post-injury; and 2) achieve mastery in situations where they are facing caregiving difficulties.

Funding: Spinal Cord Injury Ontario

Keywords: Healthcare Delivery, Self-Care, Behaviour Change

Abstract ID: #1350 - Award Recipient – Second Place General Submission

Program ID: P12 (Health Services, Economics and Policy Change)

Evaluation of a new mobile diagnostic imaging services at a tertiary Spinal Cord Rehabilitation Program during the COVID-19 pandemic

Heather M Flett^{1, 2}, Talya Wolff³, Heather Zimcik^{1, 4}, B Cathy Craven^{1, 5, 6}, Tina St Louis⁷, Mary May³, Paula Cripps-McMartin¹

¹Brain and Spinal Cord Rehabilitation Program, University Health Network, Toronto, ON, CA; ²Department of Physical Therapy, University of Toronto, Toronto, ON, CA; ³Joint Department of Medical Imaging and Lab Medicine Program, University Health Network, Toronto, ON, CA; ⁴Department of Family and Community Medicine, University of Toronto, Toronto, ON, CA; ⁵KITE, University of Toronto, Toronto, ON, CA; ⁶Department Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, CA; ⁷STL Diagnostic Imaging, Burlington, ON, CA

Background: As a standalone tertiary spinal cord rehabilitation program, our patients requiring diagnostic imaging during their inpatient stay need to be transported to an acute care hospital to receive these services. Over the course of inpatient rehabilitation, patients routinely travel to acute care hospitals for diagnostic imaging for surgical follow-up, musculoskeletal injuries, vascular complications such as deep vein thrombosis and other medical complications. Due to travel and wait time, patients typically miss at least a half day of therapy to attend imaging appointments. At the beginning of the COVID-19 pandemic, an urgent need arose to develop a new approach to diagnostic imaging due to a significant reduction in access to acute care diagnostic imaging and in order to reduce the risk of patient exposure to COVID-19.

Objective: The goal of this initiative was to implement a new, mobile diagnostic imaging service that would minimize external travel during inpatient rehab, reduce risk of exposure to COVID-19, reduce lost therapy hours, while at least remaining cost-neutral. In order to evaluate this service, the costs and benefits associated with this mobile x-ray and ultrasound service were examined.

Methods: With the support of Joint Department of Medical Imaging, our SCI rehab program partnered with STL Diagnostic Imaging to provide onsite x-ray and ultrasound imaging.The service began on May 11, 2020 and consisted of mobile x-ray imaging twice per week and mobile ultrasound scans once per week for two hours each. All imaging was conducted in patient rooms by STL technologists. Monthly STL billing costs were compared to estimated transportation costs for patients. Typical transportation costs range from $60-$284 depending on mode of transportation.

Results: Between May 11, 2020 and January 28, 2021, 144 patients received 203 x-ray images over 67 x-ray days and 81 patients received 105 ultrasound scans over 37 ultrasound days. Over this timeframe, the approximate savings in transportation costs ranged from $7114 to $20,753. In addition, it is estimated that 225 - 450 lost therapy hours were avoided since patients did not have to travel for imaging and therefore avoided missing scheduled therapy appointments. Although not formally evaluated, physician, patient and nursing staff satisfaction regarding this new service has also been extremely positive.

Conclusion: Although implemented out of necessity during the pandemic, this partnership to provide mobile diagnostic imaging has been cost-effective and beneficial to patients.

Keywords: Imaging Diagnostic, Healthcare Delivery, Physical Medicine and Rehabilitation

Abstract ID: #1364 (Health Services, Economics and Policy Change)

Parkwood’s VIP4SCI platform: Preliminary findings from the use of a novel e-health solution

Luxshmi Nageswaran^{1, 2}, Zeina Abu-Jurji^{1, 2}, Calogero Giurleo¹, Heather K. Askes¹, Julie Watson^{1, 3}, Dalton L. Wolfe^{1, 2}

¹Parkwood Institute Research, Lawson Health Research Institute, London, ON, CA; ²Western University, London, ON, CA; ³Spinal Cord Injury Ontario, Toronto, ON, CA

Background: Persons with spinal cord injury (SCI) face many challenges as they transition from inpatient to outpatients and into the community. The Parkwood VIP4SCI platform is an online e-health solution adapted from a version originally created by Spinal Cord Injury Ontario that focuses on the development of effective self-management skills.

Objective: The overall goal of this initiative is to test this e-health solution’s usability and feasibility when used by both inpatients and outpatients in partnership with caregivers and health care providers. The present submission reflects a preliminary analysis of the baseline data captured for this trial which includes various patient-reported outcomes associated with the impact on self-management behaviours (i.e., pain, pressure ulcers, physical activity, emotional well-being) and incidence of secondary complications that may affect healthcare use.

Methods: This pilot study looks at the platform’s use in both SCI inpatients and outpatients receiving care from the Parkwood Institute’s Rehab program. Inpatients were randomized into two groups (Platform or Standard Care (i.e. Platform access provided upon discharge from Rehab) and pre-post assessments using online surveys were completed by all participants at specific time points from Enrollment to 12-weeks post. Surveys included patient reported outcome measures (PROMs) with domains selected from short forms of the SCI-QOL, as well as a feasibility survey and modified version of the Mobile App Rating Scale (MARS). In addition to survey responses, analytics of the platform’s use were also collected (i.e., # of clicks/feature, # of goals set, clinician interactions [i.e., Messages, Video Calls]). Analytics and survey responses will be reviewed monthly to adjust features of the platform and collect user feedback.

Results: Preliminary findings from the PROMs surveys show that at the time of enrollment, the two measures that scored the highest in both patient populations were “completing exercise activities” and “managing their self-efficacy" (mean = 6-7/10). Feasibility surveys showed a mean of 5-6/10 and MARS results showed a mean of 3-4/5. Analytics also showed that resources on the platform were selected a total of 63 times, and that 4 self-management goals were completed.

Conclusion: Although these findings are preliminary, further data collection and analysis will help to inform the platform’s usability and feasibility within Parkwood Institute’s SCI programs. Future results will help to inform the impact of this e-health solution on improving self-management behaviours in its participants.

Funding: Craig H Neilsen Foundation 533045

Keywords: Behaviour Change, Knowledge Implementation, Health Information Technology

Abstract ID: #1367 – Award Recipient – First Place General Submission

Program ID: P11 (Health Services, Economics and Policy Change)

Evolution of a Spinal Cord Injury Implementation and Evaluation Quality Care Consortium data strategy: It's more than just the numbers

Farnoosh Farahani¹, Mohammadreza Amiri^{1, 2}, Seyed Mohammad Alavinia¹, B. Catharine Craven^{1, 3, 4}

¹KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ²Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, CA; ³Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, CA; ⁴Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA

Background: The Spinal Cord Injury Implementation and Evaluation Quality Care Consortium (SCI IEQCC) leads the implementation and evaluation of indicators across 5 rehabilitation sites in Ontario. In a learning health system, appropriate collection, analysis, and reporting of indicator data will allow for the identification of care gaps, increase performance, and enable benchmarking.

Objective: To describe the development of a data strategy for the SCI IEQCC.

Methods: The evaluation team led the following processes to support the data strategy development: assessment of available resources through stakeholders; utilization of current provincial and national datasets; adherence to privacy and legal requirements related to collection, use, and transfer of indicator data; development and execution of Data Sharing Agreement (DSA) and Confidentiality Agreement (CA) across participating organizations; acquisition of quality improvement approvals; validation of privacy and security standards; creation of data collection tools; development and dissemination of data collection spreadsheets; development of staff training and support curriculum; development of indicator data analysis plan; exploring of data visualization strategies and dashboard tools.

Results: The evaluation team followed a systematic strategy which included: planning meetings with stakeholders such as Praxis Spinal Cord Institute (n=14), Spinal Cord Injury Ontario (n=4), National Rehabilitation Reporting System officers (n=3), and Network meetings with health system leaders, clinicians, and individuals with lived experience (n=2). Meetings with legal counsel (n=10) and consultation meetings across various departments at each site (Grants & Contracts, Research Ethics Board (REB), Privacy Office, Digital) facilitated the development and execution of DSA and CA. Five Quality Improvement approvals or REB waivers were obtained across sites. Detailed data collection spreadsheets (n=8) were developed by the evaluation team reflecting data elements pertaining to each indicator. Training was provided to staff regarding the usage, storage, encryption, de-identification, and transfer of the spreadsheets. A comprehensive statistical analysis plan was developed and data visualization selected.

Conclusion: Ensuring world-class quality of care delivery to SCI patients demands a secure and timely data collection, transfer, and reporting to enable identification and subsequent achievement of benchmarks. Future success of the SCI IEQCC will be dependent on further enrichment of the current data strategy.

