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Purpose. Accelerated degradation models are emerging as ways to characterize the interaction between disability and the functional decline of aging and to provide insights about the processes of aging with disability. Typically the models employ sophisticated mathematical treatments that are beyond the scope of many clinicians, lawyers, and others who might benefit from the information they contain. The purpose of this report is to characterize some rudimentary features of the models, in more readily understandable language, and illustrate how understanding of the underlying constructs can influence decisions regarding resource allocation and other projections of future care needs. Methods. A literature review of longitudinal aging and disability studies was completed and simplified mathematical modeling undertaken, with hypothetical data, to illustrate various outcomes of the interaction of disability with the functional decline of aging. A specific example, drawn from personal injury litigation, i.e. projection of future care costs, was used to illustrate the practical applicability of this conceptual model. Conclusion. Awareness of the accelerated functional decline brought about by the superimposition of age-related functional losses on pre-existing disability reveals a need to provide for aids and personnel supports at an earlier age than might be expected because of the multiplicative interaction and the inadequacy of functional reserves to compensate for the disability. [ABSTRACT FROM AUTHOR]

Purpose. To identify and evaluate the lower limb amputation rehabilitation outcome measurement instruments that quantify those outcomes classified within the International classification of functioning, disability and health (ICF) category of body function or structure. This was done to summarise the current evidence base for the most commonly used outcome measurement tools and to provide clinicians with recommendations on how specific tools might be selected for use. Method. A systematic review of the literature associated with outcome measurement in lower limb amputation rehabilitation was conducted. Only articles containing data related to metric properties (reliability, validity or responsiveness) for an instrument were included. Articles were identified by electronic and hand-searching techniques and were subsequently classified according to the ICF. Results. Sixteen instruments were identified that were classified into one of Global mental function (12), Sensory and pain (1), Cardiovascular and respiratory (1) and Neuromusculoskeletal and movement (2). Evidence about metric properties and clinical utility was summarised in tables, which formed the basis for conclusions. Conclusions. Few well-validated body function tools exist in the amputee literature, which may explain their lack of widespread use. For all scales, responsiveness to intervention has not been well established and should be the focus of future studies along with continued establishment of validity and reliability. [ABSTRACT FROM AUTHOR]

Purpose. To identify and evaluate the lower extremity amputee (LEA) rehabilitation outcome measurement instruments that quantify those outcomes that have been classified within the ICF category of activities. This was done to assist the clinicians in the selection of the most appropriate instrument based upon four determinants of successful LEA rehabilitation and outcome measurement. Method. A systematic review of the literature associated with outcome measurement in LEA rehabilitation was conducted. Only articles containing data related to metric properties (reliability, validity or responsiveness) for an instrument were included. Articles were identified by electronic and hand-searching techniques and were subsequently classified first according to the ICF and then by their clinical use. Results. Seventeen instruments were identified that were classified into one of (A) walk tests, (B) mobility grades and (C) indices (generic and amputee-specific). Evidence about metric properties and clinical utility was summarised in tables which formed the basis for conclusions and recommendations pertaining to LEA rehabilitation. Conclusions. All instruments examined have the potential for some use within the initial rehabilitation trial following amputation. There is a universal absence of quality evidence demonstrating responsiveness and most instruments would benefit from further investigation to better define their optimal use. [ABSTRACT FROM AUTHOR]

Study design:Prospective, observational cohort study.Objectives:This paper describes the rationale and methodology for the Study of Health and Activity in People with Spinal Cord Injury (SHAPE SCI). The study aims to (1) describe physical activity levels of people with different injury levels and completeness, (2) examine the relationship between physical activity, risk and/or presence of secondary health complications and risk of chronic disease, and (3) identify determinants of physical activity in the SCI population.Setting:Ontario, Canada.Methods:Seven hundred and twenty men and women who have incurred a traumatic SCI complete self-report measures of physical activity, physical activity determinants, secondary health problems and subjective well-being during a telephone interview. A representative subsample (n=81) participate in chronic disease risk factor testing for obesity, insulin resistance and coronary heart disease. Measures are taken at baseline, 6 and 18 months.Conclusion:SHAPE SCI will provide much-needed epidemiological information on physical activity patterns, determinants and health in people with SCI. This information will provide a foundation for the establishment of evidence-based physical activity guidelines and interventions tailored to the SCI community.Spinal Cord (2008) 46, 216-221; doi:10.1038/sj.sc.3102103; published online 24 July 2007. [ABSTRACT FROM AUTHOR]

Plasma concentration profiles of the K+ channel-blocking compound Fampridine were obtained from (1) control subjects (n = 6) following oral administration of doses of 10, 15, 20, and 25 mg and (2) patients with spinal cord injury (SCI) (n = 11) following a single oral dose of 10 mg of an immediate-release formulation. Plasma concentrations were determined using a reversed-phase ion-pair high-performance liquid chromatography (HPLC) assay with ultraviolet light detection employing liquid extraction. The drug was rapidly absorbed with a tmax approximately 1 hour for both groups; tmax was independent of dose. Cmax and AUC0-infinity were linearly related to dose, and t 1/2 was 3 to 4 hours for both groups. There were no obvious differences in the (10-mg) plasma concentration profiles between control subjects and SCI patients. The drug was well tolerated, with only mild and transient side effects of light-headedness, dysesthesias, and dizziness. [ABSTRACT FROM AUTHOR]

Objective: Parkwood VIP4SCI platform is a virtual e-health solution adapted from a version created for Spinal Cord Injury Ontario (SCIO) that focused on self-management skill development for persons with spinal cord injury (SCI) transitioning between stages of care, in partnership with caregivers and clinicians. This evaluation of the platform informs the usability and feasibility of a model to facilitate service care aims postrehabilitation., Design: Participants: Inpatients and outpatients admitted to the SCI Rehabilitation Program (n = 31), and a mix of interdisciplinary clinicians on the Rehabilitation Team (n = 20). Caregivers participated at the discretion of the patient. Interventions: Inpatients were randomized into two groups (Platform or Standard Care (i.e., delayed access)). Outpatients were given access at enrollment. Pre-post assessments were completed using surveys, and platform analytics were collected. Weekly check-ins were introduced to increase engagement. Focus groups were held with a subset of participants near study completion., Results: VIP4SCI was viewed as usable and feasible. Platform satisfaction assessed on a -3 to +3 scale ranged from +0.9 to 2.5, demonstrating positive agreement. Self-efficacy related to self-management ranged from 5.4 to 7.6 out of 10. The educational resource hub was identified as the most beneficial feature. Lack of clinician uptake was a barrier to integration into day-to-day practice., Conclusions: Platform usage was low among all groups despite the perceived need for facilitating care coordination with consistent and intentional self-management programming. Despite the lack of uptake, partly due to challenges associated with the pandemic, conclusions on platform features and barriers to implementation will help to inform future programming., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Introduction: Possibilities Project Plus (PPPlus) is a free assistive device (AD) marketplace and research platform for persons with disabilities. The overall aim of PPPlus is to increase access to ADs through an integration of service, research and education. To maximize positive outcomes and reflect community needs a co-design approach informed by guiding principles of Integrated Knowledge Translation (IKT) was adopted, with examination of methods related to Experience Based Co-design. The integrated nature of PPPlus benefits from the use of specific engagement strategies that align with IKT principles to meet project objectives. The extent to which partnership and engagement strategies are specified in the rehabilitation research literature vary greatly and studies that provide information on specific strategies used to operationalize principles are limited. The objective of this manuscript is to provide a description of the co-design approach and the specific strategies that strive to achieve meaningful user engagement. By reflecting on these processes we also report on limitations and strategies for improvement., Methods: The co-design approach is highlighted through specific project activities including a representative governance structure, ongoing environmental scan and iterative Health Equity Impact Assessments (HEIA). The inherent engagement strategies that align with IKT and co-design principles are described., Discussion: The most impactful engagement strategies included early engagement of partners throughout all phases, ensuring project relevance across partners through alignment of objectives with complementary aims, using HEIAs to promote equitable outcomes from diverse stakeholders, the representative governance structure beyond individuals with disabilities and caregivers, and the use of experiences and stories to inform development., Next Steps: This examination of specific strategies related to co-design focused on partnership engagement and informed targets for enhancement of the PPPlus initiative. These include being more intentional in developing a more rigorous process for evaluation that includes an assessment of strategies and their impact-especially as related to partner engagement. In addition, ongoing and enhanced efforts will focus on developing knowledge products that bring to life the most salient experience-based user stories emerging from the environmental scan with these being used to drive distinct co-creation events as well as serve other knowledge mobilization purposes (i.e., supporting policy change)., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Jeyakumaran, Eggiman-Ketter, Spadzinski and Wolfe.)

