Home care for individuals with spinal cord injury: what does the data tell us and does it reflect reality?

Brian C.F. Chan1, James Milligan2, Peter Athanasopoulos3,4
1Toronto Rehabilitation Institute, Toronto, ON, Canada
2Centre for Family Medicine, Kitchener, ON, Canada
3Spinal Cord Injury Ontario, Toronto, ON, Canada
4Ontario SCI Solutions Alliance, Toronto, ON, Canada

Objectives: At the end of this session participants will be able to:

  • Review the results of a home care utilization study conducted using Ontario health care administrative data.
  • Contextualize the results of the study from different perspectives.
  • Develop a path forward for further evidence development and dialogue for the purpose of ensuring that individuals with SCI receive adequate home care.

Design/Methods: To understand the trends regarding home care use for individuals with SCI in Ontario, an analysis was conducted using health care administrative data. The findings from this study were interesting and surprising in terms of the volume and nature of services. However, are the study results reflective of clinician’s observations and lived experience? In this workshop, numerous stakeholders will provide different perspectives on home care support for individuals with SCI and offer context regarding the Ontario home care study. The workshop will begin with a quick summary of the methods and results presented by the clinical researcher from Toronto Rehab Institute. This will be followed-up by a 5-10 minute commentary provided by each of the panelists. An open question and answer period with participation from the audience and panel members will then follow for 15 minutes. The facilitator will then close the workshop by summarizing the key learnings.

Participants: The study was based on individuals with traumatic SCI living in Ontario.

Results: In Ontario, the median number of hours of Community Care Access Centre home care nursing received by an individual with SCI per month ranges from 2 to 8 in the first year after discharge from the initial inpatient acute hospital or inpatient rehabilitation stay. Individuals with SCI receive a median of 23 to 28 hours of personal support per month in the same period. In the first year, individuals with SCI receive less than 6 hours of care from physiotherapy, occupation therapy, speech language pathology and nutrition. Conclusions: By the end of the workshop, individuals attending this workshop will gain a better understanding of the complexities of funding and delivery of home care to individuals with SCI.

“Back to the Future”- Functional Electrical Stimulation (FES) therapy combined with task-specific training versus FES integrated to Brain-Computer Interface (BCI) technology

Julio C. Furlan1,2, Cesar Marquez-Chin 1

1 Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada;
2 University of Toronto, Toronto, ON, Canada

Objectives: This workshop will (i) examine the potential benefits of FES therapy combined to task-specific training for the rehabilitation of voluntary extremity movement after spinal cord injury or disease (SCI/D); (ii) discuss potential mechanisms of action of FES therapy combined to task-specific training; (iii) describe concept and components of brain-computer interface technology, and (iv) share the results of a FES integrated to BCI technology study.

Design/Methods: The workshop will include didactic presentations from the workshop leaders, and allow for small group discussions of pathophysiologic mechanisms and procedures. The studies that will be discussed included individuals with either SCI/D or stroke.

Participants: This workshop will be of interest to stakeholders, clinicians and scientists in the field with interest in neurorehabilitation. Results: Numerous prior studies reported improved outcomes after FES-therapy in combination with task-specific training in terms of reduction of impairment and disability after SCI/D. A recent systematic review with scoping synthesis examined the literature on the potential mechanisms of action of FES therapy along with task-specific training. While this neuromodulation strategy is well recognised, its limitations have driven investigations on a novel rehabilitative modality using FES integrated to BCI technology. This session will outline the results that were achieved using a BCI-triggered FES therapy.

Conclusion: Neuromodulation plays a key role in the rehabilitation of individuals with SCI/D. The combination of FES-therapy and task-specific training has been used in the restoration of voluntary movements for individuals with motor impairment from different neurological diseases including SCI/D. In the quest for new neuromodulation therapies, it was conceptualized the FES integrated to BCI technology that represents a challenge and opportunity increase the efficacy of FES therapy.