Funding: This work is embedded in the larger SCI-High Project funded by Praxis Spinal Research Institute (former Rick Hansen Institute - Grant #G2015-33)Ontario Neurotrauma Foundation (#2018-RHI-HIGH-1057) and the Toronto Rehab Foundation. Dr. Craven acknowledges support from the Toronto Rehab Foundation as the Toronto Rehabilitation Institute Chair in Spinal Cord Injury Rehabilitation.

Keywords: Clinical Informatics, Rehabilitation Outcome, Data Storage and Retrieval

Abstract ID: #1383 (Health Services, Economics and Policy Change)

Exploring validation of pressure injury flap reconstruction codes in Ontario administrative databases

Laura M. Teague¹, Susan Jaglal^{2, 3}, Andrew Calzavara³, Jennifer Voth³, Lehana Thabane¹, Stephen Birch¹, Karen Campbell⁴, Colleen McGillivray^{5, 6}, James Mahoney^{7, 8}, Maya Deeb⁹, Gina Browne¹

¹School of Nursing, McMaster University, Hamilton, ON, CA; ²Faculty of Rehabilitation Sciences, Department of Physiotherapy, University of Toronto, Toronto, ON, CA; ³Institute for Clinical Evaluative Studies, Toronto, ON CA; ⁴School of Nursing, Western University, London, ON, CA; ⁵Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, CA; ⁶Toronto Rehabilitation Institute-University Health Network, Toronto, ON, CA; ⁷Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, ON, CA; ⁸Unity Health, St Michael's Hospital, Toronto, ON, CA; ⁹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, CA

Objective: To explore the accuracy of procedure, diagnosis and physician billing code algorithms to identify cases of spinal cord injured (SCI) persons having undergone surgical flap closure of pelvic pressure injuries (PI) in a provincial health administrative database.

Methods: Hospital medical records with confirmed cases (true positive) were identified using physician-billing records from one plastic surgeon in Toronto, Canada between 2002-2015. 108 consecutive SCI patients with 136 cases of pelvic PI reconstruction procedures were confirmed from review of medical records. Thirty-seven control patients with SCI who were admitted to hospital with PI and no surgery were also confirmed through chart review. These records were used as the reference standard. Ontario Health Insurance Plan (OHIP) billing codes, ICD-10-CA and Canadian Classification of Health Interventions codes (CCI) were recorded for each of the cases and securely transferred to the Institute of Clinical Evaluative Studies (ICES). ICD 10-CA, CCI codes and OHIP billing codes were used to build several algorithms, which were then tested for sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

Results: The most appropriate algorithm included physician fee codes combined with diagnostic codes that included any SCI and ‘any pressure ulcer’. Inclusion of intervention codes was problematic as there were 329 discrete codes recorded in this cohort of patients. This algorithm displayed a sensitivity of 69.1% (95% confidence interval (95% CI 60, 76.75)); specificity of 97.37% (95% CI 86.19, 99.93); Positive Predictive Value of 98.95% (95% CI 94.77, 97.97); and Negative Predictive Value of 46.84% (95%cCI 35.51,58.40). In other words, 30.9% of all positive cases in this cohort were missed using the algorithm, while 97.37% of all negative cases were identified using the same algorithm.

Conclusion: Given the complexity of this patient population and the variation and missing administrative codes, it is likely that retrospective studies using administrative data to identify SCI patients who have undergone PI reconstruction is insufficient to proceed with a population-based study in Ontario. This study emphasizes the importance of evaluating accuracy and completeness of codes in administrative databases in order to reduce the risk of misclassification and subsequent reduction of power and generalizability.

Funding: Ontario Neurotrauma Foundation 2017-RHI-SURGIC-1024

Keywords: Health Information Technology, Information Retrieval, Data Retrieval

Abstract ID: #1309 (Knowledge Generation)

Sex As A Key Determinant Of The Management And Outcomes Of Individuals With Acute Traumatic Spinal Cord Injury: A Series Of Propensity-score Matched Cohort Studies

Julio C. Furlan^{1, 2}, Tian Shen³, B. Catharine Craven^{1, 2}

¹Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, CA; ²Lyndhurst Centre, KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ³Praxis Spinal Cord Institute, Vancouver, BC, CA

Objective: Limited pre-clinical studies indicated potential neuroprotective effects of estrogen and progesterone following spinal cord injury (SCI), however clinical evidence is needing. Given this background, a series of propensity-score matched cohort studies examined the potential effects of sex on injury epidemiology, management and outcomes after acute traumatic SCI.

Methods: This series of propensity-score matched cohort studies was carried out comparing subgroups of females in premenopause (age at the time of SCI < 40 years), females presumably in perimenopause (41 ≥ age ≥50) and females presumably in postmenopause (age>50), with the subgroups of males distributed similar age categories. Females were matched on a 1:1 ratio to males using the propensity score matching on age, co-morbidities, level and severity of SCI. Females were compared with males regarding injury epidemiology, management in the acute care, and clinical, neurological and functional outcomes after SCI.

Participants: Data from April 2014 to September 2019 were selected from a Canadian registry (RHSCIR). Of the 7,196 cases included in the RHSCIR, 1,245 females and 4,334 males fulfilled the inclusion/exclusion for this study and were considered during the propensity-score matching process.

Results: (i) Among individuals younger than 40 years, females (n=320) more often were white (p=0.0268) and had SCI due to falls or transportation-related accidents (p=0.0014) than males (n=320). Both subgroups under 40 years had comparable management except for females had more often surgical treatment (p=0.0326). There were no significant differences between females and males under 40 years regarding outcomes. (ii) Among individuals between 40 and 50 years, females (n=133) were comparable to males (n=133) regarding the other baseline data, management, and outcomes. (iii) Among individuals older than 50 years, females (n=531) had more often fall-related SCIs than males (n=531). Females had shorter length of stay in the rehabilitation facilities than males (p=0.0205). There were no significant differences between the older subgroups of females and males regarding the other baseline data, management, and outcomes.

Conclusion: Individuals’ sex was significantly associated with the vast majority of clinical, neurological and functional outcomes following traumatic SCI, when data analyses were controlled for major potential confounders.

Keywords: Physical Medicine and Rehabilitation, Rehabilitation Outcome, Knowledge Generation

Abstract ID: #1317 – Award Recipient – Third Place General Submission

Program ID: P3 (Knowledge Generation)

Exoskeleton use in acute rehabilitation post spinal cord injury: A qualitative study exploring patients' experiences.

Charbonneau¹, Rebecca Loyola-Sanchez¹, Adalberto McIntosh², Kyle MacKean¹, Gail Ho¹, Chester²

¹University of Calgary, Calgary, AB, CA; ²University of Alberta, Edmonton, AB, CA

Context/Objective: Spinal cord injury (SCI) is intensely life altering, affecting multiple body systems and functions, including the ability to walk. Exoskeleton assisted walking (EAW) is a rehabilitation tool that aims to support locomotor training, yet little is known about the patient experience. The purpose of this qualitative study, part of a prospective observational case series, was to increase our understanding of SCI patient experience using a robotic exoskeleton in this acute post-injury period.

Design: A qualitative descriptive approach was implemented in this study, with the aim to explore and understand participants’ experience with EAW training.

Participants: Nine of the 11 patients participating in the observational study agreed to participate in an interview. All participants had suffered a SCI, and had received their trauma care and inpatient rehabilitation at a tertiary center in Calgary, Alberta, Canada.

Results: The benefits to EAW use described by patients were primarily psychological and included the joy of eye level contact, excitement at being able to walk with assistance, improvement in mood, and hope for the future. Potential physiological benefits include increased strength, decreased spasticity and reduced pain. Challenges to EAW use include weakness and fatigue, and a fear of incontinence.

Conclusion: Qualitative methods will continue to be an important component in future research on the use of EAW training as part of the rehabilitation process. Increasing understanding of the patient experience with this novel therapeutic modality and technology will be fundamental to improve its implementation in clinical practice.

Keywords: Rehabilitation Outcome, Physiatry, Knowledge Generation

Abstract ID: #1319 (Knowledge Generation)

Exoskeleton use in acute rehabilitation post spinal cord injury: A qualitative study exploring patients’ experiences.

Rebecca Charbonneau¹, Adalberto Loyola-Sanchez², Kyle McIntosh¹, Gail MacKean¹, Chester Ho²

¹University of Calgary, Calgary, AB, CA; ²University of Alberta, Edmonton, AB, CA

Context/Objective: Spinal cord injury (SCI) is intensely life altering, affecting multiple body systems and functions, including the ability to walk. Exoskeleton assisted walking (EAW) is a rehabilitation tool that aims to support locomotor training, yet little is known about the patient experience. The purpose of this qualitative study, part of a prospective observational case series, was to increase our understanding of SCI patient experience using a robotic exoskeleton in this acute post-injury period.