Objective: This qualitative study aims to identify a comprehensive set of enablers and barriers to implementing an interdisciplinary experiential learning program for university students at a Canadian rehabilitation centre., Methods: A researcher conducted one-on-one semi-structured interviews with individuals from four key stakeholder groups (i.e., rehabilitation centre leadership, clinicians, university clinical coordinators, and health and rehabilitation students). Interviews and data analysis followed the Theoretical Domains Framework (TDF), which is designed to identify possible cognitive, affective, social, and environmental influences on program implementation. Interviews were transcribed verbatim, and two researchers coded data independently to identify the major themes of enablers and barriers to implementing an interdisciplinary experiential learning approach to rehabilitation care., Results: From a total of 12 interviews, domains of the TDF were identified to represent overarching themes, which were (1) enablers (i.e., reinforcement, beliefs and consequences, optimism, professional identity, knowledge, and skills), (2) barriers (i.e., environment/resources and beliefs and capabilities), and (3) program development (i.e., goals and evaluation that was not previously a TDF domain). A list of recommendations for implementing an interdisciplinary experiential learning program was created that represented qualitative data from each stakeholder group., Conclusion: This study provides insight into the potential enablers and barriers to developing an interdisciplinary experiential learning program for university students within rehabilitation centres. This type of program could enhance educational curriculums, student and clinical experiences, and patient outcomes. In this study, the findings inform recommendations for developing an interdisciplinary program in teaching hospitals and explore their potential impact. Future research and pilot studies must be conducted to fully understand the effects of implementing an interdisciplinary experiential learning approach within rehabilitation centres., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Eggiman-Ketter, Derrough, Wolfe and Unger.)

Background: Despite preventability, 20-50% of patients with acute spinal cord injury/disease (SCI/D) develop hospital-acquired pressure injuries (PIs). The Spinal Cord Injury Implementation and Evaluation Quality Care Consortium (SCI IEQCC) aimed to mitigate PI risk through patient-reported daily skin checks alongside usual care., Methods: This quality improvement initiative utilized an interrupted time series design, encompassing adults ≥ 18 years admitted for inpatient rehabilitation across five Ontario sites from 2020 to 2023. Patient demographics, etiology, and impairment data were obtained from a national registry, while participating sites gathered data on PI onset, location, and severity. Run charts depicted temporal trends, and statistical analyses, including chi-square and logistic regression, compared patients with and without PIs., Results: Data from 1767 discharged SCI/D patients revealed that 26% had ≥1 PI, with 59% being prevalent and 41% incident. Most severe PIs (stages III and IV and unstageable) were acquired prior to admission. Process indicator fidelity was reasonable at 68%. Patients with PIs experienced longer hospital stays, lower Functional Independence Measure (FIM) changes, and FIM efficiency during rehabilitation., Conclusions: PI prevalence is increasing, particularly sacral injuries at admission, while incident cases have decreased since 2021 due to regular skin checks. This trend calls for proactive health system interventions to reduce costs and improve patient outcomes.

Background: Most individuals living with spinal cord injuries/diseases (SCI/D) or stroke experience at least one fall each year; hence, the development of interventions and technologies that target balance control is needed. The purpose of this study was to identify and explore the priorities for balance-focused interventions and technologies from the perspectives of end-users to assist with the design of an intervention that combines functional electrical stimulation (FES) with visual feedback training for standing balance., Methods: Two individuals with SCI/D, one individual with stroke, two physical therapists (PT) and one hospital administrator were recruited. Participants attended three focus group meetings that followed a participatory co-design approach. A semi-structured interview guide, developed from the FAME (Feasibility, Appropriateness, Meaningfulness, Effectiveness, Economic Evidence) framework, was used to lead the discussion, querying participants' experiences with balance deficits and interventions, and FES. Meetings were audio-recorded and transcribed verbatim. An iterative and reflexive inductive thematic analysis was applied to the transcripts by three researchers., Results: Four themes were identified: (1) Balance is meaningful for daily life and rehabilitation. Participants acknowledged various factors influencing balance control and how balance deficits interfered with participation in activities. End-users stressed the importance of continuing to work on one's balance after discharge from hospital-based rehabilitation. (2) Desired characteristics of balance interventions. Participants explained that balance interventions should be tailored to an individual's unique needs and goals, relevant to their lives, balance their safety and risk, and be engaging. (3) Prior experiences with FES to inform future therapeutic use. Participants with stroke or SCI/D described initial apprehension with FES, but experienced numerous benefits that motivated them to continue with FES. Challenges with FES were mentioned, including wires, cost, and time of set up. (4) Potential role of FES in balance interventions. Participants felt that FES would complement balance interventions; however, they had not experienced this combination of therapies previously., Conclusions: End-users described how their experiences with balance deficits, rehabilitation, and FES informed their priorities for balance interventions. The findings inform the design and implementation of future balance interventions for individuals with SCI/D or stroke, including an intervention involving FES and visual feedback training., (© 2023. The Author(s).)

Objective: Mild traumatic brain injuries (mTBIs) are common and may result in persisting symptoms. Mobile health (mHealth) applications enhance treatment access and rehabilitation. However, there is limited evidence to support mHealth applications for individuals with an mTBI. The primary purpose of this study was to evaluate user experiences and perceptions of the Parkwood Pacing and Planning™ application, an mHealth application developed to help individuals manage their symptoms following an mTBI. The secondary purpose of this study was to identify strategies to improve the application. This study was conducted as part of the development process for this application., Methods: A mixed methods co-design encompassing an interactive focus group and a follow-up survey was conducted with patient and clinician-participants (n = 8, four per group). Each group participated in a focus group consisting of an interactive scenario-based review of the application. Additionally, participants completed the Internet Evaluation and Utility Questionnaire (UQ). Qualitative analysis on the interactive focus group recordings and notes was performed using phenomenological reflection through thematic analyses. Quantitative analysis included descriptive statistics of demographic information and UQ responses., Results: On average, clinician and patient-participants positively rated the application on the UQ (4.0 ± .3, 3.8 ± .2, respectively). User experiences and recommendations for improving the application were categorized into four themes: simplicity, adaptability, conciseness, and familiarity., Conclusion: Preliminary analyses indicates patients and clinicians have a positive experience when using the Parkwood Pacing and Planning™ application. However, modifications that improve simplicity, adaptability, conciseness, and familiarity may further improve the user's experience., Competing Interests: This mobile application was created to support a government-funded brain injury rehabilitation program. Although Laura Graham and Becky Moran are employed as clinicians at Parkwood Institute, the authors have no financial interest in the results of this study., (© The Author(s) 2023.)