Addressing the elephant in the room: Integrating sexual health practice in spinal cord injury (SCI) rehabilitation

Charlie Giurleo 1, Anna Kras-Dupuis2

1St. Joseph’s Health Care London Parkwood Institute Main Building, London, ON, Canada
2St. Joseph’s Health Care London Parkwood Institute Main Building, London, ON, Canada

Background: Sexual health, a basic human right, may be disrupted after SCI. Many people with SCI have questions about their sexuality that are often not addressed in rehabilitation. An interdisciplinary team at Parkwood Institute identified sexual health as a significant gap in clinical practice. 90% of patients surveyed were unaware of resources and their sexual health concerns were not addressed during rehabilitation. Objectives: To embed sexual health education and support for patients with SCI into clinical practice, by increasing clinicians’ knowledge and confidence.

Methods/Overview: In 2017-18, a team of clinicians, researchers and persons with lived experience followed a systematic process and Implementation Science principles (Fixsen et al., 2005) to fully develop the new sexual health practice. The PLISSIT model (Annon, 1974) and Sexual Rehabilitation Framework (Elliott et al., 2017) were incorporated into the new practice. A comprehensive education plan included awareness sessions and a 2-day interactive workshop. Adult SCI inpatients on the 15-bed Regional Rehabilitation unit and SCI outpatients have been the recipients of the new sexual health practice as of June 2018.

Results/Discussion: At 6 months into the launch of the new sexual health practice both patient and health care provider surveys were conducted. Patients reported increased awareness of sexual health resources from 39% to 55% and increased satisfaction that their sexual health concerns were addressed from 35% to 72%. Multi-faceted education on a variety of topics has been offered. A resource area on the SCI unit has been created for patients and caregivers. Clinicians reported increased knowledge and self-efficacy in addressing patients’ sexual health concerns from 62% to 85% and increased knowledge of sexual health resources from 46% to 88%. This has played a major role in normalizing sexual health concerns and questions, thereby addressing the “elephant in the room”. Pending results of chart audits and qualitative interviews with clinicians and patients will inform any potential improvements, with an ultimate goal of sustainable and consistent practice for all SCI patients. This practice will then be scaled to other patient populations. \
Conclusions: Embedding this practice facilitates reintegration of sexual health into the daily lives of SCI patients and supports a more comprehensive and holistic rehabilitation. A systematic process for practice implementation, a sound evaluation plan, and a participatory approach, have been the key factors for sustainability.

Developing an effective mentor and mentee relationship: What graduate students and young investigators should know and do.

Sukhvinder Kalsi-Ryan1, Nora Cullen2.

1Affiliate Scientist, Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network; and Assistant Professor, Department of Physical Therapy, University of Toronto
2Chief of Staff, Westpark Healthcare Centre Scientist, Toronto Rehabilitation Institute Associate Professor, Department of Medicine, University of Toronto

Objectives: At the end of this session participants will be able to:

  • Describe how to find or select the right mentor;
  • Identify the mentee’s roles and responsibilities;
  • Describe the key attributes of an effective mentor-mentee relationship;
  • Recognize quality mentorship based on the small group discussions with experienced mentors.

This workshop will provide an overview of the important aspects that graduate students and young investigators should consider prior to selecting their mentors. While interpersonal affinity plays a role in the choice for a mentor, there are many other attributes that the graduate students and young investigators should consider before making their decision. The key elements of a well suited mentor, mentee’s roles and responsibilities, and an effective mentor-mentee relationship will be reviewed. Attendees will have the opportunity to meet with experienced mentors to clarify their questions in small groups.

Spinal fracture bracing: Know which brace is appropriate for different spinal fractures and how to properly operate a spinal brace and minimize further injury.

Andrew Lok, Certified Orthotist, CO(c). 1,2

1. Back2feet, North York, Ontario, Canada
2President of the Ontario Association of Prosthetists and Orthotists

Please note that this workshop will be created for this conference specifically. This presentation has been done informally to various rehabilitation and trauma hospitals in the Greater Toronto Area by Back2feet. The hands on nature of this workshop will allow healthcare workers to familiarize themselves with spinal braces.

Objectives: At the end of this session participants will be able to:

  • Teach healthcare professionals that treat patients with acute spinal fractures and braces in both trauma and rehab settings
  • How to properly prescribe and/or operate spinal fracture braces which includes the optimal fit and function.

Rationale/Why: As a Certified Orthotist, I have come across many trauma hospitals where braces are incorrectly prescribed for acute spinal fractures and injuries. In the rehab setting, I have encountered many therapists and nursing staff that incorrectly don braces rendering them ineffective and unsafe for clients. Many healthcare workers are often timid to operate spinal braces which can often lead to a lack of rehabilitation or cleanliness for patients as well.