Design: A qualitative descriptive approach was implemented in this study, with the aim to explore and understand participants’ experience with EAW training. Participants/setting: Nine of the 11 patients participating in the observational study agreed to participate in an interview. All participants had suffered a SCI, and had received their trauma care and inpatient rehabilitation at a tertiary centre in Calgary, Alberta, Canada.

Results: The benefits to EAW use described by patients were primarily psychological and included the joy of eye level contact, excitement at being able to walk with assistance, improvement in mood, and hope for the future. Potential physiological benefits include increased strength, decreased spasticity and reduced pain. Challenges to EAW use include weakness and fatigue, and a fear of incontinence.

Conclusion: Qualitative research will continue to be an important component in future research on the use of EAW training as part of the rehabilitation process. Increasing understanding of the patient experience with this novel therapeutic modality and technology will be fundamental to improve its implementation in clinical practice.

Keywords: Rehabilitation Outcome, Physical Medicine and Rehabilitation, Healthcare Delivery

Abstract ID: #1320 – Award Recipient – Third Place (Tied) Post-doc Submission

Program ID: PD3 Knowledge Generation

A qualitative, photo-elicitation study exploring the impact of falls and the risk of falling on individuals with sub-acute spinal cord injury

Olinda D. Habib Perez¹, Samantha Martin^{1, 2}, Katherine Chan¹, Hardeep Singh^{1, 3, 4}, Karen Yoshida^{2, 4, 5}, Kristin E. Musselman^{1, 2, 4}

¹KITE, Toronto Rehab – University Health Network, Toronto, ON, CA; ²Department of Physical Therapy, University of Toronto, Toronto, ON, CA; ³Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, CA; ⁴Rehabilitation Sciences Institute, University of Toronto, ON, CA; ⁵Dalla Lana School of Public Health (Social Science Division), University of Toronto, Toronto, ON, CA

Background: Individuals with spinal cord injury or disease (SCI/D) are at an increased risk of falling, with the majority experiencing at least one fall within their first-year post-injury. Yet, little is known about how falls and the risk of falling affects individuals with SCI/D as they transition from inpatient rehabilitation to community living.

Objective: To explore the impact of falls and the risk of falling on individuals with sub-acute SCI/D.

Methods: This was a qualitative, photo-elicitation study. Inpatients with SCI/D at the Lyndhurst Centre were invited to participate through a centralized recruitment process. At six months post-discharge, photo-elicitation was used to understand the impact of falls and the risk of falling during their transition to community living. Participants completed a photo-assignment over 7-14 days, which involved taking photographs to answer the following questions: What increases/decreases your likelihood of falling? How does the risk of falling affect your ability to participate in work and/or recreational activities? Participants engaged in a semi-structured interview where they described their photographs and discussed their experiences with falling and falls training in rehabilitation. Interviews were transcribed verbatim and an inductive thematic analysis was conducted.

Results: Eight individuals (7 male, 1 female) with non-traumatic SCI/D participated. Six participants were ambulators and two were manual wheelchair users. Four themes were identified. 1) Risk factors and strategies identified through lived experience. Participants described realizing their unique fall risk factors and developing fall prevention strategies through “trial and error”. 2) Individual influences on the individual’s perception of fall risk. Experience with falls before and after SCI/D influenced their perception of fall risk. 3) Experiencing life differently due to increased fall risk. Participants reported altered participation in daily activities, increased negative emotions and reduced independence and quality of life due to their high fall risk. 4) Falls training in rehabilitation can be improved. Participants had varying experiences and opinions of falls training received, but all expressed a desire for comprehensive and individualized training.

Conclusion: Falls and the risk of falling can have a significant impact on the lives of individuals with sub-acute SCI/D. Understanding fall risk during this early phase of SCI/D will inform fall prevention initiatives for inpatient and outpatient rehabilitation.

Funding: Canadian Institutes of Health Research Grant Number: CIHR PJT 153017 - SPINAL CORD

Keywords: Healthcare Delivery, Physical Medicine and Rehabilitation, Rehabilitation Outcome

Abstract ID: #1322 – Award Recipient – First Place General Submission

Program ID: P1 (Knowledge Generation)

Safety and feasibility of early functional electrical stimulation-assisted cycling after acute spinal cord injury

Dirk G. Everaert¹, Yoshino Okuma^{1, 2}, Chester Ho^{1, 2}

¹University of Alberta, Faculty of Medicine and Dentistry, Division of Physical Medicine and Rehabilitation, Edmonton, AB, CA; ²Alberta Health Services, AB, CA

Objective: To determine safety and feasibility (practicality, acceptability, and patient-readiness) of leg cycling with functional electrical stimulation (FES) early after acute spinal cord injury (SCI).

Design: Observational study performed at a Level-1 trauma center and rehabilitation hospital in Canada.

Participants: Seven participants were enrolled with mean age of 34.1 ± 14 years, neurological injury level C4-T12, and severity AIS A-C (American Spinal Injury Association Impairment Scale).

Intervention: The goal was to perform 3 sessions/week of 15-45 minutes FES leg cycling, with a Restorative Therapies RT300 supine or sitting FES bike, started as soon as possible after injury, for up to 3 months.

Outcome Measures: Time since injury for start time of FES cycling; FES response in terms of contraction strength and pain; participant and clinician questionnaires scoring practicality, acceptability and perceived benefits; FES parameters; cycling performance; adverse events (AE).

Results: FES cycling was started as soon as 12 days, and on average 19.9 ± 7.6 days after injury, and continued for 1-36 sessions. Results are based on a total of 103 FES cycling sessions with 3 participants enrolled short term (1-3 sessions) and 4 long term (10-36 sessions). Several participants had concomitant injuries and ongoing interventions (such as chest tubes for pneumothorax, unhealed stable fractures in scapula and foot), which did not prevent the start of FES cycling. At baseline, most participants without lower motor neuron injury (5/7) had strong contractions with FES in quadriceps and hamstrings (scores 3-4/5), but 4 of 7 had stimulation-associated pain or apprehension requiring limitation of stimulation amplitudes, for up to 65 days after the start of FES cycling. The maximum tolerable stimulation levels were related to AIS classification. Three types of pain were reported: at the electrode sites, referred pain in the groin and at the injury site. Seven AEs were causally related to FES cycling (6 pain from stimulation, 1 spasms). Stimulation-associated pain has not been previously reported in early FES cycling studies, but did not lead to discontinuation of FES cycling. Participants experienced emotional and physical benefits from FES cycling, and no interference with daily care was reported by the unit staff.

Conclusion: Starting FES cycling early after SCI (12-33 days) in an acute setting appears feasible, well accepted, and safe, yet performance and progress may be limited by stimulation-associated pain, and requires a highly individualized approach.

Funding: University of Alberta Endowed Spinal Cord Research Chair

Keywords: Clinical Application, Treatment Effectiveness, Rehabilitation Outcome

Abstract ID: #1324 - Award Recipient – Second Place Student Submission

Program ID: PS2 (Knowledge Generation)

The characteristics of activity-based therapy interventions for people living with spinal cord injury or disease across the continuum of care: A scoping review.

Anita Kaiser^{1, 2, 3}, Katherine Chan¹, Maureen Pakosh⁴, Shane McCullum⁵, Chris Rice, José Zariffa^{1, 2, 6, 7}, Kristin E. Musselman^{1, 2, 8}

¹KITE, Toronto Rehab-University Health Network, Toronto, Canada; ²Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Canada; ³Canadian Spinal Research Organization, Toronto, Canada; ⁴Library & Information Services, University Health Network, Toronto Rehabilitation Institute, Toronto, Canada; ⁵Stan Cassidy Centre for Rehabilitation, Horizon Health Network, Fredericton, Canada; ⁶Institute of Biomedical Engineering, University of Toronto, Toronto, Canada; ⁷Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto, Toronto, Canada; ⁸Dept. of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada

Background: Activity-based therapies (ABT) are interventions that provide activation of the neuromuscular system below the level of injury with the goals of neurorecovery and prevention of secondary health complications. The lack of available tools to document participation and performance in ABT create implementation challenges. To address these challenges, the characteristics of ABT need to be identified and described.

Objective: To identify the characteristics of ABT that individuals with SCI/D participate in across the continuum of care.

Methods: The Joanna Briggs Institute guidelines for scoping reviews were followed. The search strategy used terms identifying the population (SCI/D) and concept (ABT). Eight databases were searched. Studies involving individuals with SCI/D >16 years of age and ABT interventions >1 session were included. Retrieved records underwent title and abstract screening, followed by full-text screening. The Downs and Black Checklist and the Mixed Methods Appraisal Tool were used to assess article quality. Data describing participant demographics, ABT interventions and their corresponding parameters, technology used, and setting were extracted and charted according to key themes. Data synthesis included frequency counts and descriptive analysis of key themes.

