Healthcare | Free Full-Text | Implementing Activity-Based Therapy for Spinal Cord Injury Rehabilitation in Canada: Challenges and Proposed Solutions

Cesca et al. [24] 2024 Qualitative exploratory (interpretive description) To explore the knowledge, perspectives, and implementation of ABT among physical and occupational therapists in non-SCI-specialized centers. Physical or occupational therapists working in a non-SCI-specialized center in Canada who have treated at least one person with SCI in the last 18 months. Non-SCI-specialized centers (acute care, inpatient rehabilitation, long-term care, outpatient rehabilitation, rural outpatient clinic) across Canada (i.e., facilities lacking SCI-specific services). 7 participants; PTs (n = 4) and OTs (n = 3); Ontario (n = 4) and Alberta (n = 3); experience ranging from 3 to 22 years in current healthcare setting. Not reported. 6 semi-structured interviews.
All individual interviews, except one, completed with a PT and OT from the same facility. Three themes:
(1) available knowledge, resources, and therapy time in non-SCI-specialized centers challenge ABT implementation, (2) how current therapy practices in non-SCI-specialized centers align with ABT, and (3) desire for ABT knowledge. The study emphasized the need for tailored ABT education in non-SCI-specialized centres. Cheung et al. [9] 2022 Exploratory qualitative (interpretive description) To understand how ABT was provided to Canadians with SCI/D in the community.
To explore the use, perceived barriers, and facilitators of ABT and its associated technologies by therapists (e.g., PTs and OTs) and other clinicians. Physical and occupational therapists, clinic employees, clinic managers, and clinic owners who work in a Canadian community-based center that offers ABT to individuals living with SCI. Community-based ABT facilities across Canada. 13 participants;
kinesiologists (n = 6), PTs (n = 4), OTs (n = 1), and clinic directors (n = 2). One PT was also a Clinician Scientist.
Ontario (n = 5), Alberta (n = 3), Quebec (n = 1), and Saskatchewan (n = 1). Male (n = 3) and female (n = 10). 10 interviews.
Each interview consisted of one to two participants from a single site. Overarching theme: ABT in the community is a client-centered approach characterized by various techniques, clinicians, and clientele.
Three main categories within this theme: (1) characteristics of ABT in the community, (2) perceived challenges, and (3) need for advocacy. The study revealed varied applications of ABT and related technologies across Canadian community-based facilities, unified by a focus on client goals and well-being. Systemic challenges hinder ABT’s implementation and accessibility in Canada. Solutions proposed include earlier ABT introduction, enhanced education, and cost reduction. Coomaran et al. [25] 2022 Mixed methods, qualitative descriptive (conventional content analysis) To characterize the overall experience of those involved in the community exercise program toward identification of key program elements. Adults (i.e., ≥18 years of age) who (1) self-reported experience of chronic motor impairment related to a stable, neurological condition and (2) provided documentation of physician clearance for exercise. Community exercise program delivered at the University of Regina Centre for Health, Wellness and Performance between September 2019 and March 2020. 11 individuals living with a neurological condition who participated in the community exercise program.
Neurological conditions included incomplete SCI (n = 1), Parkinson’s disease (n = 1), mild TBI (n = 2), TBI (n = 1), ABI (n = 1), stroke (n = 3), and MS (n = 2).
Time in program ranged from 4 weeks to 20 weeks. Male
(n = 4) and
female (n = 7). 11 interviews with program participants.
Interviews were conducted post-program activities in one-on-one format except in two cases where a spouse or caregiver supported the conversation.