Study Design: Cross-sectional equipment inventory., Objectives: The objective of this study was to describe the equipment used in activity-based therapy (ABT) programs for individuals with spinal cord injury or disorder (SCI/D) across Canada., Settings: Publicly funded and private SCI/D care settings., Methods: A survey on equipment available for ABT for different therapeutic goals was answered by Canadian sites providing SCI/D rehabilitation. Information about the setting and type of client were also collected. The survey results were compiled into an inventory of the reported types and use of ABT related equipment, with equipment grouped into varying levels of technology. Descriptive statistics and qualitative descriptive analysis were used to answer the questions: (1) 'who' used the equipment, (2) 'what' types of equipment are used, (3) 'why' (i.e., for which therapeutic goals), and (4) 'how' it is used., Results: Twenty-two sites from eight Canadian provinces completed the survey. Reported equipment was classified into 5 categories (from low to high-tech). Most equipment reported was used to train balance. The high-tech equipment reported as available, was mostly used for walking training and strengthening of the lower limbs. Low-tech equipment was reported as being used most frequently, while high-tech devices, although available, were reported as infrequently or rarely used., Conclusions: A large spectrum of equipment with varying levels of technology were reported as available, but were inconsistently used to provide ABT interventions across sites. In order to increase the clinical use of available equipment for ABT, education tools such as protocols regarding ABT principles and implementation are needed., (© 2023. The Author(s).)

Context: Endocrine-metabolic disease (EMD) is associated with functional disability, social isolation, hospitalization and even death in individuals living with a chronic spinal cord injury (SCI). There is currently very low-quality evidence that rehabilitation interventions can reduce EMD risk during chronic SCI. Non-randomized trials and alternative study designs are excluded from traditional knowledge synthesis., Objective: To characterize evidence from level 3-4 studies evaluating rehabilitation interventions for their effectiveness to improve EMD risk in community-dwelling adults with chronic SCI., Methods: Systematic searches of MEDLINE PubMed, EMBASE Ovid, CINAHL, Cochrane Database of Systematic Reviews, and PsychInfo were completed. All longitudinal trials, prospective cohort, case-control studies, and case series evaluating the effectiveness of rehabilitation/therapeutic interventions to modify/associate with EMD outcomes in adults with chronic SCI were eligible. Two authors independently selected studies and abstracted data. Mean changes from baseline were reported for EMD outcomes. The Downs and Black Checklist was used to rate evidence quality., Results: Of 489 articles identified, 44 articles ( N  = 842) were eligible for inclusion. Individual studies reported statistically significant effects of electrical stimulation-assisted training on lower-extremity bone outcomes, and the combined effects of exercise and dietary interventions to improve body composition and cardiometabolic biomarkers (lipid profiles, glucose regulation). In contrast, there were also reports of no clinically important changes in EMD outcomes, suggesting lower quality evidence (study bias, inconsistent findings)., Conclusion: Longitudinal multicentre pragmatic studies involving longer-term exercise and dietary intervention and follow-up periods are needed to fully understand the impact of these rehabilitation approaches to mitigate EMD risk. Our broad evaluation of prospective cohort and case-control studies provides new perspectives on alternative study designs, a multi-impairment paradigm approach of studying EMD outcomes, and knowledge gaps related to SCI rehabilitation.

Study Design: Clinical practice guidelines., Objectives: The objective was to update the 2016 version of the Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI)., Setting: The guidelines are relevant for inpatient, outpatient and community SCI rehabilitation settings in Canada., Methods: The guidelines were updated in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations., Results: The working group identified and reviewed 46 additional relevant articles published since the last version of the guidelines. The panel agreed on 3 new screening and diagnosis recommendations and 8 new treatment recommendations. Two key changes to these treatment recommendations included the introduction of general treatment principles and a new treatment recommendation classification system. No new recommendations to model of care were made., Conclusions: The CanPainSCI recommendations for the management of neuropathic pain after SCI should be used to inform practice., (© 2022. The Author(s).)

Purpose: Sexual health, a basic human right, maybe disrupted after a spinal cord injury (SCI) and is often not addressed in rehabilitation. This quality improvement initiative embedded sexual health education and support for patients with SCI into clinical practice., Materials and Methods: In 2017-2018 a team of clinicians, researchers and persons with SCI developed and implemented a new sexual health practice in SCI rehabilitation. A systematic process was undertaken which included implementation science principles; the PLISSIT model and Sexual Rehabilitation Framework were foundational to the new practice., Results: Adult inpatients with SCI began receiving the sexual health practice in June 2018. After 6 months, patient and health care provider surveys were conducted. Patients reported increased awareness of sexual health resources and increased satisfaction with sexual health concerns being addressed. Clinicians reported increased comfort in addressing patients' sexual health concerns and increased awareness of sexual health resources., Conclusions: Embedding the new sexual health practice facilitates the reintegration of sexual health into the daily lives of SCI patients and supports a more comprehensive and holistic rehabilitation. It normalizes sexual health concerns and questions in an SCI rehabilitation facility.IMPLICATIONS FOR REHABILITATIONSexual health is noted to be a top priority among persons with spinal cord injury, however, this area of care is often overlooked by healthcare providers across the rehabilitation continuum.A team of clinicians, researchers, and persons with SCI used a systematic process to address this gap by developing and implementing a new sexual health practice in the SCI rehabilitation program.This quality improvement initiative resulted in increased clinician knowledge and confidence in this domain of practice and greater patient satisfaction in having their sexual health needs to be addressed during rehabilitation.

Background: The current pandemic has reduced access to safe, monitored physical activity (PA) programs for persons with spinal cord injury (SCI). The use of telerehabilitation has the potential for continuing activity engagement without risking virus exposure. The present study evaluates the feasibility and 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. The program consisted of 1-hour sessions twice weekly for six weeks. Online PA satisfaction questionnaires were assessed at post-treatment. Psychosocial subscales from the NeuroQOL-SF were assessed., Results: Participants were adult females between 3 and 32 years post-injury, 1 tetraplegic and 3 paraplegics ( n  = 4). All participants were highly satisfied with the online instruction, overall content, and videoconferencing platform. Participants stated that the online program was beneficial for their overall physical and psychosocial wellbeing. The program resulted in improvement in anxiety and satisfaction with social roles and activities., Conclusion: The current pilot study demonstrates the acceptability and limited efficacy of an online PA program for those with SCI. The program resulted in improved overall perceived wellbeing and satisfaction with social roles and activities. These results have important implications for the clinical implementation of online PA programs in a hospital and community setting.

Context: Dedicated implementation efforts are critical to bridging the gaps between current practices and best practices. A quality improvement collaborative (QIC), the Spinal Cord Injury Implementation and Evaluation Quality Care Consortium (SCI IEQCC), was established to meet this need, bringing together a network of clinicians and administrators to systematically improve the quality and equity of tertiary spinal cord injury or disease (SCI/D) rehabilitation care in Ontario, Canada., Methods: Clinicians and leaders from five tertiary SCI/D rehabilitation centers and two not-for-profit SCI/D advocacy groups comprised a network dedicated to supporting implementation of the SCI-High quality indicators in prioritized domains of SCI rehabilitation and related best practices by: (1) building capacity through implementation science education of frontline clinicians; (2) providing resources and support to empower frontline clinicians to lead quality improvement efforts within their institutions; (3) promoting wider learning through a network for sharing ideas, efforts, and experiences; and (4) collecting indicator data to facilitate provincial evaluation of goal attainment., Results: Network members and sites collaborated to implement best practices within six priority domains; in 18 months, significant progress has been made in emotional wellbeing, sexual health, walking, and wheeled mobility despite disruptions due to the COVID-19 pandemic. These efforts encompass heterogeneous challenges and strategies, ranging from developing clinical skills programs, to streamlining processes, to manipulating physical space., Conclusion: A QIC targeting SCI/D rehabilitation demonstrates promise for advancing the implementation of best practices, building implementation science capacity across multiple sites, and for promoting collaboration amongst SCI/D rehabilitation centers and organizational partners.