Results: The initial search produced 2306 records, with 140 articles meeting the inclusion criteria. Ninety-eight percent of articles were appraised with the Downs and Black Checklist, with 80% of these articles receiving a moderate score. The majority of study interventions (67%) occurred in a research lab with individuals with SCI/D living in the community. The majority of studies reported single modality interventions (57%) that encompassed the whole body (71%). Sixteen types of ABT exercises were identified with treadmill training (26%), muscle strengthening (15%) and ergometer training (14%) reported most often. Electrical stimulation was used in combination with various ABT exercises 27% of the time. Overall, 82 types of parameters were reported across all interventions. A few parameters, such as frequency and duration of intervention, were common to most interventions, while others were specific to the type of ABT exercise. Sixteen main categories of technology were reported with various types of body-weight supported treadmills (60%) and ergometers (33%) being the most prevalent.

Conclusion: The characteristics of ABT are diverse in scope. The results will inform the content to include in tools that track ABT participation and performance.

Funding: Canadian Institutes of Health Research PAO 169401, Praxis Spinal Cord Institute G2020 36

Keywords: Rehabilitation Outcome, Knowledge Generation, Physical Medicine and Rehabilitation

Abstract ID: #1332 (Knowledge Generation)

Understanding the services available for persons with traumatic spinal cord injury in Alberta, Canada: A mixed methods study

Srijan S. Raha^{1, 2}, Silas Yip^{1, 3}, Olaleye Olayinka¹, Rob MacIsaac⁴, Ana K. Rame-Montiel⁵, Jessica L. VanDyke⁶, Harmanjot Kahlon⁷, Rita Henderson^{8, 9}, Ingris Peláez-Ballestas¹⁰, Katharina Kovacs Burns^{7, 11}, Jeffrey Bakal¹¹, Rebecca Charbonneau^{8, 12, 13}, Chester Ho^{1, 11}, Adalberto Loyola-Sanchez^{1, 11}

¹Division of Physical Medicine & Rehabilitation, Faculty of Medicine & Dentistry, University of Alberta; Edmonton, AB, CA; ²Cumming School of Medicine, University of Calgary; Calgary, AB, CA; ³Faculty of Science, University of British Columbia; Vancouver, BC, CA; ⁴Spinal Cord Injury Alberta; Edmonton, AB, CA; ⁵Community Health Sciences, Cumming School of Medicine, University of Calgary; Calgary, AB, CA; ⁶W21C, O'Brien Institute for Public Health, University of Calgary; Calgary, AB, CA; ⁷School of Public Health, University of Alberta; Edmonton, AB, CA; ⁸Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Calgary, AB, CA; ⁹Department of Family Medicine, Cumming School of Medicine, University of Calgary; Calgary, AB, CA; ¹⁰Hospital General de México “Dr. Eduardo Liceaga”; México City, MX; ¹¹Alberta Health Services; Edmonton, AB, CA; ¹²Alberta Health Services; Calgary, AB, CA; ¹³Department of Clinical Neurosciences, University of Calgary; Calgary, AB, CA

Background: stakeholders in Alberta have suggested there are critical gaps in the services provided to individuals with traumatic spinal cord injury (tSCI). Consequently, the goal of this study was to examine the current services available to people with tSCI in Alberta, understanding how they interact to promote community participation.

Methods: we implemented a fully sequential mixed methods embedded design guided by the World Health Organization (WHO) Community Based Rehabilitation (CBR) framework. The dominant qualitative arm consisted of a thick description that detailed the characteristics of the services available for persons living with tSCI in Alberta through the identification of documents in mainstream and grey literatures along with informal interviews. In the secondary arm we quantified the extent these services align with the 5 components and 22 sub-elements defined in the WHO-CBR matrix, assigning a binary score based on the evidence that showed an entity fulfilled an element. Qualitative (QUAL) and quantitative (QUAN) data were integrated following Onwuegbuzie and Teddlie’s mixed data analysis process.

Results: QUAL- the thick description identified several services, which were grouped into 5 main entities or organizational structures: Alberta Health Services (AHS) specialized services, AHS primary care, AHS continuing care, provincial & federal funding programs, and community-based organizations. The services provided within these 5 entities were not highly integrated as a coherent system but demonstrated different complementary strengths for the support of community reintegration for persons with tSCI. Gaps identified include low support for return to work. QUAN- community-based organizations were the only entity that contributed to all 5 components and covered 82% of the 22 elements of the WHO-CBR matrix. 100% of entities contributed to the health component. None of the AHS entities contributed to the livelihood component and no entities significantly contributed to the justice element within the social component.

Conclusion: using a novel mixed-methods approach to understand services available for tSCI in Alberta, we identified 5 main entities of services that could be further integrated into a system that synergizes their current services’ strengths and addresses current gaps in livelihood and justice support. Integrating such a system could significantly improve community reintegration for persons with tSCI in this province. Our methods could be applied to understand tSCI services in other settings.

Funding: Canadian Institutes of Health Research (CIHR) Grant Number/Funding Reference Number (FRN): 165

Keywords: Healthcare Delivery, Rehabilitation Outcome, Integrative Approaches

Abstract ID: #1342 (Knowledge Generation)

Properties of the surface electromyogram following traumatic spinal cord injury: a scoping review.

Gustavo Balbinot¹, Guijin Li^{1, 2}, Matheus Joner Wiest¹, Maureen Pakosh³, Julio C. Furlan^{1, 4, 5, 6, 7, 8}, Sukhvinder Kalsi-Ryan^{1, 4, 9}, Jose Zariffa^{1, 2, 4, 10}

¹KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ²Institute of Biomedical Engineering, University of Toronto, ON, CA; ³Library & Information Services, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ⁴Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, CA; ⁵Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, CA; ⁶Division of Physical Medicine and Rehabilitation, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ⁷Institute of Medical Sciences, University of Toronto, Toronto, ON, CA; ⁸Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, CA; ⁹Department of Physical Therapy, University of Toronto, Toronto, ON, CA; ¹⁰Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto Toronto, ON, CA

Background: Spinal cord injury (SCI) disrupts spinal pathways causing disconnection with the supraspinal nervous system. Changes in surface electromyography (sEMG) recording are observed at the site of injury and caudal to the SCI. sEMG is an informative complement to current clinical assessments and can capture the residual motor command in great detail, including in muscles below the level of injury with seemingly absent motor function.

Objective: In this comprehensive review, we sought to describe how the sEMG properties are changed after SCI.

Design/Methods: We conducted a systematic literature search in seven electronic databases to avoid a biased literature sample. Of 4522 references initially captured in the primary search, 174 references were selected and included in the scoping review.

Results: We found that early reports were mostly focused on the qualitative analysis of sEMG patterns and evolved to semi-quantitative scores and a more detailed amplitude-based quantification. Nonetheless, recent studies are still constrained to an amplitude-based analysis of the sEMG, and there are opportunities to more broadly characterize the time- and frequency-domain properties of the signal as well as to take fuller advantage of high-density EMG techniques. In the identified body of evidence, fewer studies included sEMG measurements beyond amplitude-based analysis. Most studies employed amplitude-based analysis using root mean square (RMS; 57 studies), normalized sEMG (e.g. %EMG, %maximal voluntary contraction, and %peak; 33 studies), and qualitative or semi-quantitative scores of the sEMG pattern (16 studies). In contrast, only 18 studies used time-domain or frequency-domain analysis. The findings from this review suggest that amplitude-based analysis is effective in indicating muscle strength and recovery following SCI, including important aspects of multi-muscle coordination. Despite these positive aspects, time- and frequency-domain analysis may reflect the motor unit firing patterns, either spontaneous or cortically driven, and may afford a better characterization of the impairment and recovery post-SCI.

Conclusion: The results of this review support the incorporation of a broader range of signal properties into the neurophysiological assessment post-SCI. Enhanced sEMG analysis could contribute to a more complete description of the effects of SCI on upper and lower motor neuron function and their interactions, and assist in understanding the mechanisms of change following neuromodulation or exercise therapy.

Funding: This work was supported by the Wings for Life Spinal Cord Research Foundation (Project #210).

Keywords: Diagnostic Technics and Procedures, Knowledge Translation, Engineering Biomedical

Abstract ID: #1343 (Knowledge Generation)

Predictive factors for strength recovery in individual muscles after cervical spinal cord injury.

Gustavo Balbinot¹, Guijin Li^{1, 2}, Sukhvinder Kalsi-Ryan^{1, 3, 4}, Jose Zariffa^{1, 2, 3, 5}

¹KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ²Institute of Biomedical Engineering, University of Toronto, Toronto, ON, CA; ³Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, CA; ⁴Department of Physical Therapy, University of Toronto, Toronto, ON, CA; ⁵Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto

Background: Although extensive effort has been devoted to understanding recovery at the person level, little is known about how individual muscles recover after SCI. Understanding the prognosis of individual muscles is of interest to plan therapeutic interventions more effectively, particularly when time or resources are limited and must be directed to functions more likely to respond.