A sample of the program volunteers was also interviewed. Four key program elements:
1. Support through supervision;
2. Social connection;
3. Individualized programming;
4. Experiential learning. The program was feasible and effective in addressing the needs of older adults with varied levels and types of chronic neurological conditions. Key elements for success included personalized exercise prescriptions, social connections, and a supportive environment with knowledgeable supervision. Jervis Rademeyer et al. [14] 2022 Exploratory, qualitative descriptive (interpretive description) To determine if and how occupational and physical therapists in acute care hospital settings use ABT and its associated technologies. Physical and occupational therapists licensed to practice in Canada and working in an acute care hospital setting with patients with SCI. Acute care hospital settings in Canada. 7 participants from 6 sites spanning 4 Canadian provinces: PTs (n = 5) and OTs (n = 2). Male
(n = 1) and
female
(n = 6). 6 interviews.
One interview with two participants from the same facility. Three themes: (1) impact of patient acuity on ABT participation, (2) ABT approach unique to the acute care setting, and (3) influence of acute care work environment and therapy practice. The study indicated that implementing ABT in acute care settings is difficult due to the high dosage of movement practice it demands. Enhancing ABT usage and dosage in these settings could be achieved through early patient education, leveraging social support, and integrating existing portable technology in acute care. Jervis Rademeyer et al. [15] 2023 Qualitative (interpretive description) To understand if and how physical and occupational therapists use ABT and its associated technologies for the rehabilitation of individuals living with SCI in inpatient and outpatient hospital settings in Canada. Physical and occupational therapists licensed to practice in Canada and working at a rehabilitation hospital part of the Rick Hansen Spinal Cord Registry (RHSCIR). Canadian rehabilitation hospitals participating in the RHSCIR. 22 participants from 9 rehabilitation sites across 8 Canadian provinces: PTs (n = 12) and OTs (n = 10). Not reported. 10 focus groups,
consisting of two or more participants. Three overarching themes: (1) therapists’ decision-making approach to ABT and technology, (2) therapist perceived individual factors, and (3) access to ABT and equipment. The application of technology in ABT varied, influenced by both tangible (e.g., equipment cost) and intangible barriers (e.g., departmental relations). ABT usage in Canadian rehabilitation hospitals is inconsistent. To enhance ABT utilization, ongoing education and development of tailored implementation strategies are recommended. Kaiser et al. [8] 2023 Qualitative descriptive (conventional content analysis) To understand and compare the perspectives of key interest groups on the challenges of implementing ABT in Canada for people living with SCI. Canadian, English speaking, and either participated in, supervised, or had knowledge of ABT and SCI.
A screening questionnaire was also used to query the nature and duration of experience with ABT to determine eligibility. Canadian healthcare system. 48 participants representing 6 key interest groups: people with SCI (n = 10), hospital PTs and OTs (n = 6), community exercise trainers (n = 12), hospital and community administrators (n = 8), researchers (n = 7), and advocates, funders, and policy experts (n = 5).
Experience/knowledge in ABT and SCI ranged from 0.25 to 33 years. Male
(n = 20) and
female (n = 28).
(M/F): people with SCI (7/3), hospital PTs and OTs (1/5), community exercise trainers (4/8), hospital and community administrators (1/7), researchers (4/3), and advocates, funders, and policy experts (3/2). 10 focus groups consisting of 2–6 participants.
2 one-on-one interviews. Six themes: (1) challenge of gaps in knowledge and training, (2) challenge of standardizing ABT, (3) challenge of determining the optimal timing of ABT, (4) challenge of defining, characterizing, and achieving high dosage and intensity, (5) challenge of funding ABT, and (6) challenge of measuring participation and performance in ABT. The study identified several challenges in implementing ABT in Canada, including gaps in knowledge and training, difficulties in defining and achieving appropriate dosage and intensity, funding challenges, and challenges in measuring participation and performance. These challenges varied among different interest groups, highlighting the need for tailored approaches to address these issues. Singh et al. [26] 2018 Qualitative descriptive (conventional content analysis) To understand how participation in Personalized Adaptive Locomotor Training (PALT) impacted participants’ lives, what aspects of PALT they perceived to work well, and what challenges they encountered while in the PALT program.