Objective: To conduct a scoping review to identify what components of self-management are embedded in self-management interventions for spinal cord injury (SCI). Methods: In accordance with the approach and stages outlined by Arksey and O'Malley (2005), a comprehensive literature search was conducted using five databases. Study characteristics were extracted from included articles, and intervention descriptions were coded using Practical Reviews in Self-Management Support (PRISMS) (Pearce et al, 2016), Barlow et al (2002), and Lorig and Holman's (2003) taxonomy. Results: A total of 112 studies were included representing 102 unique self-management programs. The majority of the programs took an individual approach (52.0%) as opposed to a group (27.4%) or mixed approach (17.6%). While most of the programs covered general information, some provided specific symptom management. Peers were the most common tutor delivering the program material. The most common Barlow components included symptom management ( n = 44; 43.1%), information about condition/treatment ( n = 34; 33.3%), and coping ( n = 33; 32.4%). The most common PRISMS components were information about condition and management ( n = 85; 83.3%), training/rehearsal for psychological strategies ( n = 52; 51.0%), and lifestyle advice and support ( n = 52; 51.0%). The most common Lorig components were taking action ( n = 62; 60.8%), resource utilization ( n = 57; 55.9%), and self-tailoring ( n = 55; 53.9%). Conclusion: Applying self-management concepts to complex conditions such as SCI is only in the earliest stages of development. Despite having studied the topic from a broad perspective, this review reflects an ongoing program of research that links to an initiative to continue refining and testing self-management interventions in SCI., (© 2020 Thomas Land Publishers, Inc.)

Context: Implementing research findings into clinical practice is challenging. This manuscript outlines the experiences and key learnings from a network that operated as a community of practice across seven Canadian Spinal Cord Injury (SCI) rehabilitation centers. These learnings are being used to inform a new implementation-focused network involving SCI rehabilitation programs based in Ontario, Canada. Methods: The SCI KMN adapted and applied implementation science principles based on the National Implementation Research Network's (NIRN) Active Implementation Frameworks in the implementation of best practices in pressure injury and pain prevention and management. Results: The SCI KMN was successful in implementing best practices in both pressure ulcer and pain prevention and management across the various participating sites. Other key objectives met were building capacity in implementation methods in site personnel so that project scaling could occur with these skills and expertise applied to numerous other initiatives. Additionally, various papers, abstracts and conference presentation as well as an implementation guide were disseminated to inform the field of implementation science. Conclusion: The key lessons learned from this experience are being used to develop a new implementation-focused network. Features felt to be especially important for the SCI KMN includes a highly representative governance structure, the use of indicators within an overall evaluation framework and the systematic application of implementation processes with shared learnings supporting each site.

Context/objective: The spinal cord injury (SCI) knowledge mobilization network (KMN) is a community of practice formed in 2011 as part of a national best practice implementation (BPI) effort to improve SCI care. This study objective was to determine whether completion and documentation of pain practices could be improved in a neurorehabilitation setting using the KMN implementation approach. Design: Single site, pre-post intervention study. Setting: Neurorehabilitation hospital. Participants: Twenty sequential consenting inpatients with SCI, with retrospective comparative analysis of 50 sequential SCI admissions pre-KMN. Interventions: A local Site Implementation Team (SIT) was formed to develop an implementation plan, including acceptable timeframes for completion and documentation of four specific pain best practices: (1) pain assessment on admission, (2) development of an Inter-Professional Pain Treatment Plan (IPTP), (3) pain monitoring throughout admission, and (4) a pain discharge plan. Outcomes: Provider adherences to pain best practices were the primary outcomes. The secondary outcome was patient satisfaction. Results: Provider adherence for most outcomes exceeded 70% completion within acceptable timeframes, with improvements found for all outcomes as compared to the retrospective cohort. Notably, pain education as part of the IPTP improved from 12% completion to 74%, documenting pain onset from 4.5% to 80% and pain discharge plan from 40% to 74%. Overall, participants were satisfied with their pain management. Conclusions: Pain best practices were more consistently documented after the KMN implementation. Pain practices in all four areas have now been expanded to all inpatient diagnoses using the same forms and framework created in the implementation process.

Rationale, Aims, and Objectives: The Spinal Cord Injury Knowledge Mobilization Network is a pan-Canadian community of practice composed of seven rehabilitation hospitals. The goal of this network is to utilize implementation science processes to facilitate the adoption of best practice in spinal cord injury (SCI) rehabilitation. In addition to selecting specific practices for implementation, a key aspect of effective implementation is the engagement of stakeholders in decision-making processes. To achieve this, the network utilized a Delphi process to reach consensus on two pressure ulcer prevention and management practices to be implemented in SCI inpatient rehabilitation. A diverse, multidisciplinary panel of clinicians, researchers, sponsoring agency representatives, and persons with SCI participated in this process., Method: An online Delphi process was conducted in order to prioritize pressure ulcer prevention and management best practice recommendations and performance indicators for implementation. The process was conducted in six stages: (1) steering committee selection; (2) identification and selection of evidence; (3) participant selection and recruitment; (4) survey development; (5) identification of voting criteria; and (6) five rounds of voting., Results: The Delphi process resulted in the selection of two best practices: (1) comprehensive risk assessment and (2) education for pressure ulcer prevention and management in persons with SCI., Conclusions: In this Delphi process, a large expert panel achieved consensus on best practice recommendations and associated performance indicators for implementation. This process was undertaken as a first step towards optimization of service delivery and outcomes for persons with SCI across Canada., (© 2018 John Wiley & Sons, Ltd.)

Objective: To use the theoretical frameworks of implementation science to implement pressure injury (PI) prevention best practices in spinal cord injury (SCI) rehabilitation., Design: Quality improvement., Setting: Six Canadian SCI rehabilitation centers., Participants: Inpatients (N=2371) admitted from 2011 to 2015., Interventions: The SCI Knowledge Mobilization Network (SCI KMN) selected and implemented 2 PI prevention best practices at 6 Canadian SCI rehabilitation centers: (1) completing a comprehensive PI risk assessment comprised of a structured risk assessment instrument followed by an individualized, interprofessional risk factor determination and prevention plan; and (2) providing structured and individualized PI prevention patient education. Active Implementation Frameworks provided a systematic approach to best practice implementation., Main Outcome Measures: Implementation indicators (completion rates) and patient outcomes (PI incidence, patient education survey)., Results: After implementation, risk assessment completion rates improved from 46% to 94% (P<.05). Between initial (2012-2013) and full (2014-2015) implementation stages, completion rates improved for both interprofessional risk factor determination (67% to 96%) and prevention plans (67% to 94%). Documentation of patient education also increased to 86% (vs. 71% preimplementation). At rehabilitation admission 22% of patients had PIs, with 14% of individuals developing new PIs during rehabilitation. The overall PI prevalence was 30%. Considering only PIs of stage 2 or greater, prevalence was 21% and incidence 7%. There were no statistically significant differences in PI incidence between pre- and postimplementation. Patient education surveys indicated that PI education improved patients' knowledge of prevention strategies., Conclusions: Active Implementation Frameworks supported successful implementation of PI prevention best practices across the 6 participating SCI KMN sites. Achieving a reduction in PI incidence will require additional measures, and there is an ongoing need to strengthen the evidence base underpinning PI prevention guidelines., (Copyright © 2018 American Congress of Rehabilitation Medicine. All rights reserved.)

Authors Victoria L. Goosey-Tolfrey and Karen M. Smith were listed under the incorrect affiliations at the time of publication.

Objectives: To describe the process and outcomes of using a new evidence base to develop scientific guidelines that specify the type and minimum dose of exercise necessary to improve fitness and cardiometabolic health in adults with spinal cord injury (SCI)., Setting: International., Methods: Using Appraisal of Guidelines, Research and Evaluation (AGREE) II reporting criteria, steps included (a) determining the guidelines' scope; (b) conducting a systematic review of relevant literature; (c) holding three consensus panel meetings (European, Canadian and International) to formulate the guidelines; (d) obtaining stakeholder feedback; and (e) process evaluation by an AGREE II consultant. Stakeholders were actively involved in steps (c) and (d)., Results: For cardiorespiratory fitness and muscle strength benefits, adults with a SCI should engage in at least 20 min of moderate to vigorous intensity aerobic exercise 2 times per week AND 3 sets of strength exercises for each major functioning muscle group, at a moderate to vigorous intensity, 2 times per week (strong recommendation). For cardiometabolic health benefits, adults with a SCI are suggested to engage in at least 30 min of moderate to vigorous intensity aerobic exercise 3 times per week (conditional recommendation)., Conclusions: Through a systematic, rigorous, and participatory process involving international scientists and stakeholders, a new exercise guideline was formulated for cardiometabolic health benefits. A previously published SCI guideline was endorsed for achieving fitness benefits. These guidelines represent an important step toward international harmonization of exercise guidelines for adults with SCI, and a foundation for developing exercise policies and programs for people with SCI around the world.