Objective: To determine whether recovery patterns following cervical SCI are muscle-specific, with some muscles more likely to recover.

Design/Methods: Complete longitudinal clinical data from 799 individuals with cervical SCI was extracted from the European Multicenter Study about Spinal Cord Injury (EMSCI) dataset. Data analysis was conducted after controlling for injury severity and distance from the lesion, additionally, muscles with a baseline motor score (MS) of 5 were excluded because of ceiling effects. Supervised machine learning models [Model 1: random forest using baseline AIS, MS, distance from the motor level of injury (DST), light touch (LT), and pinprick (PP) sensation] [Models 2-6: random forest for each muscle of AIS A using MS, DST, LT and PP sensation] were used to predict motor recovery (a gain ≥1 in strength at 48 weeks post-SCI). The incorporation of muscle identity as a feature in model 1 was assessed, followed by the muscle-specific models (i.e., models 2-6).

Results: Using the general model (i.e., model 1), we corroborate the importance of baseline AIS and MS in predicting motor recovery. The incorporation of muscle as a feature increased the classification performance of ‘no recovery’ by 2%, supported by the importance of the muscle identity feature in the model. The importance of AIS and muscle identity was evident in the descriptive analysis, reflected in a proximal-to-distal gradient indicating reduced strength loss and better recovery of proximal arm muscles compared to distal hand muscles in AIS A. Finally, in sensorimotor complete SCI, the prediction of strength recovery was good for proximal muscles (e.g., elbow flexors; F1-score = 0.76) but low for hand muscles (e.g., finger flexors and abductors; F1-score = 0.33 and 0.19, respectively) (models 2-6).

Conclusion: The addition of individual muscle information is important for predicting strength recovery following SCI. Hand muscles recover to a lesser extent, compared to the proximal forearm and arm muscles, and this recovery is hard to predict. Future studies should explore additional muscle-specific features to enhance the prediction of strength recovery of hand muscles.

Funding: This work was supported by the Wings for Life Spinal Cord Research Foundation (Project #210).

Keywords: Biomarkers, Clinical Prediction Rule, Physical Examinations and Diagnoses

Abstract ID: #1345 - Award Recipient – Second Place General Submission

Program ID: P2 (Knowledge Generation)

Are we doing enough? Information needs and preferences in individuals living with a pressure injury

Sharon Gabison, PhD¹, Janelle Unger, PhD², Jill Cameron, PhD^{1, 3}, Geoff Roy Fernie, PhD^{1, 4}, Tilak Dutta, PhD^{1, 5}

¹KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ²School of Physical Therapy, Western University, London, ON, CA; ³Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, CA,; ⁴Department of Surgery, University of Toronto, Toronto, ON, CA; ⁵Institute of Biomedical Engineering, University of Toronto, Toronto, ON, CA

Objectives: Pressure Injuries (PIs) are a common secondary complication of immobility and occur from prolonged tissue deformation causing unnecessary pain and suffering. Individuals at risk of developing a PI may be taught about PI prevention and management, however, may not appreciate the detrimental effects of PIs until too late. The objectives of this qualitative study were: 1) To characterize the personal experiences, prior knowledge, and information needs related to PI prevention and management; 2) To determine the preference of information delivery for individuals at risk of developing PIs; and 3) To determine the priority topics with respect to PI education. Design: Qualitative descriptive. Participants: Eight individuals (6 males, mean age 49.8 ± 13.0 years), with a past history of a PI living in the community.

Methods: One-to-two-hour semi-structured phone or in-person interviews using an interview guide with closed and open-ended questions and a questionnaire. Interviews were audio recorded, transcribed and imported into NVivo for data management. Inductive thematic analysis was used to analyze the interview data. Descriptive statistics were used to analyze the questionnaire data.

Results: Participant perception of PI information fell into three main categories: Factors considered when accessing and utilizing information, their emotional response to their PI in the context of their prior knowledge, and behaviours they engaged in when managing or preventing PIs. The emotional responses often helped guide their own behavior as it related to prevention and management of PIs and advocating for themselves. Individuals preferred to receive information by directly interacting with their healthcare provider. The top three topic areas for information were “Preventing PIs”,” Treatment of PIs”, and” Information about best wheelchair cushions”.

Conclusion: Understanding the educational needs and preferences for information delivery for individuals living with PIs may help guide healthcare providers to provide relevant information to help reduce pain and unnecessary suffering. Future studies should explore whether providing relevant and timely educational intervention reduces PI incidence.

Funding: Funding Source: Hallisey Post-Doctoral Fellowship in Technology for Family Caregivers

Keywords: Self-Management, Knowledge Generation, Community Groups

Abstract ID: #1346 – Award Recipient – Third Place (Tied) Post-doc Submission

Program ID: PD4 (Knowledge Generation)

Electrophysiological multimodal assessments improve the prediction of strength recovery in hand muscles after cervical spinal cord injury

Gustavo Balbinot¹, Guijin Li^{1, 2}, Sukhvinder Kalsi-Ryan^{1, 3, 4}, Jose Zariffa^{1, 2, 3, 5}

¹KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ²Institute of Biomedical Engineering, University of Toronto, Toronto, ON, CA; ³Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, CA; ⁴Department of Physical Therapy, University of Toronto, Toronto, ON, CA; ⁵Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON, CA

Background: Upper limb muscles show a proximal-to-distal recovery pattern after sensorimotor or motor complete spinal cord injury (SCI), where distal hand muscles present limited recovery that is difficult to predict. Identifying predictors of distal hand muscle recovery is of interest in optimizing therapeutic interventions and time or resources. Electrophysiological assessments provide information about the integrity of the neural pathways involved in sensorimotor function, and as such may improve the ability to predict recovery at the level of individual muscles.

Objective: To explore the predictive value of electrophysiological multimodal assessments in improving the prediction of strength recovery in hand muscles after cervical SCI.

Design/Methods: Complete longitudinal clinical data, as well as electrophysiological assessments from individuals with motor or sensorimotor complete cervical SCI, were extracted from the European Multicenter Study about Spinal Cord Injury (EMSCI) dataset. Motor evoked potentials (MEP), sensorimotor evoked potentials (SSEP), and nerve conduction studies (NCS) were available for 125, 179, and 159 finger abductor muscles, respectively. Backward binary logistic regression [age, motor score (MS), distance from the motor level of injury (DST), light touch (LT), and pinprick (PP) sensation] was used to predict motor recovery (a gain ≥1 in strength at 48 weeks post-SCI). The incorporation of electrophysiological variables into these models was assessed.

Results: Muscles that had greater MEP and SSEP amplitudes at baseline also displayed strength recovery 48 weeks post-SCI (p < 0.05). Similarly, the outcomes of a scoring system considering MEP and SSEP amplitude and latency indicated that a greater percentage of hand muscles with positive scores at baseline also showed strength recovery 48 weeks post-SCI. MEP but not SSEP scores at baseline were important predictors of strength recovery for the finger abductors, with a 22.8% increase in the classification performance of muscles that recover strength 48 weeks post-SCI.

Conclusion: Individuals with a sensorimotor or motor complete SCI display limited recovery of distal muscles, which is difficult to predict. The addition of electrophysiological multimodal assessments enhances the prediction of strength recovery of hand muscles in individuals with a sensorimotor or motor complete SCI.

Funding: This work was supported by the Wings for Life Spinal Cord Research Foundation (Project #210).

Keywords: Biomarkers, Diagnostic Technics Neurological, Engineering Biomedical

Abstract ID: #1356 (Knowledge Generation)

Prediction of Muscle Response to FES Therapy after Cervical Spinal Cord Injuries Using Surface Electromyography

Guijin Li^{1, 2}, Gustavo Balbinot¹, Sukhvinder Kalsi-Ryan^{1, 3, 4}, José Zariffa^{1, 2, 3, 5}

¹KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ²Institute of Biomedical Engineering, University of Toronto, Toronto, ON, CA; ³Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, CA; ⁴Department of Physical Therapy, University of Toronto, Toronto, ON, CA; ⁵Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON, CA

Background: Cervical spinal cord injuries (SCI) can severely impair the upper limbs, whose recovery has been reported to be the top priority. Functional electrical stimulation (FES) has been used to produce contractions in paretic muscles after cervical SCI and has demonstrated promising results in improving upper limb functions when utilized in therapy. However, muscles respond inconsistently, and the responsiveness is currently unpredictable. To maximize patient outcomes and reduce barriers to access, making best use of the limited therapy time available is of vital importance.

Objectives: To predict the response of target muscles to FES therapy by identifying electrophysiological biomarkers in baseline surface electromyography (SEMG) signals, in order to optimize the efficacy of the therapy in individuals with cervical SCI.