To create recommendations, based on the identified challenges, to guide improvements to the design and implementation of PALT within Canadian tertiary SCI rehabilitation settings. Traumatic, or non-progressive, non-traumatic, motor iSCI (AIS C or D), sub-acute stage of SCI (i.e., <one year post-injury), no deteriorating medical condition, capacity for generating lower extremity reciprocal alternating flexion/extension stepping pat- terns, compliance to reduce or eliminate the use of lower extremity orthotics, reside within 100 km of the training center, and access to reliable transportation. Lyndhurst Center—TRI, part of the University Health Network in Canada (i.e., outpatient rehabilitation setting in Canada). Traumatic SCI (n = 4), non-traumatic SCI (n = 3), AIS C
(n = 1), and AIS D
(n = 6).
Neurological levels of injury ranged from C2 to T8. Male (n = 5)
and female
(n = 2). 7 individual interviews conducted during the last week of the participant’s PALT. Three main themes: (1) motives for participating, (2) perceived benefits, and (3) perceived challenges. Participants reported significant physical and functional improvements from PALT but faced challenges in transferring skills learned in a controlled setting to daily walking. Specific challenges included neglect of other commitments, acquiring services for participation, re-integrating daily walking, and dealing with the rigid structure of PALT. Singh et al. [27] 2018 Qualitative (thematic analysis) To gain insight into participants’ perceptions of Personalized Adaptive Locomotor Training (PALT) and whether participation in PALT had an influence on their level of function and community living 1–2 years following discharge from PALT. Previously participated in PALT and a semi-structured interview conducted upon completion of training, and to be able to participate in a telephone interview lasting 60 min. PALT was conducted at the Lyndhurst Center—Toronto Rehabilitation Institute, part of the University Health Network in Canada (i.e., outpatient rehabilitation setting in Canada). Traumatic SCI (n = 4), non-traumatic SCI (n = 2), AIS C
(n = 1), and AIS D (n = 5).
Neurological levels of injury ranged from C4 to T8.
The age of the participants ranged from 49 to 65 years, and at the time of their interviews they had been living with SCI for between 1.9 and 2.7 years. Male (n = 4)
and female
(n = 2). 6 individual interviews conducted 1–2 years following the participants participation in PALT. Three main themes: (1) PALT outcomes, (2) continuing the rehabilitation journey, and (3) challenges experienced since discharge from PALT. This study revealed that after discharge from PALT, individuals with SCI experience varying levels of physical and psychological adjustment. Most participants improved in psychological well-being after an initial decline. Challenges included difficulty adjusting, need for medical intervention, and importance of physical activity and social support. The study recommends routine follow-ups post-PALT for psychological well-being and emphasizes the need for socially supportive networks and less abrupt discharges. Swaffield and Cheung et al. [10] 2022 Qualitative descriptive (conventional content analysis) To capture the perspectives of individuals living with SCI on community ABT programs in Canada.
To explore the benefits and challenges of ABT, the facilitators and barriers to accessing ABT in the community, and the motivations for participating in ABT programs. Adults (i.e., ≥18 years of age) with chronic (>2 years post-injury) traumatic or non-progressive, non-traumatic SCI who participated in ABT within the past year for a minimum of two months at least, weekly in a community setting in Canada. Canadian community healthcare setting. Traumatic SCI
(n = 10); involved in ABT programs in Ontario (n = 4), Saskatchewan (n = 4), Quebec (n = 1), and Nova Scotia (n = 1).
Years of ABT ranged from 1 to 11. Male (n = 6) and female
(n = 4). Ten individual interviews. Overarching theme: ABT is a key part of their evolving and lifelong recovery process.
Five categories within the theme: (1) motivation to initiate ABT, (2) participants’ experiences of recovery, (3) participants’ perceptions of how ABT contributes to recovery, (4) participants’ perceptions of factors limiting accessibility and participation in ABT, and (5) taking ABT to the next level. ABT is viewed as crucial for continuous recovery and well-being in individuals with SCI. Enhancing awareness and accessibility of ABT could lead to increased participation in ABT programs.