Background : Optimal management of neuropathic pain (NP) is essential to enhancing health-related quality of life for individuals living with spinal cord injury (SCI). A key strategic priority for the Ontario Neurotrauma Foundation (ONF) and Rick Hansen Institute (RHI) is optimizing NP management after SCI. Aims : A National Canadian Summit, sponsored by ONF and RHI, was held to develop a strategic plan to improve NP management after SCI. Methods : In a one-day meeting held in Toronto, Ontario, a multidisciplinary panel of 18 Canadian stakeholders utilized a consensus workshop methodology to (1) describe the current state of the field, (2) create a long-term vision, and (3) identify steps for moving into action. Results : A review of the current state of the field identified strengths including rigourously developed evidence syntheses and practice landscape documentation. Identified gaps included limited evidence on NP hindering recommendation development in evidence syntheses, absence of a national strategy, care silos with limited cross-continuum connections, limited consumer involvement, and limited practice standard implementation. The panel identified key themes for a long-term vision to improve the management of SCI NP in Canada, including establishing an integrated collaborative network; standardized care and outcome evaluation; education; advocacy; and directing resources to innovative solutions. The panel identified the next step as prioritization of areas that will have the greatest impact in a 5-year time frame. Conclusion : A strategic plan outlining a long-term vision to improve management of NP after SCI in Canada was developed and will inform future activities of the sponsors., (© 2017 Eldon Loh, Stacey D. Guy, B. Cathy Craven, Sara Guilcher, Keith C. Hayes, Tara Jeji, Phalgun Joshi, Anna Kras-Dupuis, Marie-Thérèse Laramée, Joseph Lee, Swati Mehta, Vanessa K. Noonan, Ethan J. Mings, Michael Salter, Christine Short, Kent Bassett-Spiers, Barry White, Dalton L. Wolfe, and Nancy Xia. Published with license by Taylor & Francis.)

Objective: To determine the implementation considerations for a targeted self-management program for individuals with spinal cord injury (SCI) from the perspective of a national stakeholder advisory group using the Theoretical Domains Framework (TDF) as a guide., Design: Qualitative descriptive approach., Setting: Two focus groups held at the 6 th National Spinal Cord Injury Conference (October 2-4 th , 2014) in Toronto, Ontario, Canada., Participants: A total of 25 stakeholders from across Canada participated in focus groups or "brainstorming sessions". The stakeholders included 5 clinicians, 14 researchers, 3 policy makers, and 3 individuals with SCI., Interventions: Not applicable., Outcome Measures: Not applicable., Results: All 14 theoretical domains were identified in the brainstorming sessions. No new themes or domains were identified. The need to consider the theoretical domains of Knowledge, Skills, Reinforcement, Intentions, Goals (e.g. the readiness of the individual with SCI), Environmental Context and Resources (e.g. considerations for governance and ownership of the program and a business model for sustainability), as well as Social Influences (e.g. issues of privacy and security in the context of on-line delivery) was identified., Conclusions: The current study provides complementary results to our previous series of studies on the implementation considerations for the development of a targeted self-management program for individuals with SCI by emphasizing the health care professional/health policy perspective. It is anticipated that such a program could not only reduce secondary complications and subsequent inappropriate health care use but it may also improve the quality of life for individuals with SCI and their caregivers.

Context: Endocrine-metabolic disease (EMD) risk following spinal cord injury (SCI) is associated with significant multi-morbidity (i.e. fracture, diabetes, heart disease), mortality, and economic burden. It is unclear to what extent rehabilitation interventions can modify EMD risk and improve health status in community-dwelling adults with chronic SCI., Objectives: To characterize rehabilitation interventions and summarize evidence on their efficacy/effectiveness to modify precursors to EMD risk in community-dwelling adults with chronic SCI., Methods: Systematic searches of MEDLINE PubMed, EMBASE Ovid, CINAHL, CDSR, and PsychInfo were completed. All randomized, quasi-experimental, and prospective controlled trials comparing rehabilitation/therapeutic interventions with control/placebo interventions in adults with chronic SCI were eligible. Two authors independently selected studies and abstracted data. Mean differences of change from baseline were reported for EMD risk outcomes. The GRADE approach was used to rate the quality of evidence., Results: Of 489 articles identified, 16 articles (11 studies; n=396) were eligible for inclusion. No studies assessed the effects of rehabilitation interventions on incident fragility fractures, heart disease, and/or diabetes. Individual studies reported that exercise and/or nutrition interventions could improve anthropometric indices, body composition/adiposity, and biomarkers. However, there were also reports of non-statistically significant between-group differences., Conclusions: There was very low-quality evidence that rehabilitation interventions can improve precursors to EMD risk in community-dwelling adults with chronic SCI. The small number of studies, imprecise estimates, and inconsistency across studies limited our ability to make conclusions. A high-quality longitudinal intervention trial is needed to inform community-based rehabilitation strategies for EMD risk after chronic SCI.

Objective: To synthesize and appraise research testing the effects of exercise interventions on fitness, cardiometabolic health, and bone health among adults with spinal cord injury (SCI)., Methods: Electronic databases were searched (1980-2016). Included studies employed exercise interventions for a period ≥2 weeks, involved adults with acute or chronic SCI, and measured fitness (cardiorespiratory fitness, power output, or muscle strength), cardiometabolic health (body composition or cardiovascular risk factors), or bone health outcomes. Evidence was synthesized and appraised using Grading of Recommendations Assessment, Development, and Evaluation (GRADE)., Results: A total of 211 studies met the inclusion criteria (22 acute, 189 chronic). For chronic SCI, GRADE confidence ratings were moderate to high for evidence showing exercise can improve all of the reviewed outcomes except bone health. For acute SCI, GRADE ratings were very low for all outcomes. For chronic SCI, there was low to moderate confidence in the evidence showing that 2-3 sessions/week of upper body aerobic exercise at a moderate to vigorous intensity for 20-40 minutes, plus upper body strength exercise (3 sets of 10 repetitions at 50%-80% 1-repetition maximum for all large muscle groups), can improve cardiorespiratory fitness, power output, and muscle strength. For chronic SCI, there was low to moderate confidence in the evidence showing that 3-5 sessions per week of upper body aerobic exercise at a moderate to vigorous intensity for 20-44 minutes can improve cardiorespiratory fitness, muscle strength, body composition, and cardiovascular risk., Conclusions: Exercise improves fitness and cardiometabolic health of adults with chronic SCI. The evidence on effective exercise types, frequencies, intensities, and durations should be used to formulate exercise guidelines for adults with SCI., (© 2017 American Academy of Neurology.)

Background: Spinal cord injury (SCI) is a complex medical condition that can be difficult to monitor., Purpose: This study aimed to establish a common set of validated outcome measures specifically for SCI clinical practice., Method: In a three-round online Delphi process, experts in SCI care across Canada suggested and ranked outcome measures for clinical practice. The facilitators provided feedback between rounds and determined if consensus (at least 75% agreement) was reached on a single outcome measure per clinical area., Findings: One hundred and forty-eight outcome measures were initially considered for inclusion. After three rounds, consensus was reached for 23 out of 30 clinical areas. In the remaining seven, more than one outcome measure was recommended. The final toolkit comprises 33 outcome measures with sufficient measurement properties for use with a SCI population., Implications: An outcome measures toolkit validated specifically for SCI should lead to improved identification of best practice and enable clinicians to monitor client progress effectively.