Methods: We analyzed 46 muscles from six participants with cervical SCI undergoing FES therapy at the Toronto Rehabilitation Institute. Prior to the therapy cycle, a list of upper extremity target muscles was identified for each participant by a specialized physiotherapist. Baseline SEMG signals were then recorded from the target muscles during resting and isometric maximal and submaximal voluntary movement attempts. Features from the SEMG signals in both time and frequency domains were extracted. Therapeutic outcome for each target muscle was determined by the net change of the manual muscle testing (MMT) score before and after the FES therapy cycle. Positive net changes indicate strength recovery, and zero or negative indicate no recovery. To predict the FES therapeutic outcome from the SEMG features for each muscle, we explored classifiers including support vector machines (SVM), k-nearest neighbors, logistic regression, and linear discriminant analysis, with dimensionality reduction using principal component analysis and leave-one-muscle-out cross validation.

Results: Linear SVM trained on 6 principal components from SEMG features extracted from submaximal contraction level yielded the best performance (F1 score = 0.77, recall = 91.7%, and precision = 66.7%).

Conclusions: This work demonstrates the feasibility of predicting strength recovery for upper limb muscles undergoing FES therapy from baseline SEMG in individuals with cervical SCI. The model was trained on a small and unbalanced sample and will be optimized with more participants in the future. The prediction will improve the level of personalization and efficacy of FES therapy, and ultimately improve quality of life after SCI.

Funding: Granting Agency: Wings for Life Spinal Cord Research Foundation Project Number: 210

Keywords: Biomarkers, Rehabilitation Outcome, Machine Learning

Abstract ID: #1366 (Knowledge Generation)

Recovery in the dominant vs. non-dominant upper extremity following acute cervical spinal cord injury

Moshi Bondi^{1, 2}, Sukhvinder Kalsi-Ryan^{3, 4}, Jude J. Delparte³, Anthony S. Burns^{3, 5, 6}

¹Department of Neurological Rehabilitation, The Chaim Sheba Medical Center, Tel Hashomer, Israel; ²Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; ³Neural Engineering and Therapeutics Team, KITE (Knowledge Innovation Talent Everywhere) Institute, University Health Network - Toronto Rehabilitation Institute, Toronto, ON, CA; ⁴Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, CA; ⁵Dept. of Medicine, Division of Physiatry, University of Toronto, Toronto, ON, CA; ⁶Staff Physiatrist, Brain & Spinal Cord Rehabilitation Program, University Health Network - Toronto Rehabilitation Institute, Toronto, ON, CA

Objective: To determine whether cerebral dominance influences upper extremity recovery following acute spinal cord injury (SCI).

Methods: Secondary analysis of prospective, longitudinal multicenter study of individuals with acute cervical SCI (n = 73). The Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) and the International Standards for the Neurological Classification of SCI (ISCNSCI), including upper extremity motor and sensory scores, were assessed at 1, 3, 6, and 12 months following injury. Absolute recovery and percent recovery were determined for both measures.

Participants: Individuals with acute cervical SCI.

Results: There were no significant differences (p < 0.05) for absolute and percent recovery, between the dominant and non-dominant upper extremities, as measured using GRASSP subtests, motor scores, and sensory scores.

Conclusion: Cerebral dominance does not appear to play a significant role in upper extremity following acute cervical SCI.

Keywords: Rehabilitation Outcome, Physical Medicine and Rehabilitation, Decision Aids

Abstract ID: #1372 (Knowledge Generation)

Cost and health care utilization in persons with spinal cord injury who have undergone surgical closure of stage 4 pelvic pressure injuries in Ontario, Canada: A descriptive study

Laura M. Teague¹, Susan Jaglal^{2, 3}, Andrew Calzavara³, Jennifer Voth³, Lehana Thabane¹, Stephen Birch¹, Karen Campbell⁴, Colleen McGillivray^{5, 6}, James Mahoney^{7, 8}, Maya Deeb⁹, Gina Browne¹

¹School of Nursing, Master University, Hamilton, ON, CA; ²Faculty of Rehabilitation Sciences, Department of Physiotherapy, University of Toronto, Toronto, ON, CA; ³Institute for Clinical Evaluative Studies, Toronto, ON CA; ⁴School of Nursing, Western University, London, ON, CA; ⁵Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, CA; ⁶Toronto Rehabilitation Institute-University Health Network, Toronto, ON, CA; ⁷Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, ON, CA; ⁸Unity Health, St Michael's Hospital, Toronto, ON, CA; ⁹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, CA

Objective: The purpose of this study was to describe cost and health care utilization in persons with SCI who have undergone surgical flap closure of pelvic PI, using provincial health administrative data in Ontario, Canada.

Methods: 79 patients with 96 confirmed surgical encounters were included in this retrospective cohort study, between April 1, 2003 and April 1, 2013. HCU and costs were recorded for one year, pre-surgery, and annually for three years post-surgery. Socio-demographics were recorded from both the patient records and from linked provincial health administrative databases.

Results: The median health care cost in the look-back year was $42,012 (IQR 21,352-64,279). At year one, two and three post-surgery, the median costs were $95,677 (IQR $45.526-140,473); $10,194 (IQR $2,606-35,475) and $13,184 (IQR $2,434-37,890. All costs were adjusted to 2016 Canadian Dollars. A repeated measures gamma regression model shows that, when comparing total costs in the look-back versus Years 2 and 3, the linear trend is for costs to decrease by approximately $8,034 per year (p <0.01)

Funding: Granting Agency/Funding Source: Ontario Neurotrauma Foundation Grant Number: # 2017-RHI-SURGIC-1024

Keywords: Health Costs, Healthcare Economics and Organizations, Cost

Abstract ID: #1311 – Award Recipient – Second Place General Submission

Program ID: P5 (Technology Innovation)

Recent advances and imminent discoveries in the treatment of primary spinal tumors and spinal metastases: A scoping review of registered clinical studies over the past two decades.

Julio C. Furlan, MD, LLB, MBA, MSc, PhD, FRCPC^{1, 2, 3, 4, 5}, Jefferson R. Wilson, MD, PhD, FRCSC^{6, 7}, Eric M. Massicotte, MD, MSc, FRCSC^{6, 8}, Michael G. Fehlings, MD, PhD, FRCSC, FACS, FRSC^{6, 8}

¹Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, CA; ²KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ³Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, CA; ⁴Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, CA; ⁵Institute of Medical Sciences, University of Toronto, Toronto, ON, CA; ⁶Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, ON, CA; ⁷St. Michael’s Hospital, Toronto, ON, CA; ⁸Toronto Western Hospital, University Health Network, Toronto, ON, CA

Objective: This scoping review was performed to synthesize and appraise what was learned and what will potentially be discovered from the recently completed and ongoing clinical studies related to the treatment of primary and secondary spinal neoplasms that were registered in the ClinicalTrials.gov website.

Methods: This scoping review included all clinical studies on the treatment of spinal neoplasms registered in the ClinicalTrials.gov website from February 2000 to December 2020. The terms “spinal cord tumor”, “spinal metastasis”, and “metastatic spinal cord compression” were used to identify the clinical studies focused on the treatment of spinal neoplasms.

Participants: Individuals with primary spinal tumors or spinal metastasis.

Results: Of the 174 registered clinical studies, the vast majority of the clinical studies registered in this American registry were interventional studies led by single institutions in the North America (n=101), Europe (n=43), Asia (n=24) or other continents (n=6). The registered clinical studies mainly focused on treatment strategies for spinal neoplams (90.2%) that included studies related to stereotactic radiosurgery (n=33), radiotherapy (n=21), chemotherapy (n=20), and surgical technique and instrumentation (n=11). There were also fewer clinical studies related to registries (3.4%) or to diagnosis (2.3%), prognosis (2.3%) and prevention (1.7%). Of the 69 completed clinical studies, the results from 44 studies were published in the medical literature including advances in surgical treatment (n=13), non-surgical interventions such as new radiotherapic techniques and chemotherapies (n=30), or a novel assessment tools in the field of spinal oncology (n=1).

Conclusion: The results of this scoping review highlight the key features of the 174 clinical studies on primary spinal tumors and spinal metastasis that were registered from 2000 to 2020. Most of those research initiatives have been interventional studies on stereotactic radiosurgery, chemotherapy, and external radiotherapy. Given that North American and European institutions led most of the clinical studies in this field, their applicability in Asian, African and Latin American countries may be limited due to the dissimilarities in the epidemiology of spinal neoplasms, healthcare access and coverage among different populations. The rarity and heterogeneity of spinal neoplasms represent a major challenge in the recruitment of participants and affordability of clinical studies in spinal oncology that often require long-term sustainability.