Design/Methods: Brief lecture on the different types of braces including but not limited to Custom and Over the Counter TLSOs, CTOs, Jewett Hyperextension Braces, Cervical Collars and CTLSOs. The lecture will touch on which brace is appropriate for respective spinal fracture levels, the principles of spinal braces, and how braces should properly fit onto patients. This is followed by optional hands on training with participants how to properly don braces safely with minimal risk to patients. Participants: Participants are attendees of the workshop and may include Physiatrists, Orthopaedic Surgeons, Physiotherapists, Occupational Therapists, Nurses, and anyone else that may work with patients requiring spinal fracture bracing.

Results: The end result is to educate other healthcare professionals that deal with spinal fracture bracing.

  • Goal 1: Patients are prescribed and properly fit with the appropriate brace respective to their injury.
  • Goal 2: Therapists and Nursing Staff know how to safely don and doff spinal braces without risking further injury to patients.
  • Goal 3: Healthcare professionals are comfortable treating patients with a spinal brace and know how to adjust braces when appropriate or call a local Certified Orthotist.

It’s legal – now what? Practical guidance for cannabis use in spinal cord injury

Colleen M O’Connell 1, Karen Ethans 2

1 Stan Cassidy Centre for Rehabilitation, Fredericton, NB CAnada
University of Manitoba, Winnipeg, MB Canada

Herbal cannabis, in various forms of administration, has emerged as a popular choice for self-management of pain and spasticity among persons with spinal cord injury. Whole cannabis contains hundreds of compounds, including approximately 60 or more cannabinoids, of which delta-9-tetrahydrocannabinol (THC), cannabidiol (CBD, non-psychoactive) are two of the major bioactive compounds. Cannabinoids show promise as therapeutic agents, but for decades their development through research, trials and clinical use has been complicated by the placement of herbal cannabis in the Schedule I category by the UN and its drug conventions. Despite the difficulties in doing research with a product that has been/is illegal depending on country, a number of clinical studies have been conducted which suggest that cannabinoid therapy may provide at least a subjective reduction of spasticity in patients, and recent reviews have concluded there is at least moderate evidence for use in chronic pain. Although research on endogenous cannabinoid systems and potential cannabinoid pharmaceuticals is increasing, there has been intense societal pressure to make herbal cannabis available for medicinal use; in Canada cannabis for medical purposes has been legal since 2002. In 2018, recreation cannabis was legalized in Canada. This interactive session will present current guidance on use of cannabis for symptom management in spinal cord injury, with focus on minimizing risks including drug interactions, misuse, and contraindications, while optimizing therapeutic outcomes, including patient selection, product choice, dosing and titration, and comprehensive management of patients using cannabis.

Autonomic dysreflexia and heterotopic ossification: Barriers to optimal management in the spinal sord injury population.

Christine Ann Short(1,2), Sonja D McVeigh(1,2), Andrea Townson(3,4) 1. Dalhousie University Faculty of Medicine 2. Nova Scotia Health Authority 3. University of British Columbia 4. Vancouver Costal Health

Background: Heterotopic Ossification (HO) and Autonomic Dysreflexia(AD) are both common complications of spinal cord injury that can be challenging to treat. Recent changes in access to medications that have some evidence base for treating these conditions has made management even more difficult. Along with this lack of knowledge in non-rehabilitation specialties often creates barriers to patients accessing timely appropriate care for these conditions.

Objective: The objective of this workshop is to review the current treatment guidelines for AD and HO and explore the barriers to managing patients under these guidelines including access to medications for treatments and knowledge of these conditions in the non-rehabilitation medical settings. Design/method: This will be an interactive focus group exercise. Participants: consumers with spinal cord injury (including families and care givers) and medical experts in spinal cord injury
Results: The hope of this session is to start preliminary work toward a Canadian document to guide the treatment of these conditions despite the current lack of access to evidence based therapies. This would include recommendations how to move forward with research and education to optimize the treatment of these two challenging complications of spinal cord injury.

Conclusions: Changes in access to medications to treat AD and HO are presenting new challenges to persons with spinal cord injury and their treatment teams. Pooling knowledge and experience from consumers and rehabilitation experts can help us find new ways to optimize management.