Background: Electrical stimulation therapy (EST) has been shown to be an effective therapy for managing pressure ulcers in individuals with spinal cord injury (SCI). However, there is a lack of uptake of this therapy, and it is often not considered as a first-line treatment, particularly in the community. Objective: To develop a pressure ulcer model of care that is adapted to the local context by understanding the perceived barriers and facilitators to implementing EST, and to describe key initial phases of the implementation process. Method: Guided by the Knowledge-to-Action (KTA) and National Implementation Research Network (NIRN) frameworks, a community-based participatory research (CBPR) approach was used to complete key initial implementation processes including (a) defining the practice, (b) identifying the barriers and facilitators to EST implementation and organizing them into implementation drivers, and (c) developing a model of care that is adapted to the local environment. Results: A model of care for healing pressure ulcers with EST was developed for the local environment while taking into account key implementation barriers including lack of interdisciplinary collaboration and communication amongst providers between and across settings, inadequate training and education, and lack of resources, such as funding, time, and staff. Conclusions: Using established implementation science frameworks with structured planning and engaging local stakeholders are important exploratory steps to achieve a successful sustainable best practice implementation project.

Purpose: To examine the scope of the peer-reviewed literature on the use of commercially available video gaming in rehabilitation., Methods: Five databases (SCOPUS, Cochrane, PsycINFO, PubMed and CINAHL) were searched for articles published between January 1990 and January 2014. The reference lists of selected articles were also reviewed to identify other relevant studies., Results: Thirty articles met the inclusion criteria. Commercially available video gaming in rehabilitation was most commonly recommended by physiotherapists (50% or 15/30 studies) for populations at risk for falls or with decreased balance (67% or 19/30 studies). The most commonly used target outcomes were those assessing balance and/or fall prevention, with the Berg Balance Scale being the most frequently used (53% or 16/30 studies) outcome measure. The Nintendo Wii was the most prevalent gaming system (90% or 27/30 studies) used in the identified studies., Conclusion: Video gaming in rehabilitation is widely used by clinicians. Preliminary findings show that video gaming technology can be applied across a wide variety of rehabilitation populations, with some evidence showing clinical gains in physical functioning (e.g. gait and balance). There is a need for more robust clinical trials evaluating the efficacy of using video game systems as an adjunct to conventional rehabilitation. Implications for Rehabilitation Video gaming is a readily available technology that has been suggested as an enjoyable and motivating activity that engages patients in rehabilitation programming. Video gaming is becoming an increasingly popular adjunct to traditional therapy. Video gaming is most commonly used by physical therapists in a hospital setting for those with balance impairments. Video gaming has been shown to improve functional outcomes.

Background: It is not known whether ongoing access to a broad-based Internet knowledge resource can influence the practice of health care providers. We undertook a study to evaluate the impact of a Web-based knowledge resource on increasing access to evidence and facilitating best practice of health care providers., Objective: The objective of this study was to evaluate (1) the impact of the Spinal Cord Injury Rehabilitation Evidence (SCIRE) project on access to information for health care providers and researchers and (2) how SCIRE influenced health care providers' management of clients., Methods: A 4-part mixed methods evaluation was undertaken: (1) monitoring website traffic and utilization using Google Analytics, (2) online survey of users who accessed the SCIRE website, (3) online survey of targeted end-users, that is, rehabilitation health care providers known to work with spinal cord injury (SCI) clients, as well as researchers, and (4) focus groups with health care providers who had previously accessed SCIRE., Results: The online format allowed the content for a relatively specialized field to have far reach (eg, 26 countries and over 6500 users per month). The website survey and targeted end-user survey confirmed that health care providers, as well as researchers perceived that the website increased their access to SCI evidence. Access to SCIRE not only improved knowledge of SCI evidence but helped inform changes to the health providers' clinical practice and improved their confidence in treating SCI clients. The SCIRE information directly influenced the health providers' clinical decision making, in terms of choice of intervention, equipment needs, or assessment tool., Conclusions: A Web-based knowledge resource may be a relatively inexpensive method to increase access to evidence-based information, increase knowledge of the evidence, inform changes to the health providers' practice, and influence their clinical decision making.

Objective: To conduct a systematic review examining the effectiveness of knowledge translation (KT) interventions in changing clinical practice and patient outcomes., Methods: MEDLINE/PubMed, CINAHL, EMBASE and PsycINFO were searched for studies published from January 1980 to July 2012 that reported and evaluated an implemented KT intervention in spinal cord injury (SCI) care. We reviewed and summarized results from studies that documented the implemented KT intervention, its impact on changing clinician behavior and patient outcomes as well as the facilitators and barriers encountered during the implementation., Results: A total of 13 articles featuring 10 studies were selected and abstracted from 4650 identified articles. KT interventions included developing and implementing patient care protocols, providing clinician education and incorporating outcome measures into clinical practice. The methods (or drivers) to facilitate the implementation included organizing training sessions for clinical staff, introducing computerized reminders and involving organizational leaders. The methodological quality of studies was mostly poor. Only 3 out of 10 studies evaluated the success of the implementation using statistical analyses, and all 3 reported significant behavior change. Out of the 10 studies, 6 evaluated the effect of the implementation on patient outcomes using statistical analyses, with 4 reporting significant improvements. The commonly cited facilitators and barriers were communication and resources, respectively., Conclusion: The field of KT in SCI is in its infancy with only a few relevant publications. However, there is some evidence that KT interventions may change clinician behavior and improve patient outcomes. Future studies should ensure rigorous study methods are used to evaluate KT interventions.

Introduction: Treatment of patients with traumatic brain injury (TBI) should be based upon the strongest evidence to achieve optimal patient outcomes. Given the challenges, efforts involved, and delays in uptake of evidence into practice, priorities for knowledge translation (KT) should be chosen carefully. An international workshop was convened to identify KT priorities for acute and rehabilitation care of TBI and develop KT projects addressing these priorities., Methods: An expert panel of 25 neurotrauma clinicians, researchers, and KT scientists representing 4 countries examined 66 neurotrauma research topics synthesized from 2 neurotrauma evidence resources: Evidence Based Review of Acquired Brain Injury and Global Evidence Mapping projects. The 2-day workshop combined KT theory presentations with small group activities to prioritize topics using a modified Delphi method., Results: Four acute care topics and 3 topics in the field of rehabilitation were identified. These were focused into 3 KT project proposals: optimization of intracranial pressure and nutrition in the first week following TBI; cognitive rehabilitation following TBI; and vocational rehabilitation following TBI., Conclusion: Three high-priority KT projects were developed: the first combined 2 important topics in acute TBI management of intracranial pressure management and nutrition, and the other projects focused on cognitive rehabilitation and vocational rehabilitation.

Background: Pharmacotherapy may not sufficiently reduce neuropathic pain in many individuals post spinal cord injury (SCI). The use of alternative therapies such as surgery may be effective in reducing neuropathic pain in these individuals. However, because of the invasive nature of surgery, it is important to examine the evidence for use of this treatment., Objective: The purpose of this study was to conduct a systematic review of published literature on the surgical treatment of neuropathic pain after SCI., Methods: MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles in which surgical treatment of pain after SCI was examined. Articles were restricted to the English language. Article selection was conducted by 2 independent reviewers with the following inclusion criteria: the subjects participated in a surgical intervention for neuropathic pain; at least 50% of the subjects had an SCI; at least 3 subjects had an SCI; and a definable intervention involving the dorsal root entry zone (DREZ) procedure was used to reduce pain. Data extracted included study design, study type, subject demographics, inclusion and exclusion criteria, sample size, outcome measures, and study results. Randomized controlled trials (RCTs) were assessed for quality using the Physiotherapy Evidence Database (PEDro) assessment scale. Levels of evidence were assigned to each intervention using a modified Sackett scale., Results: Eleven studies met the inclusion criteria. One study provided level 2 evidence, and the rest provided level 4 evidence. The DREZ procedure was shown to be more effective for segmental pain than for diffuse pain after SCI. Further, individuals with conus medullaris level injury were found to have a higher level of neuropathic pain relief than those with cervical, thoracic, or cauda equina injury., Conclusions: The studies demonstrated that the DREZ procedure may be effective in reducing segmental pain. Hence, DREZ may be important in treatment of neuropathic pain in individuals resistant to less invasive treatments. Because the studies lacked control conditions and examination of long-term effects, there is a need for larger trials with more stringent conditions.