Keywords: Technology Health, Effective Practice, Therapies

Abstract ID: #1336 – Award Recipient – First Place Post-doc Submission

Program ID: PD1 (Technology Innovation)

Automatic detection of hand-object interactions in individuals with tetraplegia living in the community via egocentric video and long-term recurrent convolutional networks

Andrea Bandini¹, Mehdy Dousty^{1, 2}, José Zariffa^{1, 2, 3, 4}

¹KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ²Institute of Biomedical Engineering, University of Toronto, Toronto, ON, CA; ³Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON, CA; ⁴Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, CA

Background: Regaining functional use of the hands is the top recovery priority for most individuals with cervical spinal cord injury (cSCI). Wearable cameras and computer vision have been used to quantify hand function in a natural context, for example by detecting the presence of hand-object interactions. These approaches constitute the basis for producing novel outcome measures of hand function in people with cSCI living in the community. However, previous approaches for detecting hand-object interactions in cSCI either considered the video as a set of independent frames or included temporal information between consecutive frames only, disregarding the temporal dependency of longer sequences of frames. Objective: To evaluate how the temporal information influences the recognition of hand-object interaction in a natural setting, by comparing frame-by-frame and temporal deep learning models for video analysis. Participants: 9 participants with cSCI (53.4±7.5 years), C3-C8, AIS A-D impairment.

Methods: Participants recorded unscripted activities of daily living with a head-mounted camera (GoPro Hero5) over 2 weeks in their homes. Video frames were processed to automatically detect the presence of hand-object interactions. After detecting the presence of hands via an object detection neural network (YOLOv2), the hand regions of interest (ROIs) were classified into “interaction” and “no-interaction” using two approaches: a frame-by-frame image classification network (VGG16) and a video classification network (VGG16 plus 2 bidirectional long-short-term-memory layers) to classify short video segments of 1s duration. The two models were retrained using our dataset and performance was evaluated in a leave-one-subject-out manner. The experiments were conducted on 92,130 frames manually labeled by a trained annotator. F1-score was used to assess the classification performance.

Results: Higher F1-score was obtained with the video classification network (0.71 vs 0.68), suggesting that temporal information can help improve the hand-object interaction detection performance.

Conclusion: The inclusion of the temporal information improved the model recognition performance and should be considered in future studies pertaining to the analysis of hand use in individuals with cSCI. The validation of this approach on an expanded dataset will allow producing novel outcome measures of hand use, with the goal of enabling remote assessment for individuals with cSCI living in the community. Funding: Craig H. Neilsen Foundation (542675).

Funding: This study was supported by the Craig H. Neilsen Foundation (542675)

Keywords: AI (Artificial Intelligence), Computer Vision Systems, Rehabilitation Outcome

Abstract ID: #1337 (Technology Innovation)

A web-based interface for monitoring hand use in people with cervical spinal cord injury living in the community

Andrea Bandini¹, Adesh Kadambi^{1, 2}, Ryan D. Ramkalawan¹, Sander L. Hitzig^{3, 4, 5}, José Zariffa^{1, 2, 3, 6}

¹KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ²Institute of Biomedical Engineering, University of Toronto, Toronto, ON, CA; ³Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, CA; ⁴St. John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, CA; ⁵Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, ON, CA; ⁶Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON, CA

Background: Functional use of the upper limbs (ULs) is the top recovery priority in individuals with cervical spinal cord injury (cSCI). Wearable cameras and computer vision have the potential to produce outcome measures that reflect hand function in a natural context. However, there is a need to identify ways to summarize and report video data in meaningful ways to support clinical decision-making.

Objective: To determine the most effective way to summarize hand information collected with wearable cameras to report metrics of hand function to clinicians and community-dwelling individuals with cSCI.

Participants: 7 clinicians (2 physiatrists, 2 physiotherapists, 3 occupational therapists) and 4 individuals with cSCI (AIS C-D, C3-C5). Individuals with cSCI had previous experience with wearable cameras, as they participated in a related study for developing computer vision techniques for monitoring hand function at home.

Methods: Clinicians were split into 2 focus groups to discuss ways of reporting hand function information collected from people with cSCI living in the community. Due to the COVID-19 pandemic, discussion with individuals with cSCI was conducted individually via remote interviews. The discussion focused on what pieces of information are relevant to clinical practice, how data can be summarized and presented in practical and convenient ways, what types of information could help better express how hands are functioning at home, and how the collected information can improve care delivery. A web-based interface prototype was designed after the first round of meetings and refined after follow-up interviews.

Results: Three rounds were required to reach a consensus among participants regarding the content to report in the web-based interface. Reports of hand function were divided into 2 pages: quantity of hand use (i.e., number and duration of hand-object interactions) and quality of hand use (i.e., type of hand grasps). Physiatrists expressed a preference for high-level information, such as plots of measures of hand function, whereas therapists preferred to watch short chunks of video recordings.

Conclusion: A modular web-based interface that allows users to select the information to show (videos or summary plots of hand function) was designed. In conjunction with wearable cameras and artificial intelligence, this interface will make it possible to bridge the gap between rehabilitation centers and patients’ homes to monitor hand function remotely and optimize UL therapy in individuals with cSCI.

Funding: Craig H. Neilsen Foundation (542675)

Funding: This study was supported by the Craig H. Neilsen Foundation (542675)

Keywords: Rehabilitation Outcome, Software Tool, Software Engineering

Abstract ID: #1344 – Award Recipient – First Place General Submission

Program ID: P4 (Technology Innovation)

Improving Activity Engagement among persons with spinal cord injury during COVID-19: Virtual Physical Activity Program Feasibility Study

Swati Mehta^{1, 2}, Eldon Loh^{1, 2}, Randy Upper¹, Jess Ahrens¹, Zeina Abu-Jurji¹, Stephanie Marrocco¹, Dalton L. Wolfe¹

¹Parkwood Institute Research, Lawson Health Research Institute, London ON, CA; ²Dept. of Physical Medicine and Rehabilitation, Western University, London ON, CA

Background: The current pandemic has reduced access to safe, monitored physical activity (PA) programs for persons with spinal cord injury (SCI). Inactivity can contribute to a multitude of secondary complications including worsening physiological and psychosocial health. The use of telerehabilitation has the potential for continuing activity engagement without the risk of virus exposure. The present study evaluates the feasibility and limited efficacy of an online group based PA program for persons with SCI.

Methods: This preliminary pre-post study delivered an online group based PA program to persons with SCI (n=5). Inclusion criteria were the following: 18 years or older; sustained an SCI; living in the community; some upper limb function permitting arm movement against gravity. The program consisted of 50-minute sessions twice weekly for six weeks. After each session participants completed an adverse events diary and rate of perceived exertion. Psychosocial subscales from the NeuroQOL-SF were assessed at baseline and post-intervention. Paired sample t-tests were used to assess limited efficacy on outcomes of interest. Online PA satisfaction questionnaires were assessed at post-treatment.

Results: Participants were between 3 - 32 years post-injury, females, and between the ages of 36 and 76 . 3 of the participants had quadriplegia and 4 had an incomplete injury. The program resulted in significant improvement post intervention on anxiety (p

Keywords: Self-Management, Technology Health Care, Healthcare Delivery

Abstract ID: #1347 (Technology Innovation)

Development of a coaching system for functional electrical stimulation rowing

Shirin Tajali¹, Pirashanth Theventhiran^{1, 2}, Gongkai Ye^{1, 2}, Hikaru Yokoyama^{1, 3}, Kento Nakagawa^{1, 4}, Kei Masani^{1, 2}

¹Lyndhurst Centre, KITE Research Institute - University Health Network, 520 Sutherland Drive, M4G 3V9, Toronto, ON, CA; ²Institute of Biomedical Engineering, University of Toronto, 164 College Street, M5S 3G9, Toronto, ON, CA; ³Tokyo University of Agriculture and Technology, Department of Electrical Engineering and Computer Science, Nakacho, Koganei, Tokyo, Japan; ⁴Graduate School of Arts and Sciences, The University of Tokyo, 3-8-1 Komaba, Meguro-ku, Tokyo, 153-8902, Japan

Background: Functional electrical stimulation (FES) rowing has substantial effects on cardiovascular fitness in individuals with spinal cord injury. Currently, the manual stimulation control where stimulation switching is controlled by the rower has been mostly utilized. However, this type of control would require training to ensure that the stimulation is applied at an appropriate time during the rowing stroke. In addition, improper timing may impair coordination between upper and lower limbs, eventually preventing the individual from receiving the full benefits of this exercise. Therefore, there seems to be a need to develop a coaching system targeting the appropriate timing of FES to the lower limb muscles.

Objectives: The aims of this study were to: (1) determine the optimal timing for FES application in the able-bodied individuals during rowing on an instrumented rowing ergometer, (2) develop a coaching system by which individuals can administer FES to the lower limb muscles at the optimal timing.

