CSCI-RA 2024 | Finding Commonalities and Seeking Consensus

An overview of the evidence for Mindfulness-based interventions for people with multiple sclerosis

Background/Objective

Heterotopic ossification (HO), the formation of a mature lamellar bone within soft tissues,1 can present asymptomati cally, but often requires intervention due to pain, range of motion deficits, or swelling. The purpose of this study is to describe diagnostic trends and treatment strategies in current clinical practice by surveying healthcare professionals treating patients with spinal cord injury (SCI) induced HO.

Methods/Overview

A cross-sectional survey, developed by a group of expert physicians was sent to all members of the Canadian Advances in Neuro-Orthopedics for Spasticity Consortium (CANOSC) and the Canadian Spinal Cord Injury Rehabilitation Association (CSICRA). This 58 question multiple choice survey probes risk factors, screening procedures, natural history, clinical significance, treatments and prophylaxis for HO. Data will be analyzed by care provider type (Physician by specialty vs. Physical vs. Occupational therapist) and by experience in treating HO.

Hypotheses

We expect that the literature for prevalence, clinical significance, natural history, and treatment approaches will not fully reflect the experiences of those involved in the management of HO in the context of SCI.

Conclusions

This survey will provide valuable information about the real-world diagnosis and management of HO. The findings from this study may be used to guide further research and to inform teaching strategies and curriculum development for physicians and allied health professionals who work in SCI. Finally, the results of this survey may lead to cross-specialty and cross-institutional discussions, collaborations, and insights to improve the identification and treatment of patients living with SCI at risk for HO.

Thomas P. Walden1, Karl F. Zabjek2, B. Catharine Craven1, 3

1. KITE Research Institute, University Health Network, Canada
2. Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Canada
3. Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Canada

Background

Ambulating individuals with a neurological disorder are at a significantly higher risk of falling when compared to aged-matched healthy peers. Due to decreased reactive ability, the likelihood of the fall causing injury also increases. The most common indicator of a fall within this population is increased postural sway (trunk movement) during static standing, with individuals lacking the ability to control their center of mass within their base of support. Currently, fall reporting within the community is subjective based on recall or a fall diary, limiting the accuracy of fall prevalence, which guides clinicians when designing rehabilitation programs. Therefore, developing accurate tools to both detect fall risks and record fall events must be prioritized.

Methods

Our objective is to determine whether a wearable garment instrumented with IMUs can track shoulder girdle, trunk, and hip movements. The study will recruit 17 healthy adults. Participants will perform static and dynamic tasks in duplicate while their kinematics are tracked using the instrumented garment (IG) and 3D motion capture. Statistical tests will include intra-class correlations for test-retest and between-session reliability and inter-class correlations and absolute agreement between testing methods for garment validity.

Results

Primary outcome measures are kinematics of the shoulder girdle, trunk, and hips via 3D motion capture and instrument garment. We hypothesize that the IG will exhibit good to excellent within and between session reliability (ICC≥0.75, CV<10%) for both static and dynamic tasks. We further hypothesize that the IG will demonstrate high levels of concurrent validity (ICC≥0.75, r2≥0.65) when compared to 3D motion capture.

Conclusion

This study is the first step towards developing a wearable technology which has the potential to track postural control, identify movement patterns associated with falling, and report fall incidents within the community. The results of this proof-of-concept study will direct future studies and IG development.

Key Words

Postural Control, Kinematics, Rehabilitation, Independence

Abstract: Impairments in manual dexterity among individuals living with cervical spinal cord injury (cSCI) and individuals living with multiple sclerosis (MS) significantly influence the ability to perform activities of daily living independently. Among individuals with cSCI, regaining hand function is a top priority, while limited research has specifically focused on upper-extremity training among individuals with MS. Considering limited time in inpatient care, there is a need for high-quality, upper extremity training tools that can be performed at home. Augmented reality (AR) systems may provide a solution by incorporating hand tracking during motor tasks with augmented feedback based on individual performance. Further, AR allows individuals to perform tasks with real objects in real environments and without the need for a supervising therapist. Thus, the current study sought to develop an AR system that can provide hand function feedback and further, to assess feasibility and meaningfulness of the system among individuals living with cSCI. While wearing the AR headset (i.e., Hololens 2) individuals use voice commands to ask for specific target postures based on the object they want to interact with. For example, saying "credit card" displays a rendering of a target lateral grasp and instructions on how to grasp the object. Once the individual grasps the object, the AR system tracks their hand posture and compares their actual posture to the target posture. Then, the individual is presented with a visual comparison of the postures and an overall score relating to the overall difference between postures. After trying the system, both structured and semi-structured interviews will be conducted to understand feasibility and meaningfulness among individuals with cSCI. Overall, although the current system was designed specifically for individuals with cSCI, it provides a potential framework of how AR systems can be used to train manual dexterity at home among individuals with MS.

Purpose

To describe the application and outcomes of a spinal cord injury (SCI) locomotor training program for a complex adult patient with multi-morbidity, including multiple sclerosis (MS).