Background: Neuropathic pain has various physiologic and psychosocial aspects. Hence, there is a growing use of adjunct nonpharmacological therapy with traditional pharmacotherapy to reduce neuropathic pain post spinal cord injury (SCI)., Objective: The purpose of this study was to conduct a systematic review of published research on nonpharmacological treatment of neuropathic pain after SCI., Methods: MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles addressing nonpharmacological treatment of pain post SCI. Articles were restricted to the English language. Article selection was conducted by 2 independent reviewers with the following inclusion criteria: the subjects participated in a treatment or intervention for neuropathic pain; at least 50% of the subjects had an SCI; at least 3 subjects had an SCI; and a definable intervention was being studied. Data extracted included study design, study type, subject demographics, inclusion and exclusion criteria, sample size, outcome measures, and study results. Randomized controlled trials (RCTs) were assessed for quality using the Physiotherapy Evidence Database (PEDro) assessment scale. Levels of evidence were assigned to each intervention using a modified Sackett scale., Results: The 16 articles selected for this review fell into 1 of 2 categories of nonpharmacological management of pain after SCI: physical and behavioral treatments. The pooled sample size of all studies included 433 participants. Of the 16 studies included, 7 were level 1, 3 were level 2, and 6 were level 4 studies., Conclusions: Physical interventions demonstrated the strongest evidence based on quality of studies and numbers of RCTs in the nonpharmacological treatment of post-SCI pain. Of these interventions, transcranial electrical stimulation had the strongest evidence of reducing pain. Despite a growing body of literature, there is still a significant lack of research on the use of nonpharmacological therapies for SCI pain.

Objective: This article is the first in a three-part series focused on designing theory-based interventions to increase leisure time physical activity (LTPA) in persons with spinal cord injury (SCI). The purpose of this first study was to compare social cognitions for LTPA between people classified as LTPA actors, intenders, and nonintenders, as per Schwarzer's Health Action Process Approach (HAPA) model., Method: Participants were 238 men and women living with a SCI (M age = 44.14, SD = 12.74; 44.5% paraplegic) who were subsequently classified as LTPA actors (n = 105), intenders (n = 73), or nonintenders (n = 60). Participants completed a questionnaire that assessed the following HAPA constructs: LTPA outcome expectancies, self-efficacy, intentions, planning, and action control., Results: A MANCOVA revealed significant between-groups differences for all variables (ps < .001). For all of the measures, actors scored significantly higher than intenders who, in turn, scored significantly higher than nonintenders., Conclusion/implications: It is both theoretically and practically important to distinguish between LTPA nonintenders, intenders, and actors when developing LTPA-enhancing interventions for people with SCI. These distinctions inform the design and testing of the interventions reported in the two accompanying articles., ((c) 2013 APA, all rights reserved.)

Objective: The majority of people with spinal cord injury (SCI) do not engage in sufficient leisure-time physical activity (LTPA) to attain fitness benefits; however, many have good intentions to be active. This paper describes two pilot interventions targeting people with SCI who are insufficiently active but intend to be active (i.e., "intenders")., Method: Study 1 examined the effects of a single, telephone-based counseling session on self-regulatory efficacy, intentions, and action plans for LTPA among seven men and women with paraplegia or tetraplegia. Study 2 examined the effects of a home-based strength-training session, delivered by a peer and a fitness trainer, on strength-training task self-efficacy, intentions, action plans, and behavior. Participants were 11 men and women with paraplegia., Results: The counseling session (Study 1) yielded medium- to large-sized increases in participants' confidence to set LTPA goals and intentions to be active. The home visit (Study 2) produced medium- to large-sized increases in task self-efficacy, barrier self-efficacy, intentions, action planning, and strength-training behavior from baseline to 4 weeks after the visit., Conclusions/implications: Study 1 findings provide preliminary evidence that a single counseling session can impact key determinants of LTPA among intenders with SCI. Study 2 findings demonstrate the potential utility of a peer-mediated, home-based strength training session for positively influencing social cognitions and strength-training behavior. Together, these studies provide evidence and resources for intervention strategies to promote LTPA among intenders with SCI, a population for whom LTPA interventions and resources are scarcely available.

This study examined whether levels of chronic disease risk factors change over time, and whether leisure-time physical activity (LTPA) can explain any of the variation in those risk factors that change, in a sample of community-dwelling people living with spinal cord injury (SCI) in or near Hamilton, Ontario, Canada. LTPA was measured using the Physical Activity Recall Assessment for People with SCI at baseline (n = 76 adults with chronic (≥1 year) paraplegia or tetraplegia), at 6 months (n = 71) and at 18 months (n = 63). Body mass index, waist circumference at the lowest rib (WC(lowest rib)) and iliac crest (WC(iliac crest)), fat mass, blood pressure, and biochemical data were collected at all 3 time points. Women's BMI was higher at baseline (least square means (LSM) = 26.2 ± SE = 1.56 kg·m(-2), p = 0.0004) and 6 months (25.9 ± 1.6, p = 0.0024) than at 18 months (22.1 ± 1.72). Men's WC(lowest rib) increased from baseline (92.1 ± 1.87 cm) to 18 months (93.6 ± 1.87, p = 0.0253). Women who were active vs. inactive at baseline had a lower BMI at 6 months (23.1 ± 2.91 vs. 29.7 ± 2.52, p = 0.0957) and WC(iliac crest) at 6 months (82.8 ± 6.59 vs. 97.7 ± 5.10, p = 0.0818). Women who were active vs. inactive at 6 months had a lower WC(iliac crest) at 18 months (73.4 ± 14.3 vs. 102.5 ± 6.41, p = 0.0723). There was little change in traditional risk factors over 18 months. Future studies should extend beyond 18 months in a larger sample, and explore traditional vs. novel risk factors and onset of cardiovascular disease and diabetes in the SCI population.

Background: Physical activity (PA) participation in persons with spinal cord injury (SCI) holds a number of benefits for quality of life (QOL) but there is a need to better understand conceptual and measurement issues., Objective: To evaluate the appropriateness of outcome measurement tools to assess QOL in relation to PA in persons with SCI., Methods: A systematic literature review was conducted using PubMed and CINAHL databases to identify studies that used a QOL measurement tool and assessed PA or employed a PA intervention to determine a relationship between PA and QOL., Results: Thirteen articles met the inclusion criteria. Within the 13 articles, 9 different QOL outcome measurement tools were used; two objective measures (Short Form-36 [SF-36] and Quality of Well-being [QWB]) and 7 subjective measures (Perceived QOL [PQoL], Satisfaction with Life Scale [SWLS], QOL Index SCI Version III, Life Satisfaction [LISAT], QOL Feedback, QOL Profile: Physical and Sensory Disabilities Version [QOLP-PSD] and Subjective QOL [SQOL]). The PQoL was the most commonly used tool (4 studies) and was used in 2 of the 3 randomized controlled trials. Twelve of the studies demonstrated a positive effect of PA on QOL., Conclusions: Outcome measurement tool selection should be guided by the specific purpose of the data collection activity as well as the context under which the tool will be used (e.g., setting, population, etc.). Therefore, different tools may rightfully be selected to assess the same construct when considering different circumstances-however, these considerations should be balanced by the evidence and demonstrated prior utility of potential tools., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background/objectives: To develop an online patient education resource for use in spinal cord injury rehabilitation., Participants: The development process involved more than 100 subject-matter experts (SMEs) (rehabilitation professionals and consumers) from across Canada. Preliminary evaluation was conducted with 25 end-users., Methods: An iterative development process was coordinated by a project team; SMEs (including patients) developed the content in working groups using wiki-based tools. Multiple rounds of feedback based on early prototypes helped improve the courses during development., Results: Five courses were created, each featuring more than 45 minutes of video content and hundreds of media assets. Preliminary evaluation results indicate that users were satisfied by the courses and perceived them to be effective., Conclusions: This is an effective process for developing multimedia patient education resources; the involvement of patients in all parts of the process was particularly helpful. Future work will focus on implementation, integration into clinical practice and other delivery formats (smart phones, tablets).