Through the lens of participants: Incorporating photovoice into research and clinical environments

Hardeep Singh1,2, Olinda Habib Perez1, & Kristin E. Musselman13

1Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada;
2Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; 3Dept. of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada

Capturing detailed information is essential for researchers, clinicians and policy makers working in healthcare. An organized approach is necessary for the collection, analysis and dissemination of such detailed information. Photovoice is a qualitative participatory research method that allows detailed information to be collected on a topic; for example, the accessibility of community environments or the factors impacting an individual’s or groups’ function, participation, and quality of life. 1 With photovoice, participants capture photographs of a issue or topic and then participate in an interview and/or focus group discussion of how the photographic content relates to their life. It is a person-centered approach that can inform potential solutions to address individual and public health needs and priorities. 2 Photovoice can also help researchers form appropriate research questions, hypotheses, and theories based on the participants’ perspectives,2 or it can be used as a needs assessment tool to guide clinical interventions.2 As well, the photographs and narratives can communicate areas of concern to policy makers, health practitioners, and/or researchers. 3 In this workshop, we will introduce the photovoice approach, outline practical steps on how to conduct photovoice, and discuss the utility of photovoice in research and clinical environments. The target audience is healthcare professionals, researchers and policy makers.

Upon completion of this course, participants will be able to:

  • Describe the principles, rationale, and value of using photovoice in research and clinical settings;
  • Create a photo-assignment and collect information using the photovoice approach for clinical or research purposes; and
  • Analyze, interpret, and synthesize photographic and narrative information generated from photovoice to fulfil their research or clinical purposes.

Information in this workshop will be delivered through small and large group discussions, and through examples from the presenters’ experiences of using photovoice to inform fall prevention initiatives for individuals with spinal cord injury. During the workshop participants will be asked to plan a photovoice project to address one of their research or clinical questions. Participants will gain a unique approach for gathering detailed information using photovoice that can be easily applied in research and clinical contexts.

1Wang & Burris. Health Educ Behav, 1997;24:369–87
2 LaVela et al. Top Spinal Cord Inj Rehabil, 2018;24:295–305
3Wang et al. Am J Public Health, 2004;94:911–13

Individualized balance assessment and training for people with spinal cord injuries: A hands on workshop

Janelle Unger 1,2, Kristin E Musselman 1,2,3

1Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
2Lyndhurst Centre, Toronto Rehabilitation Institute – University Health Network, Toronto, ON, Canada 3. Department of Physical Therapy, University of Toronto, Toronto, ON, Canada

Background: People with spinal cord injuries/disease (SCI/D) are at high risk for falls, which can have negative consequences such as injury, mobility restriction, and social isolation. Poor balance may contribute to fall risk in this population. More specifically, a deficit in reactive balance, the component of balance control that allows recovery from a loss of balance, has been linked to falls. Despite this link, standardized assessments of reactive balance are not commonly used in clinical practice(1). Further, balance training is often not prioritized during inpatient rehabilitation(2). To address the SCI/D population’s high fall risk, greater emphasis on the assessment and training of balance, and in particular reactive balance, is needed. We have used the Systems Framework for Postural Control(3) to create systematic and individualized assessment and treatment plans for individuals with SCI/D. The Systems Framework describes the components that are used to maintain postural control, with the knowledge that impairment in any component could increase fall risk(3). These components, including biomechanical constraints, movement and sensory strategies, orientation in space, control of dynamics, and cognitive processing, can be targeted through individualized treatment plans depending on where impairments exist(3).

Learning Objectives: After completing this workshop, participants will be able to:

  • Comprehensively assess balance control, including reactive balance, in individuals with SCI/D in a clinical setting. Assessments to be discussed include the Mini-Balance Evaluation Systems Test and the Lean-and-Release Test;
  • Describe the key principles of perturbation-based balance training, a method of training reactive balance control, and;
  • Plan and execute an individualized balance training program for individuals with SCI/D based on the Systems Framework for Postural Control(3). Workshop Structure: This workshop will involve lecture content, small group discussion, case-based learning and hands-on practice. Conclusions: Through this workshop, clinicians and researchers will gain knowledge about novel balance assessment and training practices for people with SCI/D, with a focus on reactive balance.