Methods

This case study included a 39-year old male with diagnoses of MS, spastic diplegic cerebral palsy, osteoporosis, and a fractured tibia and fibula six months prior. Minimal walking ability had been regained post-fracture. To facilitate walking recovery, personalized adapted locomotor training (PALT) was used. PALT is an intensive, individualized rehabilitation program developed for individuals with SCI. The program included body weight-supported treadmill training (BWSTT) and overground walking, balance and transfer training. Thirty-five one-hour training sessions occurred over 14 weeks. The 10-meter walk test (10MWT), Berg Balance Scale (BBS), and the carpet task of the SCI Functional Ambulation Profile were assessed at baseline, at the mid-point of training, and post-training.

Results

Stepping time during BWSTT ranged 5.1-17.2 minutes/session, with a mean of 11.9±3.8 minutes of stepping practice/session. The amount of body weight support provided did not vary across sessions (44.3±4.0%), but treadmill speed gradually increased from 0.13–0.32m/s. Post-training, the participant's 10MWT speed increased by 0.08m/s, which exceeds the minimal detectable change. The BBS score showed little improvement (i.e., 3 points). The participant was unable to walk on carpet at baseline, but completed the task in 25.6 seconds post-training.

Conclusions

A less intensive version of a SCI locomotor training program was successfully applied to a complex patient with MS. Small improvements in walking function were observed, enabling limited household ambulation.

Purpose:

In Canada, people with spinal cord injury (SCI) and Multiple Sclerosis primarily access activity-based therapy (ABT) through community clinics. Despite its potential benefits, ABT access in Canada is limited by a lack of funding and clinical guidelines. High quality data, collected through standardized assessments, is needed to inform practice guidelines and advocate for funding. As a step toward developing ABT assessment guidelines, this qualitative study explored the experiences and perceptions of clinicians and clinic owners/managers regarding assessment practices for SCI in community-based ABT programs.

Methods:

Nine clinicians (e.g., kinesiologists, physical and occupational therapists) and three clinic owners/managers completed semi-structured Zoom interviews. Questions, guided by the Theoretical Domains Framework, queried current assessment practices, factors influencing decision-making, challenges and needs. Recorded interviews were transcribed verbatim and analyzed using interpretive description.

Results:

Overarching theme: ABT is a developing field that lacks standardized guidelines for assessment practices. Within this theme, four categories materialized. 1) Factors influencing clinician's decisions about ABT assessment practices: financial considerations, client goals, and a tendency to maintain the status quo were highlighted. 2) Challenges with current ABT assessment practices: lack of specificity of available outcome measures, results discouraging clients, and limitations of a kinesiologist's scope of practice were perceived as barriers. 3) Advantages of current assessment practices: clinician autonomy, client-centered, and ability to track progress were discussed. 4) Progression of assessment for ABT programs: standardized assessment tools and greater access to assessments would improve future assessment practices.

Conclusions:

Canadian community-based ABT programs lack standardized assessment guidelines, resulting in variable assessment practices.

Shirin Tajali1, Derrick Lim1,2, Arya Raha1, Rayna Ghosh1,2, Kristin E. Musselman3, Dimitry G. Sayenko4, Kei Masani1,2

1The KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Canada

2Institute of Biomedical Engineering, University of Toronto, Toronto, Canada

3 Department of Physical Therapy, University of Toronto, Toronto, ON, Canada

4Department of Neurosurgery, Houston Methodist Research Institute,3603 Apple Grove Drive, 77578, Manvel, USA

Background/Objectives: Improving upright balance is an important goal for individuals with incomplete spinal cord injury (SCI) and multiple sclerosis (MS). This study aims to improve upright balance and neural recovery in individuals with incomplete SCI using combined non-invasive neuromodulation therapies-transcutaneous spinal cord stimulation (TSCS) and functional electrical stimulation (FES).

Methods/Overview: So far, 9 participants with incomplete SCI have completed 12 training sessions. The TSCS+FES group (n=5) received tonic stimulation at the lower spine concurrently with closed-loop FES targeting ankle muscles while the FES-only group (n=4) received stimulation for ankle muscles during visual feedback balance training (VFBT). Outcomes included balance confidence (Activities-specific Balance Confidence Scale), mini-Balance Evaluation Systems Test (mini-BESTest), and motor evoked potentials (MEPs), assessed pre-, post-, and at 6-week follow-up.

Results: The TSCS+FES group showed significant improvements in balance confidence, maintained at the 6-week follow-up, while only one participant in the FES-only group improved post-training. Both groups experienced immediate improvements in the mini-BESTest, but only the TSCS+FES group retained these benefits at follow-up. MEPs indicated greater amplitude changes in the TSCS+FES group than in the FES-only group.