Background: Most studies of physical activity predictors in people with disability have lacked a guiding theoretical framework. Identifying theory-based predictors is important for developing activity-enhancing strategies., Purpose: To use the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to identify predictors of leisure time physical activity among people with spinal cord injury (SCI)., Methods: Six hundred ninety-five persons with SCI (M age=47; 76% male) completed measures of Body Functions and Structures, Activities and Participation, Personal Factors, and Environmental Factors at baseline and 6-months. Activity was measured at 6 and 18 months. Logistic and linear regression models were computed to prospectively examine predictors of activity status and activity minutes per day., Results: Models explained 19%-25% of variance in leisure time physical activity. Activities and Participation and Personal Factors were the strongest, most consistent predictors., Conclusions: The ICF framework shows promise for identifying and conceptualizing predictors of leisure time physical activity in persons with disability.

Knowledge of the breadth, nature, and volume of traumatic brain injury (TBI) and spinal cord injury (SCI) research can aid in research planning. This study aimed to provide an overview of existing TBI and SCI research to inform identification of knowledge translation (KT), systematic review (SR), and primary research opportunities. Topics and relevant articles from three large neurotrauma evidence resources were synthesized: the Global Evidence Mapping (GEM) Initiative (129 topics and 1644 articles), the Acquired Brain Injury Evidence-Based Review (ERABI; 152 topics and 732 articles), and the Spinal Cord Injury Rehabilitation Evidence (SCIRE) Project (297 topics and 1650 articles). A de-duplicated dataset of SRs, randomized controlled trials (RCTs), and other studies identified by these projects was created. In all, 145 topics were identified (66 TBI and 79 SCI), yielding 3466 research articles (1256 TBI and 2210 SCI). Topics with KT potential included cognitive therapies for TBI and prevention/management of urinary tract problems post-SCI, which accounted for 17% and 18%, respectively, of the TBI and SCI yield. Topics that may require SR included management of raised intracranial pressure in TBI, and ventilation and intermittent positive pressure interventions following SCI. Topics for which primary research may be needed included pharmacological therapies for neurological recovery post-TBI, and management of sleep-disordered breathing post-SCI. There was a larger volume of non-intervention (epidemiological) studies in SCI than in TBI. This comprehensive overview of TBI and SCI research can aid funding agencies, researchers, clinicians, and other stakeholders in prioritizing and planning TBI and SCI research.

Determining the priorities of individuals with spinal cord injury (SCI) can assist in choosing research priorities that will ultimately improve their quality of life. This systematic review examined studies that directly surveyed people with SCI to ascertain their health priorities and life domains of importance. Twenty-four studies (a combined sample of 5262 subjects) that met the inclusion criteria were identified using electronic databases (Medline, EMBASE, CINAHL, and PsycINFO). The questionnaire methods and domains of importance were reviewed and described. While the questionnaires varied across studies, a consistent set of priorities emerged. Functional recovery priorities were identified for the following areas: motor function (including arm/hand function for individuals with tetraplegia, and mobility for individuals with paraplegia), bowel, bladder, and sexual function. In addition, health, as well as relationships, emerged as important life domains. The information from this study, which identified the priorities and domains of importance for individuals with SCI, may be useful for informing health care and research agenda-setting activities.

Purpose: The purpose of this review of the scientific literature was to investigate the incidence and prevalence of hemiplegia with lower limb amputation, and to identify outcomes following the dual disability of hemiplegia and amputation., Methods: Electronic searching of the literature identified major studies examining the effects of hemiplegia on rehabilitation following amputation. Data were extracted and levels of evidence assigned for each subtopic area., Results: The summary conclusions are Level 4 evidence. The prevalence of amputation and hemiplegia is 8-18% and amputation and hemiplegia occur most often in the same leg. Once individuals with hemiplegia and lower limb amputation are selected for prosthetic rehabilitation, rate of successful functional ambulation is greater than 58%. In general there is a lower rate of prosthetic success and independence with hemiplegia than without. Predictive factors associated with success include less severe hemiplegia, laterality of hemiplegia (ipsilateral and right side), transtibial level of amputation and absence of impaired mental function. There is wide variation in length of hospital stay, but a specialty multidisciplinary team reduces length of stay., Conclusions: Patients with dual disability of hemiplegia and amputation generally benefit from a prosthetic rehabilitation program. Further study on predictive factors for outcome would be beneficial., Implications for Rehabilitation: • The prevalence of hemiplegia with lower limb amputation ranges from 8 to 18%, most frequently affecting the same leg. • The majority of patients attain successful functional levels of ambulation with prosthetic rehabilitation, although lower rates than nonhemiplegic patients. • Predictive factors associated with greater success include less severe hemiplegia, ipsilateral hemiplegia, transtibial level of amputation and absence of impaired mental function.

Study Design: Systematic review., Objectives: To conduct a systematic review of evidence surrounding the effects of exercise on physical fitness in people with spinal cord injury (SCI)., Setting: Canada., Methods: The review was limited to English-language studies (published prior to March 2010) of people with SCI that evaluated the effects of an exercise intervention on at least one of the four main components of physical fitness (physical capacity, muscular strength, body composition and functional performance). Studies reported at least one of the following outcomes: oxygen uptake/consumption, power output, peak work capacity, muscle strength, body composition, exercise performance or functional performance. A total of 166 studies were identified. After screening, 82 studies (69 chronic SCI; 13 acute SCI) were included in the review. The quality of evidence derived from each study was evaluated using established procedures., Results: Most studies were of low quality; however, the evidence was consistent that exercise is effective in improving aspects of fitness. There is strong evidence that exercise, performed 2-3 times per week at moderate-to-vigorous intensity, increases physical capacity and muscular strength in the chronic SCI population; the evidence is not strong with respect to the effects of exercise on body composition or functional performance. There were insufficient high-quality studies in the acute SCI population to draw any conclusions., Conclusions: In the chronic SCI population, there is good evidence that exercise is effective in improving both physical capacity and muscular strength, but insufficient quality evidence to draw meaningful conclusions on its effect on body composition or functional capacity.

Objectives: To systematically develop evidence-informed physical activity guidelines to improve physical fitness in people with spinal cord injury (SCI)., Setting: This study was conducted in Canada., Methods: The Appraisal of Guidelines, Research and Evaluation II guideline development protocol was used to develop exercise guidelines to improve physical capacity and muscular strength. The evidence base for the guideline development process consisted of a systematic review and quality appraisal of research examining the effects of exercise on physical fitness among people with SCI. A multidisciplinary expert panel deliberated the evidence and generated the guidelines. Pilot testing led to refinement of the wording and presentation of the guidelines., Results: The expert panel generated the following guidelines: for important fitness benefits, adults with a SCI should engage in (a) at least 20 min of moderate to vigorous intensity aerobic activity two times per week and (b) strength training exercises two times per week, consisting of three sets of 8-10 repetitions of each exercise for each major muscle group., Conclusion: People with SCI, clinicians, researchers and fitness programmers are encouraged to adopt these rigorously developed guidelines.