Methods: In the first study, the electromyograms were recorded from lower limb muscles including rectus femoris (RF), vastus lateralis (VL) and medialis (VM), biceps femoris (BF), medial (MG) and lateral gastrocnemius (LG), soleus (SOL) and tibialis anterior (TA) during rowing in 10 able-bodied individuals. In the second study, we developed a coaching system (figure 1) based on the first study, and investigated its effects on the improvement of press button timing in 7 able-bodied individuals. Two trials were randomly performed including one trial with and the other without the coaching system.

Results: RF, VL, VM, MG, LG and SOL were predominantly active during the drive phase, while BF was mostly active in the both drive and recovery phases of a rowing stroke. The quadriceps femoris muscles, particularly VL, had the onset of activation at a constant timing before the end of recovery phase. Therefore, the mean of seat position at the onset of VL was used to guide the coaching system. We demonstrated that the timing of button pressing clustered significantly before the anterior-most seat position with the coaching system. However, it varied before and after the anterior-most seat position without the coaching system (figure 2).

Conclusions: The coaching system can improve the timing of manual switch during FES-rowing, which can potentially provide more exercise benefits in individuals with spinal cord injury.

Funding: CIHRProject Grant PJT148851 - Wings For LifeResearch Grant

Keywords: Bio-Engineering, Health Technology, Rehabilitation Outcome

Abstract ID: #1354 (Technology Innovation)

Using a machine learning approach to optimize collection and analysis of quality indicators across systems and services: SCI-High Cardiometabolic Health

Matheus Joner Wiest^{1, 2}, Krista L. Best^{3, 4}, Farnoosh Farahani¹, Dany H. Gagnon^{4, 5}, B. Catharine Craven^{1, 6, 7}

¹KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, CA; ²Ontario Neurotrauma Foundation, Toronto, ON, CA; ³Faculty of Medicine, Université Laval, Québec, QC, CA; ⁴Center for Interdisciplinary Research in Rehabilitation and Social Integration - CIRRIS, Québec, QC, CA; ⁵School of Rehabilitation, Université de Montréal, Montreal, QC, CA; ⁶Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ⁷Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, CA

Background: About 40% of medical records in Canada are paper-based, resulting in prolonged time periods for data extraction and quality indicator reporting. Beyond rehab discharge, there is a dearth of health system reporting in Ontario and Québec. In order to understand the rehab processes that contribute to optimal patient outcomes, it is necessary to collect data from tertiary rehab hospitals and community settings and link the data in a timely manner.

Objective: to describe the development of a machine learning platform to collect Cardiometabolic Health quality indicators for data collection in rehabilitation and community settings in Toronto and Québec City.

Design: Indicators were designed to be collected by health practitioners in rehab hospitals and community fitness centres using paper-based multiple-choice surveys in English and French. The Cardiometabolic Health process and outcome indicators capture physical exercise education during rehabilitation, adherence to at least 30-min of moderate to vigorous intensity aerobic exercise 3 times per week in the community, and the routine assessment of lipid profiles during and post-rehabilitation. Once recorded, paper-based survey data can be automatically extracted using Reachlite, which uses a combination of machine learning capabilities, optical character recognition, and optical mark recognition algorithms. Survey data elements are then linked to Excel outputs using pre-defined pathways. Reachlite can store data locally or share de-identified data with the central site for reporting and benchmarking.

Participants: two tertiary SCI rehab centres and affiliated community fitness providers.

Findings: Measures of success include: 1) positive feedback from users regarding survey clarity and ease of use; 2) ease of conversion from paper to digital format using scanners (time, type of device); 3) timely data extraction and compilation through Reachlite, which is currently done in less than 10 s/survey; 4) accuracy of data extraction and repetitive compilation; 5) software flexibility and simplified data analysis and distribution; and, 6) software compatibility with existing hardware.

Conclusion: Reachlite optimizes data collection and extracting processes across languages, settings (hospital and community), and populations (inpatients and outpatients). The availability of this machine learning approach will help to reduce health inequities and bring a greater understanding of Cardiometabolic Health across the care spectrum.

Funding: Dr. Wiest is funded by the Ontario Neurotrauma Foundation and the Canadian Institute of Health Research (CIHR - HI5-166374). The SCI-High indicator development was funded by Praxis Spinal Research Institute.

Keywords: Machine Learning, Data Processing Automatic, Clinical Application

Abstract ID: #1357 (Technology Innovation)

Postural Analysis of the Hand in Individuals with Spinal Cord Injury Using Egocentric Video

Mehdy Dousty^{1, 2}, David J. Fleet³, José Zariffa^{1, 2, 4, 5}

¹Institute of Biomedical Engineering, University of Toronto, Toronto, ON, CA; ²Kite, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, CA; ³Department of Computer Science, University of Toronto, Toronto, ON, CA; ⁴Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, CA; ⁵Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON, CA

Background: Hand function is a priority for recovery following spinal cord injury (SCI). Existing evaluation occurs in clinics, which may not reflect hand function well in the living environment, thus hampering assessment of new treatments and their impact. Wearable cameras (egocentric video) offer a novel way to analyze hand function and deliver rehabilitation in non-clinical environments, but manual processing large volumes of complex video data is fraught, emphasizing the need for automated data analysis. Hand posture and grasping strategies are important considerations in examining the impact of rehabilitation interventions targeting hand function.

Objective: The objective of this study is to introduce a novel algorithm based on state-of-the-art artificial intelligence methods to summarize the hand postures being used in an egocentric video.

Methods: An uninjured participant and three individuals with cSCI participated in this study. After estimating hand location using YOLO-v2, a pose estimation algorithm (OpenPose) was used to estimate 2D joint locations. Next, the results were lifted to 3D coordinates, which were used as input to a range of clustering methods. Finally, the cluster centers were selected to visualize the hand postures.

Results: Among the clustering methods examined, Gaussian mixture models (GMM) and spectral clustering using the Manhattan distance achieved the highest performance. For the uninjured participant, the GMM had 0.87 purity (varies between 0 and 1) and 0.31 Silhouette score (varies between -1 and 1), and spectral clustering had 0.84 purity and 0.37 Silhouette score. For individuals with cSCI, the purity was computed using 10 frames selected from the cluster centroids. The purity and Silhouette score for individuals with cSCI were 0.82 +0.01 and 0.18+- 0.01, and 0.80 +-0.01, 0.18+- 0.01 for GMM and spectral clustering, respectively.

Conclusions: This is the first attempt to summarize the hand postures used after cSCI by using wearable technology in non-clinical environments. These results demonstrate successful clustering of similar hand postures in both uninjured and injured participants.

Funding: This study was supported in part by the Natural Sciences and Engineering Research Council of Canada (RGPIN-2014-05498)the Praxis Spinal Cord Institute (G2015-30)the Ontario Early Researcher Award (ER16-12-013)and the Craig H.Neilsen Foundation (542675).

Keywords: Technology Biomedical, Personal Digital Assistant, AI (Artificial Intelligence)

Abstract ID: #1377 – Award Recipient – Third Place General Submission

Program ID: P6 (Technology Innovation)

Individualized Exergaming in Spinal Cord Injury

Sussan Askari¹, Gabriele Cimolino², T.C. Nicholas Graham²

¹Department of Physical Medicine and Rehabilitation, Queen's University, Kingston, On, CA; ²School of Computing, Queen's University, Kingston, ON, CA

Background: Physical inactivity is common following spinal cord injury. Exergaming is shown to be as effective as physiotherapy and provides a more enjoyable experience than traditional physiotherapy.

Objectives: To determine the effect of exergaming on: enjoyment of physiotherapy; effectiveness of input automation, and participants’ attitude toward the use of input automation to personalize games according to their abilities.

Methods: This exploratory study used qualitative measures based on observations and responses collected from questionnaires and interviews of 6 SCI subjects (AIS A, B and C), C4 toT11 level of injuries, mean age of 29.8 years. This was a single 90-minute session. SCI subjects used MOTOmed Symmetry Train for 5 minutes and completed a questionnaire. Subsequently, the subjects played Liberi, 2 rounds, 5 minutes each, and completed a gameplay experience questionnaire followed by a semi-structured interview. The input was automated by an Artificial Intelligence (AI) game-playing agent to allow personalization of the Liberi exergames to people with different level of SCI. To make the Liberi exergames accessible to SCI subjects, the gaming interface was adapted using an Xbox Adaptive Controller, joystick, and a GlassOuse Bite Switch.

Results: All SCI participants with different levels of injuries were able to play the adapted Liberi exergames. The subjects felt they had “greater participation” using the MOTOmed while playing Liberi. Those who were unable to actively pedal the device believed that they could take an “active role” in physiotherapy by playing Liberi. The individuals “enjoyed” that Liberi gave them something to do with their idle hands and minds.

Conclusion: Partial automation can be a promising avenue to extend a game’s accessibility to SCI subjects with different neurological level of injuries. Future research is required to guide how to convey the role of AI in shared control to subjects.

Keywords: AI (Artificial Intelligence), Innovative DiscoveryTechnology, Health