Conclusion: Preliminary findings suggest that combining TSCS with FES has the potential to enhance balance recovery and neuroplasticity. This training program can also be adapted for individuals with MS. Given that MS is characterized by demyelination in various parts of the central nervous system, a flexible approach is essential to address fluctuating impairments, including sensorimotor deficits, fatigue, and cognition. Our VFBT can integrate cognitive challenges, while neuromodulation therapy can improve corticomuscular connectivity.

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Background: Increasing evidence supports the benefits of rehabilitation in MS. Other neurological conditions have acute onset with clear indications for rehabilitation, whereas the MS disease course is variable. A multi-component Canadian knowledge mobilization summit was hosted throughout 2023 by MS Canada and the MSBEST leadership team to address gaps in MS rehabilitation. Summit participants prioritized the need to develop a Canadian MS Rehabilitation Guideline and formed an MS Rehab Network to do so.

Methods:

A working group from the larger Network convened to draft 'clinical scenarios' representing patterns at MS onset and trajectories where rehabilitation interventions could be beneficial. These scenarios will help inform the creation of a future guideline. This working group met in person x1 and virtually x 4 to create, refine and achieve consensus on the scenarios. The scenarios were presented to the Network (2024) for real-time discussion with further feedback sought via email.

Results: Results: At "MS onset" scenarios include symptoms which are predominantly: invisible; cerebellar; motor or progressive of any nature. Scenarios "over the disease course" may occur repeatedly or simultaneously in the same individual involving: MS progression; MS relapse; pseudo-progression or pseudo-relapse (pseudo indicates worsening function due to a stressor or comorbidity); compound effects of aging; late progressive and advanced MS. Other factors to consider include persistent symptoms, predominant cognitive symptoms, and pre-habilitation needs.

Conclusion: A future guideline should consider recommendations across scenarios to improve comprehensive care. Further iterative processes with multi-stakeholder engagement may help ensure the proposed scenarios are inclusive.

Background:

Individuals with Spinal Cord Injury/Disease (SCI/D) are dealing with multiple medical complications that deserves more attention through lifestyle interventions. Cardiovascular disease is the leading cause of mortality in SCI. Research has shown that majority of chronic diseases such as cardiovascular disease, type 2 diabetes, dyslipidemia are preventable by lifestyle modifications. The Paving the Path to Wellness Program (PPWP) provides an evidence-based education and coaching about 6 pillars of lifestyle medicine including physical activity, nutrition, stress management, restorative sleep, social connection, and avoidance of risky substances as well as positive psychology, gratitude, and goal setting to empower individuals to optimize their health and well-being. The goal of the PPWP is to empower individuals to cultivate healthier behaviours with a sense of purpose. This program will be adopted from Paving the Path to Wellness to Stroke survivors at Spaulding Hospital to be relevant to SCI/D population.

Objective:

The purpose of this pilot study is to evaluate the feasibility of the PPWP in SCI/D survivors.

Proposed Design/Methods:

Five to seven individuals with SCI/D from outpatient SCI clinic at Providence Care Hospital, Kingston, On, will be recruited to participate in the study. The program consists of an hour weekly session for 12 consecutive weeks. The program will be delivered virtually. The PPWP will run by a physiatrist who is board certified in lifestyle medicine. Each session includes 20-30 minutes presentation followed by group discussion and SMART goal setting. A pre- and post- survey questionnaire will be completed by participants.

Background: Enhancing provider knowledge of spinal cord injury (SCI) is key to improving transitions of care for persons with SCI.

Objective: To describe the delivery and evaluation of a provincial virtual SCI education day for nursing and allied health.

Methods: The Annual SCI Education Day was delivered virtually in 2022, 2023, and 2024. A feedback survey was sent to participants at the end of each event. A second follow up survey was sent to participants of 2022 and 2023 to assess application of knowledge in daily practice.

Participants: Nursing, allied health, persons with SCI

Results: In 2022, 40 of 265 attendees (15.1%) completed the survey. 92.5% of participants found the education day "helpful" or "extremely" helpful. Based on open-text feedback, changes were made for 2023 including fewer topics of longer duration and more time for discussion. The survey was updated for 2023 and 2024 to gather feedback on each individual topic presented, and completion was tied to obtaining a certificate of attendance. 82 of 244 (34%) in 2023 and 172 of 284 (60.6%) in 2024 completed the survey. On a 5-point scale, the overall quality of the event was rated 4 or 5 by 97% in 2023 and by 95% in 2024. Of the 19 participants who completed the secondary follow up survey, 16 (84%) had applied their learning to daily practice, particularly around pressure injuries and autonomic dysreflexia.

Conclusion: A virtual SCI education day was well received by stakeholders and surveys provided actionable feedback for improvement over three years.

Keywords: Education, program evaluation, spinal cord injuries

This presentation will summarize the state of the evidence and current clinical recommendations for exercise in MS. It will discuss the whys, whats, and challenges of supporting physical activity behaviour in MS drawing parallels to what is known in SCI. It will share existing resources and opportunities to participate in recently funded projects to advance clinical resources to support health care providers in addressing physical activity in the routine management of MS.