  1. Sibley KM et al. Gait Posture. 2013;38:1026-1031
  2. Teeter L et al. J Spinal Cord Med. 2012;35:503-5
  3. 3Horak FB. Age Aging. 2006;35(suppl_2):pp.ii7-ii11

Functional electric stimulation cycling guidelines for adults with SCI: a presentation and engagement workshop focussing on implementation

Dr Jan W. van der Scheer 12, Dr Chester Ho 3

1 University of British Columbia | Okanagan (Kelowna, BC, Canada)
2 Loughborough University (Loughborough, United Kingdom)
3 University of Alberta (Edmonton, Alberta, Canada)

Objective of the workshop:

  • Present the process and outcomes of developing evidence-based, international, co-produced functional electrical stimulation cycling guidelines for adults with spinal cord injury (SCI);
  • Provide feedback on how to best implement the guidelines in clinical and community settings

Methods of developing the guidelines: (1) Scoping review mapping the literature on various types of FES exercise for any FES user group (2) Engagement workshop and steering group meetings with researchers, clinicians, practitioners and SCI consumers to define the scope and purpose of the guidelines (3) A systematic review in accordance with the decided scope and purpose of the project, i.e. FES cycling exercise for adults with SCI (4) Deliberating the evidence synthesis and guideline recommendations from the systematic with international expert panels including researchers, practitioners and FES users to reach consensus about the guidelines (5) External feedback round about the guideline draft from SCI clinicians, practitioners and SCI consumers, leading to the final draft of the guidelines (6) Assessment of the guidelines and the development process by an independent Appraisal of Guidelines for Research and Evaluation (AGREE) consultant Participants of the workshop: Aimed at researchers, clinicians, practitioners and SCI consumers interested or engaged in functional electrical stimulation, exercise, rehabilitation and/or guideline implementation.

Methods used during the workshop: Presentations (by Dr Jan van der Scheer and Dr Chester Ho), followed by a live, interactive survey about values and preferences on how to best implement the guidelines in practice; workshop participants will answer questions using their mobile device, which will be displayed anonymously on the overhead projector’s screen, followed by discussions with the audience about the answers provided (led by Dr Jan van der Scheer and Dr Chester Ho) Conclusion: The feedback gained during the workshop will be further discussed in a steering group meeting about implementation of the guidelines in Canadian clinical and community settings, leading to a draft of national, provincial and/or local plans to use the guidelines across Canada.

A staged framework for the clinical implementation of new rehabilitation technologies after SCI

José Zariffa 1,2,3, Brian C. Chan 1, Heather Flett 1, Kristin E. Musselman 1,3,4

1Toronto Rehabilitation Institute – University Health Network, Toronto, Canada
2Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
3Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Canada
4Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada

In recent years, spinal cord injury (SCI) rehabilitation research has emphasized the promotion of functional neurorecovery, or the restoration of function through repetitive movement training of the affected limbs. Technologies including robotic devices and functional electrical stimulation have been developed to facilitate repetitive motor training. However, few of these technologies have been implemented into mainstream clinical practice. In order to facilitate the planning of clinical implementation for new rehabilitation technologies, this workshop will describe a novel staged version of the FAME (Feasibility, Appropriateness, Meaningfulness, Effectiveness, Economic Evidence) Framework. The staged FAME Framework provides researchers, clinicians and technology developers with a structured approach to evaluate the translational potential of new rehabilitation technologies and interventions.
After completing the workshop, researcher and clinicians will be able to:

  • Identify how a staged approach to the development and implementation of new rehabilitation technologies can facilitate the translation of research to rehabilitation practice for individuals with SCI.
  • Identify methods that may be used to evaluate the feasibility, appropriateness, meaningfulness, effectiveness, and economic evidence of new rehabilitation technologies. Methods discussed will include identifying implementation barriers, gathering input from literature and end-users, evaluating patient experience, and evaluating costs and resource utilization.
  • Develop a staged translation plan for a research study or clinical implementation project using the staged FAME Framework.

The workshop will involve lecture-based and case-based learning, in which participants will be asked to apply the staged FAME Framework to one of their research studies or clinical implementation projects. The workshop will provide participants with skills and resources that can be used to facilitate the translation of knowledge and technologies from research to clinical settings.